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Introduction: Atrial Fibrillation (AF) is a common arrhythmia often comorbid with systolic or diastolic heart failure (HF). Catheter ablation is a more effective treatment for AF with concurrent left ventricular dysfunction, however, the optimal timing of use in these patients is unknown. Methods: All patients that received a catheter ablation for AF(n = 9979) with 1 year of follow‐up within the Intermountain Healthcare system were included. Patients with were identified by the presence of structural disease by ejection fraction (EF): EF ≤ 35% (n = 1024) and EF > 35% (n = 8955). Recursive partitioning categories were used to separate patients into clinically meaningful strata based upon time from initial AF diagnosis until ablation: 30–180(n = 2689), 2:181–545(n = 1747), 3:546–1825(n = 2941), and 4:>1825(n = 2602) days. Results: The mean days from AF diagnosis to first ablation was 3.5 ± 3.8 years (EF > 35%: 3.5 ± 3.8 years, EF ≤ 35%: 3.4 ± 3.8 years, p =.66). In the EF > 35% group, delays in treatment (181–545 vs. 30–180, 546–1825 vs. 30–180, >1825 vs. 30–180 days) increased the risk of death with a hazard ratio (HR) of 2.02(p <.0001), 2.62(p <.0001), and 4.39(p <.0001) respectively with significant risks for HF hospitalization (HR:1.44–3.69), stroke (HR:1.11–2.14), and AF recurrence (HR:1.42–1.81). In patients with an EF ≤ 35%, treatment delays also significantly increased risk of death (HR 2.07–3.77) with similar trends in HF hospitalization (HR:1.63–1.09) and AF recurrence (HR:0.79–1.24). Conclusion: Delays in catheter ablation for AF resulted in increased all‐cause mortality in all patients with differential impact observed on HF hospitalization, stroke, and AF recurrence risks by baseline EF. These data favor earlier use of ablation for AF in patients with and without structural heart disease. [ABSTRACT FROM AUTHOR]

Background: Flecainide is a useful antiarrhythmic for atrial fibrillation (AF). However, because of ventricular proarrhythmia risk, a history of myocardial infarction (MI) or coronary artery disease (CAD) is a flecainide exclusion, and stress testing is used to exclude ischemia. We assessed whether absent/mild coronary artery calcium (CAC) can supplement or avoid the need for stress testing.Methods: We assessed ischemic burden using regadenoson Rb-82 PET/CT in 1372 AF patients ≥50 years old without symptoms or signs of clinical CAD. CAC was determined qualitatively by low dose attenuation computed tomography (CT) (n = 816) or by quantitative CT (n = 556). Ischemic burden and clinical outcomes were compared by CAC burden.Results: Patients with CAC absent or mild (n = 766, 57.2%) were younger, more frequently female, and had higher BMI but lower rates of diabetes, hypertension, and dyslipidemia. Average ischemic burden was lower in CAC-absent/mild patients, and CAC-absent/mild patients showed greater coronary flow reserve, had fewer referrals for coronary angiography, and less often had obstructive CAD. Revascularization at 90 days was lower, and the rate of longer-term major adverse cardiovascular events was favorable.Conclusions: An easily administered, inexpensive, low radiation CAC scan can identify a subset of flecainide candidates with a low ischemic burden on PET stress testing that rarely needs coronary angiography/intervention and has favorable outcomes. Absent or mild CAC-burden combined with other clinical information may avoid or complement routine stress testing. However, additional, ideally randomized and multicenter trials are indicated to confirm these findings before replacing stress testing with CAC screening in selecting patients for flecainide therapy in clinical practice. [ABSTRACT FROM AUTHOR]

Background: Multiple strategies have advocation for power titration and catheter movement during atrial fibrillation (AF) ablation. Comparative favoring evidence regarding the efficacy, logistics, and safety of a higher‐power, shorter duration (HPSD) ablation strategy compared to a lower‐power, longer duration (LPLD) ablation strategy is insubstantial. We performed a meta‐analysis to compare arrhythmia‐free survival, procedure times, and complication rates between the two strategies. Methods: We searched MEDLINE, EMBASE, and Cochrane Library from inception to September 2020. We included studies comparing patients who underwent HPSD and LPLD strategies for AF ablation and reporting either of the following outcomes: Freedom from atrial tachyarrhythmia (AT) including AF and atrial flutter, procedure time, or periprocedural complications. We combined data using the random‐effects model to calculate the odds ratio (OR) and weight mean difference (WMD) with a 95% confidence interval (CI). Results: Ten studies from 2006 to 2020 involving 2274 patients were included (1393 patients underwent HPSD strategy and 881 patients underwent LPLD strategy). HPSD strategy was not associated with increased freedom from AT at 12‐month follow‐up (OR = 1.54, 95% CI: 0.99 to 2.40, p =.054). In the subgroup analysis of the randomized controlled trial, the HPSD strategy was associated with increased freedom from AT compared to the LPLD strategy (OR = 3.12, 95% CI: 1.18 to 8.20, p =.02). There was a significant reduction in the HPSD group for the total procedure (WMD = 49.60, 95% CI: 29.76 to 69.44) and ablation (WMD = 17.92, 95% CI: 13.63 to 22.22) times, but not for fluoroscopy time (WMD = 1.15, 95% CI: −0.67 to 2.97). HPSD was not associated with a reduction in esophageal ulcer/atrioesophageal fistula (OR = 0.35, 95% CI: 0.12 to 1.06) or pericardial effusion/cardiac tamponade rates (OR = 1.16, 95% CI: 0.35 to 3.81). Conclusions: When compared to the LPLD strategy, the HPSD strategy does not improve recurrent AT nor reduce periprocedural complication risks. However, subgroup analysis of the randomized controlled trial showed that HPSD significantly reduces AT recurrence. An HPSD strategy can significantly reduce total procedure and ablation times. [ABSTRACT FROM AUTHOR]

The author reflects on the Book of the Dead and the impact of epicardial fat on atrial fibrillation (AF) vulnerability. Topics discussed include factors attributed to the increase in AF, interesting findings that implicate both obesity and right atrial pacing as mediators of AF vulnerability through similar pathways, and shorter effective refractory periods in the pulmonary veins demonstrated by animals exposed to right atrial pacing.

Introduction: Atrial fibrillation (AF) is strongly associated with dementia, including idiopathic dementias such as Alzheimer's disease. The relative risk of dementia is highest in AF patients 70 years and younger, and the burden of exposure to arrhythmia appears to underlie part of the risk. Areas covered: Anticoagulation choices and approach influence dementia risk. In warfarin patients, inadequate time spent in therapeutic range is highly associated with the increased dementia risk long-term. This risk is further accentuated with frequent over anticoagulation in patients also receiving aspirin. Direct oral anticoagulant therapies in early observational studies show that there is potential for improving long-term risk of dementia when compared to warfarin, although prospective trials are needed. AF and dementia are end manifestations of systemic disease; a systemic approach is needed with early treatment of shared risk factors to prevent disease presentation altogether. Expert commentary: In this review, we will bring together available data with regards to the link between anticoagulant use for AF and dementia. Anticoagulation initiation timing, use, and efficacy remain critical risk factors for dementia in AF patients and consequently provide opportunities to decrease risk. [ABSTRACT FROM AUTHOR]

People who the author would like to thank for their assistance in the creation of the periodical "Cardiology" are mentioned.

The author discusses the research "Comparison of left atrial area marked ablated in electro-anatomical maps with scar in MRI" by BR Parmar and others published in a 2014 issue of the periodical. The topics discussed include various tools aimed at improving atrial fibrillation ablation, and Magnetic Resonance Imaging (MRI) and electroanatomic mapping for atrial fibrillation ablation. Also discussed is creation of durable scar around pulmonary vein for treating atrial fibrillation.

Surrogate electro-anatomic-derived geometries are used as the three-dimensional (3D) basis for mapping of cardiac arrhythmias. While merged computed tomography (CT) imaging may provide stellar pulmonary vein (PV) and left atrial (LA) anatomy, the applied scans must be obtained prior to ablation, and may not reflect physiologic conditions at the time of intervention. Patient-specific, ultrasound-derived 3D imaging has been developed as an alternative basis for new generation electro-anatomic mapping. An electro-anatomic sensor positioned at the tip of the phased-array intracardiac ultrasound catheter, provides the means to specify both location and orientation of each image as the ‘context’ for creating the 3D volumes for co-registration with electro-anatomic mapping. Specific anatomic details such as the pulmonary veins, membranous fossa, papillary muscles, or valve structures derived from real-time imaging can also be integrated into each segmented volume. This presentation reviews the basis and methods for this novel multi-modality image fusion for the creation of robust, nearly real-time anatomic images for guiding electro-anatomic mapping and ablation without requiring pre-acquired CT image sets, with accompanying limitations. [ABSTRACT FROM PUBLISHER]