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Sustainability has a solid understanding on a broad level; however, in construction, there is no consensus about what it encompasses. Different practitioners perceive sustainability in construction from different perspectives. There are existing debates concerning the definition and scope of sustainable construction. Therefore, the aim of this research is to set a benchmark for the perceptions governing the understanding of sustainability in construction amongst practitioners working in the UAE’s construction sector. To collect the perceptions, the reviewed literature was condensed to develop an online survey that was validated by an expert panel and collected data from 129 industry professionals in 2022. The reliability of the collected data was confirmed using Cronbach’s alpha. Upon confirming the validity and reliability of the collected data, the analysis of the perceptions was done using descriptive statistics and the relative importance index. The findings confirm that the economic and social pillars are not as recognized as the environmental pillar. Stakeholders are familiar with implementing sustainable practices in the design and construction phases whereas contract formation, procurement and demolition phases had the lowest RII ranking. Stakeholders are informed about the environmental benefits of sustainable construction, but efforts to familiarize them with the benefits of the economic and social pillars should be amplified. The main barriers were the necessity for additional research and the difficulty to implement sustainable construction due to the lack of understanding about what it is. Data collected aligns with the main problem statement which is the lack of understanding about what sustainable construction entails. The contribution that this research has added to the body of knowledge is that the exclusive collection and analysis of the perceptions governing sustainability in the UAE’s construction industry should draw the attention of policymakers that the true meaning of sustainability has not yet infiltrated the construction industry and immediate intervention is mandatory to increase the awareness levels of the stakeholders working in the UAE’s construction industry about what sustainable construction is.

Despite the interest that environmental prudence has garnered worldwide, the construction industry remains behind in incorporating sustainable concepts in construction contracts and contrac...

Signalized urban intersections are key components of urban transportation networks. They are traditionally viewed and designed as primarily motorized traffic facilities, and thus their physical and operational designs have traditionally aimed at maximizing traffic throughput subject to constraints dictated by vehicular safety requirements and pedestrian crossing needs. Seen from a holistic viewpoint, urban intersections are hubs or effective centers of community activities of which traffic flow is only one. Those hubs have direct and indirect impacts on the overlapping traffic functionalities, the environment, public health, community wellbeing, and the local economy. This study proposes a new rating system, the Holistic Intersection Rating System (HIRS), aimed at appraising signalized intersections from a more inclusive viewpoint. This appraisal covers traffic functionality, sustainability, and public health and community wellbeing. This rating system can be used as a guide to conceive, plan, or design new intersections or revamp existing ones. HIRS rates signalized urban intersections based on the level of use of relevant enabling technologies, and the physical and operational designs that allow those intersections to operate holistically, thus leading to a more human-centric and sustainable operational performance. HIRS was validated using a panel of experts in construction, transportation, and public health. The Relative Importance Index (RII) method was used to weigh the HIRS features. The rating system was piloted on a sample of 20 intersections in different cities in the UAE. The results revealed glaring gaps in services to or the consideration of pedestrians, cyclists, and nearby households. The sample intersections scored a mean of 32% on the public health and community wellbeing section, 37% on the pedestrian subsection, and 15% on the cyclist subsection. Such relatively low scores serve as indicators of areas for improvements, and if mapped to their specific features and their relative weights, specific physical and operations designs and technology integration can be identified as actionable items for inclusion in plans and/or designs.

Background Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. Objective The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). Methods A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. Results In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. Conclusion These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

Numerous decision support systems have been developed to address the decision-making process in organizations. However, there are no developed mechanisms to track commitment down the line to the decisions made by corporate leaders. This paper is a portion of a study that establishes a framework for a comprehensive metric system to assess commitment to Sustainable Development (SD) decisions down the line in capital projects, and sets the groundwork for further development of performance indicators for SD outcomes. This ultimately leads to investigating the relationship between commitment to corporate decisions and better project performance in SD parameters. Hence, this study explores the literature to extract relevant parameters that reflect the degree of the project participants’ commitment to SD decisions and to develop commitment indicators. The study created then validated an index to track this commitment along the project stages: the Sustainable Development Commitment Tracking Tool (SDCTT). The SDCTT was tested on an infrastructure project case study. In this paper, techniques relevant to the first stage of projects (planning and definition) are presented. The SDCTT is the groundwork for the future development of performance indicators for SD outcomes, and within the postulated model should ultimately contribute towards reducing project waste, energy use, and carbon emissions.

Communities around the world are looking for ways to provide reliable and cost-effective infrastructure services to end users. Sustainable and resilient infrastructures are the demands of the day. Both public and private sectors demand resilient and sustainable infrastructure to satisfy the rising consumer demands and foster economic development. While a resilient infrastructure fares well under a catastrophic disaster event by withstanding strongly and recovering quickly, a sustainable infrastructure can function effectively over the lifetime without placing excessive demands on limited resources. There is increased awareness among government entities, municipalities, and communities about the necessity for considering both sustainability and resilience in the decision-making process. There have also been attempts within the research community to develop a common framework for sustainable and resilient infrastructures. However, the studies remained too general and limited to expressions of the need only and not often relevant to water distribution system (WDS). The objective of this chapter is to present a conceptual decision model based on the life cycle thinking (LCT) approach. The WDS from Sharjah Electricity and Water Authority (SEWA) is used as an example to illustrate the use of the model. The proposed model takes into account relevant metrics and parameters to help unify the impacts of sustainability and resilience improvements in a WDS. Improvement measures (scenarios) in the model are considered as decision alternatives. The conflicting aspects of sustainability and resilience are examined using a combination of life cycle assessment (LCA) and life cycle-based global resilience analysis (GRA) of the infrastructure. LCA includes the evaluation of sustainability using appropriate metrics. GRA is conducted to determine the resiliency of the WDS. Unified evaluation of both resilience and sustainability for the WDS provides the basis of a model for realistic assessment and critical decision-making. The study develops a LCT-based model to help determine the course(s) of action necessary to achieve sustainability and resilience goals, including the necessary trade-offs, while continuing to provide reliable service to consumers.

The conventional method in construction has many limitations and therefore needs modification. Not only is this method inefficient, but it is also harmful to the environment due to its high energy consumption. Therefore, there is a rising need for automation in construction. This need is accentuated in specific structures, such as museums, that are more creatively designed and have more specific maintenance and operation requirements. The purpose of this paper is to create a tool kit for automating the design, construction, and operation of museums while considering sustainability measures. The main methodology is research on the application of Building Information Modeling (BIM), robotics, and 3D printing during the design and construction stages, and examination of the integration of the Internet of Things (IOT) and indoor air quality management into the operation stage. The results are workable guidelines for the automated museum. The tool kit is beneficial as it will save time and cost and increase the efficiency of operation. It will also increase awareness of the necessity of new job opportunities for labor within the technology sector.

The UAE went through a huge building boom in the last twenty years, resulting in extensive useful infrastructure, yet not necessarily all were built with green design parameters in mind. As these buildings reach their retrofitting milestones, it is an opportunity for owners/developers to retrofit the necessary components for improved energy efficiency and reduced carbon footprints. Thus, this paper summarizes the rationale behind the basic elements identified in a study to develop a green retrofitting toolkit for commercial buildings in the United Arab Emirates. The study focused on refurbishing the passive systems, such as the building envelope (wall enclosures and roofs), and the active systems (lighting and HVAC systems). The methodology that was followed involved looking at the purpose of retrofitting a building for each criterion and examining the necessary issues to be considered, as well as providing the optimum solutions along with a performance matrix for the UAE climate in terms of energy and cost savings. Moreover, a Revit based model was used on a prototypical commercial building design to assess the energy efficiency and resultant cost savings. The study emphasized an all-inclusive retrofitting approach.

The proposed study investigates the differences in project owner decision outcomes for selecting the most suitable project delivery approach, using two Multi-Criteria Decision Making Methods, the Analytic Hierarchy Process and the Technique of Order Preference by Similarity to Ideal Solution. The study considers three primary project delivery approaches: Design and Build, Traditional Design Bid Build, and Construction Management. The factors affecting owners' delivery preferences were explored in the literature and data was collected from project owners across the United Arab Emirates. The analyses were carried out on the three delivery methods. The results from the two methods were compared to find the differences in decision outcomes related to delivery type selection. The analysis showed that both methods yield the same results. Hence, both methods are applicable to use as a basis for decision making regarding the appropriate project delivery method and based on typical owners' preferences.

Direct oral anticoagulants (DOACs) are contraindicated in patients with atrial fibrillation (AF) and mechanical cardiac valves. However, safety and efficacy are controversial in patients with biological cardiac valves. We report the safety and feasibility of periprocedural and long-term treatment with DOACs in patients with biological valves undergoing ablation for AF. A total of 127 patients with AF and biological cardiac valve undergoing CA on uninterrupted DOAC were matched by gender and age with 127 patients with AF and biological cardiac valves undergoing CA on uninterrupted warfarin. All patients were anticoagulated for at least 3–4 weeks prior to ablation with either rivaroxaban (70%) or apixaban (30%), which were continued for at least 3 months and subsequently based on CHA2DS2-VASc score. Mean age of the study population was 63.0 ± 10.9 with 66% being male. The majority of patients on NOACs had aortic valve replacement (59%), while mitral valve was replaced in 41% of patients, which did not differ from the matched cohort on coumadin (aortic valve 57% and mitral valve 43%, (p = 0.8) (p = 0.8), respectively). The CHADS2 score was ≥ 2 in 90 patients (71.0%) on DOAC and 86 patients in (68%) the control (p = 0.6) group. Patients underwent ablation predominantly with uninterrupted rivaroxaban [89 (70%)], while the remaining 38 patients (30%) underwent ablation while on apixaban. Two groin hematomas were observed periprocedurally in both groups. No stroke/transient ischemic attack (TIA) was observed both periprocedurally and at long-term follow-up in either group. Periprocedural and long-term administration of DOACs in patients with biological cardiac valves undergoing AF ablation appears as safe as warfarin therapy.

Introduction This study reports the procedural findings and ablation outcome in AF patients referred after ≥2 failed PV isolation (PVI). Methods Three hundred and five consecutive AF patients referred after ≥2 PVI were included in the analysis. High-dose isoproterenol challenge was used to identify PV reconnection and non-PV triggers; the latter were ablated based on the operator's discretion during the index procedure. At the repeat procedure, non-PV triggers were ablated in all. Empirical isolation of LA appendage (LAA) and coronary sinus (CS) was performed if the PVs were silent and no non-PV triggers were detected. Results PV reconnection was detected in 226 and non-PV triggers were identified or empirically isolated in 285 patients during the index procedure. At follow-up, 182 (60%) patients were recurrence-free off-AAD; the success rate with and without non-PV ablation was 81% vs. 8% (P

As investment increases in capital projects, financial risks increase, and cash flow prediction and control become more paramount. Higher risks could hinder project performance and increase the chances of failure in multiple aspects of a project. While there are models that aim to assess and forecast risks in the construction industry, none present a technique to include the impact of risks on a project’s cash flow. Therefore, cash flow forecasts tend to exceed the actual cash flow of a project due to inaccurate risk assessment. Thus, this paper presents the Cash Flow Risk Index (CFRI) development process quantifying the impact of risks on a project’s cash flow from an owner’s perspective. To that end, the study explored the literature to identify the risk factors that might impact a construction projects’ cash flow and uncovered 44 factors. The study also validated and consolidated these factors to build a CFRI via a Delphi exercise, which reduced the factors from 44 to 36. In further iterations, the 36 factors were also shared with 32 construction industry professionals to rate their relative importance on a five-point Likert scale, from which relative importance index and weights were obtained. As a result, the CFRI was developed to measure the impact of different risk factors on a typical construction project’s cash flow.

Aims Left atrial (LA) scarring, a consequence of cardiac fibrosis is a powerful predictor of procedure-outcome in atrial fibrillation (AF) patients undergoing catheter ablation. We sought to compare the long-term outcome in patients with paroxysmal AF (PAF) and severe LA scarring identified by 3D mapping, undergoing pulmonary vein isolation (PVAI) only or PVAI and the entire scar areas (scar homogenization) or PVAI+ ablation of the non-PV triggers. Methods and results Totally, 177 consecutive patients with PAF and severe LA scarring were included. Patients underwent PVAI only ( n = 45, Group 1), PVAI+ scar homogenization ( n = 66, Group 2) or PVAI+ ablation of non-PV triggers ( n = 66, Group 3) based on operator’s choice. Baseline characteristics were similar across the groups. After first procedure, all patients were followed-up for a minimum of 2 years. The success rate at the end of the follow-up was 18% (8 pts), 21% (14 pts), and 61% (40 pts) in Groups 1, 2, and 3, respectively. Cumulative probability of AF-free survival was significantly higher in Group 3 (overall log-rank P

Background: Longstanding persistent (LSP) atrial fibrillation (AF) is the most challenging type of AF. In addition to pulmonary vein isolation, substrate modification and triggers ablation ...

Purpose Over the past decade, the United Arab Emirates (UAE) introduced several green regulatory guidelines, federal decrees, and a considerable number of environmentally friendly initiatives. Hence, the purpose of this paper is to investigate the top green materials and systems used currently in the UAE construction industry as per the new laws dictate as well as see if professionals are switching over to incorporate more green materials, systems, and/or designs. Design/methodology/approach The work involved reviewing internationally popular green materials and systems for construction, developing a questionnaire based on the literature review, surveying professionals in the seven UAE emirates, and ranking the findings based on the relative importance index. Findings Findings found the top used green materials and system in the UAE’s construction industry. As well as identified that there is a communication gap between the design and implementation phases that is possibly hindering the use of more green materials and systems. Originality/value This study sets a baseline to measure the UAE’s progress over the coming years in terms of integrating more green construction materials, systems, methodologies, and trends.

Purpose– The purpose of this paper is to develop a decision matrix for green project management processes (GPMPs) in commercial construction projects. GPMPs can assist in decoding all of the information required to make green-conscious decisions at various stages of a project.Design/methodology/approach– Integrate the environmental factors into the traditional project management processes (PMPs) of major construction projects. The integrated product is worked into a process index, and the analytical hierarchy processes (AHP) method is used to prioritize the GPMPs according to pre-set criteria.Findings– Research established the theoretical backing of green practices integration in the traditional PMPs, by creating an AHP weighted GPMP index that is linked to usable decision matrix.Originality/value– Develops a fresh methodology to facilitate green decision-making in the project management of commercial construction projects.

Management of Tamponade Following AF Ablation With FXaIIntroduction Because of the absence of a dedicated reversal agent, the outcome of pericardial effusion (PE) following procedures performed with uninterrupted apixaban or rivaroxaban is unknown. We report the characteristics of PEs presenting with tamponade in patients undergoing AF ablation with uninterrupted factor Xa inhibition (FXaI) to understand their management and prognosis. Methods and Results We performed a multicenter cross-sectional survey in 10 centers across the United States. Patient data were obtained by chart review. In all patients the procedure was performed with uninterrupted FXaI. A total of 16 PEs requiring intervention were reported from 5 centers. Two patients were on apixaban 5 mg BD, the remaining on rivaroxaban 20 mg OD. Eleven PEs occurred in the periprocedural setting, and 5 PEs occurred from 1 to 28 days after the procedure. Pericardiocentesis and drainage were performed in all cases. Protamine and 4-factor prothrombin complex concentrate (4F-PCC) were given in all periprocedural cases. Two patients required surgery: in one case coagulation of the pericardial blood prevented effective drainage, and in the other bleeding was secondary to a steam pop-induced atrial tear. None of the postprocedural cases required FXaI reversal and the dose of rivaroxaban was temporarily reduced. No fatal outcomes or thromboembolic events were reported. Conclusion Pericardiocentesis and drainage with FXaI reversal proved effective in the management of acute PEs with tamponade occurring periprocedurally in patients undergoing AF ablation with uninterrupted FXaI. Early postprocedural effusions can be treated with pericardiocentesis without the need of a reversal agent.

Aims Manual compression (MC), widely used to achieve venous access haemostasis, needs prolonged immobilization and extended time-to-haemostasis. Vascular closure devices (VCD) have been reported to have significantly shorter time to haemostasis and ambulation in arterial access-site management. The current study aimed to evaluate the safety and efficacy as well as rate of urinary tract complications in patients receiving MC vs. VCD for venous access-site closure. Methods and results A total of 803 consecutive patients undergoing catheter ablation or left atrial appendage closure were classified into the VCD (n = 304) and the MC (n = 499) group, based on the methods used for haemostasis at the venous access site. Foley catheter was used for bladder-emptying in all MC cases and 15 VCD patients. At one site, VCD group patients with experience of MC in prior ablations were asked to describe their overall satisfaction level after comparing the past experience with the present. Haemostasis was achieved effectively in both populations. No VCD cases required >2 h bed rest, whereas 7 (1.4%) patients in the MC group needed prolonged immobilization (P = 0.04). Significantly higher incidence of access-site haematoma (P = 0.004) and urinary complications (P Conclusion Vascular closure devices provided effective haemostasis, while reducing the access-site complications, ambulation time, and urinary complications.

Background Catheter ablation reduces ventricular tachycardia (VT) recurrence and implantable cardioverter defibrillator shocks in patients with VT and ischemic cardiomyopathy. The most effective catheter ablation technique is unknown. Objectives This study determined rates of VT recurrence in patients undergoing ablation limited to clinical VT along with mappable VTs (“clinical ablation”) versus substrate-based ablation. Methods Subjects with ischemic cardiomyopathy and hemodynamically tolerated VT were randomized to clinical ablation (n = 60) versus substrate-based ablation that targeted all “abnormal” electrograms in the scar (n = 58). Primary endpoint was recurrence of VT. Secondary endpoints included periprocedural complications, 12-month mortality, and rehospitalizations. Results At 12-month follow-up, 9 (15.5%) and 29 (48.3%) patients had VT recurrence in substrate-based and clinical VT ablation groups, respectively (log-rank p Conclusions An extensive substrate-based ablation approach is superior to ablation targeting only clinical and stable VTs in patients with ischemic cardiomyopathy presenting with tolerated VT. (Ablation of Clinical Ventricular Tachycardia Versus Addition of Substrate Ablation on the Long Term Success Rate of VT Ablation (VISTA); NCT01045668 )

The goal of this study was to evaluate the impact of hypertension on the outcome of atrial fibrillation (AF) ablation.Hypertension is a well-known independent risk factor for incident AF.A total of 531 consecutive patients undergoing AF ablation were enrolled in this study and divided into 3 groups: patients with uncontrolled hypertension despite medical treatment (group I, n = 160), patients with controlled hypertension (group II, n = 192), and patients without hypertension (group III, n = 179). Pulmonary vein (PV) antrum and posterior wall isolation was always performed, and non-PV triggers were identified during isoproterenol infusion. All patients underwent extensive follow-up.Three groups differed in terms of left atrial (LA) size, non-PV triggers, and moderate/severe LA scar. Non-PV triggers were present in 94 (58.8%), 64 (33.3%), and 50 (27.9%) patients in groups I, II, and III, respectively (p 0.001). After 19 ± 7.7 months of follow-up, 65 (40.6%), 54 (28.1%), and 46 (25.7%) patients in groups I, II, and III had recurrences (log-rank test, p = 0.003). Among patients in group I who underwent additional non-PV trigger ablation, freedom from AF/atrial tachycardia was 69.8%, which was similar to groups II and III procedural success (log-rank p = 0.7). After adjusting for confounders, uncontrolled hypertension (group I) (hazard ratio [HR]: 1.52, p = 0.045), non-PV triggers (HR: 1.85, p 0.001), and nonparoxysmal AF (HR: 1.64, p = 0.002) demonstrated significant association with arrhythmia recurrence.Controlled hypertension does not affect the AF ablation outcome when compared with patients without hypertension. By contrast, uncontrolled hypertension confers higher AF recurrence risk and requires more extensive ablation.

Benefits of PVI in Patients with Atrial Flutter Background This study examined incidence of AF following cavotricuspid isthmus (CTI) ablation alone or CTI plus prophylactic pulmonary vein isolation (PVI) in patients presenting with isolated atrial flutter (AFL) with no history of AF. Methods and Results We enrolled 216 patients with isolated typical atrial flutter and randomized them to CTI alone (group 1, n = 108, 61.2 ± 9.7 year, 75% male) or CTI+PVI ablation (group 2, n = 108, 62.4 ± 9.3 year, 73% male). Insertible loop recorder (ILR) was implanted in 21 and 19 patients from groups 1 and 2, respectively. Remaining patients were monitored with event recorders, ECG, 7-day Holter. Follow-up period was for 18 ± 6 months. Compared to group 1, group 2 had significantly longer procedural duration (75.9 ± 33 min vs. 161 ± 48 min [P < 0.001]) and fluoroscopy time (15.9 ± 12.3 min vs. 56.4+21 min [P < 0.001]). At the end of follow-up, 65 (60.2%) in group 1 and 77 (71.3%) in group 2 were arrhythmia free off-AAD (log-rank P = 0.044). A subgroup analysis was performed with 55 year age cut-off. In the

Neurocardiogenic syncope (NCS) is a common clinical condition characterized by abrupt cardiovascular autonomic changes resulting in syncope. This is a recurring condition with mixed results from current strategies of treatment. Subjects with a diagnosis of NCS were screened and enrolled. All the participants were given a DVD containing yoga videos and were instructed to practice yoga therapy for 60 min, three times a week for 3 consecutive months. Syncope functional status questionnaire score (SFSQS) was administered at the beginning and the end of the study. The subjects were followed for 3 months and underwent repeat tilt table testing at the end of the study. Of the 60 patients screened, 44 subjects were enrolled, 21 in the intervention group and 23 in the control group. Most of the participants were females, and the mean age was 21 ± 3 years. In the intervention group, who finished the yoga regimen, there was a statistically significant improvement from control phase to the intervention phase, in number of episodes of syncope (4 ± 1 vs 1.3 ± 0.7, p

AIMS This study investigated the impact of weight loss in longstanding persistent (LSPAF) patients undergoing catheter ablation (CA). METHODS Ninety consecutive obese LSPAF patients were approached; 58 volunteered to try weight loss interventions for up to 1 year (group 1), while 32 patients declined weight loss interventions and were included as a control (group 2). Both groups remained on antiarrhythmic drugs. If they continued to experience AF, CA was performed. Body weight was measured at 6-month intervals and arrhythmia status was assessed by event recorder, electrocardiogram (ECG), and Holter monitoring. Symptom severity and quality of life (QoL) were evaluated by AFSS and SF-36 survey, respectively. A scoring algorithm with two summary measures, physical component score (PCS) and mental component score (MCS), was prepared for QoL analysis. RESULTS Significant reduction in body weight (median -24.9 (IQR -19.1 to -56.7) kg, P

Ablation Outcome in Silent Longstanding Persistent AFBackground Impact of catheter ablation on exercise performance, quality of life (QoL) and symptom perception in asymptomatic longstanding persistent AF (LSP-AF) patients has not been reported yet. Methods and Results Sixty-one consecutive patients (mean age 62 ±13 years, 71% males) with asymptomatic LSP-AF undergoing first catheter ablation were enrolled. Extended pulmonary vein antrum isolation plus ablation of complex fractionated atrial electrograms and nonpulmonary vein triggers was performed in all. QoL survey was taken at baseline and 12-months postablation, using Short Form-36 (SF-36). Information on arrhythmia perception was obtained using a standard questionnaire and corroborating symptoms with documented evidence of arrhythmia. Exercise tests were performed on 38 patients at baseline and 5 months after procedure. Recurrence was assessed using event recorder, cardiology evaluation, electrocardiogram, and 7-day holter monitoring. After 20 ± 5 months follow-up, 36 (57%) patients remained recurrence-free off-AAD. Of the 25 patients experiencing recurrence, 21 (84%) were symptomatic. Compared to baseline, follow-up SF-36 scores improved significantly in many measures. For patients with successful ablation, physical component summary (PCS) and mental component summary (MCS) demonstrated substantial improvement (MCS: 64.2 ± 22.3 to 70.1 ± 18.6 [P = 0.041]; PCS: 62.6 ± 18.4 to 70.0 ± 14.4 [P = 0.032]). Postablation exercise study in recurrence-free patients showed significant reduction in resting and peak heart rate (75 ± 11 vs. 90 ± 17 and 132 ± 20 vs. 154.5 ± 36, respectively, P < 0.001), increase in peak oxygen pulse (13.4 ± 3 vs. 18.9 ± 16 mL/beat, Δ5.5 ± 15, P = 0.001), peak VO2/kg (19.7 ± 5 to 23.4 ± 13 mL/kg/min [Δ 3.7 ± 10, P = 0.043]), and corresponding MET (5.6 ± 1 to 6.7 ± 4 [Δ1.1 ± 3, P = 0.03]). No improvement was observed in patients with failed procedures. Conclusion Successful ablation improves exercise performance and QoL in asymptomatic LSP-AF patients.

Ablation Outcome in AF with Concurrent MS and OSA Introduction Metabolic syndrome (MS) and obstructive sleep apnea (OSA) are well-known independent risk factors for atrial fibrillation (AF) recurrence. This study evaluated ablation outcome in AF patients with coexistent MS and OSA and influence of lifestyle modifications (LSM) on arrhythmia recurrence. Methods and Results We included 1,257 AF patients undergoing first catheter ablation (30% paroxysmal AF). Patients having MS + OSA were classified into Group 1 (n = 126; 64 ± 8 years; 76% male). Group 2 (n = 1,131; 62 ± 11 years; 72% male) included those with either MS (n = 431) or OSA (n = 112; no CPAP users) or neither of these comorbidities (n = 588). Patients experiencing recurrence after first procedure were divided into 2 subgroups; those having sporadic events (frequency < 2 months) remained on previously ineffective antiarrhythmic drugs (AAD) and aggressive LSM, while those with persistent arrhythmia (incessant or ≥2 months) underwent repeat ablation. After 34 ± 8 months of first procedure, 66 (52%) in Group 1 and 386 (34%) in Group 2 had recurrence (P < 0.001). Recurrence rate in only-MS, only-OSA, and without MS/OSA groups were 40%, 38%, and 29%, respectively. Patients with MS + OSA experienced substantially higher recurrence compared to those with lone MS or OSA (52% vs. 40% vs. 38%; P = 0.036). Of the 452 patients having recurrence, 250 underwent redo-ablation and 194 remained on AAD and LSM. At 20 ± 6 months, 76% of the redo group remained arrhythmia-free off AAD whereas 74% of the LSM group were free from recurrence (P = 0.71), 33% of which were off AAD. Conclusions MS and OSA have additive negative effect on arrhythmia recurrence following single procedure. Repeat ablation or compliant LSM increase freedom from recurrent AF.

Long-Term Outcome of AF Ablation in MMV PatientsIntroduction It is unclear whether extended pulmonary vein antrum isolation (PVAI) plus nonpulmonary vein (non-PV) trigger elimination prevents more arrhythmia recurrence than PVAI alone in patients with mechanical mitral valve (MMV) undergoing AF ablation. This study compared the efficacy and long-term outcome of 2 ablation strategies—PVAI alone versus extended PVAI plus non-PV trigger elimination—for the treatment of AF in patients with MMV. Methods and Results One hundred and nine consecutive AF patients with MMV were divided into 2 groups: standard PVAI was performed in group 1 (N = 45); in group 2 (N = 64) PVAI was extended to the LA posterior wall, LA septum, and CS; and all non-PV triggers were eliminated. Patients were followed up for 3 years. At the 12th month, 7 (15.6%) patients in group 1, and 39 (60.9%) patients in group 2 were arrhythmia free (log-rank P < 0.001). Four patients (8.9%; 3 cases of AT and 1 case of AF) from group 1, and 12 patients (18.8%; 9 cases of AT, and 3 cases of AFL) from group 2 experienced very late recurrence. At 36 ± 7 months follow-up, the cumulative recurrence after a single procedure was 42/45 (93.3%) in group 1, and 37/64 (57.8%) in group 2 (log-rank P < 0.001). Conclusion Compared with the standard PVAI alone, a strategy including extended PVAI and non-PV trigger elimination is associated with a higher 12-month and long-term arrhythmia-free survival in patients with MMV undergoing AF ablation. Very late recurrence may occur years after the initial procedure with focal AT as the most common type of recurrent arrhythmia.

Construction practices tend to have an adverse impact on the environment through their contribution to CO2 emission, increased waste and energy consumption. The United Arab Emirates (UAE) has launched many initiatives to encourage green design over the past years and to work towards a sustainable community. Nonetheless, such initiatives require a considerable amount of time to penetrate the professional psyche and showcase real results that are easily utilised by the construction community. The aim of this research was to study the current degree of use of Green Design Parameters (GDPs) in the UAE construction projects and to identify the main constraints that hinder their application. To achieve the study's objective, a survey was designed and distributed to engineering design professionals in different consulting and contracting companies in the seven emirates of the UAE. Feedback from 112 projects was examined and statistically analysed. The analysis showed a degree of awareness and use of some key GDP...

Administration of Isuprel/Adenosine After PulmonaryVein Antrum IsolationBackground Pulmonary vein antrum isolation (PVAI) remains associated with atrial fibrillation (AF) recurrence. We administered adenosine and isoproterenol (ISP) after PVAI to uncover non-PV atrial triggers and PV reconnection, potentially increasing ablation success rate. Methods One hundred and ninety-two consecutive patients with symptomatic AF presenting for PVAI were prospectively studied (group 1). Following PVAI, adenosine (18–24 mg) and ISP (20–30 mcg/min) were administered intravenously. Supplemental ablation was performed in patients with non-PV triggers that induced AF (group 1A). Other subgroups included patients with (group 1B) or without (group 1C) consistent non-PV atrial foci that did not induce AF. A cohort of 196 matched control patients undergoing PVAI without drug challenge was used for comparison (group 2). Results A total of 132 atrial non-PV foci were revealed (31 inducing AF). The majority of atrial foci were observed with ISP (113/132, 86%). Less than 5% of patients had persistent PV recovery during the drug challenge. During a mean follow-up of 22 ± 8 months, PVAI was successful in 110/192 (57%, group 1) versus 100/196 (52%, group 2), P = 0.038. Furthermore, the success rate was statistically different between group 1A (25/32, 78%), group 1B (28/83, 34%), and group 1C (57/74, 74%), P < 0.001. Conclusion After PVAI, ablation guided by the administration of adenosine and ISP to target non-PV triggers inducing AF increased AF ablation outcomes. Patients with non-PV foci that did not induce AF had no further ablation, with the lowest ablation success rate. This group may likely benefit from further ablation after PVAI.

We read with interest the letters by Kosiuk et al, Skolnik, Turco, Liu and Yang, and Willey and Biviano. We thank these authors for their interest in our study. We agree with Kosiuk et al that the restoration of sinus rhythm in patients with heart failure and persistent atrial fibrillation (AF) is key to improving ejection fraction and 6-minute walk distance, and we agree with the authors’ data showing a reduction of inappropriate shocks attributable to atrial arrhythmias in patients undergoing ablation.1 Unfortunately, in our trial,2 we did not prospectively collect implantable cardioverter defibrillator inappropriate shocks, and we will not be able to provide solid data. We respectfully disagree with the idea of Dr Skolnik. As mentioned in the discussion and in the clinical perspective of the article, we are not proposing AF ablation in all patients with heart failure, but we are suggesting that this underused therapeutic approach is considered more and more in patients with heart failure.2 The PABA CHF (Comparison of Pulmonary Vein Isolation Versus AV Nodal Ablation With Biventricular Pacing for Patients With Atrial Fibrillation With Congestive Heart Failure) trial,3 although small, showed little improvement with the atrioventricular node ablation and cardiac resynchronization therapy (CRT) device implantation in comparison with ablation. In …

Scar homogenization improves long-term ventricular arrhythmia-free survival compared with standard limited-substrate ablation in patients with post-infarction ventricular tachycardia (VT). Whether such benefit extends to patients with nonischemic cardiomyopathy and scar-related VT is unclear.The aim of this study was to assess the long-term efficacy of an endoepicardial scar homogenization approach compared with standard ablation in this population.Consecutive patients with dilated nonischemic cardiomyopathy (n = 93), scar-related VTs, and evidence of low-voltage regions on the basis of pre-defined criteria on electroanatomic mapping (i.e., bipolar voltage 1.5 mV) underwent either standard VT ablation (group 1 [n = 57]) or endoepicardial ablation of all abnormal potentials within the electroanatomic scar (group 2 [n = 36]). Acute procedural success was defined as noninducibility of any VT at the end of the procedure; long-term success was defined as freedom from any ventricular arrhythmia at follow-up.Acute procedural success rates were 69.4% and 42.1% after scar homogenization and standard ablation, respectively (p = 0.01). During a mean follow-up period of 14 ± 2 months, single-procedure success rates were 63.9% after scar homogenization and 38.6% after standard ablation (p = 0.031). After multivariate analysis, scar homogenization and left ventricular ejection fraction were predictors of long-term success. During follow-up, the rehospitalization rate was significantly lower in the scar homogenization group (p = 0.035).In patients with dilated nonischemic cardiomyopathy, scar-related VT, and evidence of low-voltage regions on electroanatomic mapping, endoepicardial homogenization of the scar significantly increased freedom from any recurrent ventricular arrhythmia compared with a standard limited-substrate ablation. However, the success rate with this approach appeared to be lower than previously reported with ischemic cardiomyopathy, presumably because of the septal and midmyocardial distribution of the scar in some patients.

Whether ablation of non-pulmonary vein (PV) triggers after pulmonary vein antrum isolation (PVAI) improves the long-term procedure outcome in patients with paroxysmal atrial fibrillation (PAF) and left ventricular systolic dysfunction is unknown.We sought to evaluate whether a more extensive ablation procedure improves outcomes at follow-up.Consecutive patients with PAF refractory to antiarrhythmic drugs presenting for PVAI were prospectively studied. Patients were categorized into 2 groups: patients with left ventricular ejection fraction (LVEF) ≤35% (group I; n = 175) and patients with LVEF ≥50% (group II; n = 545). Patients in group I were further divided according to whether additional ablation of non-PV triggers was performed (group IA; n = 88) or not (group IB; n = 87). Long-term ablation success off antiarrhythmic drugs after a single procedure was analyzed.Patients in group I had more non-PV triggers than did patients in group II (69.1% vs 26.6%; P.001). During a follow-up of 15.8 ± 4.7 months, fewer patients in group I remained free from recurrences than those in group II (53.7% vs 81.7%; P.001). Long-term ablation success was higher in group IA than in group IB (75.0% vs 32.2%; P.001) and similar to that in group II (75.0% vs 81.7%; P = .44). In multivariate analysis, LVEF ≤35% (hazard ratio 1.68; P = .003) and non-PV triggers (hazard ratio 3.12; P.001) were independent predictors of recurrences.In patients with PAF and left ventricular systolic dysfunction, ablation of non-PV triggers in addition to PVAI significantly improves their long-term procedure outcome.