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Background: Women respond more favorably to biventricular pacing (BIVP) than men. Sex differences in atrioventricular and interventricular conduction have been described in BIVP studies. Left bundle branch area pacing (LBBAP) offers advantages due to direct capture of the conduction system. We hypothesized that men could respond better to LBBAP than BIVP., Objectives: This study aims to describe the sex differences in response to LBBAP vs BIVP as the initial cardiac resynchronization therapy (CRT)., Methods: In this multicenter prospective registry, we included patients with left ventricular ejection fraction ≤35% and left bundle branch block or a left ventricular ejection fraction ≤40% with an expected right ventricular pacing exceeding 40% undergoing initial CRT with LBBAP or BIVP. The composite primary outcome was heart failure-related hospitalization and all-cause mortality. The primary safety outcome included all procedure-related complications., Results: There was no significant difference in the primary outcome when comparing men and women receiving LBBAP (P = 0.46), whereas the primary outcome was less frequent in women in the BIVP group than men treated with BIVP (P = 0.03). The primary outcome occurred less frequently in men undergoing LBBAP (29.9%) compared to those treated with BIVP (46.5%) (P = 0.004). In women, the incidence of the primary endpoint was 24.14% in the LBBAP group and 36.2% in the BIVP group; however, this difference was not statistically significant (P = 0.23). Complication rates remained consistent across all groups., Conclusions: Men and women undergoing LBBAP for CRT had similar clinical outcomes. Men undergoing LBBAP showed a lower risk of heart failure-related hospitalizations and all-cause mortality compared to men undergoing BIVP, whereas there was no difference between LBBAP and BIVP in women., Competing Interests: Funding Support and Author Disclosures Dr Diaz has received speaker honoraria and has been a proctor for Medtronic for conduction system pacing. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Rationale & Objective: The incidence of arrhythmia varies by time of day. How this affects individuals on maintenance dialysis is uncertain. Our objective was to quantify the relationship of arrhythmia with the time of day and timing of dialysis., Study Design: Secondary analysis of the Monitoring in Dialysis study, a multicenter prospective cohort study., Settings & Participants: Loop recorders were implanted for continuous cardiac monitoring in 66 participants on maintenance dialysis with a follow up of 6 months., Exposure: Time of day based on 6-hour intervals., Outcomes: Event rates of clinically significant arrhythmia., Analytical Approach: Negative binomial mixed effects regression models for repeated measures were used to evaluate data from the Monitoring in Dialysis study for differences in diurnal patterns of clinically significant arrhythmia among those with end-stage kidney disease with heart failure and end-stage kidney disease alone. We additionally analyzed rates according to presence of heart failure, time of dialysis shift, and dialysis versus nondialysis day., Results: Rates of clinically significant arrhythmia peaked between 12:00 AM and 5:59 AM and were more than 1.5-fold as frequent during this interval than the rest of the day. In contrast, variations in atrial fibrillation peaked between 6:00 AM and 11:59 AM, but variations across the day were qualitatively small. Clinically significant arrhythmia occurred at numerically higher rate in individuals with end-stage kidney disease and heart failure (5.9 events/mo; 95% CI, 1.3-26.8) than those without heart failure (4.0 events/mo; 95% CI, 0.9-17.9). Although differences in overall rate were not significant, their periodicity was significantly different ( P  < 0.001), with a peak between 12:00 AM and 6:00 AM with kidney failure alone and between 6:00 AM and 11:59 AM in those with heart failure. Although the overall clinically significant arrhythmia rate was similar in morning compared with evening dialysis shifts ( P  = 0.43), their periodicity differed with a peak between 12:00 AM and 5:59 AM in those with AM dialysis and a later peak between 6:00 AM and 11:59 AM in those with PM shifts., Limitations: Post hoc analysis, unable to account for unmeasured confounders., Conclusion: Clinically significant arrhythmias showed strong diurnal patterns with a maximal peak between 12:00 AM and 5:59 AM and noon. Although overall arrhythmia rates were similar, the peak rate occurred overnight in individuals without heart failure and during the morning in individuals with heart failure. Further exploration of the influence of circadian rhythm on arrhythmia in the setting of hemodialysis is needed., (© 2024 The Authors.)

Background: Left bundle branch pacing (LBBP) and left ventricular septal pacing (LVSP) are considered to be acceptable as LBBAP strategies. Differences in clinical outcomes between LBBP and LVSP are yet to be determined., Objectives: The purpose of this study was to compare the outcomes of LBBP vs LVSP vs BIVP for CRT., Methods: In this prospective multicenter observational study, LBBP was compared with LVSP and BIVP in patients undergoing CRT. The primary composite outcome was freedom from heart failure (HF)-related hospitalization and all-cause mortality. Secondary outcomes included individual components of the primary outcome, postprocedural NYHA functional class, and electrocardiographic and echocardiographic parameters., Results: A total of 415 patients were included (LBBP: n = 141; LVSP: n = 31; BIVP: n = 243), with a median follow-up of 399 days (Q1-Q3: 249.5-554.8 days). Freedom from the primary composite outcomes was 76.6% in the LBBP group and 48.4% in the LVSP group (HR: 1.37; 95% CI: 1.143-1.649; P = 0.001), driven by a 31.4% absolute increase in freedom from HF-related hospitalizations (83% vs 51.6%; HR: 3.55; 95% CI: 1.856-6.791; P < 0.001) without differences in all-cause mortality. LBBP was also associated with a higher freedom from the primary composite outcome compared with BIVP (HR: 1.43; 95% CI: 1.175-1.730; P < 0.001), with no difference between LVSP and BIVP., Conclusions: In patients undergoing CRT, LBBP was associated with improved outcomes compared with LVSP and BIVP, while outcomes between BIVP and LVSP are similar., Competing Interests: Funding Support and Author Disclosures Dr Diaz has received speaker honoraria from and is a proctor for Medtronic for LBBAP. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Left bundle branch area pacing (LBBAP) for cardiac resynchronization therapy (CRT) is an alternative to biventricular pacing (BiVp)., Objectives: The purpose of this study was to compare the outcomes between LBBAP and BiVp as an initial implant strategy for CRT., Methods: In this prospective multicenter, observational, nonrandomized study, first-time CRT implant recipients with LBBAP or BiVp were included. The primary efficacy outcome was a composite of heart failure (HF)-related hospitalization and all-cause mortality. The primary safety outcomes were acute and long-term complications. Secondary outcomes included postprocedural New York Heart Association functional class and electrocardiographic and echocardiographic parameters., Results: A total of 371 patients (median follow-up of 340 days [IQR: 206-477 days]) were included. The primary efficacy outcome occurred in 24.2% in the LBBAP vs 42.4% in the BiVp (HR: 0.621 [95% CI: 0.415-0.93]; P = 0.021) group, driven by a reduction in HF-related hospitalizations (22.6% vs 39.5%; HR: 0.607 [95% CI: 0.397-0.927]; P = 0.021) without significant difference in all-cause mortality (5.5% vs 11.9%; P = 0.19) or differences in long-term complications (LBBAP: 9.4% vs BiVp: 15.2%; P = 0.146). LBBAP resulted in shorter procedural (95 minutes [IQR: 65-120 minutes] vs 129 minutes [IQR: 103-162 minutes]; P < 0.001) and fluoroscopy times (12 minutes [IQR: 7.4-21.1 minutes] vs 21.7 minutes [IQR: 14.3-30 minutes]; P < 0.001), shorter QRS duration (123.7 ± 18 milliseconds vs 149.3 ± 29.1 milliseconds; P < 0.001), and higher postprocedural left ventricular ejection fraction (34.1% ± 12.5% vs 31.4% ± 10.8%; P = 0.041)., Conclusions: LBBAP as an initial CRT strategy resulted in a lower risk of HF-related hospitalizations compared to BiVp. A reduction in procedural and fluoroscopy times, shorter paced QRS duration, and improvements in left ventricular ejection fraction compared with BiVp were observed., Competing Interests: Funding Support and Author Disclosures Dr Diaz has received speaker honoraria and is a proctor for Medtronic for conduction system pacing. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Epicardial access (EA) has emerged as an increasingly important approach for the treatment of ventricular arrhythmias and to perform other interventional cardiology procedures. EA is frequently underutilized because the current approach is challenging and carries a high risk of life-threatening complications., Objective: The purpose of this study was to determine the efficacy and safety of the SAFER (Sustained Apnea for Epicardial Access With Right Ventriculography) epicardial approach., Methods: Consecutive patients who underwent EA with the SAFER technique were included in this multicenter study. The primary efficacy outcome was the successful achievement of EA. The primary safety outcomes included right ventricular (RV) perforation, major hemorrhagic pericardial effusion (HPE), and bleeding requiring surgical intervention. Secondary outcomes included procedural characteristics and any complications. Our results were compared with those from previous studies describing other EA techniques to assess differences in outcomes., Results: A total of 105 patients undergoing EA with the SAFER approach from June 2021 to February 2023 were included. EA was used for ventricular tachycardia ablation in 98 patients (93.4%), left atrial appendage closure in 6 patients (5.7%), and phrenic nerve displacement in 1 patient (0.9%). EA was successful in all subjects (100%). The median time to EA was 7 minutes (IQR: 5-14 minutes). No cases of RV perforation, HPE, or need of surgical intervention were observed in this cohort. Comparing our results with previous studies about EA, the SAFER epicardial approach resulted in a significant reduction in major pericardial bleeding., Conclusions: The SAFER epicardial approach is a simple, efficient, effective, and low-cost technique easily reproducible across multiple centers. It is associated with lower complication rates than previously reported techniques for EA., Competing Interests: Funding Support and Author Disclosures All authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to evaluate the incidence and significance of atrioventricular (AV) block associated with ventricular arrhythmia (VA) ablation., Background: Attempted ablation of VAs that arise from the septum carries a risk of AV block., Methods: Data from 1,418 patients who had catheter ablation for drug-refractory VAs were evaluated. Two analyses were conducted. The first analysis assessed the patient and procedure characteristics associated with ablation-induced AV block. The second analysis investigated outcome differences between patients with and without AV block. For the second analysis, patients with AV block (Group I) were compared with a 1:2 propensity score-matched control group (Group II) and with patients with pre-existing AV block before ablation (Group III)., Results: Twenty-one (1.6%) patients developed AV block. In multivariable analysis, nonischemic cardiomyopathy (odds ratio: 3.33; 95% confidence interval: 1.32 to 8.40; p = 0.011) and transcoronary ethanol ablation (odds ratio: 46.50; 95% confidence interval: 14.10 to 153.00; p < 0.001) were independently associated with AV block. Subsequent to the AV block, 9 patients were upgraded from an implantable cardioverter-defibrillator to cardiac resynchronization therapy with defibrillator (CRT-D), 2 had de novo CRT-D implantation, 5 had pre-existing CRT-D, and 5 had pacing without CRT. VAs recurred in 33% of patients in Group I, 17% in Group II (log-rank p = 0.842), and 35% in Group III (p = 0.636). The composite outcome of heart failure hospitalization, heart transplantation, or death occurred in 29% of patients in Group I, 17% in Group II (p = 0.723), and 45% in Group III (p = 0.303)., Conclusions: Complete AV block occurs in fewer than 2% of patients undergoing VA ablation and does not appear to be associated with the worse outcome of heart failure hospitalization, heart transplantation, or death., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to examine the relationship between the number of oral antiarrhythmic drug (AAD) failures before referral for ventricular tachycardia (VT) ablation and subsequent clinical outcomes., Background: Failure of AADs prompts referral for VT ablation., Methods: Consecutive patients (n = 669) with sustained VT who were referred for a first-time ablation were divided into 2 groups according to the number of oral Class 1 or 3 AAD failures before referral: single-drug failure (≤1 AAD; n = 256) or multidrug failure (>1 AADs; n = 413). Outcomes were stratified according to underlying disease type (no structural heart disease [SHD] [n = 87]; ischemic cardiomyopathy [ICM] [n = 368]; and ischemic cardiomyopathy [NICM] [n = 214]) and reported at a mean follow-up of 35 ± 46 months., Results: Patients with multidrug failure, compared with patients with single-drug failure, had more advanced SHD and required more extensive ablation to control arrhythmia. Multidrug failure, compared with single-drug failure, was associated with lower ventricular arrhythmia-free survival in ICM (46 ± 4% vs. 58 ± 6%; p = 0.03) and NICM (26 ± 5% vs. 49 ± 6%; p = 0.008), but not in the absence of SHD (71 ± 8% vs. 85 ± 7%; p = 0.10). Overall survival was lower in multidrug failure versus single-drug failure groups in patients with ICM (71 ± 3% vs. 84 ± 4%; p = 0.03) and NICM (70 ± 5% vs. 88 ± 4%; p < 0.001). Multidrug failure was independently associated with a higher risk of ventricular arrhythmia recurrence (hazard ratio: 1.6; p = 0.01) and mortality in NICM (hazard ratio: 2.6; p = 0.008), but not in ICM., Conclusions: Patients with SHD and failure of multiple oral AADs before VT ablation referral have more advanced heart disease and worse clinical outcomes following ablation, especially in NICM., (Crown Copyright © 2018. Published by Elsevier Inc. All rights reserved.)

Objectives: The authors sought to investigate the effect of low irrigation flow rate on lesion characteristics and ablation outcomes in a clinicopathological study., Background: Irrigated ablation produces deeper lesions compared with nonirrigated ablation, which may not be desirable in the thin-walled posterior left atrium (LA), where collateral esophageal injury is possible., Methods: Lesions were placed on the smooth posterior right atrium in 20 swine and posterior LA in 60 patients at a maximum power of 20 to 25 W with either: 1) power-controlled ablation at an irrigation flow rate of 17 ml/min (high-flow group 10 swine; n = 40) or 2) temperature-controlled ablation at an irrigation flow rate of 2 ml/min (low-flow group 10 swine; n = 20). Safety and efficacy was also compared in 326 patients undergoing AF ablation using high-flow (n = 160) or low-flow settings (n = 166) for posterior LA ablation., Results: Low-flow, compared with high-flow, lesions in swine had a higher incidence of lesions with: impedance fall ≥10 Ω, loss of pace capture, electrograms characteristic of transmural lesions, and visible lesions on anatomic inspection (p < 0.05 for all). Low-flow lesions had a maximal diameter at the endocardial surface, whereas high-flow lesions had a maximal diameter at the epicardial surface. In humans, impedance, pace capture, and transmurality data also strongly favored low-flow lesions. There was no difference in acute pulmonary vein isolation, complications, or 12-month arrhythmia-free survival between the groups., Conclusions: Low-flow irrigated ablation provides favorable lesion characteristics for posterior LA ablation without increasing the risk of adverse events., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to assess the incidence, operator demographics, clinical characteristics, procedural factors, and prognosis of esophageal perforation and fistula after atrial fibrillation ablation., Background: Esophageal injury is a feared complication of atrial fibrillation ablation., Methods: An Internet-based global survey soliciting anonymous information regarding esophageal perforation and fistula was emailed to 3,080 physicians. Detailed information regarding physician, patient, and procedural characteristics related to esophageal perforation with or without fistula was collected., Results: The survey was completed by 405 of 3,080 physicians (13%). Responding physicians performed 191,215 atrial fibrillation ablations and esophageal perforation with or without fistula occurred in 31 patients (0.016%) with multiple ablation catheter types despite monitoring of esophageal position or temperature during ablation in 90% of patients. Among patients who present with esophageal perforation, death, or severe neurologic injury occurred more frequently in patients with greater body mass index (30.9 ± 6.8 kg/m 2 vs. 25.8 ± 3.3 kg/m 2 ; p = 0.03), and lower left ventricular ejection fraction (55.1 ± 9.1% vs. 61.7 ± 5.4%; p = 0.04). Among analyzed patients, atrial-esophageal fistula was seen in 72%, pericardial-esophageal fistula in 14%, and esophageal perforation without fistula in 14%. Mortality was 79% with atrial-esophageal fistula and 13% in esophageal perforation without atrial-esophageal fistula., Conclusions: Esophageal perforation is rare but continues to occur with multiple catheter types despite esophageal monitoring during ablation. The prognosis of esophageal perforation is substantially improved if diagnosed and treated before development of atrial-esophageal fistula. An early surgical approach to esophageal perforation should be strongly considered regardless of evidence of fistula., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)