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Atrial fibrillation (AF) is a common cardiac arrhythmia that is associated with increased mortality. Heart failure, hypertension, valvular disease, and obstructive sleep apnea are risk factors for incident AF. A common characteristic of these diseases is that they increase atrial wall stretch. Multiple experimental studies confirm a proarrhythmic effect of atrial stretch. Conversely, a reduction in stretch is antiarrhythmic. A therapeutic target for AF, therefore, lies in local reduction of atrial stretch. This review focuses on atrial stretch and its clinical associations in patients with AF and its downstream effects on electrophysiology. We discuss the possible application of targeted atrial stretch reduction in AF prevention. We conclude that a reduction in local atrial stretch should be considered an essential element in rhythm control.

Background: Minimal evidence is available of the reduction in healthcare utilization of remote care in ICD patients over a longer period of follow-up. Objectives: This study compared healthcare utilization up to 3 year follow-up in implantable cardioverter-defibrillator (ICD) patients with remote care compared to conventional care. Methods: We conducted a retrospective cohort study of patients who received a single or dual-chamber ICD or cardiac resynchronization therapy-defibrillator (CRT-D) between 2016 and 2018. Patients with remote care and patients were compared with patients with received conventional care (control group). The primary endpoint was a composite of cardiac follow-up visits, ICD follow-up visits, telephone consultations, emergency department (ED) visits and hospital admissions and was defined as total healthcare utilization. The secondary endpoints were the individual care activities and one-year all-cause mortality. Results: A total of 497 patients were included in the study, of which 299 patients were allocated to the remote care and 198 patients to the control group. Mean follow-up was 815 ± 279 days. Remote care was associated with a significantly lower rate of adjusted total healthcare utilization in comparison to the control group that sustained for 3 subsequent follow-up years (IRR = 0.78, 95% CI [0.67 to 0.92], p Conclusions: Compared to the standard follow-up of in-office care, a remote care program was associated with a sustained lower rate of planned and unplanned healthcare utilization up to 3 subsequent years after ICD/CRT-D implantation.

BACKGROUND: Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial fibrillation (AF) recurrence; the impact of first-line CBA on quality of life (QoL) and symptoms has not been well characterized. METHODS: Patients aged 18 to 75 with symptomatic paroxysmal AF naïve to rhythm control therapy were randomized (1:1) to CBA (Arctic Front Advance, Medtronic) or AAD (Class I or III). Symptoms and QoL were assessed at baseline, 1, 3, 6, 9, and 12 months using the EHRA classification and Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) and SF-36v2 questionnaires. Symptomatic palpitations were evaluated via patient diary. RESULTS: Overall, 107 patients were randomized to CBA and 111 to AAD; crossovers occurred in 9%. Larger improvements in the AFEQT summary, subscale and treatment satisfaction scores were observed at 12 months with CBA vs AAD (all P

Background Left ventricular (LV) reverse remodeling has been identified as a strong predictor of long-term survival in patients receiving CRT. Interestingly, CRT induces reverse remodeling in the left atrium (LA) as well. It is currently unknown to what extent LA reverse remodeling is correlated to long-term survival after CRT. This study aims to assess the long-term prognostic value of left atrium (LA) reverse remodeling in patients undergoing cardiac resynchronization therapy (CRT). Methods Baseline and 3-months follow-up echocardiograms after CRT implantation were prospectively assessed to determine changes in left ventricular end-systolic volume (LVESV), left ventricular ejection fraction (LVEF), left atrial volume (LAV), and left atrial reservoir strain (LAS(r)). Multivariate Cox regression analysis was performed to identify predictors for long-term survival. Results In our study population of 99 patients with a mean follow-up of 6.3 +/- 2.1 years, 43 patients (43%) reached the end-point of all-cause mortality. More extensive LA reverse remodeling, as measured by a relative increase in LAS(r), was observed in survivors compared to non-survivors (43 [29-64] % vs. 8 [2-28] %, P < 0.001, respectively). After multivariate analysis, delta LAS(r) remained the only significant predictor of mortality [HR per 5%: 0.90 (0.86-0.95); AUC 0.78 (0.68-0.88)]. Conclusion An increase in LAS(r) is associated with favorable long-term outcome after CRT. The observed clinical importance of LA reverse remodeling after CRT asks for further validation in larger prospective cohorts.

Objective We sought to investigate real-world outcomes of patients with degenerated biological aortic valve prostheses who had undergone valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) or reoperative surgical aortic valve replacement (redo-SAVR) in the Netherlands. Methods Patients who had undergone ViV-TAVI or redo-SAVR for a degenerated biological aortic valve prosthesis in the Netherlands between January 2014 and December 2018 were eligible for this retrospective study. Patients with a prior homograft, active endocarditis or mechanical aortic valve prosthesis were excluded. Patients were matched using the propensity score. The primary endpoint was a composite of 30-day all-cause mortality and in-hospital postoperative stroke. Secondary endpoints were all-cause mortality at different time points, in-hospital postoperative stroke, pacemaker implantation and redo procedures within one year. Baseline characteristics and outcome data were collected from the Netherlands Heart Registration. Results From 16 cardiac centres, 653 patients were included in the study (374 ViV-TAVI and 279 redo-SAVR). European System for Cardiac Operative Risk Evaluation I (EuroSCORE I) was higher in ViV-TAVI patients (19.4, interquartile range (IQR) 13.3–27.9 vs 13.8, IQR 8.3–21.9, p Conclusion Patients with degenerated aortic bioprostheses treated with ViV-TAVI or redo-SAVR have similar mortality and morbidity.

OBJECTIVES The objective of this retrospective study was to assess differences in clinical outcomes between patients on acetylsalicylic acid (ASA) monotherapy and patients on other antithrombotic (AT) regimens undergoing elective coronary artery bypass grafting (CABG). METHODS Patients who underwent elective isolated CABG between 2017 and 2019 at the Catharina Hospital Eindhoven were eligible for this study. The primary end points were re-exploration for bleeding and postoperative blood product transfusion. Secondary end points included 30-day mortality, in-hospital stroke, in-hospital myocardial infarction and duration of hospitalization. Propensity matching was used to compare outcomes of the main study groups (ASA vs other AT therapy) and subgroups of AT therapy (guideline adherence vs non-adherence). RESULTS A total of 1068 patients were included: 710 patients on ASA monotherapy and 358 patients on other AT regimens. In the 256 matched patients in the main study groups, using AT regimens other than ASA monotherapy was associated with increased risk of re-exploration for bleeding [6.6% vs 2.0%, P = 0.017; odds ratio (OR) 3.57 (1.29–9.83)] and increased use of blood products [37.5% vs 20.3%, P CONCLUSIONS Preoperative use of AT therapy other than ASA monotherapy in patients who elected CABG was associated with the increased postoperative use of blood products and risk of re-exploration for bleeding; this finding was even more pronounced in non-guideline-adherent patients.

BACKGROUND: It is already known that high coronary microvascular resistance (Rμ) is linked to altered left ventricular stiffness and might be an early indicator of heart failure with preserved ejection fraction (HFpEF). Left atrial dysfunction, on the other hand, varies according to the grade of left ventricular diastolic dysfunction. This is the first study to use the latest development for invasive assessment of Rμ and to combine it with echocardiographic assessment of left atrial strain during reservoir phase (LASr) by speckle tracking in relation to left ventricular (LV) diastolic function.METHODS AND RESULTS: An invasive angiogram was performed in 97 patients because of suspected ANOCA. All patients underwent comprehensive echocardiography, yet image quality was poor in 15 patients leaving 82 patients to include in the final analysis. In order to compare Rμ with LASr values, patients were divided into 4 groups based upon normal values of Rμ as defined by Fournier et al. The mean LASr was plotted against the four resistance groups. The LASr was 48.6% in the lowest resistance group, and 40.1%, 36.3% and 30.1% in the low intermediate, high intermediate and high resistance group respectively. These differences were significant compared to the lowest resistance group (p < 0.05). Although higher Rμ groups showed more diastolic dysfunction, LASr was already decreased irrespective of the severity of diastolic dysfunction.CONCLUSION: This study shows a relationship between increased Rμ and reduced LASr, that seems to precede conventional measures of left ventricular diastolic dysfunction. This suggests that microvascular dysfunction might be an early indicator for the development of impaired LA function.

The aim of this systematic review is to provide an overview of the literature on the effects of bariatric surgery on obesity-associated electrocardiogram (ECG) abnormalities and cardiac arrhythmias. Fourteen studies were included with a methodological quality ranging from poor to good. Majority of the studies showed a significant decrease of QT interval and related measures after bariatric surgery. Seven studies were included in the meta-analysis on effects of bariatric surgery on QTc interval and a significant decrease in QTc interval of - 33.6 ms, 95%CI [- 49.8 to - 17.4] was seen. Bariatric surgery results in significant decrease in QTc interval and P-wave dispersion, i.e., a normalization of initial pathology. The effects on atrial fibrillation are conflicting and not yet fully understood.

Atrial fibrillation (AF) causes heart failure, ischemic strokes, and poor quality of life. The number of patients with AF is estimated to increase to 18 million in Europe in 2050. Pharmacological therapy does not cure AF in all patients. Ablative pulmonary vein isolation is recommended for patients with drug-resistant symptomatic paroxysmal AF but is successful in only about 60%. In patients in whom ablative therapy is successful on the long term, recurrence of AF may occur in the first weeks to months after pulmonary vein ablation. The early recurrence (or delayed cure) of AF is not understood but forms the basis for the generally accepted 3-month blinding (or blanking) period after ablation therapy, which is not included in the evaluation of the eventual success rate of the procedures. The underlying pathophysiological processes responsible for early recurrence and the delayed cure are unknown. The implicit assumption of the blinding period is that the AF mechanism in this period is different from the ablation-targeted AF mechanism (ectopy from the pulmonary veins). In this review, we evaluate the temporary and long-lasting pro- and antiarrhythmic effects of each of the pathophysiological processes and interventions (necrosis, ischemia, oxidative stress, edema, inflammation, autonomic nervous activity, tissue repair, mechanical remodeling, and use of antiarrhythmic drugs) occurring in the blinding period that can modulate AF mechanisms. We propose that stretch-reducing ablation scar is a permanent antiarrhythmic mechanism that develops during the blinding period and is the reason for delayed cure.

Introduction eHealth interventions have the potential to improve the quality of healthcare and reduce costs. However, to implement eHealth interventions successfully instruments are needed to facilitate this process. This study aims to develop an eHealth implementation guideline for implementation of eHealth interventions in daily practice. Methods In June and July 2019 a literature research was conducted and, subsequently, a two-round Delphi study including 13 international eHealth experts in the field of healthcare, ICT & technology, and research was performed. Within the Delphi study, experts scored specific determinants using an online survey. Based on mean scores and interquartile ranges (IQRs) in the online survey, consensus between the experts was assessed. Results A total of five domains (i.e., Technology, Acceptance, Financing, Organizational, and Legislation & Policy) with 24 corresponding determinants were assessed by the experts. After the second Delphi round, consensus was achieved on the five domains and 23 determinants (mean scores ≥ 8; IQR ≤ 2). Only for the determinant ‘Evidence-Based Medicine’ was no consensus reached (mean score Conclusion The eHealth implementation guideline developed in this study may help healthcare providers/researchers assess the determinants of successful eHealth intervention prior to the implementation of the eHealth program

All over the world, awareness exists to change healthcare systems from the volume-based to the value-based models. The move to value-based healthcare (VBHC) is a promising strategy to deliver bette...

Background: Value Based Health Care (VBHC) is a well-known strategy in most countries, amongst whom the Netherlands, to improve patient-relevant outcomes and reduce healthcare costs. However, a met...

Background Value-based healthcare (VBHC) is a promising strategy to increase patient value. For a successful implementation of VBHC, intensive collaborations between organizations and integrated care delivery systems are key conditions. Our aim was to evaluate the effects of a pilot study regarding enhancing regional integration between a cardiac centre and a referring hospital on patient-relevant clinical outcomes and patient satisfaction. Methods The study population consisted of a sample of patients treated for coronary artery disease by use of a coronary artery bypass graft (CABG) or a percutaneous coronary intervention between 2011 and 2016. Since 2013, the two hospitals have implemented different interventions to improve clinical outcomes and the degree of patient satisfaction, e.g. improvement of communication, increased consultant capacity, introduction of outpatient clinic for complex patients, and improved guideline adherence. To identify intervention effects, logistic regression analyses were conducted. Patients’ initial conditions, like demographics and health status, were included in the model as predictors. Clinical data extracted from the electronic health records and the hospitals’ cardiac databases as well as survey-based data were used. Results Our findings indicate a non-significant increase of event-free survival of patients treated for coronary artery disease between 2014 and 2016 compared to patients treated between 2011 and 2013 (97.4% vs. 96.7% respectively). This non-significant improvement over time has led to significant better outcomes for patients referred from the study referring hospital compared to patients referred from other hospitals. The level of patient satisfaction (response rate 32.2%; 216 out of 669) was improved and reached statistically significant higher scores regarding patient information and education (p = .013), quality of care (p = .007), hospital admission and stay (p = .032), personal contact with the physician (p = .024), and total impression (p = .007). Conclusions This study shows a promising effect of regional integration. An intensified collaboration in the care chain, organized in a structured manner between a cardiac centre and a referring hospital and aiming at high quality, resulted in successful improvement of clinical outcomes and degree of patient satisfaction. The applied method may be used as a starting point of regional integration with other referring hospitals. We encourage others to organize the whole care chain to continuously improve patient-relevant outcomes and patient satisfaction. Trial registration ISRCTN11311830. Registered 01 October 2018 (retrospectively registered).

Early detection and diagnosis of atrial fibrillation (AF) is essential in order to prevent stroke and other severe health consequences. The challenges in diagnosing AF arise from its intermittent and asymptomatic nature. Wrist-worn devices that use monitoring based on photoplethysmography have been proposed recently as a possible solution because of their ability to monitor heart rate and rhythm for long periods of time at low cost. Long-term continuous monitoring with implantable devices has been shown to increase the percentage of detected AF episodes, but the additional value of wrist-worn devices has yet to be determined. In this review, we present the state of the art in AF detection with wrist-worn devices, discuss the potential of the technology and current knowledge gaps, and propose directions for future research. The state-of-the-art methods show excellent accuracy for AF detection. However, most of the studies were conducted in hospital settings, and more studies showing the accuracy of the technology for ambulatory long-term monitoring are needed. Objective comparison of results and methodologies among different studies currently is difficult due to the lack of adequate public datasets.

Background: Guideline non-adherence and variations in therapeutic and diagnostic trajectories result in suboptimal atrial fibrillation (AF) treatments. Large academic and referral hospitals demonstrated positive effects of dedicated outpatient AF clinics. Although similar results have not been indicated in (small) non-academic hospitals yet, ample opportunities are present when collaboration is initiated on a regional level. Therefore, this study assesses the effectiveness of outpatient AF clinics in a collaborative region in the Netherlands. Methods: For this study baseline and 6 months follow-up data of a prospective cohort including newly or recently diagnosed AF-patients of 4 hospitals involved in the Netherlands Heart Network are used. From January’15 to March’16 patient relevant outcome measures (ie EHRA score, stroke, major bleedings, hospitalizations, serious adverse effects of medication, and mortality) are gathered. Descriptive and regression analyses are performed to assess the effectiveness of outpatient AF clinics. Results: In the analyses 448 AF-patients were included. After 6 months, significant improvements regarding EHRA score (P

Pulmonary vein (PV) stretch is proarrhythmic for atrial fibrillation (AF). AF patients often report that a left lateral (LL) body position can trigger arrhythmia symptoms. Because the PV myocardium is thought to trigger AF, we hypothesized that the LL compared to the supine body position increases PV wall stress. Functional cardiac magnetic resonance imaging was performed in supine and LL recumbent body position in awake condition in healthy human volunteers (n = 20). Following a change from supine to LL position, the heart moved in an anterior‐LL direction in the thorax. The right superior PV diameter was increased by 19% (24.6 ± 3.1 vs. 20.7 ± 3.2 mm, p = 0.009) and left atrial (LA) volume was larger by 17% (61.7[15.4] vs. 51.0[17.8] ml, p = 0.015) in LL than supine position, respectively. The passive LA conduit fraction (normalized difference between maximum and pre‐contraction LA volume) increased by 25% in LL compared to supine position (19.6 ± 9.0 vs. 15.7 ± 7.6%, respectively, p = 0.016). Local wall stress in the PV regions increased in LL compared to supine position (overall mean: 1.01 ± 0.12 vs. 1.10 ± 0.10 arb. unit, LL vs. supine, position effect p = 0.041), whereas this was not the case in the LA walls (overall mean: 1.18 ± 0.31 vs. 1.21 ± 0.21 arb. unit, LL vs. supine, position effect p = 0.381). In conclusion, a left lateral body position increases PV myocardial stress during the atrial relaxation phase of healthy volunteers. These results have implications for the mechanisms of posture‐triggered AF., Atrial fibrillation can be triggered by taking a left lateral recumbent position. We show that a left lateral position causes anterior‐left localization of the heart and increases stress in the pulmonary veins.

Background Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB. Purpose To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF. Methods This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia. Results Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias. Conclusion Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston Scientific

Atrial fibrillation is becoming a disease that needs to be addressed with definitive long‐term treatment as opposed to medical management options. Ablation or isolation of focal triggers around the pulmonary veins can eliminate arrhythmia substrates for patients with paroxysmal, lone atrial fibrillation. However, limited pulmonary vein isolation strategies do not address reentrant circuits common in persistent and longstanding persistent patients with structural heart disease and enlarged atria. The convergent procedure is a hybrid ablation treatment for atrial fibrillation. It consists of surgical ablation of the posterior left atrium through a minimally invasive closed-chest approach followed by endocardial catheter ablation. The convergent procedure was developed to treat atrial fibrillation by creating a complete and comprehensive pattern of linear lesions on the left atrial backwall under direct endoscopic visualization while avoiding chest incisions and deflation of the lungs. Endocardial ablation follows the epicardial procedure to confirm lesion integrity and supplement the epicardial procedure, which is performed in a staged fashion.

Introduction: Low nadir temperature (N T ) and long thaw times with cryoballoon ablation are associated with successful PVI. Recently, a cryo-system was designed to improve catheter stability during ablation via a balloon (CB, POLARx™, Boston Scientific) that maintains uniform pressure and size. The purpose of this study was to evaluate whether the CB biophysical parameters, including time to -40 o C (TT40), N T , time to thaw (iTT0), and time to 15 o C (iTT15), are associated with acute PVI success in paroxysmal AF patients. Methods: Ablation was delivered for 180s if isolation was achieved in ≤ 60s or 240s if isolation occurred after 60s. PVI was confirmed via entrance and exit block. Biophysical parameters were evaluated for 3 groups: block with 180s ablation, block with 240s ablation, and for unsuccessful initial treatments (gap veins). The diagnostic accuracy for predicting PVI was assessed using area under (AUC) the receiver operator characteristic (ROC) curve for ablations > 120s. Results: Forty-six consecutive de novo PVI procedures at 4 centers were analyzed (n=234 ablations). All PVs were isolated using the CB alone, with the vast majority within 60s. During freeze, TT40 and N T were significantly shorter and colder for isolated veins compared to gap veins (Table). During thaw, iTT0 and iTT15 were significantly longer for isolated veins compared to gap veins (Table). ROC analysis found iTT15 had the highest diagnostic accuracy for isolation (AUC: 0.85) followed by N T (AUC: 0.81), iTT0 (AUC: 0.77), and TT40 (AUC: 0.72). Optimal cutoff values for iTT15 and N T were 33.5s and -48 o C, which had positive predictive values for acute block of 96.6% and 93.5%. Conclusions: When using the novel CB, ablations reaching < -48 o C and having thaw times to 15 o C > 33.5s were predictive of acute block in PVI, providing guidance toward improved workflow and potential reduction in procedural time.

ObjectiveThe aim of this study is to assess the effects on procedural, 30-day, and 1‑year all-cause mortality by a newly introduced quality improvement strategy in patients after transcatheter aortic valve replacement (TAVR).MethodsIn October 2015, a coherent set of quality improving interventions with respect to patient geriatric screening, general diagnostic examination and safety of the procedure was implemented at a single centre in the Netherlands. Patients undergoing TAVR in 2013–2018 were included for retrospective analysis. Mortality was assessed in the pre-quality improvement strategy cohort (January 2013 to October 2015; cohort A) and in the post-quality improvement strategy cohort (November 2015 to December 2018; cohort B). Logistic regression analysis was used to estimate the influence of patient and procedural characteristics on the results of the quality improvement strategy in terms of procedural, 30-day, and 1‑year all-cause mortality.ResultsIn total, 806 patients were analysed with 274 patients in cohort A and 532 patients in cohort B. After introduction of the quality improvement strategy, procedural (4.4% to 1.3%,p p p ConclusionStructural meetings on evaluation of outcomes highlight potential areas for improvement and subsequent outcome-based quality improvement initiatives can result in lower procedural, 30-day, and 1‑year all-cause mortality.

Background Current electroanatomic mapping systems for catheter ablation often require pre-procedural cardiac imaging, and special catheters. KODEX-EPD is a novel open-platform system that uses dielectric imaging to provide real-time, high-resolution cardiac images, with a potential for tissue characterisation and wall thickness to guide ablation. Purpose We report our initial experience with the KODEX-EPD system. Methods The KODEX-EPD uses body surface patches (“sensors”) to emit and receive radiofrequency waves across the thorax. Anatomical structures cause gradients in the electrical field, which are measured by a standard electrophysiology catheter and used to generate an anatomical shell of the cardiac chambers. The system requires no direct physical surface contact or fluoroscopy to acquire anatomical information. If direct physical surface contact is added, a voltage map can be created. After mapping with the KODEX-EPD, ablation was continued according to standard of care using radiofrequency or cryoablation. Results Since November 2019, 26 patients were included (mean age 57.7 (±13.2), 16 (61.5%) male). Ablations were performed for atrial fibrillation in 13 (50.0%) patients, atrial flutter in 10 (38.5%), atrial tachycardia in 1 (3.8%), AVNRT in 1 (3.8%), AVRT in 2 (7.7%) and ventricular extrasystole in 2 (7.7%). The median procedure time was 99.5 [68.8; 112.3] minutes, and fluoroscopy time 14.4 [10.0; 16.9] minutes. All procedures were successful. No adverse events occurred during follow up. Conclusion KODEX-EPD is a novel electroanatomic system for cardiac mapping as well as anatomical imaging that can be safely and effectively utilised for a variety of cardiac arrhythmia ablations. Future versions will allow wall thickness measurement and lesion quality to optimise the ablation process. KODEX-EPD CTI Ablation Funding Acknowledgement Type of funding source: None

Background After coronary artery bypass grafting (CABG), healthcare utilisation is high and is partly unplanned. eHealth applications have been proposed to reduce healthcare consumption and to enable patients to get actively involved in their recovery. This way, healthcare expenses can be reduced and the quality of care can be improved. Objectives We aim to evaluate whether the use of an eHealth programme can reduce unplanned healthcare utilisation and improve mental and physical health in the first 6 weeks after discharge in patients who underwent CABG. In addition, patient satisfaction and use of the eHealth programme will be evaluated. Methods For this single-centre randomised controlled trial, at least 280 patients referred for CABG will be included at the preoperative outpatient clinic and randomised to an intervention or control group. The intervention group will have access to an eHealth programme, which consists of online educational videos developed by the Dutch Heart Foundation and postoperative video consultations with a physician. The control group will receive standard care and will not have access to the eHealth programme. The primary endpoint is healthcare utilisation; other endpoints include anxiety, duration of recovery, quality of life and patient satisfaction. Participants will complete several questionnaires at 6 time points during the study. Results Patient enrolment started in February 2020 and completion of the follow-up period is expected in August 2021. Conclusion This randomised trial was initiated to test the hypothesis that patients who are partaking in our eHealth programme use less unplanned care and experience a better quality of life, less anxiety and a faster recovery than controls.

Cardiovascular disease is the most common cause of death in Western countries. Physician adherence to guidelines is often suboptimal, resulting in impaired patient outcome and prognosis. Multiple studies have been conducted to evaluate patterns and the influencing factors of patient adherence, but little is known about factors influencing physician guideline adherence. This review aims to identify factors influencing physician guideline adherence relevant to cardiology and to provide insights and suggestions for future improvement. Physician adherence was measured as adherence to standard local medical practice and applicable guidelines. Female gender and older age had a negative effect on physician guideline adherence. In addition, independent of the type of heart disease, physicians without cardiologic specialization were linked to physician noncompliance. Also, guideline adherence in primary care centers was at a lower level compared with secondary or tertiary care centers. The importance of guideline adherence increases as patients age, and complex diseases and comorbidity arise. Appropriate resources and interventions, taking important factors for nonadherence in account, are necessary to improve guideline adoption and adherence in every level of the chain. This in turn should improve patient outcome.

Background Successful delivery of continuous and durable pulmonary vein isolation (PVI) lesion sets is recognized as being critical to long-term clinical outcomes following ablation for atrial fibrillation (AF). Confirmation of PVI following cryoballoon ablation is commonly achieved using a 3.3F circular mapping catheter (CMC) which can be delivered through the central lumen of the cryoballoon, but other diagnostic tools may be used alone or in conjunction with the 3.3F CMC. A high-density, grid-style mapping catheter is now available in multiple geographies; use in cryoballoon ablation procedures and associated outcomes has not been previously reported. Purpose To evaluate diagnostic catheter usage patterns in cryoablation procedures and identify associated trends in procedural characteristics and acute outcomes. Methods Self-reported procedural data was prospectively collected in AF cryoablation cases utilizing various diagnostic catheter tools, including the 3.3F CMC and high-density, grid-style mapping catheter (HD Grid). Procedural characteristics and acute outcomes, including the incidence and location of gaps post-ablation, were recorded and analyzed. Results Data was collected in 23 cryoablation procedures performed in 7 centers across the United States and Europe. De novo and repeat ablations represented 65.2% and 21.7% of cases, respectively (13.0% not reported). 3D mapping was employed in 95.7% of cases. A left common pulmonary vein was present and ablated in 8.7% (2/23). The 28mm cryoballoon was utilized in all cases, with a single case using both a 23mm and 28mm cryoballoon. The 3.3F CMC was used to confirm isolation in all cases using a variety of techniques: voltage mapping (60.9%), exit block (56.5%), entrance block (30.4%), propagation mapping (4.3%), and activation mapping (4.3%); note: total exceeds 100% as more than one technique may be employed in a single case. In 18 cases, PVI was confirmed using a 3.3F CMC followed by secondary confirmation with HD Grid, enabling a direct comparison of the two technologies. The HD Grid identified a total of 12 gaps in 4 (22.2%) patients, which were missed by the 3.3F CMC (Figure 1). No adenosine or isoproterenol use was documented in any case. Conclusion(s): The 3.3F CMC is routinely used to confirm PVI following cryoballoon ablation for atrial fibrillation, but it may fail to identify gaps in some patients. Subsequent assessment of PVI using the HD Grid identified residual gaps in nearly a quarter of patients, suggesting that sensitivity for gap detection may be improved with this tool. Limitations of this analysis include the small sample size and workflows which consistently assessed PVI with the high-density mapping catheter after confirming isolation with the 3.3F CMC. Despite these limitations, the incidence of residual gaps observed is noteworthy and may warrant additional study. Abstract Figure.

Surgical ablation is a safe and effective treatment for atrial fibrillation. In the procedure demonstrated in this video tutorial, surgery was performed under general anesthesia with a double-lumen tube. After opening of the pericardium and blunt dissection of the oblique and transverse sinuses, surgical ablation was performed. Two guidance catheters were introduced through the oblique and transverse sinus from the left side. A bipolar radiofrequency clamp was attached to the guidance catheters and positioned to encircle the pulmonary veins and posterior left atrium. Complete electrical isolation was confirmed by measurement of bidirectional block. The left atrial appendage was excluded using an Atriclip PRO II device.

Obesity, defined as a body mass index of ≥30 kg/m2 , is the most common chronic metabolic disease worldwide and its prevalence has been strongly increasing. Obesity has deleterious effects on cardiac function. The purpose of this review is to evaluate the effects of obesity and excessive weight loss due to bariatric surgery on cardiac function, structural changes and haemodynamic responses of both the left and right ventricle.

Innovative forms of value-based purchasing contracts, based on outcome instead of volume, are imperative to face the imminent cost crisis in health care. The objective of this study was to design and implement a model for an outcome-based purchasing contract between a hospital and a health insurance company. The model was implemented in 2015. A study cohort (n = 14,944) from patients with coronary artery disease or atrial fibrillation treated in 2014 was compared to a historical reference cohort from patients treated between 2010 and 2013. The outcome measures and the model are based on Porter's value-based healthcare principles. Improvements in outcomes were observed, leading to a financial incentive to be spent on further quality improvement. Implementation of this model is a first step towards enabling inclusion of patient-relevant outcomes in purchasing for healthcare. It aligns the focus of health insurance companies and hospitals on patient value.

Aims Intermittent change in p-wave discernibility during periods of ectopy and sinus arrhythmia is a cause of inappropriate atrial fibrillation (AF) detection in insertable cardiac monitors (ICM). To address this, we developed and validated an enhanced AF detection algorithm. Methods and results Atrial fibrillation detection in Reveal LINQ ICM uses patterns of incoherence in RR intervals and absence of P-wave evidence over a 2-min period. The enhanced algorithm includes P-wave evidence during RR irregularity as evidence of sinus arrhythmia or ectopy to adaptively optimize sensitivity for AF detection. The algorithm was developed and validated using Holter data from the XPECT and LINQ Usability studies which collected surface electrocardiogram (ECG) and continuous ICM ECG over a 24–48 h period. The algorithm detections were compared with Holter annotations, performed by multiple reviewers, to compute episode and duration detection performance. The validation dataset comprised of 3187 h of valid Holter and LINQ recordings from 138 patients, with true AF in 37 patients yielding 108 true AF episodes ≥2-min and 449 h of AF. The enhanced algorithm reduced inappropriately detected episodes by 49% and duration by 66% with

Aims: This study independently evaluated the diagnostic performance of electrocardiographic (ECG) criteria to predict the infarct-related artery (IRA) in patients with an acute ST-segment elevation myocardial infarction (STEMI). While a number of ECG criteria have been proposed to predict the IRA in STEMI, many of these "rules" came from modestly sized populations and did not undergo external validation. Therefore, we aimed to evaluate popular criteria from the literature in an independent cohort. Methods and results: All acute STEMI cases over a 10-year period from a single hospital were retrospectively identified. We excluded patients with a missing pre-intervention ECG, irretrievable angiographic films, prior coronary artery bypass grafting, left bundle branch block, ventricular pacing, or not meeting strict STEMI criteria. After review of the angiograms for the IRA, cases with either no or multiple culprits were excluded. We included 480 subjects meeting STEMI criteria in inferior leads (192, 40%), anterior leads (184, 38%), both anterior and inferior leads (88, 18%), isolated lateral leads (nine, 2%), or a posterior pattern (seven, 1%). Notably, every pattern except isolated lateral STEMI included an IRA in both the right and left coronary arteries. Conclusions: Existing ECG criteria to predict the IRA in STEMI have modest diagnostic performance when externally validated, and lower than in the original reports. Distinguishing the level of obstruction in the left anterior descending artery remains especially challenging. Hence, their use should be pragmatic when selecting an initial catheter for treating STEMI, since discordances will occur when compared to the actual angiogram.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. Yet tools and techniques used for confirmation of PVI vary greatly, and it is unclear whether the use of any particular combination of tools and techniques provides greater sensitivity for identifying gaps periprocedurally. It has been suggested the use of a high-density mapping catheter, which enables simultaneous recording of adjacent bipolar EGMs in two directions, may provide improved sensitivity for gap identification. Anonymized, acute procedural data was prospectively collected in AF ablation cases utilizing various workflows for confirmation of PVI. Post-hoc analysis was performed to evaluate the incidence of gaps detected by different diagnostic catheter technologies, including a high-density mapping catheter and circular mapping catheters (CMCs), and common techniques such as pacing the ablation lines. A total of 139 cases were included across three subgroup analyses: 99 cases were included in an indirect comparison of three mapping catheter technologies, revealing gaps in 36.7%, 38.9%, and 81.8% of cases utilizing a 10-pole CMC, 20-pole CMC, and a high-density mapping catheter, respectively; a direct comparison of diagnostic catheter technologies in 18 cryoballoon ablation cases revealed residual gaps in 22.2% of patients identified by high-density mapping which were missed previously with the use of a 3.3F CMC; in 22 cases utilizing a technique of pacing the ablation lines, high-density mapping identified residual gaps in 68.2% of patients. This proof of concept analysis demonstrated that the use of a high-density catheter which records orthogonal bipoles simultaneously, appears to improve acute detection of gaps in PVI lines relative to other commonly utilized techniques and technologies. The long-term impact of ablating these concealed gaps remains unclear. Further study, including direct comparison of diagnostic catheter technologies in a randomized setting with long-term followup, is warranted.

Background Central sleep apnea syndrome, correlated with the occurrence of heart failure, is characterized by periods of insufficient ventilation during sleep. This acute study in 15 patients aims to map the venous system and determine if diaphragmatic movement can be achieved by phrenic nerve stimulation at various locations within the venous system. Methods Subjects underwent a scheduled catheter ablation procedure. During the procedural waiting time, one multielectrode electrophysiology catheter was subsequently placed at the superior and inferior vena cava and the junctions of the left jugular and left brachiocephalic vein and right jugular and right brachiocephalic vein, for phrenic nerve stimulation (1-2 seconds ON/2-3 seconds OFF, 40 Hz, pulse width 210 μs). Diaphragmatic movement was assessed manually and by a breathing mask. During a follow-up assessment between 2 and 4 weeks postprocedure, occurrence of adverse events was assessed. Results In all patients diaphragmatic movement was induced at one or more locations using a median threshold of at least 2 V and maximally 7.5 V (i.e., e 3.3 mA, 14.2 mA). The lowest median current to obtain diaphragmatic stimulation without discomfort was found for the right brachiocephalic vein (4.7 mA). In 12/15 patients diaphragmatic movement could be induced without any discomfort, but in three patients hiccups occurred. Conclusion Diaphragmatic stimulation from the brachiocephalic and caval veins is feasible. Potential side effects should be eliminated by adapting the stimulation pattern. This information could be used to design a catheter, combining cardiac pacing with enhancing diaphragm movement during a sleep apnea episode.

Atrial fibrillation (AF) is the most commonly experienced sustained arrhythmia, and it increases risks of stroke and congestive heart failure. Unobtrusive wearable solutions with photoplethysmography (PPG) have been proposed for AF detection and the performance has been mainly evaluated for short-term measurements in controlled measurement settings. In this study, we evaluate the predictive value of features from PPG for AF detection under both hospital and free-living conditions. PPG from the wrist was measured from 18 patients before and after cardioversion and from 16 patients (4 with 100% AF) for 24 hours. Single-lead ECG and 24-hour Holter were used respectively as gold standards. Six PPG-based inter-beat interval (IBI) variability and irregularity features were computed in three different sliding time windows. Thresholds for AF classification for every individual feature were determined with the data from the hospital conditions and tested with the measurements from free-living conditions. Overall, the best classification results were obtained by using a 120-s window, pNN40 resulting as the best feature. On average, the sensitivity was higher in the hospital conditions (92.3% vs. 71.6%) and the specificity higher in the free-living conditions (60.7% vs. 84.9%). In conclusion, testing the classification perfomance in free-living conditions is essential to properly evaluate AF detection models.

AIM: This study explores clinical outcome in cytochrome P450 2C19 (CYP2C19)-related poor metaboliser patients treated with either clopidogrel or prasugrel after percutaneous coronary intervention (PCI) and investigates whether this could be cost-effective.METHODS AND RESULTS: This single-centre, observational study included 3260 patients scheduled for elective PCI between October 2010 and June 2013 and followed for adverse cardiovascular events until October 2014. Post PCI, CYP2C19 poor metaboliser patients were treated with clopidogrel or prasugrel, in addition to aspirin. In total, 32 poor metabolisers were treated with clopidogrel and 41 with prasugrel. The number of adverse cardiovascular events, defined as death from cardiovascular cause, myocardial infarction, stent thrombosis, every second visit to the catheterisation room for re-PCI in the same artery, or stroke, within 1.5 years of PCI, was significantly higher in the CYP2C19 poor metaboliser group treated with clopidogrel (n = 10, 31 %) compared with the poor metaboliser group treated with prasugrel (n = 2, 5 %) (p = 0.003). Costs per gained quality-adjusted life years (QALY) were estimated, showing that genotype-guided post-PCI treatment with prasugrel could be cost-effective with less than € 10,000 per gained QALY.CONCLUSION: This study provides evidence that for CYP2C19-related poor metabolisers prasugrel may be more effective than clopidogrel to prevent major adverse cardiovascular events after PCI and this approach could be cost-effective.

Introduction: Recurrence of atrial fibrillation after pulmonary vein isolation (PVI) occurs frequently and may be associated with electrical reconnection of the pulmonary veins (PV). We investigated spatial distribution of electrical reconnection during re-do procedures in patients with paroxysmal atrial fibrillation who had previous successful acute electrical PVI with either single irrigated tip, antral ablation (s-RF; n = 38) or multi-electrode, duty-cycled ablation (PVAC; n = 48). Methods and Results: EP navigator, mapping and irrigated tip ablation catheters were used in all re-do procedures. Sites of reconnection were assessed in a 12-segment model. Baseline clinical and demographic characteristics were similar in both groups. The number of PVs reconnected per patient was similar in both groups (2.9 ± 0.9 and 3.2 ± 0.7 (p = 0.193), s-RF and PVAC, respectively), and each PV was equally affected. However, the inferior quadrant of the right lower PV was significantly more vulnerable to reconnection after previous PVAC ablation, whereas the superior quadrant of the right upper PV showed significantly more reconnection in the s-RF group. Conclusion: The overall number of PVs reconnected was equally high in both groups, and each PV was affected equally. However, there were significant differences in the spatial distribution of electrical reconnection. Better understanding of predilection sites for reconnection might help to improve the long-term success rate of PVI.

Background For clinicians, confidence in atrial fibrillation (AF) episode classification is an important consideration when electing to use insertable cardiac monitors (ICMs). Objective The purpose of this study was to report on the improved AF detection algorithm in the Reveal LINQ ICM. Methods The Reveal LINQ Usability Study is a nonrandomized, prospective, multicenter trial. The ICM has been miniaturized, uses wireless telemetry for remote patient monitoring, and its AF algorithm includes a new p-wave filter. At 1 month post-device insertion, Holter monitor data were collected and annotated for true AF episodes ≥2 minutes, and performance metrics were evaluated by comparing Holter annotations with ICM detections. Results The study enrolled 151 patients (age 56.6 ± 12.1, male 67%). Reasons for monitoring included AF ablation or AF management in 81.5% (n = 123), syncope in 12.6% (n = 19), and other indications in 5.9% (n = 9) of patients. Of the 138 patients with an analyzable Holter recording, a total of 112 true AF episodes were identified in 38 patients (27.5%). The overall accuracy of the ICM to detect durations of AF or non-AF episodes was 99.4%, and the AF burden measured by the ICM was highly correlated with the Holter (Pearson coefficient 0.995). Conclusion The new AF detection algorithm in the Reveal LINQ ICM accurately detects the presence or absence of AF. Additionally, it showed high sensitivity in detecting AF duration in patients with a history of intermittent and symptomatic AF.

Background Atrial fibrillation (AF) is an arrhythmia that can be difficult to identify and classify with short-term monitoring. However, current standard of practice requires only short-term monitoring to determine AF classifications and identify symptom-arrhythmia correlations prior to AF ablation procedures. Insertable cardiac monitors (ICMs) offer continuous arrhythmia monitoring, which could lead to a more accurate measurement of AF burden than standard of practice. Methods This analysis focused on 121 patients enrolled in the LINQ Usability Study indicated for an AF ablation. Patients were followed for up to 1 year after ICM insertion. Clinical AF classifications were made by physicians prior to ICM implantation based on available clinical information. Device-detected AF burden and maximum daily burden were collected from device interrogations and remote transmissions. Device AF classifications were determined by categorizing the AF burden based on guidelines. Results Agreement between clinical and device AF classifications preablation was poor (48.3%, N = 58). The strongest agreement was in the paroxysmal AF group but still was only 61.8%. Furthermore, device-detected preablation AF burden led to the decision to defer AF ablation procedures in 16 (13.2%) patients. The median AF burden in patients with ≥6 months follow-up postablation (n = 71) was reduced from 7.8% (interquartile range [IQR]: 0-32.1%) to 0% (IQR: 0-0.7%). Conclusions ICM monitoring to determine AF burden pre- and post-AF ablation may have clinical utility for management of ablation candidates through more accurate AF classification and guiding treatment decisions.

Force-interval relationships (FIRs) of the heart represent the relationships between inter-beat intervals (IBIs) and strength of the ventricular contractions. These relationships are typically measured invasively and are altered from normal in heart failure (HF). An unobtrusive and continuous measurement of FIRs could be beneficial when HF and atrial fibrillation (AF) coexist in order to understand if AF causes progression of HF. We hypothesize that FIRs could be assessed during AF with IBIs and hemodynamic changes captured unobtrusively by photo-plethysmography (PPG) at the wrist. FIRs were assessed by using Spearman's rank correlation between the pulse onset change in the PPG waveform and either the preceding or pre-preceding IBIs (r pre\ and r pre-pre) in 5-minute segments. 32 patients (14 continuous AF, 18 no AF) were measured during the night with PPG and electrocardiography as a reference. The mean and standard deviation of r pre were -0.25± 0.08 and 0.05± 0.12(p < 0.0001), and of r pre-pre} 0.60± 0.09 and 0.16± 0.14 (p < 0.0001), during AF and sinus rhythm, respectively. Areas under the Receiver Operating Characteristics curve were 0.987 and 0.998, respectively. Thus, during AF the IBIs correlate with the beat-to-beat changes of blood volume measured with PPG, likely to indicate that FIRs can be measured unobtrusively with the PPG signal.

OBJECTIVE: Atrial fibrillation (AF) is the most commonly experienced arrhythmia and it increases the risk of stroke and heart failure. The challenge in detecting the presence of AF is the occasional and asymptomatic manifestation of the condition. Long-term monitoring can increase the sensitivity of detecting intermittent AF episodes, however it is either cumbersome or invasive and costly with electrocardiography (ECG). Photoplethysmography (PPG) is an unobtrusive measuring modality enabling heart rate monitoring, and promising results have been presented in detecting AF. However, there is still limited knowledge about the applicability of the PPG solutions in free-living conditions. The aim of this study was to compare the inter-beat interval derived features for AF detection between ECG and wrist-worn PPG in daily life.APPROACH: The data consisted of 24 h ECG, PPG, and accelerometer measurements from 27 patients (eight AF, 19 non-AF). In total, seven features (Shannon entropy, root mean square of successive differences (RMSSD), normalized RMSSD, pNN40, pNN70, sample entropy, and coefficient of sample entropy (CosEn)) were compared. Body movement was measured with the accelerometer and used with three different thresholds to exclude PPG segments affected by movement.MAIN RESULTS: CosEn resulted as the best performing feature from ECG with Cohens kappa 0.95. When the strictest movement threshold was applied, the same performance was obtained with PPG (kappa = 0.96). In addition, pNN40 and pNN70 reached similar results with the same threshold (kappa = 0.95 and 0.94), but were more robust with respect to movement artefacts. The coverage of PPG was 24.0%-57.6% depending on the movement threshold compared to 92.1% of ECG.SIGNIFICANCE: The inter-beat interval features derived from PPG are equivalent to the ones from ECG for AF detection. Movement artefacts substantially worsen PPG-based AF monitoring in free-living conditions, therefore monitoring coverage needs to be carefully selected. Wrist-worn PPG still provides a promising technology for long-term AF monitoring.

Background Insertable cardiac monitors (ICMs) are used to continuously monitor the patient's electrocardiogram. In response to patient activation or based on automated device algorithms, arrhythmia episodes are stored and automatically transmitted daily to the clinician. Thus, ICMs can be used to diagnose arrhythmias in at-risk patients and in those with symptoms potentially attributable to arrhythmias. The ICM described in this report has undergone a dramatic change in size and method of insertion. Methods To evaluate the safety profile of the ICM procedure, we analyzed procedure-related adverse events (AEs) from two separate trials: A controlled, nonrandomized multicenter study (Reveal LINQTM Usability study) and a multicenter registry (Reveal LINQTM Registry) evaluating real-world experience. For the Registry we reported all procedure-related AEs upon occurrence, whereas for the Usability study, we reported events occurring during the first month of follow-up. Results The Usability study enrolled 151 patients (age 56.6 ± 12.1 years; male 67%) at 16 centers; during follow-up, an infection was observed in 1.3% patients and a procedure-related serious AE (SAE) in 0.7% patients. The Registry enrolled 122 patients (age 61.0 ± 17.8 years; male 47%) at seven centers; during follow-up, an infection was observed in 1.6% patients and a procedure-related SAE in 1.6% patients. Conclusions The cumulative experience from a controlled clinical trial and a “real-world” registry demonstrate that the new ICM can be inserted with very low incidence of AEs.