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The presence of bipolar low-voltage zone (LVZ) is a predictor of AF recurrence after PV isolation (PVI). However, changes of wavefront and bipole directions may cause different electrogram characteristics. We aimed to investigate whether using omnipolar maximum voltage (Vmax) map derived from high density (HD) Grid mapping catheter could assess LVZ and AF ablation outcome accurately.Fifty paroxysmal AF patients (27 males, 57.8 ± 9.5 years old) who underwent 3D mapping guided PVI were enrolled. Left atrial voltage mapping during sinus rhythm before ablation was performed. The significant LVZ (0.5 mV with area 5 cmPVI was performed in all patients, and there were 2 patients (4%) who also received additional non-PV triggers ablation. After a follow-up of 11.4 ± 5.4 months, recurrence of AF occurred in 12 patients (24%). The presence of a significant LVZ was less detected by omnipolar Vmax map, compared to HD wave map (24.0% vs. 58.0%, p = 0.001). LVZ detected by omnipolar Vmax map independently predicted the AF recurrence (odds ratio 16.91; 95% CI, 3.17-90.10; p = 0.001).LVZ detected by omnipolar Vmax map accurately predicts the AF recurrence following ablation in paroxysmal AF, compared to conventional bipolar and HD wave maps, suggesting the omnipolar Vmax map can precisely define the atrial substrate property.

To evaluate the performance of a single‑lead, 14-day continuous electrocardiogram (ECG) patch for the detection of arrhythmias compared to conventional 24-h monitoring.This prospective clinical trial enrolled patients suspected of arrhythmias but not diagnosed by 12‑lead ECGs. Each patient underwent a 24-h Holter and 14-day ECG patch simultaneously. Seven types of arrhythmias were classified: supraventricular tachycardia (SVT, repetitive atrial beats4 beats), irregular SVT without P wave (4 beats), AF/AFL (irregular SVT without P wave ≥30 s), pause ≥3 s, atrioventricular block (AVB; Mobitz type II, third-degree, two to one or high degree AVB), ventricular tachycardia (VT), and polymorphic VT.A total of 158 patients were recruited (mean wear time:12.3 ± 3.2 days). The overall arrhythmia detection rate was higher with 14-day ECG patches (59.5%) compared to 24-h Holter (19.0%, P0.001). Up to 87.2% of arrhythmias recorded with 14-day ECG patches were not associated with symptoms. The 14-day ECG patch was associated with higher detection rates compared to the 24-h Holter in patients with SVT (52.5% versus 15.8%, P0.001), irregular SVT without P wave (12.7% versus 4.4%, P = 0.002), AF/AFL (9.5% versus 3.8%, P = 0.042), and critical arrhythmias (pause ≥3 s, AVB, VT, polymorphic VT) (16.5% versus 2.5%, P0.001). The 14-day ECG patch detected more than 2 types of arrhythmias in 5.1% of patients. No serious adverse events in patients wearing the 14-day ECG patch were reported.The 14-day ECG patch outperformed 24-h Holter to detect overall, asymptomatic, critical and multiple arrhythmias. It is safe and has the potential to identify individuals with hidden arrhythmias, especially those with critical arrhythmias.

Background Intracardiac electrogram recording is influenced by the electrode size and inter-electrode spacing. Smaller electrodes with a closer inter-electrode spacing may improve the mapping resolution and outcome. Methods Substrate mapping of the left atrium and residual pulmonary vein (PV) potentials during sinus rhythm was sequentially performed using a 3.5-mm electrode tip catheter and a 1-mm electrode multielectrode catheter in 33 patients (Group 1) that underwent repeat atrial fibrillation (AF) procedures. PV gap identification and electrophysiological characteristics were compared. Arrhythmia freedom was compared with a propensity matched (1:2) control group (66 patients, Group 2) undergoing repeat AF procedures guided by wide inter-electrode spacing catheter. Results In the Group 1 patients, the total area of residual PV potentials measured using the 1-mm catheter was larger than that measured by the 3.5-mm catheter. Overall 1.97 ± 0.59 (1–3) and 1.49 ± 0.62 (1–3) PVs were identified by the 1-mm electrode and 3.5 mm catheters, respectively (P = 0.02). The gaps not identified by the 3.5 mm catheter had a smaller width and lower voltage. Radiofrequency catheter ablation in the areas with residual PV potentials identified by the 1-mm catheter resulted in complete electrical isolation of the PVs. Arrhythmia freedom at one year of follow-up was achieved in 26 of 33 (78.8%) patients in Group 1, which was significantly higher than the matched control group (33/66 [50%], P Conclusion In the patients with a previous PV isolation, mapping with small, closely spaced electrodes can increase the detection rate of residual PV potentials and improve the outcome.

Background While modifiable bleeding risks should be addressed in all patients with atrial fibrillation (AF), use of a bleeding risk score enables clinicians to ‘flag up' those at risk of bleeding for more regular patient contact reviews. We compared a risk assessment strategy for major bleeding and intracranial hemorrhage (ICH) based on modifiable bleeding risk factors (referred to as a ‘MBR factors' score) against established bleeding risk stratification scores (HEMORR 2 HAGES, HAS-BLED, ATRIA, ORBIT). Methods A nationwide cohort study of 40,450 AF patients who received warfarin for stroke prevention was performed. The clinical endpoints included ICH and major bleeding. Bleeding scores were compared using receiver operating characteristic (ROC) curves (areas under the ROC curves [AUCs], or c-index) and the net reclassification index (NRI). Results During a follow up of 4.60±3.62years, 1581 (3.91%) patients sustained ICH and 6889 (17.03%) patients sustained major bleeding events. All tested bleeding risk scores at baseline were higher in those sustaining major bleeds. When compared to no ICH, patients sustaining ICH had higher baseline HEMORR 2 HAGES (p=0.003), HAS-BLED (p Conclusion All contemporary bleeding risk scores had modest predictive value for predicting major bleeding but the best predictive value and NRI was found for the HAS-BLED score. Simply depending on modifiable bleeding risk factors had suboptimal predictive value for the prediction of major bleeding in AF patients, when compared to the HAS-BLED score.

Background The changes of signal averaged ECG (SAECG) in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) undergoing radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) remains unknown. Methods Between 2010 and 2014, a total of 81 ARVD/C patients underwent endocardial and/or epicardial RFCA for drug-refractory VAs. Seventy patients (mean age 46.2±14.1years, 37 males) achieving acute procedure success (negative inducibility) were enrolled. Baseline characteristics, non-invasive examinations and SAECG (before and 3months after RFCA) were collected retrospectively. Results After successful RFCA, the electrical parameters of SAECG changed in 39 patients (55.7%), including 28 patients (40%) with electrical regression (group 1), and 11 patients (15.7%) with electrical progression (group 3). Thirty-one patients (44.3%) showed no significant SAECG change (group 2). During a mean follow-up of 17.8±10.7months, 23 patients (32.9%) had VA recurrences, including 4 in group 1, 12 in group 2, and 7 in group 3. In comparisons with groups 2 and 3, group 1 patients had a significantly better VA recurrence-free survival ( P =0.02). In multivariable Cox regression analysis, electrical regression was found to be associated with fewer VA recurrences ( P =0.02, OR: 0.28, 95% CI: 0.10–0.83). Conclusions Electrical regression of SAECG after RFCA in ARVD/C was found to be associated with fewer VA recurrences.

Catheter ablation is an effective treatment for atrioventricular nodal reentrant tachycardia (AVNRT). However, the characteristics of extremely late (3 years) recurrences of AVNRT after a successful initial ablation are not fully elucidated. We aimed to explore the electrophysiological characteristics of extremely late recurrences of AVNRT after a successful ablation.From 1991 to 2018, 3311 patients (mean age: 48.7 ± 17.4 years; men: 1328 [40.1%]) who underwent catheter ablation for AVNRT were investigated. Baseline characteristics of the patients, recurrence status, and detailed electrophysiological parameters of the index and repeat ablation procedures were obtained for analysis.After a mean follow-up period of 129.5 ± 58.0 months, 65 (2.0%) patients underwent repeat ablation for recurrences of AVNRT, of whom 17 (0.5%) presented with extremely late recurrences. The incidence of transient AV block was significantly higher in patients with extremely late recurrences (5.9%) than in those without recurrences (1.9%) but lower than that in patients with recurrences within3 years (12.5%, P .001). In addition, among patients with extremely late recurrences of AVNRT, the atrial-His bundle interval was significantly longer (99.1 ± 23.4 vs. 76.5 ± 13.1 ms, P .01) and the need for intravenous isoproterenol and/or atropine for the induction of AVNRT (88.2% vs. 47.1%, P = .03) was higher in the repeat ablation procedure than in the index ablation procedure.Recurrences of AVNRT can occur 3 years after a successful initial ablation. The electrophysiological features of the index and repeat ablation procedures differed between patients with extremely late recurrences of AVNRT and those with recurrences within3 years.

Aims Patients with atrial fibrillation (AF) may be at higher risk for cancer, possibly due to the presence of coexisting risk factors. In this study, we investigate the magnitude and predictors of this potential risk within a population-based study. Methods and results The study cohort included 332,555 AF patients aged ≥20 years without past history of cancer. Standardized incidence ratio (SIR) was used as a measure of relative risk, comparing observed cancer incidence among patients with AF with that expected based on cancer incidence in the Taiwanese population. During the observation period, 22,911 incident cancers occurred with an incidence of 1.65%/year. Compared with the general population, AF patients had a significantly higher cancer risk with a SIR of 1.37 (95%CI = 1.36–1.39). Patients with new-onset AF had an elevated cancer risk which was highest within 1 year (SIR = 2.30; 95%CI, 2.25–2.36) and persisted beyond 10 years after AF was diagnosed (SIR = 1.18; 95%CI, 1.11–1.25). Age ≥ 65 years, male gender, hypertension, diabetes, chronic obstructive pulmonary disease (COPD) and liver cirrhosis were significantly associated with development of cancers among AF patients. The hazard ratio of cancers increased from 1.40 (95%CI = 1.28–1.53) for patients having 1 risk factor to 5.14 (95%CI = 4.03–6.06) for patients with 6 risk factors, in comparison to those without any risk factors. Conclusion In the nationwide cohort study, we show that AF patients had a higher risk of cancer. Age, male gender, hypertension, diabetes, COPD and liver cirrhosis are important risk factors of cancer among AF patients. Prompt and detailed examinations may be considered for incident AF patients with multiple risk factors to early detect the occult malignancy.

Background Gender differences in the penetrance and clinical expression of genetic mutations have been reported in patients with arrhythmogenic right ventricular (RV) dysplasia/cardiomyopathy (ARVD/C). Our study aimed at clarifying the impact of gender on ventricular substrates and clinical outcomes after radiofrequency catheter ablation (RFCA). Methods Patients with ARVD/C underwent RFCA for drug-refractory ventricular arrhythmias (VAs) were consecutively enrolled. Baseline characteristics, electrocardiograms, ventricular substrates, and VA recurrences after RFCA were extracted for comparison between genders. Results A total of 70 consecutive unselected patients with definite ARVD/C (36 men [51%], age 45±14years) were studied. Male patients had a higher incidence of sustained ventricular tachycardia and ventricular fibrillation or sudden cardiac arrest as initial manifestations. Electroanatomical mapping demonstrated that men with ARVD/C had a larger epicardial RV unipolar low-voltage zone, a larger endocardial and epicardial area with late potentials, and longer local abnormal ventricular activity. Cox regression analysis demonstrated that gender and late potential area predicted the recurrences of VAs. Conclusion Patients with ARVD/C displayed different characteristics of VAs and substrate properties between men and women. Male gender and the presence of larger area of abnormal electrograms independently predicted VA recurrences after RFCA.

Background Atrial fibrillation (AF) is associated with an increased risk of cognitive impairment and functional decline, and may contribute to development of dementia. Objectives Data from a nationwide large-scale population-based cohort study are lacking. Besides, how best to predict the occurrence of incident dementia among AF subjects remains uncertain. Methods A total of 332,665 AF subjects without dementia were identified as the study group from the "National Health Insurance Research Database" in Taiwan. For each study patient, one age- and sex-matched subject without AF and dementia was selected as the control group. The study end point was occurrence of dementia, and the usefulness of CHADS 2 and CHA 2 DS 2 -VASc scores in predicting dementia was analyzed. Results During the follow-up, 29,012 AF patients experienced dementia with an annual incidence of 2.12%, higher than non-AF subjects (1.50%). Patients with AF possessed a higher risk of dementia with a hazard ratio (HR) of 1.420 after adjustments for age, gender, baseline differences and medication use. Among AF patients, the CHADS 2 and CHA 2 DS 2 -VASc scores were significant predictors of dementia with an adjusted HR of 1.520 and 1.497 per 1 increment of the CHADS 2 and CHA 2 DS 2 -VASc scores, respectively. The c-index for CHA 2 DS 2 -VASc in predicting dementia (0.611, 95% confidence interval [CI]=0.608–0.614) was significantly higher than the CHADS 2 score (0.589, 95% CI=0.586–0.592) (DeLong test p Conclusions In this nationwide cohort study, AF was independently associated with a higher risk of dementia. The CHA 2 DS 2 -VASc score can be used to estimate the risk of dementia in AF patients.

Background Multiform premature ventricular complexes (PVCs) are common electrocardiographic abnormalities in patients with structurally normal hearts. However, the prognostic value of these complexes remains unclear. This study aimed to clarify the role of PVC polymorphism in predicting adverse outcomes. Methods and result We examined the database for 24-hour electrocardiography monitoring between January 1, 2002 and December 31, 2004. We analyzed 3351 individuals with apparently normal hearts. Kaplan–Meier curves and multivariate Cox proportional hazards models were employed to estimate the effect of multiform PVC and uniform PVC on the number of incident adverse events. Average follow-up time was 10±1years. Patients with multiform PVC were older and had a higher prevalence of comorbidities. In multivariate analysis, patients with multiform PVC had an increased incidence of mortality (hazard ratio [HR]: 1.642, 95% confidence interval [CI]: 1.327–2.031), hospitalization (HR: 1.196, 95% CI: 1.059–1.350), cardiovascular hospitalization (HR: 1.289, 95% CI: 1.030–1.613), new-onset heart failure (HF; HR: 1.456, 95% CI: 1.062–1.997), transient ischemic accident (HR: 1.411, 95% CI 1.063–1.873), and new-onset atrial fibrillation (AF; HR: 1.546, 95% CI: 1.058–2.258) compared to the group without PVC. Patients with multiform PVC had a higher rate of mortality (HR: 1.231, 95% CI: 1.033–1.468) and all cause-hospitalization (HR: 1.147, 95% CI: 1.025–1.283) compared with patients with uniform PVC. Conclusion The presence of multiform PVC was associated with a higher incidence of mortality, hospitalization, transient ischemic attack, new-onset AF, and new-onset HF independent of other clinical risk factors.

Vasovagal responses (VR) encountered during radiofrequency pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF) suggest ablation of the atrial tissue subjacent to the ganglionic plexi (GP) and confer durability of PVI.We hypothesized that VR during cryoballoon PVI (CB-PVI) in PAF can predict mid-term AF recurrence.We enrolled 39 patients who underwent PVI using 2nd generation cryoballoon for PAF from November 2014 to July 2016. We evaluated the long term outcomes for those who had VR during index procedure.A total of 39 patients (76% male, mean age 57 ± 9 years) underwent CB-PVI for PAF and 66.67% (26/39) had VR. VR was frequently observed in the LSPV (100%), followed by RSPV (64%), LIPV (60%), and less frequently, RIPV (28%). Overall, the mean difference in the HR and SBP, and the relative differences in the HR and SBP were observed during CB-PVI in the LSPV (mean difference in HR, p 0.001; mean difference in SBP, p 0.001; relative difference in HR, p 0.001); relative difference in SBP, p 0.001). After PVI, 22/26 (84.62%) and 5/13 (38.46%) of patients in the VR and NVR group, respectively, maintained SR at 14 ± 6 months follow-up. The Kaplan-Meier analysis showed statistical difference in favor of patients with VR during CB-PVI (log rank p 0.01) with a better mid-term outcome.In a small cohort of patients, VR during CB-PVI in PAF is a surrogate marker for ablation of atrial tissue subjacent to the GP and predicts a favorable mid-term outcome for AF recurrence.

Signal averaged electrocardiogram (SAECG) is a specific and non-invasive tool useful for arrhythmogenic right ventricular cardiomyopathy (ARVC) diagnosis. However, its role in risk stratification of patients with ARVC remains largely undefined.Sixty-four patients fulfilling Task Force ARVC criteria (mean age: 47 ± 14 years-old, 56% male, 50% definite ARVC) were enrolled. The baseline demographic, electrocardiographic, structural, and electrophysiological characteristics were collected. Patients with SAECG fulfilling all 3 Task Force criteria (3+ SAECG) were categorized into group 1, and those fulfilled 2 or less criterion were categorized into group 2. The study endpoints were unstable ventricular arrhythmia (VA), device detectable sustained fast VA (cycle lengths240 ms) and cardiovascular death.During a mean follow-up of 21 ± 20 months, 15 primary endpoints including 12 unstable VAs and 3 device-detected fast VAs were met. One patient died of electrical storm, and one patient underwent heart transplantation. The presence of 3+ SAECG predicted malignant events in all patients with definite and non-definite ARVC (p0.01, OR = 30.5, 95% CI = 2.5-373.7) and in patients with definite ARVC alone (p = 0.03, OR = 11.1, 95% CI = 1.3-93.9). Patients diagnosed with non-definite ARVC without 3+ SAECG were free from malignant events.SAECG fulfilling all 3 Task Force criteria was an independent risk predictor of malignant events in ARVC patients. SAECG may play a valuable role in ARVC risk stratification.

There are limited literatures regarding the non-pulmonary vein (NPV) triggers in long-standing persistent atrial fibrillation (LSPAF). The goal of the present study was to investigate the characteristics and long-term outcome of catheter ablation among these patients.The study included 776 patients (age 53.59±11.38years-old, 556 males) who received catheter ablation for drug-refractory atrial fibrillation (AF). We divided these patients into 3 groups. Group 1 consisted of 579 patients with paroxysmal AF (PAF), group 2 consisted of 103 patients with persistent AF (PerAF) and group 3 consisted of 94 patients with long-standing persistent AF (LSPAF). The average follow-up duration was 28.53±23.21months.The clinical endpoint was the recurrence of atrial tachyarrhythmia. Among these 3 groups, higher percentages of male (93.6%, P0.001), NPV triggers (44.7%, P0.001), longer AF duration (6.65±6.72years, P=0.029), larger left atrium diameter (44.44±6.79mm, P0.001), and longer procedure time (181.94±70.02min, P0.001) were noted in LSPAF. After the first catheter ablation, the recurrence rate of AF was highest in LSPAF (Log Rank, P0.001). Larger left atrium diameters (LAD) (P=0.006; HR: 1.063; CI: 1.018-1.111) and NPV triggers (P=0.035; HR: 1.707; 1.037-2.809) independently predicted AF recurrence in LSPAF.Compared with PAF and PerAF, LSPAF had a higher incidence of NPV triggers and worse long-term outcome after catheter ablation. NPV triggers and LAD independently predicted AF recurrence after catheter ablation in LSPAF.

Aortic dilatation was frequently observed in patients with atrial fibrillation (AF) and non-pulmonary vein (PV) triggers are important for mapping and ablation of AF. We hypothesized that the aortic encroachment area over left atrium (LA) could contribute to the local substrate characteristics.We studied 32 consecutive patients of AF (age=57.34±8.07, male=30), including 26 paroxysmal and 6 persistent AFs. Anatomic relationship between LA and aorta, and electrophysiological characteristics of the encroachment areas were investigated. IRB approval was taken.The LA bipolar voltage (mean 0.49±0.26mV) was lower at aortic encroached area compared to global LA (mean 1.52±0.48mV) and it was statistically significant (p0.001). There was a linear correlation between the voltages of LA and distance from the aorta to the aortic encroachment area of LA (p0.001, R=0.616). Non-PV triggers were observed in 34.37% (n=11) of total patients. The initiation of AF in aortic encroached area was seen in 45.45% (n=5) of non-PV trigger and 15.62% of total patients. All the patients were followed up for 6months and 4 (14.81%) out of 27 patients without trigger at aortic encroached site of LA and 1 (20%) out of 5 patients with trigger at aortic encroached site of LA had recurrence of AF.The aorta contributed to low voltages on its encroachment area over the anterior wall of LA. Non-pulmonary vein triggers originating from the aortic encroachment area were found in 15.62% of total patients. Careful evaluation of the anatomical relationship between LA and aorta is important during AF ablation for a better long term outcome.

Sarcoidosis is an important diagnostic consideration in patients with ventricular tachycardia (VT) of unknown origin. The clinical course of VT as the primary presentation in patients with sarcoidosis is mostly unknown. This study aimed to investigate the incidence of life-threatening VT and mortality during long term follow-up in patients with sarcoidosis.We analyzed the epidemiological features of sarcoidosis in Taiwan using the National Health Insurance Research Database from 2000 to 2004. Patients with sarcoidosis were identified, and healthy controls without prior histories of structural heart disease were matched with a 1:1 propensity-score to the sarcoidosis group. The risk of life-threatening VT and mortality with sarcoidosis was analyzed.A total of 2237 sarcoidosis cases were enrolled with a matching number of healthy controls, and the baseline characteristics between the two groups were similar. After a mean follow-up of 11.4±2.15years (IQR: 12, 11.3-12), the VT incidence in the sarcoidosis group was higher than in healthy controls (0.94% [85 per 100,000 person-year] in the sarcoidosis group, and 0.09% [8 per 100,000 person-year] in healthy controls). After a multivariate adjustment including the sex, age, and other comorbidities, the VT risk was still higher in the sarcoidosis group (hazard ratio: 12.7, 95% confidence interval: 2.82-56.9; P0.001). The risk of defibrillator implantations for secondary prevention, cardiovascular death, and total mortality between the groups was equivalent.Sarcoidosis may increase the predisposition to ventricular arrhythmias with a cumulative incidence of 0.94% during a very long term follow-up of nearly 10years from initially diagnosing sarcoidosis.

a Division of Cardiovascular Medicine, Department of Internal Medicine, Wan-Fang Hospital, Taipei Medical University, Taipei, Taiwan b Division of Cardiology and Cardiovascular Research Center, Taipei Veterans General Hospital, Taipei, Taiwan c Institute of Clinical Medicine, and Cardiovascular Research Institute, National Yang-Ming University, Taipei, Taiwan d Medical Department, Taipei City Hospital, Taipei, Taiwan e Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan f National Yang-Ming University Hospital, Taiwan

Background The clinical characteristics and prognostic value of early repolarization (ER) in patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) and symptomatic ventricular arrhythmias remain unclear. We investigated the prevalence, clinical features, and cardiovascular outcomes of patients with symptomatic ARVD/C and ER. Methods A total of 59 consecutive ARVD/C patients hospitalized for catheter ablation, presenting with and without J-point elevations of ≥0.1mV in at least 2 inferior leads or lateral leads were enrolled. Clinical characteristics, electrophysiological study, substrate mapping, catheter ablation, and future clinical outcomes in a prospective patient registry were investigated. Results ER was observed in 38 patients (64.4%). Among these patients, ER was found in the inferior leads in 18 patients (47.4%), in the lateral leads in 2 patients (5.3%), and in both inferior and lateral leads in 18 patients (47.4%). Patients exhibiting ER were commonly men, had lower right ventricular ejection fraction, had higher incidence of clinical ventricular fibrillation or aborted sudden cardiac death, had more defibrillator implantations, had higher the need of epicardial ablation, and had more major criteria according to the task force criteria. Significant higher incidence of induced ventricular fibrillation and shorter tachycardia cycle length of induced ventricular tachycardia were found during procedure. The recurrence rate of ventricular arrhythmias did not differ between patients with and without ER after catheter ablation. Conclusions A high prevalence of electrocardiographic ER was found among symptomatic ARVD/C patients undergoing catheter ablation. ER in 12-lead ECG is associated with an increased risk of clinical fatal ventricular arrhythmias.