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Aims As a first step in developing a decision aid to support shared decision-making (SDM) for patients with atrial fibrillation (AF) to evaluate treatment options for rhythm and symptom control, we aimed to measure decision quality and describe decision-making processes among patients and clinicians involved in decision-making around catheter ablation for AF. Methods and results We conducted a cross-sectional, mixed-methods study guided by an SDM model outlining decision antecedents, processes, and outcomes. Patients and clinicians completed semi-structured interviews about decision-making around ablation, feelings of decision conflict and regret, and preferences for the content, delivery, and format of a hypothetical decision aid for ablation. Patients also completed surveys about AF symptoms and aspects of decision quality. Fifteen patients (mean age 71.1 ± 8.6 years; 27% female) and five clinicians were recruited. For most patients, decisional conflict and regret were low, but they also reported low levels of information and agency in the decision-making process. Most clinicians report routinely providing patients with information and encouraging engagement during consultations. Patients reported preferences for an interactive, web-based decision aid that clearly presents evidence regarding outcomes using data, visualizations, videos, and personalized risk assessments, and is available in multiple languages. Conclusion Disconnects between clinician efforts to provide information and bolster agency and patient experiences of decision-making suggest decision aids may be needed to improve decision quality in practice. Reported experiences with current decision-making practices and preferences for decision aid content, format, and delivery can support the user-centred design and development of a decision aid.

Use of dual-chamber implantable cardioverter-defibrillator (ICD) systems among patients without a pacing indication is an example of low-value care given higher procedural risks, higher costs, and little evidence for benefit from an atrial lead. However, variation in the use of dual-chamber systems was present among patients without a pacing indication.To examine the temporal trends and hospital variation in use of single- and dual-chamber ICD implantation among patients without a pacing indication undergoing first-time ICD implantation.A multicenter cross-sectional study was conducted using the US National Cardiovascular Data Registry ICD Registry. A total of 266 182 patients undergoing initial implantation of a single- or dual-chamber transvenous ICD without a bradycardia pacing indication, class I or II cardiac resynchronization therapy indication, or history of atrial fibrillation or atrial flutter were included. The study was conducted from April 1, 2010, to December 31, 2018; data analysis was performed from October 19, 2020, to January 5, 2022.Implantation of a single- or dual-chamber ICD.Temporal trends among patients undergoing single- vs dual-chamber ICDs were determined using the Cochran-Armitage trend test, and hospital-level variation using adjusted hospital median odds ratios was examined.A total of 266 182 patients (single-chamber ICD, 134 925; dual-chamber ICD, 131 257) were included in this analysis; mean (SD) age was 58.0 (14.0) years and 91 990 patients (68.2%) were men. The use of dual-chamber ICDs decreased from 64.7% (n = 15 694) in 2010 to 42.2% (n = 9762) in 2018 (P .001). Adjusted for patient characteristics, the median hospital-level proportion of single-chamber ICDs increased from 42.9% (95% CI, 42.6%-45.0%) in 2010 to 50.0% (95% CI, 47.8%-51.0%) in 2018. The median odds ratio for the use of dual-chamber ICDs, adjusted for patient characteristics, was 1.6 (95% CI, 1.6-1.8) in 2010 and 1.5 (95% CI, 1.5-1.8) in 2018, indicating decreasing but persistent variation in use.In this national study of US patients undergoing first-time ICD implantation without a clinical indication for an atrial lead, the use of dual-chamber devices decreased. However, institutional variability in the use of atrial leads persists, suggesting differences in individual or institutional cultures of real-world practice and opportunity to reduce this low-value practice.

BACKGROUND Decisions regarding initial rhythm management strategy for patients with newly diagnosed atrial fibrillation (AF) are challenging to individualize. Prior work by our team has demonstrated feasibility of using machine learning algorithms at the level of diagnostic codes to predict rhythm management strategies; however, this work did not examine prediction models at the individual level. OBJECTIVE We aimed to examine decisions about rhythm management for AF and associated outcomes at the individual patient level, through mapping clinical trajectories within the electronic health record. We examined use of quantitative methods to predict the use of rate- or rhythm-control therapy in patients with a new diagnosis of AF. METHODS We performed a targeted chart review of patients with a new diagnosis of atrial fibrillation in the University of Colorado healthcare system from 2011 to 2020. We used clinical and demographic information to develop and test machine learning algorithms for predicting initial rhythm management strategy, and compared models based on accuracy as well as interpretability. Time-to-event and regression analyses were performed to predict the likelihood of change in rhythm management and the risk of subsequent hospitalization or death. RESULTS Of 419 patients with an EHR-diagnosis of new AF, we confirmed the diagnosis in 289 patients, 194 of whom we classified as paroxysmal and 95 persistent. For all patients with AF, rhythm-control therapy resulted in more total management changes. For paroxysmal AF, rhythm-control therapy resulted in fewer hospitalizations (incidence rate ratio 0.32, 95% CI 0.19-0.34) and no difference in mortality compared to rate-control therapy. For persistent AF, rhythm control resulted in more hospitalizations (incidence rate ratio 2.44, 95% CI 1.41-4.22) with no difference in mortality. Machine learning models could predict the initial strategy with limited accuracy, which was higher in patients with persistent than paroxysmal AF. CONCLUSIONS Quantitative decision models for rhythm management of AF can be developed through trajectory mapping using chart review. Discussion about patient-centered outcomes should be considered when selecting initial therapy for atrial fibrillation. CLINICALTRIAL n/a

The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.REAL-AF operators were high volume low fluoroscopy "real world" operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

We introduce a simple, widely applicable formalism for designing "error-divisible" two qubit gates: a quantum gate set where fractional rotations have proportionally reduced error compared to the full entangling gate. In current noisy intermediate-scale quantum (NISQ) algorithms, performance is largely constrained by error proliferation at high circuit depths, of which two-qubit gate error is generally the dominant contribution. Further, in many hardware implementations, arbitrary two qubit rotations must be composed from multiple two-qubit stock gates, further increasing error. This work introduces a set of criteria, and example waveforms and protocols to satisfy them, using superconducting qubits with tunable couplers for constructing continuous gate sets with significantly reduced error for small-angle rotations. If implemented at scale, NISQ algorithm performance would be significantly improved by our error-divisible gate protocols., 5 pages main text, 11 pages total, 5 figures main text, 10 figures total, 3 tables in appendix

In this work we introduce an open source suite of quantum application-oriented performance benchmarks that is designed to measure the effectiveness of quantum computing hardware at executing quantum applications. These benchmarks probe a quantum computer's performance on various algorithms and small applications as the problem size is varied, by mapping out the fidelity of the results as a function of circuit width and depth using the framework of volumetric benchmarking. In addition to estimating the fidelity of results generated by quantum execution, the suite is designed to benchmark certain aspects of the execution pipeline in order to provide end-users with a practical measure of both the quality of and the time to solution. Our methodology is constructed to anticipate advances in quantum computing hardware that are likely to emerge in the next five years. This benchmarking suite is designed to be readily accessible to a broad audience of users and provides benchmarks that correspond to many well-known quantum computing algorithms., Comment: 33 pages, 36 figures; Added to Section VI about Impact of Compiler Optimization Techniques; Updated 20230105 for clarity after review feedback

Use of the CHAAmong patients with AF enrolled in the American College of Cardiology National Cardiovascular Data Registry's outpatient Practice Innovation and Clinical Excellence registry (2008-2014) CHADSAdoption of the CHA

The recent DANISH-ICD trial challenged the benefit of ICD in patients with NICM. We describe characteristics, and outcomes of elderly NICM patients with ICD/CRT in the NCDR ICD Registry. Using the NCDR ICD Registry linked with CMS claims, we identified 14,701 patients with NICM receiving de novo

The consequences of ICD generator recalls are not well defined. We compared complications from generator exchange (GE) of malfunctioning and/or recalled ICD generators vs elective GE. We also compared the operator-reported device malfunction with reasons for FDA recall. GE in the NCDR ICD Registry

The US WATCHMAN New Enrollment Post Approval Surveillance Analysis Plan (NESTed SAP) is designed to assess safety and effectiveness of the WATCHMAN Device. Eligible patients undergoing WATCHMAN implantation were collected through the NCDR Left Atrial Appendage Occlusion Registry (LAAO Registry).

Background: Transvenous lead extraction (TLE) carries a small but measurable risk of serious adverse events. Few studies have examined the potential benefit of continuous monitoring with transesophageal echocardiography (TEE) during this procedure. Objective: Evaluate the utility of TEE during TLE involving both conventional and laser lead removal. Methods: TEE was performed in 100 consecutive patients undergoing TLE. All patients underwent TLE in the operating room with general anesthesia and continuous TEE monitoring. TLE was attempted for 193 leads in 100 patients. Eighty patients required laser lead extraction (80%). Indications for extraction were device endocarditis (28), lead fracture (28), recalled lead (21), pocket infection (17), and other (6). Results: Sixty-seven patients were male and the average age was 56.96 +- 17.01 years. The average length since lead implant was 78±55.19 (1.4-274.43) months. Complete success occurred in 181 leads (94%), partial success in 4 leads (2%), and failure in 8 leads (4%). Major complications included right ventricle laceration (1) and right atrium/superior vena cava laceration (2) which resulted in detection and localization within 1-2 minutes and prompt surgical repair. Premature termination and unnecessary surgery were prevented in 4 patients with hypotension but no intracardiac abnormalities seen on TEE (Figure 1). There was one upper gastrointestinal bleed from the TEE probe (1). In-hospital mortality was 0%. Conclusion: In total the clinical management was changed in 7 patients (7%) based on real-time TEE monitoring helping to decrease the TLE related mortality and premature termination of the procedure. Figure 1 Monitoring with real time TEE prevented premature termination of cases with severe hypotension showing RV obstruction due to invagination of the free wall. RA: right atrium; RV: right ventricle.

Patients electively receiving a primary prevention implantable cardioverter-defibrillator (ICD) are commonly observed overnight in the hospital; the prevalence, implementation, and associated outcomes of same-day discharge have not been characterized. Using data from the National Cardiovascular

The use and in-hospital outcomes of the subcutaneous (S) implantable cardioverter defibrillator (ICD) in the US have not been described. We studied patients (pts) in the National Cardiovascular Data Registry (NCDR) ICD registry who underwent ICD implant between September 28, 2012 (SICD FDA approval

Background: Randomized trials demonstrating the efficacy of implantable cardioverter defibrillator (ICD) therapy for primary prevention of sudden cardiac death in patients with systolic heart failure (HF) predominantly used single chamber devices. However, in clinical practice, patients often receive dual chamber ICDs even in the absence of indications for pacing. The long-term safety of dual chamber devices relative to single chamber devices is uncertain. Methods: We identified all Medicare patients in the National Cardiovascular Data Registry's (NCDR®) ICD Registry™ from 2006-2009 who received an ICD for primary prevention that could be matched to CMS claims data. Patients were excluded if they had an EF >35%, received a bi-ventricular device or had a documented indication for pacing. Adjusted risks of complications, mortality, all cause readmission and HF readmission were estimated with propensity-score matching based on demographic, clinical and diagnostic information. Results: Among 32,034 eligible patients, 38% (n=12,246) received single chamber device and 62% (n=19,788) received a dual chamber device. Unadjusted rates of complications and 6-month all-cause readmission were lower among patients who received a single chamber device (3.5% vs. 4.8%; p Conclusions: Dual chamber ICDs are associated with higher rates of complications. No significant differences between single and dual chamber ICDs were observed for death, all-cause readmission or HF readmission. Future studies should evaluate the potential benefit of dual chamber devices in reducing inappropriate shocks. In Medicare patients undergoing primary prevention ICD placement without clear indications for pacing, the decision to implant a dual chamber device should be considered carefully given the higher risk of complications with this strategy.