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Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in non-paroxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results.The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (non LVA ablation) in patients with non-paroxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time.A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus non LVA ablation group [RR 0.63 (27% vs 36%),95% CI 0.48-0.62, P0.001]. Also, redo ablation was significantly lower in LVA ablation group [RR 0.52 (18% vs 26.7%),95% CI 0.38-0.69, P0.00133]. No difference was found in the overall adverse event [RR 0.7 (4.3% vs 5.4), 95% CI 0.36-1.35, P= 0.29].LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events. This article is protected by copyright. All rights reserved.

Chronic obstructive pulmonary disease (COPD) is a risk factor for the development of atrial fibrillation (AF). There is a paucity of contemporary data studying the association between COPD and outcomes of AF ablation. The objective of this study was to investigate the impact of COPD on AF ablation outcomes using a large nationwide database. This study was a retrospective analysis of the National Readmission Database for the years 2016-2018 and included patients admitted with a diagnosis of AF who underwent catheter ablation. Admissions were stratified according to COPD diagnosis using International Classification of Diseases, 10th Revision, Clinical Modification codes. Multivariate, linear, Cox, and logistic regressions were performed to study the impact of COPD on AF ablation. A total of 18,224 admissions (mean age, 68 years; standard deviation, 10 years) were included, of whom 3,494 (19%) had a diagnosis of COPD. The COPD group was older (72 ± 8 vs. 67 ± 11 years

Progressive remodeling of left atrial posterior wall (LAPW) plays an important role in the pathology of persistent/ long-standing persistent atrial fibrillation. The role of pulmonary veins isolation (PVI) and adjunctive LAPW isolation using cryothermal energy in non-paroxysmal atrial fibrillation is yet to be established. The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to April 2022. Relevant randomized trials and observational studies comparing de novo cryoballoon PVI only versus PVI+LAPWI in patients with non paroxysmal AF were identified and a meta-analysis was performed using the random effect model. The efficacy endpoints of interest were recurrence of AF, recurrence of non-AF and all atrial arrhythmias at 1-year post ablation. The safety endpoint of interest was all adverse events between the two groups. A total of 6 studies (3 prospective trials and 3 observational studies) with 1037 patients were included. A significant reduction in AF recurrence at 1-year was observed in PVI+LAPWI group (OR 0.36 (17% vs 39%), 95% CI 0.26-0.49, P0.001). Also, lower incidence of overall atrial arrhythmias was found in PVI+LAPWI (OR 0.37 (23% vs 47%),95% CI 0.28-0.49, P0.001). For safety endpoints, the overall adverse event rate was low without the significant difference between the groups (OR: 0.86, (3% vs 3.5%) 95% CI 0.36-2.07, P = 0.74). Cryoballoon LAPWI plus PVI provides a significant reduction in recurrence of all atrial arrhythmias and AF at 1-year compared with PVI alone in non paroxysmal AF population without increase in adverse events rate.

Patients with Friedreich ataxia typically die of cardiomyopathy, marked by myocardial fibrosis and abnormal left ventricular (LV) geometry. We measured procollagen I carboxyterminal propeptide (PICP), a serum biomarker of collagen production, and characterized genotypes, phenotypes, and outcomes in these patients. Twenty-nine patients with Friedreich ataxia (mean age, 34.2 ± 2.2 yr) and 29 healthy subjects (mean age, 32.5 ± 1.1 yr) underwent serum PICP measurements. Patients underwent cardiac magnetic resonance imaging and outcome evaluations at baseline and 12 months. Baseline PICP values were significantly higher in the patients than in the control group (1,048 ± 77 vs 614 ± 23 ng/mL; P We conclude that PICP, a serum marker of collagen synthesis, is elevated in Friedreich ataxia and indicates baseline abnormal LV geometry and subsequent dilation. Cardiac magnetic resonance and PICP warrant consideration as complementary biomarkers in therapeutic trials of Friedreich ataxia cardiomyopathy.

Despite significant pharmacological advances in recent years have improved morbidity and mortality in progressive heart failure, the presence of prolonged QRS interval has been associated with increased mortality. Cardiac resynchronization aims to restore the electrical dyssynchrony that in turn offers improved left ventricular ejection fraction, NYHA functional class, quality of life, as well as improvement in morbidity and overall mortality. Although the initial studies have focused on patients with significant disease (NYHA classes III and IV), the same benefit was not demonstrated with mild symptoms despite improvement in reverse remodeling. The review is a brief summary of the landmark trials that validated the therapeutic benefit of biventricular pacing with a brief discussion on the limitations and ongoing research to address them.

Sickle cell disease (SCD) is an inherited disorder in which microvascular occlusion causes complications across multiple organ systems. The precise incidence of myocardial ischemia and infarction (MI), potentially under-recognized microvascular disease-related complications, remains unknown. The absence of typical atherosclerotic lesions seen in other patients with MI suggests a microvascular mechanism of myocardial injury. Cardiac magnetic resonance (CMR) can demonstrate microvascular disease, making it an appealing modality to assess symptomatic SCD patients. We demonstrate in several dramatic instances how CMR is uniquely able to depict cardiac microvascular obstruction in patients with SCD and chest pain, without which the possibility of myocardial injury would almost certainly be otherwise neglected. Much remains unknown regarding ischemic heart disease in patients with SCD including prevalence, detection, and management. Further work to define evaluation and management algorithms for chest pain in SCD and to develop risk assessment tools may reduce sudden cardiac death in this population.

Background: Friedreich ataxia (FA) is the most common recessive hereditary ataxia. Triplet expansion (GAA) of the frataxin gene leads to intramitochondrial iron accumulation, and cardiomyopathy is the leading cause of death in FA. Histopathologic analysis of autopsy hearts has shown myocardial fibrosis and concentric left ventricular (LV) thickening, which our group has previously shown in vivo in FA patients using cardiac magnetic resonance with late gadolinium enhancement (LGE-CMR). Procollagen I carboxyterminal propeptide (PICP) is a serum marker of collagen synthesis, suggesting potential utility as a biomarker of myocardial fibrosis and remodeling. Objectives: The aims of this work were to 1) determine PICP levels in FA patients compared to similar-aged healthy controls, 2) evaluate PICP levels relative to GAA repeat length, 3) evaluate PICP in the context of cardiac remodeling and 4) compare serum PICP levels to presence or absence of fibrosis by LGE-CMR. Methods: 30 FA patients (34.2±11.8 years) underwent measurement of serum PICP using sandwich ELISA as well as CMR examination with cine and LGE acquisitions. Southern blot analysis was performed to measure GAA repeats, recording the minimum of 2 values for each FA patient. 5 healthy volunteers (37.6±8.4 years) served as controls for PICP measurement. Cine images were analyzed at end-diastole to compute relative wall thickness (RWT), a marker of concentric remodeling. Results: PICP values were markedly elevated in FA patients compared to normal controls (1034±76 vs. 657±89 ng/mL, p=0.004). Minimum GAA repeat length was moderately correlated with greater RWT (r=0.40, p=0.041) but did not predict PICP level. Higher PICP level modestly predicted worse concentric remodeling (r=0.39, p=0.033). However, PICP did not distinguish between 15 patients with evident myocardial fibrosis by LGE vs. 15 LGE-negative FA patients (1042±128 vs 1027±87 ng/mL, p=0.925). Conclusions: PICP, a serum marker of collagen synthesis, is significantly elevated in FA patients with higher values indicating adverse LV remodeling. PICP may provide complementary information to direct myocardial fibrosis imaging, and warrants further evaluation as a biomarker of disease severity and treatment response.

Acute decompensated heart failure (ADHF) is a clinical scenario that stems from the underlying pathophysiology of fluid overload. Diuretic therapy has been the mainstay of restoration of homeostatic balance toward euvolemia but has limited success in the setting of diuretic resistance. With increased mortality in ADHF attributed to renal impairment and morbidity related to repeat hospitalization being a concern, strategy to effectively reduce congestion without putting renal function in further jeopardy has been demonstrated with ultrafiltration (UF). This review illustrates the pathophysiology and pitfalls of hypervolemia and examines the data validating the extracorporeal removal of fluid with UF.

With an increasing number of heart transplants being performed around the world and the improvement in survival rates, more transplant recipients may present to the emergency department with comorbidities unique to the transplanted heart and related immunosuppression, including heart failure. This article is aimed at enabling the emergency department physician identify and better manage this unique group of patients for whom time is life.

Duration of dual antiplatelet therapy (DAPT) in patients undergoing percutaneous coronary intervention (PCI) remains uncertain, with increasing data suggestive of acceptable short-term duration. Metabolically accelerated atherosclerosis associated with diabetes makes it essential to study short-term DAPT in this subgroup. With limited studies determining optimal DAPT strategies after second-generation stents in this subset, we aimed to establish the optimal duration of DAPT in the diabetic population using second-generation stents.To determine optimal DAPT duration in diabetic population undergoing PCI in 2nd generation stents.We conducted an electronic database search of randomized controlled trials from PubMed/Medline, Embase, Cochrane, and Web of Science databases.A meta-analysis was conducted comparing outcomes of short-term (3-6 months) DAPT therapy versus long-term (12 months) DAPT therapy in the diabetic population undergoing PCI with second-generation stents.A total of 5 randomized controlled trials were included with a total of 3117 diabetic patients. Short-term DAPT did not show any statistical difference from long-term DAPT in achieving primary outcomes (relative ratio: 0.96, 95% confidence interval (CI) 0.68-1.35, P = 0.84). Overall mortality (OR 0.92; 95% CI, 0.52-1.63, P = 0.98), myocardial infarction [odds ratio (OR)OR 1.02; 95% CI, 0.53-1.94, P = 0.85], stent thrombosis (OR 1.20; 95% CI, 0.55-2.60, P = 0.55), target vessel revascularization (OR 1.10; 95% CI, 0.45-2.73, P = 0.74), and stroke (OR 0.50; 95% CI, 0.082-2.43, P = 0.81) did not show any statistical difference between the 2 groups. Similarly, a subgroup analysis of study population comparing 6 versus 12 months of DAPT in diabetic population did not show any difference in net primary outcomes (relative ratio: 0.86, 95% CI 0.45-1.45, P = 0.60). There was no significant heterogeneity noted between the 2 groups.This meta-analysis showed no statistically significant benefit of longer DAPT over shorter DAPT therapy in patients undergoing PCI with drug-eluting stent in patients with diabetes.