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Background: Using DAs for preference‐sensitive decisions is an evidence‐based way to improve patient‐centered decisions. Reimbursement mandates have increased the need for DAs in ICD care, although none have been formally evaluated. The objectives were to develop and pilot implantable cardioverter‐defibrillator (ICD) decision aids (DAs) for patients considering primary prevention ICDs. Methods: Development Phase: An expert panel, including patients and physicians, iteratively developed four DAs: a one‐page Option GridTM conversation aid, a four‐page in‐depth paper tool, a 17‐minute video, and an interactive website. Trial Phase: At three sites, patients with heart failure who were eligible for primary prevention ICDs were randomly assigned 2:1 to intervention (received DAs) or control (usual care). We conducted a mixed‐methods evaluation exploring acceptability and feasibility. Results: Twenty‐one eligible patients enrolled (15 intervention). Most intervention participants found the DAs to be unbiased (67%), helpful (89%), and would recommend them to others (100%). The pilot was feasible at all sites; however, using clinic staff to identify eligible patients was more efficient than chart review. Although the main goals were to measure acceptability and feasibility, intervention participants trended towards increased concordance between longevity values and ICD decisions (71% concordant vs. 29%, p =.06). Participants preferred the in‐depth paper tool and video DAs. Access to a nurse during the decision‐making window encouraged questions and improved participant‐perceived confidence. Conclusions: Participants felt the DAs provided helpful, balanced information that they would recommend to other patients. Further exploration of this larger context of DA use and strategies to promote independent use related to electrophysiology (EP) visits are needed. [ABSTRACT FROM AUTHOR]

Remote Monitoring (RM) has been shown to provide useful information about arrhythmic events in patients with implantable loop recorders (ILRs), however there is few and conflicting data about the false positive (FP) alarms burden and characteristics among ILR recipients. The aim of the present systematic review was to evaluate incidence and characteristics of FP alarms among ILR patients followed by RM. We developed a systematic research in Embase, MEDLINE and PubMed databases and selected all papers focused on false positive ILR transmissions published from June 1, 2013 to June 1, 2023. Case reports, meeting summaries, posters and simple reviews were excluded. Twelve reports were finally selected, including five prospective and seven retrospective studies. Information about population characteristics, device type and setting, overall transmissions and FP alarms and any adopted strategies to reduce them were extracted from an overall population of 3.305 patients. FP alarms were 59.7% of the overall remote transmissions and were found in 1/5 of the analyzed population. FP alarms for atrial fibrillation were the most common cause of false transmissions and were mainly due to premature atrial and ventricular complexes. No clinical predictors of FP alarms were identified, except for nonparasternal ILR implantation site. Since the overload work due to FP alarms might reduce the benefit of remote monitoring of ILR patients, the device optimization is an important step until an help from machine‐learning algorithms is available. [ABSTRACT FROM AUTHOR]

Background: The subcutaneous implantable‐defibrillator (S‐ICD) is a relatively new alternative to the transvenous ICD system to minimize intravascular lead‐related complications. This paper presents outcome of SICD implantation in patients enrolled in Iran S‐ICD registry. Methods: Between October 2015 and June 2022, this prospective multicenter national registry included 223 patients with a standard indication for an ICD, who neither required bradycardia pacing nor needed cardiac resynchronization to evaluate the early post‐implant complications and long‐term follow‐up results of the S‐ICD system. Results: The mean age of the patients was 45 ± 17 years. The majority (79.4%) were male. Ischemic cardiomyopathy (39.5%) was the most common underlying disorder among patients selected for S‐ICD implant. Most study patients (68.6%) had ICD for primary prevention of sudden cardiac death. Seven patients (3.1%) were found to have suboptimal lead positions. Six patients (2.7%) developed a pocket hematoma; all were managed medically. During a mean follow‐up of 2 years, the appropriate therapy was recorded in 13% of the patients and inappropriate ICD intervention mainly due to supraventricular tachycardia in 8.9%. Pocket infection was observed in four patients (1.8%) and five patients (2.2%) died mainly due to heart failure. Conclusion: S‐ICDs were effective at detecting and treating both induced and spontaneous ventricular arrhythmias. Major clinical complications were rare. [ABSTRACT FROM AUTHOR]

Pseudo‐pacemaker syndrome (PPMS) is a rare complication of first‐degree atrio‐ventricular (AV) block in which a very prolonged PR interval causes AV dyssynchrony and subsequent symptoms of hemodynamic instability in the absence of an implanted pacemaker. The aim of this manuscript was to describe a unique case of PPMS and to provide a comprehensive review of the topic to help clinicians in the diagnosis and management of this condition. Through systematic research on PubMed, Google Scholar, EBSCO, and Ovid MEDLINE and using the search strings "pseudo‐pacemaker syndrome" and "symptomatic first‐degree AV block," we identified 14 articles accounting for 17 cases of PPMS, including our case report. The most common age group for PPMS was middle‐aged and young adults, with an average age of 47 years. Palpitations were the most common presenting symptom and four main etiologies of PPMS were identified, as follows: (1) Idiopathic PPMS with evidence of impaired conduction over the AV node (20% of cases), (2) PPMS associated with reversable inflammatory causes (13%) or (3) associated with iatrogenic surgical or interventional procedures leading to the permanent damage of the normal AV conduction system (20%), and, finally, (4) PPM related to dual AV nodal physiology (DAVNP) as a primary finding (27%) or occurring after fast or slow pathway ablation for treatment of AV nodal re‐entrant tachycardia (AVNRT) (20%). Treatment should be patient‐tailored and based on the specific etiology once identified. However, the treatment of PPMS due to DAVNP without AVNRT presentation is yet to be clarified. [ABSTRACT FROM AUTHOR]

Background: Device complications, such as infection or lead dysfunction necessitating transvenous lead extraction (TLE) are continuously rising amongst patients with transvenous implantable‐cardioverter‐defibrillator (ICD). Objectives: Aim of this study was to characterize the procedural outcome and risk‐factors of patients with indwelling 1‐ and 2‐chamber ICD undergoing TLE. Methods: We conducted a subgroup analysis of all ICD patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) database. Predictors for procedural failure and all‐cause mortality were assessed. Results: We identified 842 patients with an ICD undergoing TLE with the mean age of 62.8 ± 13.8 years. A total number of 1610 leads were treated with lead dysfunction (48.5%) as leading indication for extraction, followed by device‐related infection (45.4%). Lead‐per‐patient ratio was 1.91 ± 0.88 and 60.0% of patients had dual‐coil defibrillator leads. Additional extraction tools, such as mechanical rotating dilator sheaths and snares were utilized in 6.5% of cases. Overall procedural complications occurred in 4.3% with 2.0% major complications and a procedure‐related mortality of 0.8%. Clinical success rate was 97.9%. All‐cause in‐hospital mortality was 3.4%, with sepsis being the leading cause for mortality. Multivariate analysis revealed lead‐age ≥10 years (OR:5.82, 95%CI:2.1‐16.6; p =.001) as independent predictor for procedural failure. Systemic infection (OR:9.57, 95%CI:2.2‐42.4; p <.001) and procedural complications (OR:8.0, 95%CI:2.8‐23.3; p <.001) were identified as risk factors for all‐cause mortality. Conclusions: TLE is safe and efficacious in patients with 1‐ and 2‐chamber ICD. Although lead dysfunction is the leading indication for extraction, systemic device‐related infection is the main driver of all‐cause mortality for ICD patients undergoing TLE. [ABSTRACT FROM AUTHOR]

Background: Outcomes of transvenous lead extraction (TLE) are well reported in the general population, However, data on safety, efficacy of TLE in octogenarians with a long lead dwell time, using powered extraction tools are limited. The aim of this multicenter study was to evaluate the safety, effectiveness of TLE in octogenarians using the bidirectional rotational mechanical sheaths and mid‐term outcome after TLE. Methods: The study population comprised 83 patients (78.3% male; mean age 85 ± 3 years; [range 80–94 years]) with 181 target leads. All the leads (mean implant duration 112 ± 77 months [range 12–377]) were extracted exclusively using the Evolution RL sheaths (Cook Medical, Bloomington, IN, USA). Results: The main indication for TLE was infection in 84.3% of cases. Complete procedural success rate, clinical success rate, per lead were 93.9% and 98.3%, respectively. Failure of lead extraction was seen in 1.7% of leads. The additional use of a snare was required in 8.4% of patients. Major complications occurred in one patient (1.2%). Thirty‐day mortality after TLE was 6%. During a mean time follow‐up of 22 ± 21 months, 24 patients (29%) died. No procedure‐related mortality occurred. Predictors of mortality included ischemic cardiomyopathy (HR 4.35; 95% CI 1.87–10.13; p =.001), left ventricularejection fraction ≤35% (HR 7.89; 95% CI 3.20–19.48; p <.001), and TLE for systemic infection (HR 4.24; 95% CI 1.69–10.66; p =.002). Conclusions: At experienced centers bidirectional rotational mechanical sheaths combined with different mechanical tools and femoral approach allowreasonable success and safety in octogenarian with long lead dwell time. Patient's age should not influence the decision to extract or not the leads, although the 30‐day and mid‐term mortality are significant, especially in the present of specific comorbidities. [ABSTRACT FROM AUTHOR]

Introduction: Cephalic vein cutdown (CVC) and axillary vein puncture (AVP) are both recommended for transvenous implantation of leads for cardiac implantable electronic devices (CIEDs). Nonetheless, it is still debated which of the two techniques has a better safety and efficacy profile. Methods: We systematically searched Medline, Embase, and Cochrane electronic databases up to September 5, 2022, for studies that evaluated the efficacy and safety of AVP and CVC reporting at least one clinical outcome of interest. The primary endpoints were acute procedural success and overall complications. The effect size was estimated using a random‐effect model as risk ratio (RR) and relative 95% confidence interval (CI). Results: Overall, seven studies were included, which enrolled 1771 and 3067 transvenous leads (65.6% [n = 1162] males, average age 73.4 ± 14.3 years). Compared to CVC, AVP showed a significant increase in the primary endpoint (95.7 % vs. 76.1 %; RR: 1.24; 95% CI: 1.09–1.40; p =.001) (Figure 1). Total procedural time (mean difference [MD]: −8.25 min; 95% CI: −10.23 to −6.27; p <.0001; I2 = 0%) and venous access time (MD: −6.24 min; 95% CI: −7.01 to −5.47; p <.0001; I2 = 0%) were significantly shorter with AVP compared to CVC. No differences were found between AVP and CVC for incidence overall complications (RR: 0.56; 95% CI: 0.28–1.10; p =.09), pneumothorax (RR: 0.72; 95% CI: 0.13−4.0; p =.71), lead failure (RR: 0.58; 95% CI: 0.23–1.48; p =.26), pocket hematoma/bleeding (RR: 0.58; 95% CI: 0.15–2.23; p =.43), device infection (RR: 0.95; 95% CI: 0.14–6.60; p =.96) and fluoroscopy time (MD: −0.24 min; 95% CI: −0.75 to 0.28; p =.36). Conclusion: Our meta‐analysis suggests that AVP may improve procedural success and reduce total procedural time and venous access time compared to CVC. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) remains challenging due to suboptimal success rates in persistent atrial fibrillation (AF). Existing mapping technologies cannot reliably distinguish sources in this patient population. Recently, the novel electrographic flow (EGF) mapping system was developed using a modified Horn‐Schunk optical flow algorithm to detect and quantify patterns of electrical wavefront propagation in the atria. Objectives: To test the hypothesis that targeted source ablation based on EGF mapping is superior to empiric AF ablation. Methods: We included all consecutive patients undergoing EGF guided ablation for persistent AF. All patients underwent pulmonary vein isolation (PVI) and were treated with the same EAM system (CARTO). The outcome of PVI+EGF guided CA was compared with data of PVI‐only procedures (PVI‐only group) and PVI plus additional empiric adjunctive linear and substrate ablations (PVI+LINES group). 12‐months outcome as freedom from AF and atrial tachycardia/flutter (AT/AFL), procedural safety and efficiency characterized by procedure duration, fluoroscopy use, radiofrequency applications and duration, were analyzed. Both intention‐to‐treat and per protocol analysis were conducted. Results: A total number of 70 patients (39 in PVI+EGF, 16 in PVI‐only and 15 patients in PVI+LINES group) were enrolled. Intention‐to‐treat analysis showed fewer AF recurrences in PVI+EGF as compared with the PVI‐only or PVI+LINES groups at 12 months (25.6% vs. 62.5% vs. 53.3%, p =.02). There were no differences in AT/AFL recurrence (17.9% vs. 37.5% vs. 20.0%, p =.37). Procedure times were longer in PVI+EGF group (p <.01), and there were no differences in fluoroscopy use (p =.67). Conclusion: Our data suggest that patients treated with EGF‐guided CA developed fewer AF recurrences. Although the procedure times are longer, it seems to be safe and offers a more targeted, patient‐specific ablation strategy beyond PVI than adjunctive empiric lines and substrate ablation in this complex group of patients. [ABSTRACT FROM AUTHOR]

Background: Late‐gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) is a predictor of adverse events in patients with cardiac sarcoidosis (CS), but available studies had small sample sizes and did not consider all relevant endpoints. Objective: To evaluate the association between LGE on CMR in patients with CS and mortality, ventricular arrhythmias (VA) and sudden cardiac death (SCD), and heart failure (HF) hospitalization. Methods: A literature search was conducted for studies reporting the association between LGE in CS and the study endpoints. The endpoints were mortality, VA and SCD, and HF hospitalization. The search included the following databases: Ovid MEDLINE, EMBASE, Web of Science, and Google Scholar. The search was not restricted to time or publication status. The minimum follow‐up duration was 1 year. Results: A total of 17 studies and 1915 CS patients (595 with LGE vs. 1320 without LGE) were included; mean follow‐up was 3.3 years (ranging between 17 and 84 months). LGE was associated with increased all‐cause mortality (OR 6.05, 95% CI 3.16–11.58; p <.01), cardiovascular mortality (OR 5.83, 95% CI 2.89–11.77; p <.01), and VA and SCD (OR 16.48, 95% CI 8.29–32.73; p <.01). Biventricular LGE was associated with increased VA and SCD (OR 6.11, 95% CI 1.14–32.68; p =.035). LGE was associated with an increased HF hospitalization (OR 17.47, 95% CI 5.54–55.03; p <.01). Heterogeneity was low: df = 7 (p =.43), I2 = 0%. Conclusions: LGE in CS patients is associated with increased mortality, VA and SCD, and HF hospitalization. Biventricular LGE is associated with an increased risk of VA and SCD. [ABSTRACT FROM AUTHOR]

Aims: Evidence for CRT in adults with congenital heart disease (ACHD) and chronic heart failure is limited, with recommendations for its use extrapolated from the population with structurally normal hearts. This retrospective observational study investigates the efficacy of CRT in this heterogenous group, discussing factors predicting response to CRT. Methods: Twenty‐seven patients with structural ACHD who underwent CRT insertion or upgrade at a tertiary center in the United Kingdom were retrospectively studied. The primary outcome measure was clinical response to CRT, defined as improvement of NYHA class and/or improvement in systemic ventricular ejection fraction by one category. Secondary outcomes included change in QRS duration and adverse events. Results: Thirty‐seven percent of patients had a systemic right ventricle (sRV). RBBB was the commonest baseline QRS morphology (40.7%) despite this being an unfavorable characteristic for CRT. Overall, positive response to CRT was demonstrated in 18 patients (66.7%). NYHA class improved in 55.5% following CRT (p =.001) and 40.7% showed improvement in systemic ventricular ejection fraction (p =.118). There were no baseline characteristics that predicted response to CRT, and electrocardiographic measures such as QRS shortening post‐CRT was not associated with positive response. Good response rates (60.0%) were demonstrated in those with sRV. Conclusion: CRT is efficacious in structural ACHD including in those who do not meet conventional criteria. Extrapolation of recommendations from adults with structurally normal hearts may be inappropriate. Future research should focus on improving patient selection for CRT, for example using techniques to better quantify mechanical dysynchrony and intra‐procedural electrical activation mapping in these complex patients. [ABSTRACT FROM AUTHOR]

Background: Transesophageal echocardiography (TEE) and cardiac computed tomography angiography (CCTA) are currently utilized for left atrial appendage closure (LAAC) planning. During the recent global iodine contrast media shortage in 2022, cardiac magnetic resonance imaging (CMR) was utilized for the first time for LAAC planning. This study sought to assess the utility of CMR versus TEE for LAAC planning. Methods: This single center retrospective study consisted of all patients who underwent preoperative CMR for LAAC with Watchman FLX or Amplatzer Amulet. Key measures were accuracy of LAA thrombus exclusion, ostial diameter, depth, lobe count, morphology, accuracy of predicted device size, and devices deployed per case. Bland‐Altman Analysis was used to compare CMR versus TEE measurements of LAA ostial diameter and depth. Results: 25 patients underwent preoperative CMR for LAAC planning. A total of 24 (96%) cases were successfully completed with 1.2 ± 0.5 devices deployed per case. Among the 18 patients who underwent intraoperative TEE, there was no significant difference between CMR versus TEE in LAA thrombus exclusion (CMR 83% vs. TEE 100% cases, p =.229), lobe count (CMR 1.7 ± 0.8 vs. TEE 1.4 ± 0.6, p =.177), morphology (p =.422), and accuracy of predicted device size (CMR 67% vs. TEE 72% cases, p = 1.000). When comparing the difference between CMR and TEE measurements, Bland‐Altman analysis demonstrated no significant difference in LAA ostial diameter (CMR‐TEE bias 0.7 mm, 95% CI [−1.1, 2.4], p =.420), but LAA depth was significantly larger with CMR versus TEE (CMR‐TEE bias 7.4 mm, 95% CI [1.6, 13.2], p =.015). Conclusions: CMR is a promising alternative for LAAC planning in cases where TEE or CCTA are contraindicated or unavailable. [ABSTRACT FROM AUTHOR]

Background: Leadless pacemakers were developed to reduce complications associated with transvenous pacemaker implantation and long‐term follow‐up. Existing international guidelines lack detailed instructions on patients suitable for leadless pacemaker implantation. Our aim was to develop a consensus document that provides medical guidance for all health professionals involved in the indication and implantation of Transcatheter Pacing System single‐chamber device (VR leadless) pacemakers for patients with atrial fibrillation or in sinus rhythm. Methods: A panel of experts, including interventional and non‐interventional cardiologists, used the Research ANd Development/University of California at Los Angeles (RAND/UCLA) method to rate the appropriateness of leadless pacemaker implantation for 64 scenarios in patients with atrial fibrillation and 192 scenarios in sinus rhythm. The scenarios were rated individually and again during a moderated group session. Median ratings and level of agreement were calculated to classify each scenario as appropriate, inappropriate, or questionable. Results: This consensus statement, based on available literature and the experts' opinions, summarizes recommendations for standardizing and optimizing leadless pacemaker implantation. The limitation for vascular access via the superior vena cava was the most influential variable when indicating leadless pacemaker implantation in both patients with atrial fibrillation and patients in sinus rhythm. Conclusions: Life expectancy, risk of infection, prosthetic valve, left ventricular ejection fraction (LVEF), limitation for vascular access via the superior vena cava, and mobility and exercise capacity determine who is advised to undergo VR leadless pacemaker implantation. More prospective studies are needed to optimize existing recommendations. [ABSTRACT FROM AUTHOR]

Background: Achieving bi‐directional conduction block, as assessed by differential pacing and change in activation along tricuspid annulus (TA), across the cavo‐tricuspid isthmus (CTI), is considered a satisfactory end point during catheter ablation of atrial flutter (AFL). Aim: To assess role of subclinical conduction by observing polarity reversal of local bipolar signals from RS to QR pattern lateral to the line of ablation, in predicting recurrence of CTI dependant AFL after ablation in patients with bidirectional conduction block. Method and Results: Of 683 patients undergoing ablation of CTI dependent AFL, 73 (10.6%) patients underwent redo flutter ablation and were evaluated further. The mean age was 60.8 years and 51% were males. Evidence of bidirectional block by differential pacing and change is activation along multipolar catheter and reversal of local bipolar signals from RS to QR pattern lateral to the line of ablation, during the 1st and subsequent procedure, were studied. 60% patients had confirmed bidirectional block of which 71% had lack of voltage reversal, at the end of 1st procedure. All patients with bidirectional block with lack of reversal of bipolar signals, after the first procedure had recurrence of AFL whereas only 3/11 (27%) people with bidirectional block and with absence of subclinical conduction had recurrence of AFL. Conclusion: Achieving bidirectional conduction block is not sufficient to prevent recurrence of AFL after CTI ablation. Reversal of local bipolar signals, from RS to QR pattern along with achieving bidirectional conduction delay would reduce recurrence of AFL, post ablation. [ABSTRACT FROM AUTHOR]

Introduction: Unidirectional block, left atrium to pulmonary vein (LA‐PV) entrance block without PV‐LA exit block, has not been fully investigated in the setting of ablation index (AI)‐guided pulmonary vein (PV) isolation (PVI). The aim of this study was to investigate unidirectional blocks during AI‐guided PVI. Methods: After achieving entrance block, exit block was evaluated by pacing from the catheter placed in the PV. Local PV musculature capture without conduction to the LA was necessary to prove exit block. Results: In total, 441 PVs (including nine left common PVs) from 113 consecutive patients (mean age: 71 ± 12 years, 77 men, 61 paroxysmal atrial fibrillation cases) who underwent initial AI‐guided PVI for atrial fibrillation were studied. Entrance block was achieved in all PVs. of the 247/441 (56%) PVs showing local PV musculature capture, 5/247 (2.0%) showed unidirectional blocks. Three of the five PVs (left superior and inferior PVs in one patient; right superior PV in another patient) showed LA‐PV reconnection, requiring additional ablation to achieve bidirectional block during the procedure. Two of the five PVs (left superior and inferior PVs in one patient) showed LA‐PV reconnection, and thereafter, LA‐PV conduction became blocked again spontaneously, leading to bidirectional block without further ablation during the procedure. Conclusion: AI‐guided PVI presented a low prevalence of unidirectional block (2%), using entrance block alone as the endpoint of PVI could therefore be justified. [ABSTRACT FROM AUTHOR]

Background: Appropriate implantable cardioverter‐defibrillator (ICD) shocks are associated with an increased risk of mortality and heart failure (HF) events. The first appropriate shock may occur late after implantation. However, whether the timing of the first appropriate shock influences prognosis is unknown. This study aimed to evaluate the clinical significance of the timing of the first appropriate shock in patients with ICD. Methods: This retrospective and observational study enrolled 565 consecutive ICD patients. Patients who received an appropriate shock were divided into the early group (first appropriate shock <1 year after ICD implantation) and late group (first appropriate shock ≥1 year after ICD implantation). All‐cause mortality was compared between the two groups. Results: Over a median follow‐up of 5.6 years, 112 (19.8%) patients received an appropriate shock, including 32 patients (28.6%) in the early group and 80 patients (71.4%) in the late group. Comparisons of baseline characteristics at ICD implantation revealed that the late group was more likely to receive cardiac resynchronization therapy (66.3% vs. 31.3%, p < 0.001), ICD for primary prevention (60.0% vs. 31.3%, p = 0.001), and angiotensin‐converting enzyme inhibitor or angiotensin‐receptor blocker treatment (88.8% vs. 71.9%, p = 0.028). Survival after shock was significantly worse in the late group than in the early group (p = 0.027). In multivariable Cox proportional hazards analysis, the late group had an increased risk of all‐cause mortality compared with the early group (HR: 2.22; 95% CI 1.01–4.53; p = 0.029). In both groups, the most common cause of death was HF. Conclusions: Late occurrence of the first appropriate ICD shock was associated with a worse prognosis compared with early occurrence of the first appropriate shock. Cardiac death was the most common cause of death in patients who experienced late occurrence of the first appropriate ICD shock, resulting from HF in most cases. [ABSTRACT FROM AUTHOR]

Introduction: Failure to isolate ipsilateral pulmonary veins (PV) "en bloc" by wide‐area circumferential ablation (WACA) may necessitate ablation at the intervenous carina. It is unknown how this scenario impacts rates of atrial fibrillation (AF) recurrence. Methods: A standard random‐effect meta‐analysis of randomized or observational studies were performed, where the outcome of first‐time AF ablation was reported in patients with "en bloc" isolation of PVs by WACA as compared with those in whom ablation at the intervenous carina was needed after WACA to achieve complete isolation. Results: A total of five single‐center, observational studies (N = 1185) and one, multi‐center randomized trial (N = 234) were enrolled. PV isolation could be achieved by WACA "en bloc" in 902/1419 (63.6%) cases. The rest required additional ablation at one or both of the left and right intervenous carinas to achieve isolation. The follow‐up time after ablation ranged from 1 to 2 years in the included trials. The incidence of AF recurrence proved to be significantly lower in patients with successful "en bloc" isolation compared to those requiring carina ablation(s) to achieve complete bilateral PV isolation (MH‐OR 1.89, 95% CI 1.42–2.53, p <.01) Conclusion: This present meta‐analysis demonstrates a lower arrhythmia recurrence rate in patients with bilateral "en bloc" isolation, as compared to those who needed additional carina ablation for complete PVI. Therefore, it is imperative that every effort be made to isolate ipsilateral PVs "en bloc" during PVI. [ABSTRACT FROM AUTHOR]

Background: Data on long‐term outcomes of catheter ablation (CA) for atrial fibrillation (AF) in outside of clinical trials settings are sparse. Objective: We aimed to assess outcomes and readmissions at 1 year following admission for CA for AF. Methods: Utilizing the Nationwide Readmissions Database (2016–2018), we identified patients with CA among all patients with a primary admission diagnosis of AF, and a control group by propensity score match adjusted for age, sex, comorbidities, CHA₂DS₂‐VASc scores, and the hospital characteristics. The primary outcome was a composite of unplanned heart failure (HF), AF and stroke‐related readmissions, and death at 1 year, and secondary outcomes were hospital outcomes and all‐cause readmission rates. Results: The study cohort consisted of 29,771 patients undergoing CA and 63,988 controls. Patients undergoing CA were younger with lower CHA₂DS₂‐VASc scores and less comorbidities. Over a follow‐up of 170 ±1.1 days, the primary outcome occurred in 5.2% in CA group and 6.0% of controls (hazard ratio [HR] and 95% confidence interval [CI]: 0.86 [0.76–0.94], p =.002). CA affected AF and stroke related readmission, but showed no effect on HF and mortality outcome. Male sex (HR: 0.83 [0.74–0.94], p =.03), younger age (HR: 0.71 [0.61–0.83], p <.001], and lower CHA₂DS₂‐VASc scores (HR: 0.68 [0.55–0.84], p <.001) were associated with lower risk of primary outcome with CA. Conclusion: In this study, CA for AF was associated with significantly lower AF and stroke‐related admissions, but not to HF or all‐cause readmission. Better outcomes were seen among males, younger patients, and in patients with less comorbidities and low CHA₂DS₂‐VASc scores. [ABSTRACT FROM AUTHOR]

Background: Hybrid ablation combines the advantages of surgical and catheter ablation. Many studies have explored the efficiency and safety of hybrid ablation in patients with nonparoxysmal AF. Methods: We systematically searched for prospective controlled trials that compared hybrid ablation with catheter/surgical ablation in PubMed, Web of Science, Wiley Library, and CNKI. Our main assessment indicators included maintenance of sinus rhythm (SR) without antiarrhythmic drugs for more than 12 months, major adverse events (MAEs), procedure time and fluoroscopy time. Results: Of 1214 identified studies, five were eligible and were included in our analysis (N = 451 participants). The pooled results showed that hybrid ablation was more effective in maintaining SR than a single procedure (surgical ablation or catheter ablation) (OR = 2.52, 95% confidence interval [CI]: 1.63–3.89, p <.001). Little significant heterogeneity was revealed (p =.32 for heterogeneity, I2 = 14%). More MAEs occurred in the hybrid group than in the single procedure group (OR = 7.47, 95% CI: 1.90–29.41, p =.004; I2 = 0%). Two trials reported the procedure and fluoroscopy times, and the procedure time for hybrid ablation was significantly longer than that of a single procedure (mean difference = 107.42, 95% CI: 88.62 to 126.22, p <.001; I2 = 82%). There was no significant difference in fluoroscopy time between the 2 groups (mean difference = –1.00, 95% CI: –5.37 to 3.36, p =.65; I2 = 12%). Conclusions: Hybrid ablation was more effective than catheter ablation and was as effective as surgical ablation in patients with nonparoxysmal AF. Meanwhile, hybrid ablation, especially concomitant hybrid ablation, increases the incidence of MAEs and prolongs the procedure time. [ABSTRACT FROM AUTHOR]

Background: It has been observed that the fourth‐generation cryoballoon (CB4) ablation catheter increased the rate of acute real‐time recordings of pulmonary vein isolation (PVI) during the ablation for the treatment of atrial fibrillation (AF). The aim of this analysis was to compare the long‐term outcome results between patients treated with the CB4 and second‐generation cryoballoon (CB2). Methods: In total, 492 patients suffering from AF, underwent PVI ablation with either the CB2 or CB4 catheter within this examination of the 1STOP real‐world Italian project and were included in the analysis. Specifically, 246 consecutive patients treated by CB4 were compared to 246 propensity‐matched control patients who underwent PVI using CB2. Results: When comparing the patient cohorts treated with CB2 versus CB4, acute success rate (99.6 ± 4.7% vs. 99.7 ± 3.6%, p =.949) and peri‐procedural complications (3.7% vs.1.2%, p =.080) were similar in both groups, respectively. However, procedure time (100 vs.75 min, p <.001) and fluoroscopy duration (21 vs.17 min, p <.001) were all significantly lower in the CB4 treated patient cohort. At the 12‐month follow‐up, the freedom from AF recurrence after a 90‐day blanking period was significant higher in the CB4 as compared with the CB2 group (93.3% vs.81.3%, p <.001). Conclusions: In summary, usage of the CB4 ablation catheter increased the rate of acute PVI recording capability and resulted in a higher rate of long‐term PVI success, as demonstrated by the reduced rate of AF recurrence in comparison to the CB2 cohort at the 12‐month follow‐up period. [ABSTRACT FROM AUTHOR]

Background: Conventional superior access for cardiac implantable electronic devices (CIEDs) is not always possible and femoral CIEDs (F‐CIED) are an alternative option when leadless systems are not suitable. The long‐term outcomes and extraction experiences with F‐CIEDs, in particular complex F‐CIED (ICD/CRT devices), remain poorly understood. Methods: Patients referred for F‐CIEDs implantation between 2002 and 2019 at two tertiary centers were included. Early complications were defined as ≤30 days following implant and late complications >30 days. Results: Thirty‐one patients (66% male; age 56 ± 20 years; 35% [11] patients with congenital heart disease) were implanted with F‐CIEDs (10 ICD/CRT and 21 pacemakers). Early complications were observed in 6.5% of patients: two lead displacements. Late complications at 6.8 ± 4.4 years occurred in 29.0% of patients. This was higher with complex F‐CIED compared to simple F‐CIED (60.0% vs. 14.3%, p =.02). Late complications were predominantly generator site related (n = 8, 25.8%) including seven infections/erosions and one generator migration. Eight femoral generators and 14 leads (median duration in situ seven [range 6–11] years) were extracted without complication. Conclusions: Procedural success with F‐CIEDs is high with clinically acceptable early complication rates. There is a notable risk of late complications, particularly involving the generator site of complex devices following repeat femoral procedures. Extraction of chronic F‐CIED in experienced centers is feasible and safe. [ABSTRACT FROM AUTHOR]

Background: Restricted outdoor activity during COVID‐19 related lockdown may accelerate heart failure (HF) progression and thereby increase cardiac arrhythmias. We analyzed the impact of March/April 2020 lockdown on physical activity and arrhythmia burden in HF patients treated with cardiac resynchronization therapy (CRT) devices with daily, automatic remote monitoring (RM) function. Methods: The study cohort included 405 HF patients enrolled in Observation of Clinical Routine Care for Heart Failure Patients Implanted with BIOTRONIK CRT Devices (BIO|STREAM.HF) registry in 16 countries, who had left ventricular ejection fraction (LVEF) ≤40% (mean 28.2 ± 6.6%) and NYHA class II/III/IV (47.9%/49.6%/2.5%) before CRT pacemaker/defibrillator implantation. The analyzed RM data comprised physical activity detected by accelerometer, mean heart rate and nocturnal rate, PP variability, percentage of biventricular pacing, atrial high rate episode (AHRE) burden, ventricular extrasystoles and tachyarrhythmias, defibrillator shocks, and number of implant interrogations (i.e., follow‐ups). Intraindividual differences in RM parameters before (4‐week period) versus during (4‐week period) lockdown were tested for statistical significance and independent predictors were identified. Results: There was a significant relative change in activity (mean −6.5%, p <.001), AHRE burden (+17%, p =.013), and follow‐up rate (−75%, p <.001) during lockdown, with no significant changes in other RM parameters. Activity decreased by ≥8 min/day in 46.5% of patients; predictors were higher LVEF, lower NYHA class, no defibrillator indication, and more activity before lockdown. AHRE burden increased by ≥17 min/day in 4.7% of patients; predictors were history of atrial fibrillation, higher LVEF, higher body mass index, and activity decrease during lockdown. Conclusion: Unfavorable changes in physical activity, AHRE burden, and follow‐up rate were observed during lockdown, but not in ventricular arrhythmia. [ABSTRACT FROM AUTHOR]

Background: The displacement of cardiac implantable electronic devices (CIEDs) toward the caudal side during standing after CIED implantation could cause lead dislodgement. This study investigated the relationship between supine pocket position and standing CIEDs' displacement distance after the implantation. Methods: After CIED surgeries performed at 2 hospitals between 2012 and 2020, 134 patients underwent postoperative chest x‐rays in the supine and standing positions during hospitalization. To measure the displacement distance of CIEDs from the supine to the standing position, we identified the first thoracic vertebrae (Th1) in the supine position using the first rib as an index, drew a horizontal line at the lower edge of the Th1, and calculated the distance from that point to the upper edge of the CIED. The difference between measures for the two positions was compared. At the position of the pocket in the thorax in the supine position, the ratio of the distance between the thorax and the device is defined as the device thorax ratio (DTR). We examined the relationship between DTR and CIED displacement distance. Results: In this study, we included 134 patients (53% men; median age, 79 years, body mass index, 22.3 ± 3.4; pacemaker 93%, left implantation 96%). We found that the more lateral the position of the CIED pocket, the more the CIED fell when standing (confidence interval = 0.34–0.60, P <.001). Conclusions: The farther the CIED was implanted outside the thorax in the supine position, the more significantly the CIED was displaced in the standing position. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) has emerged as an effective therapy for the treatment of paroxysmal atrial fibrillation (AF); however it is unclear whether proceeding expeditiously to CA improves clinical outcomes in a real‐world population. This study compares outcomes of CA for new AF within 6 months of diagnosis (very early) 6 to 12 months after diagnosis (early) and 12 to 24 months after diagnosis (later). Methods: A large nationally‐representative sample of patients ages 18 to 64 who underwent CA from January 2011 to June 2019 was studied using the IBM MarketScan Database. The primary outcome was a composite of healthcare utilization over the following 24 months. Propensity score‐matching was used to match patients in each cohort. Risk difference in outcomes were compared between matched patients. Results: Two thousand six hundred thirty one patients were identified postmatching, with 1649 in the very early cohort and 982 in the early cohort. The very early referral group was less likely to experience the primary composite outcome postablation (Absolute risk difference [ARD]: −3.9%; 95% Confidence interval [CI]: −5.8%, −2.0%), with the difference driven by fewer cardioversions (ARD: −2.9%, 95% CI: −5.3%, −0.5%) and outpatient visits (ARD: −6.6%, 95% CI: −10.5%, −2.7%). There was no difference in outcomes between early and later referral groups, with only very early referral showing decreased healthcare utilization. Conclusions: Patients who underwent ablation within 6 months of diagnosis had lower healthcare utilization in the ensuing 24 months, driven by fewer outpatient visits and cardioversions, supporting expeditious referral for ablation for symptomatic AF. [ABSTRACT FROM AUTHOR]

Introduction: Electrogram (EGM) fractionation is often associated with diseased atrial tissue; however, mechanisms for fractionation occurring above an established threshold of 0.5 mV have never been characterized. We sought to investigate during sinus rhythm (SR) the mechanisms underlying bipolar EGM fractionation with high‐density mapping in patients with atrial fibrillation (AF). Methods: Forty‐five patients undergoing AF ablation (73% paroxysmal, 27% persistent) were mapped at high density (18562 ± 2551 points) during SR (Rhythmia). Only bipolar EGMs with voltages above 0.5 mV were considered for analysis. When fractionation (> 40 ms and >4 deflections) was detected, we classified the mechanisms as slow conduction, wave‐front collision, or a pivot point. The relationship between EGM duration and amplitude, and tissue anisotropy and slow conduction, was then studied using a computational model. Results: Of the 45 left atria analyzed, 133 sites of EGM fragmentation were identified with voltages above 0.5 mV. The most frequent mechanism (64%) was slow conduction (velocity 0.45 m/s ± 0.2) with mean EGM voltage of 1.1 ± 0.5 mV and duration of 54.9 ± 9.4 ms. Wavefront collision was the second most frequent (19%), characterized by higher voltage (1.6 ± 0.9 mV) and shorter duration (51.3 ± 11.3 ms). Pivot points (9%) were associated with the highest degree of fractionation with 70.7 ± 6.6 ms and 1.8 ± 1 mV. In 10 sites (8%) fractionation was unexplained. The EGM duration was significantly different among the 3 mechanisms (p =.0351). Conclusion: In patients with a history of AF, EGM fractionation can occur at amplitudes > 0.5 mV when in SR in areas often considered not to be diseased tissue. The main mechanism of EGM fractionation is slow conduction, followed by wavefront collision and pivot sites. [ABSTRACT FROM AUTHOR]

Aims: Goal of Transvenous Lead Extraction (TLE) is complete removal of all targeted leads, without complications. Despite counter traction manoeuvres, efficacy rates are often hampered by broken right ventricle lead (RV‐lead) tips. Mechanically powered lead extraction (Evolution sheath) is effective, however safety of dissection up to the lead tip is unclear. Therefore, we examined the feasibility and safety of RV‐lead extraction requiring dissection up to the myocardium. Methods and results: From 2009 to 2018, all TLE in the Isala Heart Centre (Zwolle, The Netherlands) requiring the hand‐powered mechanical Evolution system to extract RV‐leads (n = 185) were examined from a prospective registry. We assessed 4 groups: TLE with the first generation Evolution (n = 43) with (A1,n = 18) and without (A2,n = 25) adhesions up to the myocardium and TLE with the Novel R/L type (n = 142) of sheath with (B1, n = 59) and without (B2, n = 83) adhesions up to the myocardium. Complete success rate in Group B was significantly higher than group A (96.5 vs 76.7%, p = 0.0354). When comparing the patients with adhesions up to the myocardium, total complete success is higher in the R/L group (61.1% vs 90.5%, p = 0.0067). There were no deaths. Overall major complication rates were low (2/185; 1.1%) and there was no statistically significant difference in major and minor complications between the two groups. Conclusion: Extraction strategy with the bidirectional Evolution R/L sheath for right ventricular leads with adhesions up to the myocardium is safe and feasible. [ABSTRACT FROM AUTHOR]

Background: When compared to patients with normal renal function, patients with chronic kidney disease develop higher in‐hospital complications post implantable cardioverter‐defibrillator (ICD) therapy. However, real world data on in‐hospital complications post ICD therapy in patients with end stage renal disease (ESRD) is limited. In this study, we aim to explore the procedure‐related complications of ICD therapy in patients with ESRD. Methods: Using the nationwide inpatient sample (NIS) database, we conducted a retrospective analysis on ESRD patients who underwent inpatient ICD placement from 2010 to 2016. Using 1:2 propensity score matching, we compared ESRD patients to those with normal renal function. Outcomes of interest were postoperative hemorrhage and hematoma formation, blood transfusion, pericardial complications, mechanical complications requiring lead revision, vascular injury, in‐hospital mortality, and length of stay. Results: Our sample included 40,075 cases with subsequent propensity score matching between ESRD and normal renal function. Comparatively, patients with ESRD had higher odds of postoperative hemorrhage (Odds ratio [OR] = 1.67, 95% confidence interval [CI] 1.4–1.99, p = <.0001), blood transfusion (OR, 3.88; CI 3.29–4.56; p = <.0001), mechanical complications requiring lead revision (OR, 1.24; CI 1.01–1.51; p =.035), vascular injury (OR, 2.02; CI 1.27–3.24; p =.0027), in‐hospital mortality (OR, 4.56; CI 3.08–6.76; p = <.0001), and longer hospitalization (11 vs. 7 days, p = <.0001), but without significant difference in pericardial complications (OR, 1.9; CI 0.92–1.54; p = <.18). Conclusion: In this large contemporary cohort, patients with ESRD undergoing inpatient ICD therapy are at higher risk of developing postprocedural complications including hemorrhage and hematoma, blood transfusion, mechanical complications requiring lead revision, and in hospital mortality, without increased risk of pericardial complications. [ABSTRACT FROM AUTHOR]

Background: Recent studies have shown that Evolution RL bidirectional rotational mechanical sheath (Cook Medical, USA) is an effective and safe technique for transvenous lead extraction (TLE). We reported our experience with the bidirectional rotational mechanical tools using a multidisciplinary approach highlighting the value of a joint cardiac surgeon and electrophysiologist collaboration. Methods: The study population comprised 84 patients (77% male; mean age 65 ± 18 years) undergoing TLE. After a multidisciplinary evaluation, a combined procedure was considered. Results: The main indication for TLE was infection in 54 cases (64%). Overall, 152 leads were extracted with a mean implant duration of 94 ± 63 months (range 12–421). Complete procedural success rate, clinical success rate, and lead removal with clinical success rate were 91.6% (77/84), 97.6% (82/84), and 98.6% (150/152), respectively. Eighteen combined procedures were performed in 12 patients (14%), such as "hybrid approach" (n = 2) or TLE concomitant to: 1) transcatheter aspiration procedure for large vegetation (n = 8); 2) left ventricular assistance device implantation as bridge to cardiac transplantation (n = 1); 3) permanent pacing with epicardial leads (n = 6); 4) tricuspid valve replacement (n = 1). One major complication (1.2%) and 11 (13%) minor complications were encountered. No injury to the superior vena cava occurred and no procedure‐related deaths were reported. During a mean time follow‐up of 21 ± 18 months, 17 patients (20%) died. They were more often diabetics (p =.02), and they underwent TLE more often for infection (p =.004). Conclusions: Our results support the finding that excellent outcomes can be achieved in performing TLE of chronically implanted leads by using the Evolution RL bidirectional rotational mechanical sheath and a multidisciplinary team approach involving both electrophysiologist and cardiac surgeon as first line operators. [ABSTRACT FROM AUTHOR]

Background: Left atrial appendage (LAA) thrombosis increases the risk of stroke and its management has to be assessed. The aim of the present study is to evaluate short and long‐term safety and efficacy of a standardized approach of percutaneous LAA closure (LAAC) routinely using a cerebral protection device (CPD) in patients with LAA thrombosis or sludge (LAAT). Methods: We prospectively enrolled 14 consecutive patients with atrial fibrillation complicated by LAAT presenting in a high‐volume tertiary center. In seven patients (50%) LAAT was found after anticoagulant withdrawal for severe bleedings and in the remaining half LAAT was found despite appropriate anticoagulant therapy. All patients were treated with a standardized interventional approach of LAAC routinely using a CPD and guided by transoesophageal echocardiography. Results: Mean age was 68 ± 14 years and nine patients (64%) were male. Mean CHA2DS2‐VASc and HAS‐BLED scores were 3.3 ± 1.6 and 2.3 ± 1.1, respectively. Six patients (42.8%) presented organized thrombi while eight LAA sludge (57.1%). In 13 patients (92.8%) CPD was positioned through a right radial arterial access. Procedural success was achieved in all patients. In one patient we assisted to embolization of the thrombus during deployment of the device in the absence of neurological consequences. During a mean follow up of 426 ± 307 days, one patient died for non‐cardiac cause while no embolic event or major bleeding were reported. Conclusion: In an unselected cohort, LAAC with the systematic use of CPD was a feasible, safe and effective therapeutic option for LAAT both acutely and after long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Background: Due to an increasing need for cardiac implantable electronic device (CIED) placement, the cost of healthcare has been rising including the cost of hospital stay after the procedure. We conducted this systematic review and meta‐analysis to assess the safety and feasibility of same‐day discharge (SDD) after cardiac device implantations. Methods: We searched MEDLINE, and Embase databases from inception to March 2021 to identify studies that compared clinical outcomes between SDD group and hospital overnight stay (HO) group after cardiac device implantations. Outcomes included complications after the procedure, mortality, and re‐hospitalization. Data from each study were combined using the random‐effects model to calculate pooled odds ratio (OR) with 95% confidence interval (CI). Results: Eight studies (one randomized control trial, three prospective cohort and four retrospective cohort studies) with a total of 61,602 patients (4153 in SDD group and 57,449 in HO group) were included. SDD was not associated with more procedure‐related complications. The rates of wound problems (0.94% vs 1.84%, pooled OR = 0.86, 95%CI: 0.2‐3.68, p =.834), pneumothorax (1.15% vs 0.73%, pooled OR = 1.36, 95%CI: 0.26‐7.12, p =.718), hematoma (0.59% vs 2.32%, pooled OR = 0.35, 95%CI:0.01‐9.85, p =.534), lead/device dislodgement (4% vs 2.48%, pooled OR = 1.71, 95%CI: 0.64‐4.54, p =.281), readmission rate (17.6% vs 17.5%, pooled OR = 0.95, 95%CI: 0.74‐1.21, p =.667), and mortality rate (1.66% vs 1.44%, pooled OR = 0.77, 95%CI: 0.58‐1.01, p =.059) were similar between in SDD and HO groups respectively. Conclusions: Our meta‐analysis suggested that SDD after cardiac device implantations might be a safe and feasible alternative to HO without differences in procedure‐related complications, readmission rates, or mortality rates. [ABSTRACT FROM AUTHOR]

Background: On surface electrocardiographic (ECGs), it is difficult to differentiate Ito‐mediated J waves, a repolarization phenomenon seen in J wave syndromes (JWS) from terminal QRS deflections that mimic J waves (pseudo J waves) in intraventricular conduction delay (IVCD), an abnormality in depolarization. We hypothesize that the difference between the "maximum QRS duration" inclusive of J point or terminal QRS deflections and the minimum QRS duration identified across a 12‐lead ECG is significantly larger in Ito‐mediated J waves, and can serve as a marker to make this distinction. Methods: A retrospective analysis was performed on adults with ECGs consisting of one of the four following manifestations: J waves associated with hypothermia and early repolarization, and pseudo J waves associated with right bundle branch block (RBBB) and non‐specific intraventricular conduction delay (NS‐IVCD). All ECGs were assessed individually and the maximum and minimum discrete QRS deflections on 12‐lead tracings, defined as "QRSmax" and QRSmin, were identified. The difference between "QRSmax" and QRSmin, designated as ∆QRS, was calculated and compared across the studied populations. Results: A total of 60 patients consisting of 15 patients in each arm were included in the study. ΔQRS was significantly larger in the hypothermia and early repolarization groups, compared to RBBB and NS‐IVCD (p <.0001), with the following mean ∆QRS: hypothermia 54.3 ± 13.7 ms, early repolarization pattern 47.3 ± 15.3 ms, RBBB 19.3 ± 6.5 ms, and NS‐IVCD 16.0 ± 6.6 ms. Conclusion: ∆QRS may serve as a reliable ECG parameter for distinguishing Ito‐mediated J waves from pseudo J waves produced by delayed intraventricular conduction. [ABSTRACT FROM AUTHOR]

Background: Although frequently considered a benign condition, new evidence has shown that mitral valve prolapse (MVP) is associated with complex ventricular arrhythmias (VAs) and sudden cardiac death (SCD). Therefore, we conducted a systematic review and meta‐analysis of the relevant studies to investigate the parameters that could identify MVP patients at higher risk of experiencing complex VAs. Method: We performed a systematic literature search of PubMed for potential studies between January 2010 and January 2021. Our meta‐analysis included studies comparing MVP patients with complex VAs (A‐MVP) and those without (NA‐MVP). We used the fixed‐effects model to obtain the odds ratio (OR), risk ratio (RR), or mean difference (MD) and 95% confidence interval (CI) for each analyzed parameter. Results: Six studies with 848 individuals were included in the meta‐analysis. As compared to the NA‐MVP patients, A‐MVP patients had a higher prevalence of inverted T‐wave (OR: 2.73; 95% CI: 1.85‐4.02; p <.00001) and longer QTc interval on the resting ECG (MD: 14.73; 95% CI: 9.39‐20.08; p <.00001), longer anterior mitral leaflet length (MD: 2.67; 95% CI: 2.02‐3.31; p <.00001), bi‐leaflet prolapse (OR: 1.65; 95% CI: 1.22‐2.24; p =.001), and mitral annulus disjunction (MAD) on echocardiogram (RR: 1.90; 95% CI: 1.50‐2.40; p <.00001), and late gadolinium enhancement (LGE) on cardiac magnetic resonance (RR: 4.38; 95% CI: 1.77‐10.86; p =.001). Conclusion: Our comprehensive meta‐analysis suggests that risk factors related to A‐MVP are T‐wave inversion, longer QTc interval, bi‐leaflet prolapse, longer anterior mitral valve leaflet, MAD, and LGE. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency catheter ablation remains the most effective management option for atrioventricular nodal reentry tachycardia (AVNRT). The risk of atrioventricular (AV) block requiring permanent pacemaker is substantial, but, currently, a reliable method to predict this complication is lacking. Methods: The electrophysiologic studies (EPS) and baseline characteristics of patients who underwent catheter ablation for the treatment of AVNRT were retrospectively analyzed to investigate predisposing factors for AV block after treatment. Patients were followed for AV block at one month and one year after hospital discharge. Results: Among 784 patients treated with catheter ablation for AVNRT between 1999 to 2019, 15 developed AV block. Patients with AV block were older (p =.001). Among the recorded EPS parameters, patients with AV block had significantly higher Atrial His interval (120 vs. 110 ms, p =.049), Wenckebach cycle length (WCL) (400 vs. 353 ms, p <.001) and tachycardia CL (400 vs. 387 ms, P =.01) during the ablation compared to their peers without AV block. Additionally, only WCL (OR = 1.1, 95% CI 1.02‐1.19, p =.017) remained significant after adjustment for age, gender, ERP, AH interval, and HR. This association was confirmed by comparing patients with (n = 15) and without (n = 15) AV block using propensity score‐matching. A WCL≥400ms was associated with a 4‐fold higher incidence of AV block (4.79% vs. 1.25%). Conclusion: Increased pre‐procedural WCL was associated with a high risk for AV block after catheter ablation treatment for AVNRT. These findings suggest that this readily available EPS‐derived parameter may be a novel marker of risk for severe complications in these patients. [ABSTRACT FROM AUTHOR]

Background: To test in vivo a new design prototype for radio frequency (RF) ablation. Methods: A prototype based on a concept of endo‐epicardial biparietal bipolar RF ablation with the atrial tissue interposed and consisting of two specular endocardial‐epicardial catheters was tested in four pigs (80±5 kg). The endocardial catheter was introduced into the left atrium through the left atrial appendage on the beating heart. The epicardial counterpart was placed manually on the atrial epicardial surface. The coupling of the two catheters was achieved using a neodymium magnet around the gold plate electrode, and RF was applied to the interposed tissue. The hearts were excised, and the lesions were examined using morphometric evaluation. Results: The RF application resulted in transmural lesions in all of the four animals tested. In these animals the maximum endocardial width (Wendo) was 6.34 ± 0.25, 6.54 ± 0.33, 6.36 ± 0.57, and 6.49 ± 0.96 mm. The pericardial width (Wepi) was similar: 6.37 ± 0.47, 6.58 ± 0.32, 6.35 ± 0.56 and 6.53 ± 0.94 mm. The lesion area was 924.78, 949.25, 944.25, and 926.05 mm2, and the lesion volume was 92.47, 94.92, 94.42, and 92.60 mm3, respectively. Conclusions: The idea of an endocardial‐epicardial bidirectional biparietal bipolar radiofrequency tool such that the atrial tissue is fully interposed between the two RF poles might be promising for future clinical applications. Further research is warranted. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular implantable electronic device (CIED) infections are associated with significant morbidity and mortality making the identification of the causative organism critical. The vast majority of CIED infections are caused by Staphylococcal species. CIED infections associated with atypical pathogens are rare and have not been systematically investigated. The objective of this study is to characterize the clinical course, management and outcome in patients with CIED infection secondary to atypical pathogens. Methods: Medical records of all patients who underwent CIED system extraction at the University of Chicago Medical Center between January 2010 and November 2020 were retrospectively reviewed to identify patients with CIED infection. Demographic, clinical, infection‐related and outcome data were collected. CIED infections were divided into typical and atypical groups based on the pathogens isolated. Results: Among 356 CIED extraction procedures, 130 (37%) were performed for CIED infection. Atypical pathogens were found in 5.4% (n = 7) and included Pantoea species (n = 2), Kocuria species (n = 1), Cutibacterium acnes (n = 1), Corynebacterium tuberculostearicum (n = 1), Corynebacterium striatum (n = 1), Stenotrophomonas maltophilia (n = 1), and Pseudozyma ahidis (n = 1). All patients with atypical CIED infections were successfully treated with total system removal and tailored antibiotic therapy. There were no infection‐related deaths. Conclusions: CIED infections with atypical pathogens were rare and associated with good outcome if diagnosed early and treated with total system removal and tailored antimicrobial therapy. Atypical pathogens cultured from blood, tissue or hardware in patients with CIED infection should be considered pathogens and not contaminants. [ABSTRACT FROM AUTHOR]

Purpose: To compare the outcome of paroxysmal atrial fibrillation (AF) ablation via pulmonary vein isolation using Ablation Index (AI) with strict or standard stability criteria. Methods: We enrolled 130 consecutive naive patients affected by paroxysmal AF who underwent PVI at two high‐volume centers. AI target was ≥380 at the posterior wall and ≥500 at the anterior wall. Strict versus standard stability criteria were set for Group 1 (65 patients) and Group 2 (65 patients), respectively. We compared those strategies with a historical cohort of 72 consecutive patients treated at same centers in the VISITALY study, using average force ≥10 g and strict stability criteria as target parameters. Interlesion distance target was <6 mm. Recurrence was defined as any AF, atrial tachycardia (AT) or atrial flutter (AFL) during the 12 months after ablation, excluding a 90‐days blanking period. Results: Procedure duration (224.05 ± 47.21 vs. 175.61 ± 51.29 min; p <.001), fluoroscopy time (11.85 ± 4.38 vs. 10.46 ± 6.49 min; p =.019) and pericardial effusion rate (9.23% vs. 0%; p =.01) were higher in Group 1 than in Group 2. Freedom from AF/AT/AFL at 12 months was not significantly different (Group 1: 86.15%; Group 2: 90.77%; p =.42). Compared to VISITALY study, there were not significant differences in terms of recurrences. Conclusion: A strategy of PVI using AI with standard stability criteria performed the best in terms of procedure efficiency and safety. Twelve‐months arrhythmia‐free survival rate was comparable with other strategies pursuing an interlesion distance target <6 mm, regardless of the use of AI. [ABSTRACT FROM AUTHOR]