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Background: Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known., Objective: The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF., Methods: Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings., Results: Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581)., Conclusion: In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Crown Copyright © 2024. Published by Elsevier Inc. All rights reserved.)

Background: In nonvalvular atrial fibrillation (NVAF), the left atrial appendage (LAA) is the source of thrombus in up to 90% of patients. LAA pseudothrombus (LAAPT), defined as a filling defect on the initial but not the 60-second delayed acquisition on cardiovascular computed tomography scan (CCT), is a recognized phenomenon in NVAF, with unknown clinical relevance. We aimed to determine the relationship between LAAPT and history of stroke in patients with NVAF., Methods and Results: The study included 213 consecutive patients with NVAF undergoing CCT who were assessed for LAAPT. LA and LAA dimensions and LAA morphology correlated with clinical demographics including cardiovascular risk factors, history of stroke, thromboembolic stroke, and transient ischemic attack. Mean age (±SD) was 65.1±10.5 years (range 31-89) and 150 of 213 (70.4%) were men. LAAPT was present in 59 of 213 (27.7%) patients. Greater mean LAA ostium area (5.7 versus 4.5, P <0.001), greater mean LAA ostium area:curved length (0.11 versus 0.08, P <0.001), increased LAA volume (14.0 versus 10.2, P <0.001), and lower mean LAA tortuosity index (1.17 versus 1.38, P <0.001) were all associated with the presence of LAAPT. On multivariable analysis, LAAPT on CCT (odds ratio [OR], 3.20 [95% CI, 1.40-7.20]; P <0.006) and higher CHA 2 DS 2 -VASc score (OR, 1.65 [95% CI, 1.16-2.35]; P =0.01) were associated with all strokes, with LAAPT remaining a statistically significant risk factor even after adjustment for CHA 2 DS 2 -VASc score., Conclusions: LAAPT on CCT is common in patients with NVAF. It has a strong positive association with stroke prevalence, even after adjustment for CHA 2 DS 2 -VASc score. LAAPT on CCT may potentially allow further stratification for stroke risk, additive to the CHA 2 DS 2 -VASc score.

Aims: This proof-of-concept study sought to evaluate changes in heart rate (HR) obtained from a consumer wearable device and compare against implantable loop recorder (ILR)-detected recurrence of atrial fibrillation (AF) and atrial tachycardia (AT) after AF ablation., Methods and Results: REMOTE-AF (NCT05037136) was a prospectively designed sub-study of the CASA-AF randomized controlled trial (NCT04280042). Participants without a permanent pacemaker had an ILR implanted at their index ablation procedure for longstanding persistent AF. Heart rate and step count were continuously monitored using photoplethysmography (PPG) from a commercially available wrist-worn wearable. Photoplethysmography-recorded HR data were pre-processed with noise filtration and episodes at 1-min interval over 30 min of HR elevations ( Z -score = 2) were compared with corresponding ILR data. Thirty-five patients were enrolled, with mean age 70.3 ± 6.8 years and median follow-up 10 months (interquartile range 8-12 months). Implantable loop recorder analysis revealed 17 out of 35 patients (49%) had recurrence of AF/AT. Compared with ILR recurrence, wearable-derived elevations in HR ≥ 110 beats per minute had a sensitivity of 95.3%, specificity 54.1%, positive predictive value (PPV) 15.8%, negative predictive value (NPV) 99.2%, and overall accuracy 57.4%. With PPG-recorded HR elevation spikes (non-exercise related), the sensitivity was 87.5%, specificity 62.2%, PPV 39.2%, NPV 92.3%, and overall accuracy 64.0% in the entire patient cohort. In the AF/AT recurrence only group, sensitivity was 87.6%, specificity 68.3%, PPV 53.6%, NPV 93.0%, and overall accuracy 75.0%., Conclusion: Consumer wearable devices have the potential to contribute to arrhythmia detection after AF ablation., Study Registration: ClinicalTrials.gov Identifier: NCT05037136 https://clinicaltrials.gov/ct2/show/NCT05037136., Competing Interests: Conflict of interest: S.G. reports funding through the BigData@Heart Innovative Medicines Initiative [grant no. 116074]. A.B. reports funding from the BigData@Heart Innovative Medicines Initiative [grant no. 116074] during the conduct of the study. D.K. reports grants from the National Institute for Health Research (NIHR CDF-2015-08-074 RATE-AF; NIHR130280 DaRe2THINK; NIHR132974 D2T-NeuroVascular; and NIHR203326 BRC), the British Heart Foundation (PG/17/55/33087, AA/18/2/34218, and FS/CDRF/21/21032), the EU/EFPIA Innovative Medicines Initiative (BigData@Heart 116074), EU Horizon (HYPERMARKER 101095480), UK National Health Service—Data for R&D—Subnational Secure Data Environment programme, and the ESC supported by educational grants from Boehringer Ingelheim/BMS-Pfizer Alliance/Bayer/Daiichi Sankyo/Boston Scientific, the NIHR/University of Oxford Biomedical Research Centre, and British Heart Foundation/University of Birmingham Accelerator Award (STEEER-AF). In addition, he has received research grants and advisory board fees from Bayer, Amomed, and Protherics Medicines Development; all outside the submitted work. G.G. reports support from the NIHR Birmingham Experimental Cancer Medicine Centre, NIHR Birmingham Surgical Reconstruction and Microbiology Research Centre, Nanocommons H2020-EU (731032), and the MRC Heath Data Research UK (HDRUK/CFC/01). S.H. reports speaker fees from Alivercor, consultancy fees from BMS, a research grant from Abbott, and the NIHR grants (CASA and LOTO). G.A., I.K.H., Z.C., J.J., D.J., V.M., W.H., and T.W. have no relevant disclosures., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)