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Background: Electrical cardioversion (ECV) is frequently performed in symptomatic atrial fibrillation., Objective: This study aimed to assess the association of ECV with infarcts on brain magnetic resonance imaging (bMRI) and clinical outcomes., Methods: The Swiss Atrial Fibrillation Cohort Study included 2386 patients; 1731 patients were evaluated by bMRI. ECVs were recorded by questionnaire. Patients were assigned to categories by number of ECVs performed before enrollment (0, 1, ≥2). A bMRI study was conducted at baseline and after 2 years (n = 1227) and analyzed for large noncortical or cortical infarcts and small noncortical infarcts. Clinical outcomes were recorded during follow-up. Associations of ECV and outcome measures were assessed by multivariate analyses., Results: There was no independent association between the number of ECVs and infarct prevalence (large noncortical or cortical infarcts and small noncortical infarcts) on baseline bMRI (ECV 1 vs 0: odds ratio [OR], 0.95 [95% CI, 0.68-1.24]; ECV ≥2 vs 0: OR, 1.04 [0.72-1.44]) or between ECVs performed during follow-up and new infarcts on bMRI at 2 years (OR, 1.46 [0.54-3.31]). ECVs were not associated with overt stroke or transient ischemic attack (ECV 1 vs 0: hazard ratio [HR], 1.36 [0.88-2.10]; ECV ≥2 vs 0: HR, 1.53 [0.94-2.48]), hospitalization for heart failure (ECV 1 vs 0: HR, 1.06 [0.82-1.37]; ECV ≥2 vs 0: HR, 1.03 [0.77-1.38]), or death (ECV 1 vs 0: HR, 0.90 [0.70-1.15]; ECV ≥2 vs 0: HR, 0.91 [0.69-1.20])., Conclusion: There was no association between ECV performed before enrollment and cerebral infarcts on baseline bMRI or between ECV performed during follow-up and new infarcts at 2 years. Moreover, ECV was not associated with clinical events., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Early recurrences of atrial tachyarrythmias (ERAT) after pulmonary vein isolation (PVI) are common. While many correlate to late recurrences (LR), some do not. The impact of ERAT timing is difficult to assess with non-invasive holter monitoring due to undersampling. The recommended duration of the blanking period (BP) was recently shortened from 90 days to 8 weeks., Objective: To evaluate the impact of ERAT timing after PVI and the effect of a shorter BP, using implantable cardiac monitors (ICM) for continuous rhythm monitoring., Methods: This is a prespecified substudy of the COMPARE-CRYO study, which enrolled patients with paroxysmal atrial fibrillation undergoing cryoballoon ablation. All patients underwent ICM implantation and the BP duration was 90 days., Results: A total of 5285 ERAT episodes occurred in 117/201 patients (58%). Freedom from LR was 82% vs. 37% in patients without vs. with ERAT (p<0.001). When patients were classified according to their last episode of ERAT occurring between days 0-30, 31-60 and 61-90, freedom from LR was 60%, 56% and 11% (p<0.001). Seven of the 201 patients (3.4%) had AF recurrence in the third month after ablation, but not between days 91-365, which reclassifies them from ablation success to ablation failure with the shortened 8-week BP., Conclusion: ERAT after PVI is common. The presence of ERAT in the third month after PVI was highly predictive for ablation failure, supporting the shortening of the BP duration to 8 weeks, however, the shorter BP reclassifies 3.4% of the patients to ablation failure instead of ablation success., (Copyright © 2024. Published by Elsevier Inc.)

Background: Stroke remains one of the most serious complications in atrial fibrillation (AF) patients and has been linked to disturbances of the autonomic nervous system., Objective: The purpose of this study was to test the hypothesis that impaired cardiac autonomic function might be associated with an enhanced stroke risk in AF patients., Methods: A total of 1922 AF patients who were in either sinus rhythm (SR group; n = 1121) or AF (AF group; n = 801) on a 5-minute resting electrocardiographic (ECG) recording were enrolled in the study. Heart rate variability triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-minute total power, and power in the high-frequency, low-frequency, and very-low-frequency ranges were calculated. Cox regression models were constructed to examine the association of heart rate variability (HRV) parameters with the composite endpoint of stroke or systemic embolism., Results: Mean age was 71 ± 8 years in the SR group and 75 ± 8 years in the AF group. Thirty-seven patients in the SR group (3.4%) and 60 patients in the AF group (8.0%) experienced a stroke or systemic embolism during follow-up of 5 years. In patients with SR, HRVI <15 was the strongest HRV parameter to be associated with stroke or systemic embolism (hazard ratio 3.04; 95% confidence interval 1.3-7.0; P = .009) after adjustment for multiple confounders. In the AF group, no HRV parameter was found to be associated with the composite endpoint., Conclusion: HRVI measured during SR on a single 5-minute ECG recording is independently associated with stroke or systemic embolism in AF patients. HRV analysis in SR may help to improve risk stratification in AF patients., Competing Interests: Disclosures Dr Beer reports grants from the Swiss National Foundation of Science, The Swiss Heart Foundation, and Bayer; and lecture fees from Sanofi Aventis and Amgen, to the institution outside the submitted work. Dr Blum has received research grants from the Swiss National Science Foundation and the Swiss Heart Foundation, all for work outside the submitted study. Dr Bonati has received an unrestricted research grant from AstraZeneca; consultancy or advisory board fees or speaker honoraria from Amgen, Bayer, Bristol-Myers Squibb, and Claret Medical; and travel grants from AstraZeneca and Bayer, outside the submitted work. Dr Conen received consultancy fees from Roche Diagnostics and Trimedics; and speaker fees from Servier and BMS/Pfizer, outside the submitted work. Dr Kühne received personal fees from Daiichi Sankyo and grants from the Swiss National Science Foundation, Swiss Heart Foundation, Foundation for CardioVascular Research Basel, Bayer, Pfizer, Boston Scientific, BMS, Biotronik, and Daiichi Sankyo, outside the submitted work. Dr Krisai has speaker fees from BMS/Pfizer, outside the submitted work. Dr Müller reports fellowship and training support from Biotronik, Boston Scientific, Medtronic, Abbott/St. Jude Medical, and Biosense Webster; speaker honoraria from Biosense Webster, Medtronic, Abbott/St. Jude Medical, AstraZeneca, Daiichi Sankyo, Biotronik, MicroPort, Novartis, Zoll, and Bristol Myers Squibb; consultant fees from Biosense Webster, Medtronic, Abbott/St. Jude Medical, and Biotronik, outside the submitted work. Dr Moschovitis has received advisory board and/or speaker fees from Astra Zeneca, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Gebro Pharma, Novartis, and Vifor, outside the submitted work. Dr Osswald received research grants from the Swiss National Science Foundation and Swiss Heart Foundation, Foundation for CardioVascular Research Basel, and F. Hoffmann-La Roche Ltd.; and educational and speaker grants from F. Hoffmann-La Roche Ltd., Bayer, Novartis, Sanofi, AstraZeneca, Daiichi-Sankyo, and Pfizer, outside the submitted work. Dr Reichlin has recieved research grants from the Swiss National Science Foundation, the Swiss Heart Foundation, and the sitem insel support funds; speaker/consulting honoraria or travel support from Abbott/SJM, Astra Zeneca, Brahms, Bayer, Biosense-Webster, Biotronik, Boston-Scientific, Daiichi Sankyo, Farapulse, Medtronic, Pfizer-,BMS and Roche; and support for his institution’s fellowship program from Abbott/SJM, Biosense Webster, Biotronik, Boston Scientific, and Medtronic for work, outside the submitted study. Dr Zuern has received funding from the “Freiwillige Akademische Gesellschaft Basel”; and personal fees from Cardiomatics, outside the submitted work. All other authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Left atrial appendage (LAA) occluder embolization is an infrequent but serious complication., Objectives: We aim to describe timing, management and clinical outcomes of device embolization in a multi-center registry., Methods: Patient characteristics, imaging findings and procedure and follow-up data were collected retrospectively. Device embolizations were categorized according to 1) timing 2) management and 3) clinical outcomes., Results: Sixty-seven centers contributed data. Device embolization occurred in 108 patients. In 70.4 % of cases, it happened within the first 24 h of the procedure. The device was purposefully left in the LA and the aorta in two (1.9 %) patients, an initial percutaneous retrieval was attempted in 81 (75.0 %) and surgery without prior percutaneous retrieval attempt was performed in 23 (21.3 %) patients. Two patients died before a retrieval attempt could be made. In 28/81 (34.6 %) patients with an initial percutaneous retrieval attempt a second, additional attempt was performed, which was associated with a high mortality (death in patients with one attempt: 2.9 % vs. second attempt: 21.4 %, p < 0.001). The primary outcome (bailout surgery, cardiogenic shock, stroke, TIA, and/or death) occurred in 47 (43.5 %) patients. Other major complications related to device embolization occurred in 21 (19.4 %) patients., Conclusions: The majority of device embolizations after LAA closure occurs early. A percutaneous approach is often the preferred method for a first rescue attempt. Major adverse event rates, including death, are high particularly if the first retrieval attempt was unsuccessful., Condensed Abstract: This dedicated multicenter registry examined timing, management, and clinical outcome of device embolization. Early embolization (70.4 %) was most frequent. As a first rescue attempt, percutaneous retrieval was preferred in 75.0 %, followed by surgical removal (21.3 %). In patients with a second retrieval attempt a higher mortality (death first attempt: 2.9 % vs. death second attempt: 24.1 %, p < 0.001) was observed. Mortality (10.2 %) and the major complication rate after device embolization were high., Competing Interests: Declaration of competing interest A. Aminian is a consultant and proctor for Boston Scientific and Abbott. I. Akin received lecture and proctoring fees from Boston Scientific for the Watchman Okkluder. J. Lund discloses a clinical advisor (proctor) role in LAAC (Abbott) and lecture fees (Abbott, Boston scientific). E. Guerios serves as proctor for LAA closure for Abbott and Lifetech Scientific. N. Amabile has received proctoring and consulting fees from Abbott Vascular and Boston Scientific. C. Skurk has received proctor honoraria from Boston Scientific and speaker fees from Boston Scientific and Lifetech Scientific. J. Harvey is proctor for Abiomed, Boston Scientific and Medtronic and part of the Speaker's bureau for Abiomed, Boston Scientific and Medtronic. He also is part of the advisory board for Avail, Boston Scientific and Medtronic. H. Sievert has received study honoraria to institution, travel expenses and consulting fees from 4tech Cardio, Abbott, Ablative Solutions, Adona Medical, Akura Medical, Ancora Heart, Append Medical, Axon, Bavaria Medizin Technologie GmbH, Bioventrix, Boston Scientific, Cardiac Dimensions, Cardiac Success, Cardimed, Cardionovum, Celonova, Contego, Coramaze, Croivalve, CSL Behring LLC, CVRx, Dinova, Edwards, Endobar, Endologix, Endomatic, Esperion Therapeutics, Inc., Hangzhou Nuomao Medtech, Holistick Medical, Intershunt, Intervene, K2, Laminar, Lifetech, Magenta, Maquet Getinge Group, Metavention, Mitralix, Mokita, Neurotronic, NXT Biomedical, Occlutech, Recor, Renal Guard, Shifamed, Terumo, Trisol, Vascular Dynamics, Vectorious Medtech, Venus, Venock, Vivasure Medical, Vvital Biomed and Whiteswell. M. Kühne received personal fees from Bayer, Böhringer Ingelheim, Pfizer BMS, Daiichi Sankyo, Medtronic, Biotronik, Boston Scientific, Johnson & Johnson, and F. Hoffmann-La Roche Ltd., as well as grants from Bayer, Pfizer, Boston Scientific, BMS, Biotronik, and Daiichi Sankyo. S. Sabir is part of the Boston Scientific WATCHMAN advisory board. J. Kim has received proctoring fees from Abbott Vascular. M. Montorfano received consultant fees from Abbott, Boston Scientific, Kardia. M. Ancona received consultant fees from Abbott. Relevant research funding went to Vanderbilt University Medical Center from Boston Scientific, Boehringer-Ingelheim, Medtronic and Atricure, where C. Ellis is practicing. He also reseves a consultant and advisor fee from Abbott Medical, Atricure, Boston Scientific, Medtronic. L. Nombela-Franco is proctor for Abbott Vascular and has received lectures fees from Boston Scientific. A. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic. He also is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors declare that they have no competing interests., (Copyright © 2024. Published by Elsevier Inc.)

Objectives: Randomized controlled trials of pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have proven the procedure's efficacy. Studies assessing its empirical cost-effectiveness outside randomized trial settings are lacking. We aimed to evaluate the effectiveness and cost-effectiveness of PVI versus medical therapy for AF., Methods: We followed a target trial approach using the Swiss-AF cohort, a prospective observational cohort study that enrolled patients with AF between 2014 and 2017. Resource utilization and cost information were collected through claims data. Quality of life was measured with EQ-5D-3L utilities. We estimated incremental cost-effectiveness ratios (ICERs) from the perspective of the Swiss statutory health insurance system., Results: Patients undergoing PVI compared with medical therapy had a 5-year overall survival advantage with a hazard ratio of 0.75 (95% CI 0.46-1.21; P = .69) and a 19.8% SD improvement in quality of life (95% CI 15.5-22.9; P < .001), at an incremental cost of 29 604 Swiss francs (CHF) (95% CI 16 354-42 855; P < .001). The estimated ICER was CHF 158 612 per quality-adjusted life-year (QALY) gained within a 5-year time horizon. Assuming similar health effects and costs over 5 additional years changed the ICER to CHF 82 195 per QALY gained. Results were robust to the sensitivity analyses performed., Conclusions: Our results show that PVI might be a cost-effective intervention within the Swiss healthcare context in a 10-year time horizon, but unlikely to be so at 5 years, if a willingness-to-pay threshold of CHF 100 000 per QALY gained is assumed. Given data availability, we find target trial designs are a valuable tool for assessing the cost-effectiveness of healthcare interventions outside of randomized controlled trial settings., Competing Interests: Author Disclosures Links to the individual disclosure forms provided by the authors are available here., (Copyright © 2023 International Society for Pharmacoeconomics and Outcomes Research, Inc. Published by Elsevier Inc. All rights reserved.)

Background: Current American College of Cardiology/American Heart Association/Heart Rhythm Society (ACC/AHA/HRS) and European Society of Cardiology (ESC) guidelines recommend different strategies to avoid low-yield admissions in patients with syncope., Objective: The purpose of this study was to directly compare the safety and efficacy of applying admission criteria of both guidelines to patients presenting with syncope to the emergency department in 2 multicenter studies., Methods: The international BASEL IX (BAsel Syncope EvaLuation) study (median age 71 years) and the U.S. SRS (Improving Syncope Risk Stratification in Older Adults) study (median age 72 years) were investigated. Primary endpoints were sensitivity/specificity for the adjudicated diagnosis of cardiac syncope (BASEL IX only) and 30-day major adverse cardiovascular events (30d-MACE)., Results: Among 2560 patients in the BASEL IX and 2085 in SRS studies, ACC/AHA/HRS and ESC criteria recommended admission for a comparable number of patients in BASEL IX (27% vs 28%), but ACC/AHA/HRS criteria less often in SRS (19% vs 32%; P <.01). Recommendations were discordant in ∼25% of patients. In BASEL IX, sensitivity for cardiac syncope and 30d-MACE among patients without admission criteria was comparable for ACC/AHA/HRS and ESC criteria (64% vs 65%, P = .86; and 67% vs 71%, P = .15, respectively). In SRS, sensitivity for 30d-MACE was lower with ACC/AHA/HRS (54%) vs ESC criteria (88%; P <.001). Similarly, specificity for cardiac syncope and 30d-MACE in BASEL IX was comparable for both guidelines, but in SRS the ACC/AHA/HRS guidelines showed a higher specificity for 30d-MACE than the ESC guidelines., Conclusion: ACC/AHA/HRS and ESC guidelines showed disagreement regarding admission for 1 in 4 patients and had only modest sensitivity, all indicating possible opportunities for improvements., (Copyright © 2022 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The effect of the ventricular repolarization heterogeneity has not been systematically assessed in patients with atrial fibrillation (AF). Aim of this study is to assess ventricular repolarization heterogeneity as predictor of cardiovascular (CV) death and/or other CV events in patients with AF., Methods: From the multicenter prospective Swiss-AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1711 patients who were in sinus rhythm (995) or AF (716). Resting ECG recordings of 5-min duration were obtained at baseline. Parameters assessing ventricular repolarization were computed (QTc, Tpeak-Tend, J-Tpeak and V-index)., Results: During AF, the V-index was found repeatable (no differences when computed over the whole recording, on the first 2.5-min and on the last 2.5-min segments). During a mean follow-up time of 2.6 ± 1.0 years, 90 patients died for CV reasons. In bivariate Cox regression analysis (adjusted for age only), the V-index was associated with an increased risk of CV death, both in the subgroup of patients in sinus rhythm (SR) as well as those in AF. In multivariate analysis adjusted for clinical risk factors and medications, both prolonged QTc and V-index were independently associated with an increased risk of CV death (QTc: hazard ratio [HR] 2.78, 95% CI 1.79-4.32, p < 0.001; V-index: HR 1.73, 95% CI 1.12-2.69, p = 0.014)., Conclusions: QTc and V-index, measured in a single 5-min ECG recording, were independent predictors of CV death in a cohort of patients with AF and might be a valuable tool for further risk stratification to guide patient management. Clinical Trial Identifier Swiss-AF study: NCT02105844., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Objective: Balancing bleeding risk and stroke risk in patients with atrial fibrillation (AF) is a common challenge. Though several bleeding risk scores exist, most have not included patients on direct oral anticoagulants (DOACs). We aimed at developing a novel bleeding risk score for patients with AF on oral anticoagulants (OAC) including both vitamin K antagonists (VKA) and DOACs., Methods: We included patients with AF on OACs from a prospective multicenter cohort study in Switzerland (SWISS-AF). The outcome was time to first bleeding. Bleeding events were defined as major or clinically relevant non-major bleeding. We used backward elimination to identify bleeding risk variables. We derived the score using a point score system based on the β-coefficients from the multivariable model. We used the Brier score for model calibration (<0.25 indicating good calibration), and Harrel's c-statistics for model discrimination., Results: We included 2147 patients with AF on OAC (72.5% male, mean age 73.4 ± 8.2 years), of whom 1209 (56.3%) took DOACs. After a follow-up of 4.4 years, a total of 255 (11.9%) bleeding events occurred. After backward elimination, age > 75 years, history of cancer, prior major hemorrhage, and arterial hypertension remained in the final prediction model. The Brier score was 0.23 (95% confidence interval [CI] 0.19-0.27), the c-statistic at 12 months was 0.71 (95% CI 0.63-0.80)., Conclusion: In this prospective cohort study of AF patients and predominantly DOAC users, we successfully derived a bleeding risk prediction model with good calibration and discrimination., (© 2021 International Society on Thrombosis and Haemostasis.)

Background: The occurrence of congestive heart failure (CHF) hospitalization among patients with atrial fibrillation (AF) is a poor prognostic marker., Objective: The purpose of this study was to assess whether insulin-like growth factor-binding protein 7 (IGFBP-7), a marker of myocardial damage, identifies AF patients at high risk for this complication., Methods: We analyzed 2 prospective multicenter observational cohort studies that included 3691 AF patients. Levels of IGFBP-7 and N-terminal pro-brain natriuretic peptide (NT-proBNP) were measured from frozen plasma samples at baseline. The primary endpoint was hospitalization for CHF. Multivariable adjusted Cox regression analyses were constructed., Results: Mean patient age was 69 ± 12 years, 1028 (28%) were female, and 879 (24%) had a history of CHF. The incidence per 1000 patient-years across increasing IGFBP-7 quartiles was 7, 10, 32, and 85. The corresponding multivariable adjusted hazard ratios (aHRs) (95% confidence interval [CI]) were 1.0, 1.05 (0.63-1.77), 2.38 (1.50-3.79), and 4.37 (2.72-7.04) (P for trend <.001). In a subgroup of 2812 patients without pre-existing CHF at baseline, the corresponding aHRs were 1.0, 0.90 (0.47-1.72), 1.69 (0.94-3.04), and 3.48 (1.94-6.24) (P for trend <.001). Patients with IGFBP-7 and NT-proBNP levels above the biomarker-specific median had a higher risk of incident CHF hospitalization (aHR 5.20; 3.35-8.09) compared to those with only 1 elevated marker (elevated IGFBP-7 aHR 2.17; 1.30-3.60); elevated NT-proBNP aHR 1.97; 1.17-3.33); or no elevated marker (reference)., Conclusion: Higher plasma levels of IGFBP-7 were strongly and independently associated with CHF hospitalization in AF patients. The prognostic information provided by IGFBP-7 was additive to that of NT-proBNP., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) is a growing health burden, and pulmonary vein isolation (PVI) using cryoballoon (CB) or radiofrequency (RF) represents an attractive therapeutic option. Sex-specific differences in the epidemiology, pathophysiology, and clinical presentation of AF and PVI are recognized., Objective: We aimed at comparing the efficacy, safety, and procedural characteristics of CB and RF in women and men undergoing a first PVI procedure., Methods: We searched for randomized controlled trials and prospective observational studies comparing CB and RF ablation with at least 1 year of follow-up. After merging individual patient data from 18 data sets, we investigated the sex-specific (procedure failure defined as recurrence of atrial arrhythmia, reablation, and reinitiation of antiarrhythmic medication), safety (periprocedural complications), and procedural characteristics of CB vs RF using Kaplan-Meier and multilevel models., Results: From the 18 studies, 4840 men and 1979 women were analyzed. An analysis stratified by sex correcting for several covariates showed a better efficacy of CB in men (hazard ratio for recurrence 0.88; 95% confidence interval 0.78-0.98, P = .02) but not in women (hazard ratio 0.98; 95% confidence interval 0.83-1.16; P = .82). For women and men, the energy source had no influence on the occurrence of at least 1 complication. For both sexes, the procedure time was significantly shorter with CB (-22.5 minutes for women and -27.1 minutes for men)., Conclusion: CB is associated with less long-term failures in men. A better understanding of AF-causal sex-specific mechanisms and refinements in CB technologies could lead to higher success rates in women., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in selected heart failure patients, but decision-making regarding selection of CRT-defibrillator or CRT-pacemaker is an ongoing debate., Objective: The purpose of this study was to construct predictive models and scoring systems for implantable cardioverter-defibrillator (ICD) therapy and death without ICD therapy (prior death)., Methods: We pooled 2 prospective cohorts of CRT-D patients with primary prevention indication and used Fine and Gray models to develop independent prognostic models for time to first ICD therapy (event of interest) or death without prior ICD therapy (competing event). We defined CRT-D benefit as a high probability of ICD therapy combined with moderate/low probability of prior death., Results: Seven hundred twenty patients were included. Median follow-up was 7.2 years, and 247 patients (34%) died. Cumulative incidence of ICD therapy/prior death at 5 years was 24%/17%. In multivariable models, higher New York Heart Association classes, diuretic use, and ischemic cardiomyopathy were predictors of ICD therapy (hazard ratio 1.89 [1.30-2.75], 1.91 [1.12-3.24], and 1.40[1.02-1.92], respectively) but not of prior death. Males with comorbidities (cancer, renal failure, peripheral artery disease, body mass index >30) or systolic blood pressure ≤100 were at higher risk for prior death. Higher age was associated with lower risk of ICD therapy but higher risk of prior death. One-quarter of patients had low predicted benefit from CRT-D implantation using a scoring system for the dual prediction of appropriate ICD therapy and death without appropriate ICD-therapy., Conclusion: Different factors predict ICD therapy or prior death in CRT-D patients using competing risk models. Scoring allows identifying patients with predicted low benefit of CRT-D (low chance of ICD therapy, high chance of prior death)., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Catheter ablation of atrial fibrillation (AF) by means of pulmonary vein isolation (PVI) focuses on the PVs as the putative trigger of AF. However, which classification should be used to identify patients that are most suitable for PVI is uncertain. The aim of the study was to evaluate rhythm-, burden-, and anatomically-based classification schemes to predict success rates after up to two procedures of an ablation strategy strictly aimed at isolation of the PVs., Methods: Patients with paroxysmal or non-longstanding persistent AF undergoing PVI-only ablation with the option of one repeat PVI in case of AF recurrence were included. An AF burden score (AFB) was determined based on frequency, episode duration, and number of previous cardioversions and then categorized as minimal, mild, moderate, or severe. Two- and three-dimensional anatomical assessment of the left atrium (LA) was performed based on pre-interventional imaging by computed tomography or magnetic resonance imaging., Results: Of 195 patients analyzed, 24 presented with recurrence after the last intervention (12%, median follow up: 16±11 months). In multivariable analysis, a more than 6-fold increase of risk for AF recurrence was identified for patients with a severe compared to a mild AFB [hazard ratio: 6.241 (95% confidence interval: 1.914-20.167, p=0.002)]. In contrast to univariable analysis, no other parameter was associated with recurrence in multivariable analysis., Conclusions: Burden-based (AFB) classification was identified as a significant predictor for AF recurrence even after repeat PVI, while neither anatomical parameters nor the established rhythm-based classification of paroxysmal and persistent AF did., (Copyright © 2019 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: Various scores have been derived for the assessment of syncope patients in the emergency department (ED) but stay inconsistently validated. We aim to compare their performance to the one of a common, easy-to-use CHADS 2 score., Methods: We prospectively enrolled patients ≥ 40 years old presenting with syncope to the ED in a multicenter study. Early clinical judgment (ECJ) of the treating ED-physician regarding the probability of cardiac syncope was quantified. Two independent physicians adjudicated the final diagnosis after 1-year follow-up. Major cardiovascular events (MACE) and death were recorded during 2 years of follow-up. Nine scores were compared by their area under the receiver-operator characteristics curve (AUC) for death, MACE or the diagnosis of cardiac syncope., Results: 1490 patients were available for score validation. The CHADS 2 -score presented a higher or equally high accuracy for death in the long- and short-term follow-up than other syncope-specific risk scores. This score also performed well for the prediction of MACE in the long- and short-term evaluation and stratified patients with accuracy comparative to OESIL, one of the best performing syncope-specific risk score. All scores performed poorly for diagnosing cardiac syncope when compared to the ECJ., Conclusions: The CHADS 2 -score performed comparably to more complicated syncope-specific risk scores in the prediction of death and MACE in ED syncope patients. While better tools incorporating biochemical and electrocardiographic markers are needed, this study suggests that the CHADS 2 -score is currently a good option to stratify risk in syncope patients in the ED., Trial Registration: NCT01548352., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: A longer QTc interval has been associated with more adverse cardiovascular events and death in the general population. Little evidence is available on these relationships among patients with atrial fibrillation (AF)., Methods: We performed a prospective observational multicenter cohort study of 1413 patients with AF. A resting 12‑lead electrocardiogram (ECG) was performed at baseline. QT interval was corrected for heart rate using the Bazett formula (QTc). Endpoints for this study included hospitalizations for congestive heart failure (CHF), a combination of cardiovascular death, myocardial infarction, stroke, systemic arterial embolism (MACE) and all-cause mortality., Results: Mean age of our population was 68±12years and 420 (30%) participants were female. Median QTc was 432ms (interquartile range 409; 457). The mean follow-up time was 3.6±1.5years. After multivariable adjustment, there was a linear increase in risk with increasing QTc interval for incident CHF (hazard ratio (HR) per 1-SD increase in QTc 1.3 [95% CI 1.1; 1.6], p=0.008), MACE (HR 1.2 [1.0; 1.4], p=0.02) and all-cause mortality (HR 1.3 [1.0; 1.6], p=0.002). Results were consistent whether or not patients were in sinus rhythm on the baseline ECG (HR for CHF 1.7 versus 1.3, p interaction 0.08; HR for MACE 1.3 versus 1.2, p interaction 0.9; HR for all-cause mortality 1.4 versus 1.4, p interaction 0.9)., Conclusions: In this large well-characterized cohort of AF patients, QTc interval was independently associated with adverse outcomes. These results were independent of the rhythm on the baseline ECG., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: The role of tachycardia-induced cardiomyopathy vs tachycardia-related short diastolic filling period and reduced atrial contraction in decline of left ventricular ejection fraction (LVEF) in atrial fibrillation (AF) is uncertain. We aimed to characterize left heart changes over time in patients with AF who undergo electrical cardioversion (ECV)., Methods: Consecutive AF patients who were to undergo ECV were enrolled. Patients with unstable or acute heart failure, severe valvular diseases, recent open-heart surgery, major disorders, or an unsuccessful ECV were excluded. Transthoracic echocardiography, including 3-dimensional left atrial and ventricular volume acquisitions, was performed 1-2 hours before and after ECV, and 4-6 weeks later., Results: In 73 patients (77% male, 66 ± 11 years), ECV resulted in an immediate increase in LVEF (from 43 [interquartile range (IQR), 33-50%] to 48 [IQR, 40-53%]; P < 0.0001). Four to 6 weeks after ECV, ejection fraction increased further in patients who remained in sinus rhythm (SR) (n = 55) to 55 (IQR, 44-62)%; P < 0.001. In patients with AF relapse, LVEF returned to values comparable to pre-ECV (n = 18) (44 [IQR, 32-51]%; P = 0.03). The atrial emptying fraction did not significantly change immediately after ECV (n = 69; from 20 [IQR, 13-25]% to 20 [IQR, 15-28]%; P = 0.14). Only patients who remained in SR showed an increase in atrial emptying fraction after 4-6 weeks (n = 51; to 37 [IQR, 26-48]%; P < 0.0001 vs post-ECV)., Conclusions: Immediate improvement in LVEF after ECV explains approximately 50% of total LVEF increase over time. However, in SR, LVEF, and atrial function continuously increase over 4-6 weeks after ECV. This might be attributable to recovery of tachycardia-induced cardiomyopathy., (Copyright © 2015 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Although radiofrequency (RF) and cryoballoon (CB) based technologies for pulmonary vein isolation (PVI) have both individually been demonstrated to be effective and safe for the treatment of paroxysmal AF, head-to-head comparisons are lacking. The purpose of this study was to compare the outcome of cryoballoon versus radiofrequency ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation., Methods: Out of a prospective registry of 327 patients undergoing PVI, 208 patients (age 58±11 years, ejection fraction 59±6%, left atrial size 39±6 mm) with paroxysmal AF were identified. The presented dataset was obtained by 1:1 propensity score matching and contained 142 patients undergoing CB-PVI or RF-PVI in conjunction with a 3D mapping system, respectively. We compared single procedure efficacy of the two methods using a Cox proportional hazards model., Results: After a mean follow-up of 28 months and a single procedure, AF recurred in 37 of 71 (52%) in the CB-PVI group and in 31 of 71 patients (44%) in the RF-PVI group (HR [95% CI]=1.19 [0.74, 1.92], p=0.48). Recurrence of AF for PVI using solely the CB was observed in 23 of 51 (45%) patients and in 23 of 51 (45%) patients in the corresponding RF-PVI group (HR [95% CI]=0.93 [0.52, 1.66], p=0.81). Complication rate was not different between the groups., Conclusion: A propensity score matched comparison between CB-PVI and RF-PVI using a 3D-mapping system for AF ablation showed similar long-term success rates., (Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.)

Background: Good catheter-tissue contact force (CF) is critical for transmural and durable lesion formation during radiofrequency (RF) ablation but is difficult to assess in clinical practice. Tissue heating during RF application results in an impedance decrease at the catheter tip., Objective: The purpose of this study was to correlate achieved CF and initial impedance decreases during atrial fibrillation (AF) ablation., Methods: We correlated achieved CF and initial impedance decreases in patients undergoing ablation for AF with two novel open-irrigated CF-sensing RF catheters (Biosense Webster SmartTouch, n = 647 RF applications; and Endosense TactiCath, n = 637 RF applications). We then compared those impedance decreases to 691 RF applications with a standard open-irrigated RF catheter (Biosense Webster ThermoCool)., Results: When RF applications with the CF-sensing catheters were analyzed according to an achieved average CF <5 g, 5-10 g, 10-20 g, and >20 g, the initial impedance decreases during ablation were larger with greater CF. Corresponding median values at 20 seconds were 5 Ω (interquartile range [IQR] 2-7), 8 Ω (4-11), 10 Ω (7-16), and 14 Ω (10-19) with the SmartTouch and n/a, 4 Ω (0-10), 8 Ω (5-12), and 13 Ω (8-18) with the TactiCath (P <.001 between categories for both catheters). When RF applications with the SmartTouch (CF-sensing catheter, median achieved CF 12 g) and ThermoCool (standard catheter) were compared, the initial impedance decrease was significantly greater in the CF-sensing group with median decreases of 10 Ω (6-14 Ω) vs 5 Ω (2-10 Ω) at 20 seconds (P <.001 between catheters)., Conclusion: The initial impedance decrease during RF applications in AF ablations is larger when greater catheter contact is achieved. Monitoring of the initial impedance decrease is a widely available indicator of catheter contact and may help to improve formation of durable ablation lesions., (© 2013 Heart Rhythm Society Published by Heart Rhythm Society All rights reserved.)

Background: The Achieve mapping catheter allows real-time recordings from the pulmonary veins (PVs) during cryoballoon (CB) ablation of atrial fibrillation (AF)., Objective: To assess the clinical applicability of the Achieve mapping catheter and the value of real-time recordings from the PVs during CB., Methods: Patients with paroxysmal AF undergoing CB ablation were studied. Recordings from the PVs were analyzed during (real-time recordings) and after CB ablation and validated by using a variable circumferential mapping catheter (Achieve group; n = 20). A comparison was made by using a group of patients in whom CB ablation with a guidewire and a variable circumferential mapping catheter was performed (Guidewire group; n = 20)., Results: Forty patients (age 58±11 years; ejection fraction 0.59±0.07; left atrial size 40±6 mm) with paroxysmal AF were included. In the Achieve group, real-time recordings from the PVs could be obtained in 40 of 80 (50%) PVs and could be seen more often at the left-sided PVs (25 of 39, 64%) than at the right-sided PVs (15 of 41, 37%; P = .02). Validation with a standard circumferential mapping catheter confirmed PV isolation in 75 of 80 (93%) PVs. After a single procedure and a follow-up of 14±4 months, 25 of 40 (63%) patients were in sinus rhythm with no significant difference between groups., Conclusions: The Achieve catheter can be used as a substitute for a guidewire during CB ablation, but real-time recordings can be obtained only in half of the PVs and are not sufficient to accurately confirm isolation of all PVs., (Copyright © 2013 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

We report the case of a faulty lead that led to failure to defibrillate during defibrillation threshold testing at the time of elective generator replacement. Standard lead measurements failed to detect the malfunction. Many centres perform neither defibrillation threshold testing nor commanded high-energy shock delivery. Even changes in the position of the lead in relation to the generator may cause problems that will go undetected without high-voltage shock delivery. We therefore caution against the wholesale abandonment of high-voltage shock testing in patients with pre-existing implanted leads., (Copyright © 2012 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

To obtain estimates for the prevalence of Toxoplasma gondii infection in ducks and geese in Germany, enzyme-linked immunosorbent assays (ELISA) were established based on affinity-purified T. gondii tachyzoite surface antigen 1 (TgSAG1) and used to examine duck and goose sera for T. gondii-specific antibodies. The results of 186 sera from 60 non-infected ducks (Anas platyrhynchos) and 101 sera from 36 non-infected geese (Anser anser) as well as 72 sera from 11 ducks and 89 sera from 12 geese inoculated experimentally with T. gondii tachyzoites (intravenously) or oocysts (orally) and positive in a T. gondii immunofluorescent antibody test (IFAT) were used to select a cut-off value for the TgSAG1-ELISA. Sera obtained by serial bleeding of experimentally inoculated ducks and geese were tested to analyze the time course of anti-TgSAG1 antibodies after inoculation and to assess the sensitivity of the assays in comparison with IFAT. In ducks, IFAT titres and ELISA indices peaked 2 and 5 weeks p.i with tachyzoites, respectively. Only three of six geese inoculated with tachyzoites at the same time as the ducks elicited a low and non-permanent antibody response as detected by the IFAT. In the TgSAG1-ELISA, only a slight increase of the ELISA indices was observed in four of six tachyzoite-inoculated geese. By contrast, inoculation of ducks and geese with oocysts led to an increase in anti-TgSAG1 antibodies within 1 or 2 weeks, which were still detectable at the end of the observation period, i.e. 11 weeks p.i. Inoculation of three ducks and three geese with oocysts of Hammondia hammondi, a protozoon closely related to T. gondii, resulted in a transient seroconversion in ducks and geese as measured by IFAT or TgSAG1-ELISA. Using the newly established TgSAG1-ELISA, sera from naturally exposed ducks and geese sampled in the course of a monitoring program for avian influenza were examined for antibodies to T. gondii; 145/2534 (5.7%) of the ducks and 94/373 (25.2%) of the geese had antibodies against TgSAG1. Seropositive animals were detected on 20 of 61 duck and in 11 of 13 goose farms; the seroprevalences within positive submissions of single farms ranged from 2.2% to 78.6%. Farms keeping ducks or geese exclusively indoors had a significantly lower risk (odds ratio 0.05, 95% confidence interval 0.01-0.3) of harboring serologically positive animals as compared with farms where the animals had access to an enclosure outside the barn., (Copyright © 2011 Elsevier B.V. All rights reserved.)

Background: Cryoballoon ablation has emerged as a novel treatment strategy for patients with atrial fibrillation (AF)., Objective: The purpose of this study was to compare pulmonary vein isolation (PVI) using cryoballoon ablation versus RF ablation with regard to myocardial injury, pulmonary vein (PV) reconnection patterns, and outcome., Methods: Fifty patients (age 59 ± 9 years, ejection fraction 0.59 ± 0.06, left atrial size 41 ± 5 mm) with paroxysmal AF were studied. Twenty-five patients underwent PVI using a 28-mm cryoballoon. A control group of 25 patients underwent PVI using an open-irrigation RF ablation catheter. Myocardial injury was determined by measuring troponin T (TnT). PV reconnection patterns were studied in case of repeat procedures., Results: Procedure duration was 166 ± 32 minutes in the cryoballoon group versus 197 ± 52 minutes in the RF group (P = .014), with similar ablation times (cryoballoon: 45 minutes [interquartile range 40-52.5 minutes]; RF: 47 minutes [interquartile range 44-65 minutes], P = .17). Postprocedural TnT in the RF group was 1.29 ± 0.41 μg/L versus 0.76 ± 0.55 μg/L in the cryoballoon group (P = .002). In 12 patients who underwent repeat ablation, 74% of PV reconnection sites were inferiorly located in the cryoballoon group compared to 17% in the RF group (P = .0004). With 1.2 ± 0.4 and 1.3 ± 0.6 procedures per patient, 88% of patients in the cryoballoon group and 92% in the RF group were in stable sinus rhythm after follow-up of 12 ± 3 months (P = NS)., Conclusion: Differences in the extent of myocardial injury and patterns of PV reconnection were observed between cryoballoon ablation and RF ablation of paroxysmal AF., (Copyright © 2010 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

The elimination of specified risk material from food is crucial to restricting the risk to public health arising from bovine spongiform encephalopathy. The distribution of lymphoreticular tissue as potential specified risk material of the bovine lingual tonsil is described in relation to topographical anatomical landmarks. The definition of a proper landmark is a prerequisite for establishing adequate legal regulations concerning the removal of the lingual tonsil after slaughter. The main parameter to identify the lymphoreticular tissue in this study was the immunohistochemical identification of the follicular dendritic cells in the lingual tonsil. Lymph nodules were detected in areas up to 30 mm rostral of a given macroscopic landmark, i.e., the most caudal of the papillae vallatae. This area must therefore be adequately removed from the bovine tongue in the slaughterhouse. The current method for the removal of the lingual tonsil tissue according to Regulation (EC) 999/2001 at the slaughterhouse and alternatives to this method are discussed.

Immunofluorescence detection of gammaH2AX foci is a widely used tool to quantify the induction and repair of DNA double-strand breaks (DSBs) induced by ionising radiation. We observed that X-irradiation of mammalian cells exposed on glass slides induced twofold higher foci numbers compared to irradiation with gamma-rays. Here, we show that the excess gammaH2AX foci after X-irradiation are produced from secondary radiation particles generated from the irradiation of glass slides. Both 120 kV X-rays and (137)Cs gamma-rays induce approximately 20 gammaH2AX foci per Gy in cells growing on thin ( approximately 2 microm) plastic foils immersed in water. The same yield is obtained following gamma-irradiation of cells growing on glass slides. However, 120 kV X-rays produce approximately 40 gammaH2AX foci per Gy in cells growing on glass, twofold greater than obtained using cells irradiated on plastic surfaces. The same increase in gammaH2AX foci number is obtained if the plastic foil on which the cells are grown is irradiated on a glass slide. Thus, the physical proximity to the glass material and not morphological differences of cells growing on different surfaces accounts for the excess gammaH2AX foci. The increase in foci number depends on the energy and is considerably smaller for 25 kV relative to 120 kV X-rays, a finding which can be explained by known physical properties of radiation. The kinetics for the loss of foci, which is taken to represent the rate of DSB repair, as well as the Artemis dependent repair fraction, was similar following X- or gamma-irradiation, demonstrating that DSBs induced by this range of treatments are repaired in an identical manner.

The objective of this study was to investigate the effects of aging prior to deboning and deep-freezing on the tenderness of cooked broiler breast fillets. Broilers (Ross-208) that were 37 and 38 d old were slaughtered in a licensed poultry meat plant. After spray chilling, carcasses with BW between 1,080 and 1,300 g were selected for the study and transported to a chilling room (2 to 4 degrees C). The whole carcasses were aged for up to 24 h. During the aging process, continuous measurements were made of pH values, electric conductivity, and firmness of the raw fillets. After the aging process, the carcasses were deboned, and the breast fillets were immediately frozen to an internal temperature of -20 degrees C. Tenderness was measured both mechanically with a Warner-Bratzler shear force device and by sensory testing. The ultimate pH values in the fillets were reached during the first 5 h of aging. Electric conductivity increased during the whole aging period. During the first hours of aging, firmness increased significantly, corresponding with the onset of rigor mortis. After between 8 and 9 h of aging, firmness decreased significantly. Shear force values of aged fillets also changed significantly; the highest values were found at the beginning of aging, which then decreased from the sixth hour. The results of the instrumental tenderness measurements were confirmed by the sensory evaluations. Implementation of in-plant measurements of firmness, thus, seemed to be useful in predicting the sensory quality of poultry meat.

In this study, the m. longissimus dorsi and the m. semimembranosus of pigs with normal and accelerated glycolysis (pale, soft and exudative, PSE) were used to evaluate the effect of ultrarapid chilling methods (with short-term freezing of the muscle surface) and ageing up to 72 h post-mortem on length of sarcomeres, Warner Bratzler shear force and firmness. The short-term freezing after ultrarapid chilling of musculature with normal glycolysis led to cold shortening with contraction of the sarcomeres by 33·5% (m. longissimus dorsi) and 38·3% (m. semimembranosus). At the same time, a massive increase in shear force and firmness was observed. After ageing up to 48h post-mortem the sarcomeres increased in length, whereby, in comparison with the measurements before the beginning of the chilling, 88 and 84% of the original length was attained, respectively. In addition, ageing led to a significant improvement of tenderness. After ageing for more than 72h the shear force and the firmness of meat specimens chilled under normal and ultrarapid conditions became more similar. The lenghts of the sarcomeres and the shear force of musculature with accelerated glycolysis were glycolysis were not affected by the chilling procedure., (Copyright © 1992. Published by Elsevier Ltd.)