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AimsAblation of ventricular tachycardias (VTs) in patients with structural heart disease has been established in the past decades as an effective and safe treatment. However, the prognosis and long-term outcome remains poor.Methods and resultsWe investigated 309 patients with ischaemic cardiomyopathy (ICM) and non-ischaemic cardiomyopathy (NICM) (186 ICM, 123 NICM; 271 males; mean age 64.1 ± 12 years; ejection fraction 34 ± 13%) after ≥1 VT ablations over a mean follow-up period of 34 ± 28 months. Electrical storm was the indication for 224 patients (73%), whereas 86 patients (28%) underwent epicardial as well as endocardial ablation. During follow-up, 132 patients (43%) experienced VT recurrence and 97 (31%) died. Ischaemic cardiomyopathy and NICM patients showed comparable results, regarding procedural endpoints, complications, VT recurrence and survival. The Cox-regression analysis for all-cause mortality revealed that the presence of higher left ventricular end-diastolic volume (LVEDV; P ConclusionIschaemic cardiomyopathy and NICM patients undergoing VT ablation had comparable results regarding procedural endpoints, complications, VT recurrence and 3-year mortality. Higher LVEDV, male gender, COPD, AF, polymorphic VTs, use of antiarrhythmics, and periprocedural complications are strong and independent predictors for increased mortality. The PAINESD score accurately predicted the long-term outcome in our cohort.

Aims To establish a cardiovascular magnetic resonance (CMR)-based prediction model for complete systolic left ventricular ejection fraction (LVEF) recovery for the distinction of ‘arrhythmia-induced’ from ‘arrhythmia-mediated’ cardiomyopathy in patients with atrial tachyarrhythmias. Methods and results Two hundred and fifty-three tachyarrhythmia patients referred for catheter ablation were enrolled and underwent CMR baseline imaging; patients with a reduced LVEF Conclusion CMR-derived assessment of LVEDVI category and LGE allowed for identification of arrhythmia-induced cardiomyopathy with acceptable discriminative performance. Probabilities for complete LVEF recovery for the combination of opposite LVEDVI/LGE negativity and enlarged LVEDVI/LGE positivity were 94% and 8%, respectively. The CMR-based prediction model of complete LVEF recovery can be used to perform upfront stratification in atrial tachyarrhythmia-related LVEF impairment.

Social media (SoMe) becomes more and more popular in the cardiological community. Among them, Twitter is an emerging and dynamic medium to connect, communicate and educate academic and clinical cardiologists. However, in contrast to traditional scientific communications, the content provided through SoMe is not peer-reviewed and may not necessarily always represent scientific evidence or may even be used to unjustifiably promote therapies for commercial purposes. For the unintended, this means of communication might be appear difficult to handle. This article aims to provide a practical guide on how to use Twitter efficiently for professional use to keep yourself up-to-date about new techniques, the latest study results and news presented at national or international conferences. Additionally, important limitations will be discussed.

Funding Acknowledgements Type of funding sources: None. Background Intramural septal ventricular arrhythmia remains challenging, requiring emergent technologies and experimental approaches. Although conduction system pacing (CSP) has allowed us to reach deep in the septum, ablation though pacing electrodes has not been examined yet. Purpose To evaluate lesion creation by radiofrequency ablation (RFA) through pacing electrodes. Methods A custom ex vivo swine model in a saline bath with an indifferent electrode was used to apply RFA with an 8 mm non-irrigated catheter (SJM, MN, USA) on the proximal end of pacing (CapSureFix 5086) or CSP-electrodes (SelectSecure 3830, Medtronic, MN, USA), screwed in perpendicularly to the slab. A generator (Ampere, SJM, MN, USA) applied RFA at varying settings (1-10 W, 1-20 sec). Lesion depth (D), width (W) and volume (V=3,14*W2*D/4) were assessed and analyzed (SPSS 23). Results A total of 80 lesions were used for analysis. Median RFA with 3 W over 6 sec resulted in an impedance drop from 200 to 140 Ω and a lesion of 2x3 mm or 9.4 mm3 (Figure 1). Higher energy settings caused impedance rise with abort (n=3, 4%) or charring (n=3, 4%). Compared to conventional electrodes, lesions with CSP-electrodes had similar volume (9.3±7 vs. 10.8±9 mm3, p=0.45) and width (2±0.8 vs. 2±0.7, p=0.58), but more depth (2.6±0.5 vs. 3±0.6, p=0.0.01). Regression analysis showed final-impedance (FI), power and duration (WS=W*Sec) as independent predictors of lesion volume (V=4.7WS-4.1WS2+4.5FI-4, p Conclusions Effective ablation through pacing electrodes is possible, but lesion size is limited and low-power settings are necessary. Using CSP-electrodes for effective intramural lesions is possibly a new tool for septal arrhythmias. Further in vivo studies are warranted and bailout use should be considered.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction A single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (the DX ICD system) can potentially give additive information concerning atrial diagnostics in patients requiring only a single-chamber ICD. We therefore report the real-world experience from large DX registry on implantation, atrial signal quality and detection and the long-term stability of the atrial signal. Methods The prospective, single-arm MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems, NCT01774357) registry study effectively enrolled 2041 patients at 119 sites in 24 countries. All patients had a DX system implanted for a single-chamber ICD indication for primary or secondary prevention of sudden cardiac death. Patients were followed for 24 months including remote monitoring. Implantation and follow-up data are reported for the whole patient set. For the analyses on atrial sensing amplitude values, remotely transmitted device measurements of patients without history of long-standing persistent or permanent AF at baseline were used. Results The mean follow-up period was 677±173 days. Implantation took place at 15±22 days before enrollment. Baseline and implantation data are shown in the table. Implantation procedure and lead insertion were rated as "easy" or "very easy" in 91.0% and 96.3% of assessments, respectively. At implantation, the investigators rated the quality of the atrial sensing amplitude as "sufficient" in 97% of the assessed cases. At enrollment (12-month/24-month follow-up), the atrial signal quality and detection were rated as "good" or "excellent" in 92.3% (89.8%/89.9%) and 92.4% (90.1%/91.3%) of assessments, respectively. For 1841 patients (90.2%), remotely transmitted device information was received. The median (mean ± SD, IQR) transmission rate was 92.5% (85.4±18.2%, 81.4-97.3%). 1746 patients (85.5%) matched the inclusion criteria for the quantitative analyses on atrial sensing. 95.6% of available RA sensing amplitude values were ≥1 mV. Based on each patient’s overall median value, the median (mean ± SD, IQR) RA sensing amplitude was 4.6 mV (4.4±2.0 mV, 2.8-6.2 mV). The time course of patient median values stratified by month is shown in the figure. Conclusion The study followed 2041 patients implanted with the DX ICD system for two years. In the vast majority of cases, investigators rated implantation as (very) easy and the atrial signal over 24 months as good/excellent. According to daily, automatic Home Monitoring data, the overall mean P-wave amplitude remained stable throughout the whole follow-up. The MATRIX study demonstrated functionality and clinical utility of the DX concept in an unselected, real-life setting.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy. Purpose This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications. Methods Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Complete interatrial block (cIAB) was defined as PWD≥120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment and data extraction, to report odds ratio (OR) and confidence intervals (CI). Results Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, p120 ms (13 studies, p=0.01), 2.42 (1.12-5.21) for PWD>140 ms (2 studies, p=0.02), 3.97 (1.79-8.85) for cIAB (6 studies, p150 ms (2 studies, p Conclusion PWD is an independent predictor for AF recurrence after LA ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk-stratification by identifying high-risk patients (cIAB, PWD>150 ms) and adjusting follow-up or interventions.

Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction Device-detected atrial high-rate episodes (AHRE) and their burden progression are associated with an increased risk for thromboembolic events in correlation with CHA2DS2-VASc score and AHRE burden. To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend the monitoring of AHRE progression along pre-specified strata (6min… Methods From the MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems) registry, we analyzed remotely transmitted, and electrogram (IEGM) AHREs in a subset of patients with remote transmissions and without history of long-standing AF at baseline. For each patient, we selected the first occurring episode per duration stratum and the first subsequent occurrence when progressing to a stratum of any longer duration. After episode adjudication by an independent electrophysiologist, we assessed the classification performance of the device (positive predictive value [PPV]) and analyzed AHRE onset and progression pathways. Results Of the MATRIX cohort, 1,746 patients matched the inclusions criteria (see table for patient characteristics) and 1,451 had no AF history. Of the 258 patients with AHREs (14.8%), 450 out of 465 evaluated episodes were correctly classified as AHRE. Reasons for misclassification were artifact (13) and R-wave oversensing (2). PPV was 96.8% (95% confidence interval 94.7%-98.2%). Grouped by stratum, PPV was 93.9%, 99.5% and 100% for 6min… Discussion and Conclusion: The single-chamber ICD with atrial sensing capabilities correctly classified ≈97% of all adjudicated AHREs ≥6min. About 7% of patients had device-detected AHRE onset and/or progression and a mid to high stroke risk. These patients would potentially benefit the most from a guideline-conform AF monitoring strategy to timely initiate anticoagulation medication for stroke prevention.

Aims Arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) still remain an important management issue. Recently, the APPLE score had been introduced to predict rhythm outcomes within 12 months after catheter ablation, while the simple MB-LATER score was developed for the prediction of very late recurrence of AF (VLRAF) occurring after 12 months. The aim of this study was to compare APPLE and MB-LATER scores in predicting VLRAF. Methods and results The study population included arrhythmia-free patients within first 12 months after first radiofrequency catheter ablation from The Heart Center Leipzig AF Ablation Registry. The APPLE [one point for Age >65 years, Persistent AF, imPaired eGFR 120 ms, LA diameter ≥47 mm, AF Type (persistent AF), Early Recurrence Conclusion Prediction of VLRAF is similar for both APPLE and MB-LATER scores. A better score remains still a clinical unmet need.

Aims To determine the clinical utility of a combined single-session cardiovascular magnetic resonance (CMR) imaging protocol integrating adenosine stress perfusion and three-dimensional pulmonary vein angiography for stratification of atrial fibrillation (AF) patients referred for pulmonary vein isolation (PVI) and complaining about chest pain syndromes. Methods and results The preprocedural CMR examination (adenosine stress perfusion, late gadolinium enhancement, and three-dimensional pulmonary vein angiography) was performed in 357 consecutive AF patients with chest pain syndromes referred for PVI. Stress perfusion results were used for stratification: ischaemia positive patients underwent invasive coronary angiography, ischaemia negative patients underwent PVI, and follow-up/outcome data were collected (combined primary endpoint of cardiac death/non-fatal myocardial infarction). The integrated CMR protocol had a high success rate (356/357, 99.7%), a short total examination duration ( Conclusion Combined single-session CMR as a routine diagnostic workup for AF patients with chest pain syndromes prior to PVI proved to represent a time-efficient and effective stratification tool.

Aims Cardiovascular magnetic resonance (CMR) imaging has long been a contraindication for patients with a cardiac implantable electronic device (CIED). Recent studies support the feasibility and safety for non-thoracic magnetic resonance imaging, but data for CMR are sparse. The aim of the current study was to determine the safety in patients with magnetic resonance (MR)-conditional or non-MR-conditional CIED and to develop a best practice approach. Methods and results All patients with a CIED undergoing CMR imaging (1.5 T) between April 2014 and April 2017 were included in the study. Devices were programmed according to the standardized protocol directly before and after the CMR examination. Follow-up interrogation was performed 6 months after CMR examination. Results were compared with a large, reference cohort of CIED patients not undergoing any MR examination. A total of 200 consecutive patients with a CIED (non-MR-conditional, n = 103) were included in the study. Directly after CMR imaging, one device failure (0.5%, battery status = end of service) was noted necessitating premature generator replacement. In three patients (2%) of pacemaker/implantable cardioverter-defibrillator (ICD) carriers a sustained ventricular tachycardia (VT) occurred during CMR imaging. Ten ICD showed a decrease in battery capacity immediately after CMR. Overall, the reference cohort showed comparable changes of CIED function during follow-up. Conclusion With adherence to a standardized protocol and established exclusion criteria CMR imaging could safely be performed in patients with a CIED. The potential risks of device malfunction necessitate the presence of a device trained individual during the entire CMR examination. If there is a history of VT storm the attendance of an experienced cardiologist, should be mandatory.

Aims We sought to investigate the overlap between late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR) and electro-anatomical maps (EAM) of patients with non-ischaemic dilated cardiomyopathy (NIDCM) and how it relates with the outcomes after catheter ablation of ventricular arrhythmias (VA). Methods and results We identified 50 patients with NIDCM who received CMR and ablation for VA. Late gadolinium enhancement was detected in 16 (32%) patients, mostly in those presenting with sustained ventricular tachycardia (VT): 15 patients. Low-voltage areas ( Conclusions In NIDCM, the agreement between LGE and bipolar EAM was fairly poor but can be improved with adjustment of the thresholds for EAM according to the amount of LGE. The outcomes were related to the volume of LGE.

Aims The objective of this study was to verify acute safety, performance, and usage of a novel ultra-high density mapping system in patients undergoing ablation procedure in a real-world clinical setting. Methods and results The TRUE HD study enrolled patients undergoing catheter ablation with mapping for all arrhythmias (excluding de novo atrial fibrillation) who were followed for 1 month. Safety was determined by collecting all serious adverse events and adverse events associated with the study devices. Performance was determined as the composite of: ability to map the arrhythmia/substrate, complete the ablation applications, arrhythmia termination (where applicable), and ablation validation. Use of mapping system in the ablation validation workflow was also evaluated. Among the 519 patients who underwent a complete (504) or attempted (15) procedure, 21 (4%) serious ablation-related complications were collected, with 3 (0.57%) potentially related to the mapping catheter. Four hundred and twenty treated patients resulted in a successful procedure confirmed by arrhythmia-specific validation techniques (83.3%; 95% confidence interval: 79.8–86.5%). A total of 1419 electroanatomical maps were created with a median acquisition time of 9:23 min per map. Of these, 372 maps in 222 (44%) patients were collected for ablation validation purposes. Following validation mapping, 162/222 (73%) patients required additional ablation. Conclusion In the TRUE HD study mapping was associated with rates of acute success and complications consistent with previously published reports. Importantly, a low percentage of events (0.57%) was attributed to the mapping catheter. When performed, validation mapping was useful for identifying additional targets for ablation in the majority of patients.

Aims Presence of late gadolinium enhancement (LGE) is related to adverse cardiovascular outcome. Many patients suffering from atrial fibrillation (AF) undergo cardiovascular magnetic resonance (CMR) imaging prior to ablation. Since quantification of atrial fibrosis still lacks reproducibility, we sought to investigate risk factors for the presence of left ventricular (LV)-LGE and a possible correlation between ventricular fibrosis as defined by positive LGE and pathological atrial voltage maps evaluated by 3D mapping systems. Methods and results Between May 2015 and January 2017, 241 patients with AF (73% persistent AF, 71% male, mean age 62.8 ± 10.1 years, Redo procedure in 24%, AF history 4.5 ± 5.2 years) underwent CMR including LV LGE prior to pulmonary vein (PV) isolation at Heart Center Leipzig. Depending on CMR results, two groups were separated: 'LV-LGE negative' (Group A, n = 197, 82%) and 'LV-LGE positive' (Group B, n = 44, 18%). To identify low voltage areas (LVA), a 3D electro-anatomic map was created during PV isolation. Multivariate analysis revealed male gender [odds ratio (OR) 7.6, 95% confidence interval (95% CI) 2.4-23.9, P = 0.001] and an increased CHA2DS2VASc Score (OR 1.6, 95% CI 1.2-2.2, P = 0.004) as significantly associated with LV-LGE. Impaired left ventricular ejection fraction, LV dilatation, larger LA size and, enlarged septum diameter occurred significantly more often in the 'LGE positive' group. Low voltage areas were detected in 83 patients overall (34%): Group A: n = 64/197 (33%), Group B: n = 19/44 (43%) (P = 0.177). Conclusion Male gender and high CHA2DS2VASc Score are significantly associated with presence of LV-LGE, but LV-LGE is not associated with left atrial LVA.

Aims Efforts to reduce radiation exposure during catheter ablation procedures have included the use of various technological measures. Significant results have been achieved to the point where near lead-free procedures in routine clinical practice has become a realistic goal. The integration of MediGuide technology [non-fluoroscopic catheter visualization technology (NFCV)] and three-dimensional electroanatomical mapping is one of the methods developed in response to radiation reduction initiatives. We aimed to evaluate the impact of this NFCV technology on atrial fibrillation (AF) catheter ablation in terms of reduction in procedural and radiation time as well as safety aspects. Methods and results Between March 2012 and March 2017, a total of 1000 patients underwent AF ablation using NFCV. Patient and procedural data and complications within the first 3 months were entered into a prospective registry and analysed. We assessed procedure time, fluoroscopy time, and dose and complications. In a cohort of 1000 patients (62.9 ± 11 years; 72% men; left ventricular ejection fraction 57%; and left atrial diameter 43.2 mm), the median procedure time was 120 min, median fluoroscopy time was 0.90 min, and the median fluoroscopy dose of was 345.1 cGy · cm2. Stratification of the first (Group 1) and the last 250 (Group 2) cases showed significant improvement in the median procedure time (140-110 min) and reduction in the median fluoroscopy time (6-0.5 min) and the median dose (2263-151.9 cGy · cm2). The overall complication rate was 2.0%. Conclusion The use of NFCV technology enables safe, consistent, and 'near lead-free' performance of AF ablation in routine clinical practice.

Aims Electrical cardioversion (ECV) is frequently required for early atrial fibrillation (AF) recurrence after catheter ablation. However, in some cases, ECV is unsuccessful, and factors associated with long-term rhythm outcomes after failed ECV are unknown. This study aimed to identify possible predictors of ECV failure early after AF ablation and to analyse management and long-term rhythm outcome of these patients. Methods and results Between 2010 and 2012, 180 consecutive patients (mean age 63.7 ± 9.4 years, male 53.3%, persistent AF 60%) underwent successful radiofrequency AF ablation but required post-procedural ECV due to early AF recurrence (≤ 7 days). Of these, 120 patients were successful (Group A, n = 120, 66.7%) and 60 failed (Group B, n = 60, 33.3%). ECV failure was associated with diabetes [odds ratio (OR) 2.34, 95% confidence interval (CI) 1.154-4.763; P = 0.01] and lack of beta-blocker medication (OR 2.38, 95% CI 1.005-5.635; P = 0.04). In contrast, there were no significant differences in echocardiographic or procedure-related parameters. Atrial fibrillation recurrence was monitored with sequential 7 days of Holter electrocardiogram for 24 months (on average 10.8 ± 8.8 months) and was documented in 56%, n = 102 in total (Group A: 57%, n = 69 vs. Group B: 55%, n = 33; P = 0.75). Compared with successful ECV, ECV failure shortly after AF ablation had no predictive value on rhythm outcome in the long term (P = 0.98). The necessity of additional linear lesions during catheter ablation [hazard ratio (HR) 2.72, 95% CI 1.47-5.05; P = 0.001], AF duration (HR 1.08, 95% CI 1.04-1.12; P