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Background: Studies have identified significant sex‐based differences and disparities in the clinical presentation and treatment of atrial fibrillation (AF). Studies have shown women are less likely to be referred for catheter ablation, are older at the time of ablation, and are more likely to have recurrence after ablation. However, in most studies investigating AF ablation outcomes, the female cohorts were relatively small. The impact of sex on the outcome and safety of ablation procedures is still unclear. Objective: To investigate sex‐based differences in outcomes and complications after AF catheter ablation, with a significant female cohort Method: In this retrospective study, patients undergoing AF ablation from January 1, 2014, to March 31, 2021, were included. We investigated clinical characteristics, duration and progression of AF, number of EP appointments from diagnosis to ablation, procedural data, and procedure complications. Results: Total of 1346 patients underwent first catheter ablation for AF during this period, including 896 (66.5%) male and 450 (33.4%) female patients. Female patients were older at the time of ablation (66.2 vs. 62.4 years; p <.001). Women had higher CHA2DS2‐VASc (congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, sex category) scores (3 vs. 2; p <.001) than men, expectedly, as the female sex warrants an additional point. 25.3% female patients had PersAF at the time of diagnosis versus 35.3% male patients (p <.001). At the time of ablation, 31.8% female patients had PersAF as compared to 43.1% male patients (p <.001), indicating progression of PAF to PersAF in both sexes. Women tried more AADs than men before ablation (1.13 vs. 0.98; p =.002). Male and female patients had no statistically significant difference in (a) arrhythmia recurrence at 1‐year post ablation (27.7% vs. 30%; p =.38) or (b) procedural complication rate (1.8% vs. 3.1%; p =.56). Conclusion: Female patients were older and had higher CHA2DS2‐VASc scores compared to males at the time of AF ablation. Women tried more AADs than men before ablation. One‐year arrhythmia recurrence rates and procedural complications were similar in both sexes. No sex‐based differences were observed in safety and efficacy of ablation. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for atrial fibrillation (AF) is a common therapeutic strategy for patients with either paroxysmal AF (PAF) or persistent AF (persAF), but long‐term ablation success rates are imperfect. Maintenance of sinus rhythm immediately before ablation with antiarrhythmic drug (AAD) therapy has been associated with improved outcomes in patients undergoing ablation. Amiodarone has superior efficacy relative to other AADs. Whether failure of amiodarone to maintain sinus rhythm before ablation for either PAF or persAF is associated with poor outcomes is unknown. Methods: A total of 307 patients who received amiodarone in a 1‐year window before undergoing catheter ablation for AF were included. Patients were divided into amiodarone success (n = 183) and amiodarone failure (n = 124) groups based on the response to pre‐ablation amiodarone treatment. Analysis of procedural outcomes as a function of response to amiodarone therapy was performed. Patients were followed for at least 12 months postablation, to assess outcomes (adverse events and arrhythmia recurrence). Procedural success was defined by the absence of documented arrhythmia (>30 s) without any antiarrhythmic agents beyond a 90‐day blanking period. Results: Following ablation for either PAF or persAF, freedom from any recurrent atrial arrhythmia at 1 year was 57.7% for the entire cohort. One‐year freedom from recurrent arrhythmia in the amiodarone success group was comparable to that in the amiodarone failure group (55.7% vs. 60.5%; p =.54). Success rates following ablation did not vary by the response to amiodarone when analyzed for PAF or persAF subgroups. Conclusion: Failure to restore and maintain sinus rhythm with amiodarone before ablation for either PAF or persAF is not a predictor of ablation procedural failure. Amiodarone failure alone should not deter practitioners from considering ablation therapy for patients with AF. [ABSTRACT FROM AUTHOR]

Introduction: Use of a novel magnetic sensor enabled optical contact force ablation catheter has been established to be safe and effective for treatment of symptomatic drug‐refractory paroxysmal atrial fibrillation (AF) but has yet to be demonstrated in the persistent AF (PersAF) population. Methods: PERSIST‐END was a multicenter, prospective, nonrandomized, investigational study designed to demonstrate the safety and effectiveness of TactiCath™ Ablation Catheter, Sensor Enabled™(SE) (TactiCath SE) for use in the treatment of subjects with documented PersAF refractory or intolerant to at least one Class I/III AAD. The ablation strategy included pulmonary vein isolation and additional targets at physician discretion. Follow‐up through 15‐months, including a 3‐month blanking period and 3‐month therapy consolidation period, was performed with cardiac event and Holter monitoring. Primary safety, primary effectiveness, clinical success, and quality of life (QOL) endpoints were analyzed. Results: Of 224 subjects enrolled at 21 investigational sites in the United States and Australia, 223 underwent ablation with the investigational catheter. The primary safety event rate was 3.1% (seven events in seven subjects). The Kaplan–Meier estimate of freedom from AF/atrial flutter/atrial tachycardia recurrence at 15‐months was 61.6% and clinical success at 15 months was 89.8%. Subject QOL significantly improved following ablation as assessed via AFEQT (31.6 point increase, p <.0001) and EQ‐5D‐5L (10.7 point increase, p <.0001) and was met with a 53% reduction in all cause cardiovascular healthcare utilization. Conclusion: The sensor‐enabled force‐sensing catheter is safe and effective for the treatment of drug refractory recurrent symptomatic PersAF, reducing arrhythmia recurrence while improving QOL and healthcare utilization. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF) is a common comorbid condition in heart failure with preserved ejection fraction (HFpEF). The effect of AF on heart failure (HF) exacerbation in HFpEF has not been well described. This study investigated how AF modifies the clinical trajectory of HFpEF patients after hospitalization for decompensated HF. Methods and results: We stratified HFpEF subjects by AF diagnosis and performed longitudinal analysis to compare risk for HF hospitalization after index hospitalization for decompensated HF. All‐cause mortality, 30 day all‐cause readmissions, and response to inpatient diuresis were also evaluated. Of 90 subjects enrolled, 35.6% (n = 32) had AF. Subjects with AF were older (72.5 vs. 60.5 years; P < 0.01), more often male (46.9% vs. 24.1%; P = 0.03), and had greater left atrial diameter (4.9 vs. 3.8 cm; P < 0.01) compared with those without AF. Subjects with AF had a higher risk for HF hospitalization than their counterparts without AF (P = 0.02); this relationship remained significant following multivariable competing risk regression with propensity score weighting (hazard ratio 2.53, P = 0.04 and hazard ratio 2.91, P = 0.04, with overlap and inverse probability weighting, respectively). Although having AF appeared to increase the risk of all‐cause hospital readmission within 30 days of discharge (37.5% vs. 17.5%; P = 0.036), this relationship failed to remain significant following propensity score adjustment for clinical covariates. Conclusions: Atrial fibrillation is an independent risk factor for HF rehospitalization in HFpEF. Further understanding of the interplay between AF and HFpEF will be critical to guide the selection of appropriate rhythm management strategies in this population. [ABSTRACT FROM AUTHOR]

Aims: Heart failure is an increasingly recognized later stage manifestation of arrhythmogenic right ventricular cardiomyopathy (ARVC) that can require heart transplantation (HT) to appropriately treat. We aimed to study contemporary ARVC HT outcomes in a national registry. Methods and results: The United Network for Organ Sharing registry was queried for HT recipients from 1/1994 through 2/2020. ARVC patients were compared with non‐ARVC dilated, restrictive, and hypertrophic cardiomyopathy HT patients (HT for ischaemic and valvular disease was excluded from analysis). Post‐HT survival was assessed using Kaplan–Meier estimates. A total of 189 of 252 (75%) waitlisted ARVC patients (median age 48 years, 65% male) underwent HT, representing 0.3% of the total 65 559 HT during the study time period. Annual frequency of HT for ARVC increased significantly over time. ARVC patients had less diabetes (5% vs. 17%, P < 0.001), less cigarette use (15% vs. 23%, P < 0.001), lower pulmonary artery and pulmonary capillary wedge pressures, and lower cardiac output than the 33 659 non‐ARVC patients (P < 0.001). Ventricular assist device use was significantly lower in ARVC patients (8% vs. 32%, P < 0.001); 1 and 5 year post‐HT survival was 97% and 93% for ARVC vs. 95% and 82% for non‐ARVC HT recipients (P < 0.001). On adjusted multivariable Cox regression, ARVC had decreased risk of post‐HT death compared with non‐ARVC aetiologies (hazard ratio 0.48, 95% confidence interval 0.28–0.82, P = 0.008). Patients with ARVC also had lower risk of death or graft failure than non‐ARVC patients (hazard ratio 0.51, 95% confidence interval 0.32–0.81, P = 0.004). Conclusions: In the largest series of HT in ARVC, we found that HT is increasingly performed in ARVC, with higher survival compared with other cardiomyopathy aetiologies. The right ventricular predominant pathophysiology may require unique considerations for heart failure management, including HT. [ABSTRACT FROM AUTHOR]

Aims: End‐stage heart failure necessitating evaluation for heart transplantation is increasingly recognized in arrhythmogenic right ventricular cardiomyopathy (ARVC). These patients present unique challenges in pre‐transplant and peri‐transplant management given their predominantly right ventricular (RV) failure and propensity for ventricular arrhythmias. We sought to utilize a tertiary ARVC referral and heart transplant centre experience to describe management of a series of patients with ARVC undergoing heart transplantation at our centre. Methods and results: We queried the Johns Hopkins ARVC Registry for all patients who underwent heart transplantation and further studied the subset undergoing transplantation at the Johns Hopkins Hospital. Patient demographics, clinical characteristics, and pre‐transplant clinical course were obtained from the registry and electronic medical records. Of the 532 patients in the ARVC Registry, 63 (12%) underwent heart transplantation. Nine (six male) of these patients both had known ARVC prior to transplant and were transplanted at Johns Hopkins Hospital between 2006 and 2020 at a mean age of 42 ± 14 years old. Pathogenic ARVC genetic variants were identified in six (67%) patients, all of whom had variants in the plakophilin‐2 (PKP2) gene. RV failure was universal with median right atrial to pulmonary capillary wedge pressure (RA/PCWP) ratio of 1.4 [interquartile range (IQR) 1.2–1.5] and median right ventricular stroke work index (RVSWI) of 0 g·m/m2/beat (IQR 0–0.3). Six had a history of catheter ablation for ventricular arrhythmia with five of the six having at least three ablations. Transplant evaluation was initiated an average of 344 ± 407 days after first developing heart failure symptoms. The most common bridge to transplant support included inotropes (n = 3) and extracorporeal membrane oxygenation (ECMO) (n = 2). Contraindication to inotropes or mechanical support was common due to ventricular arrhythmia and RV predominant cardiomyopathy. Conclusions: Heart transplantation is a curative treatment for ARVC, but due to frequent ventricular arrhythmias and RV predominant pathology, patients require unique considerations in regard to timing of evaluation, haemodynamic support options, and wait listing qualification. [ABSTRACT FROM AUTHOR]

Genetic testing and genetic counseling (GC) are increasingly recommended in the cardiovascular setting, with multiple guidelines recommending GC for patients with or at risk for inherited cardiovascular conditions. There are scant data, however, describing patient outcomes to guide evidence‐based care. No studies have quantified the influence of the strength of the genetic counselor:patient relationship on outcomes. Individuals referred for first time GC at the Johns Hopkins Arrhythmogenic Cardiomyopathy (ACM) center were surveyed prior to their visit and immediately after, before any genetic test results ordered at the session had been returned. Outcomes and measures were selected based on the Reciprocal Engagement Model of GC and include empowerment assessed by the Genetic Counseling Outcome Scale (GCOS), anxiety assessed by the Cardiac Anxiety Questionnaire (CAQ), and genetic counselor:patient therapeutic alliance assessed by the Working Alliance Inventory (WAI‐SR). Response rate was 59% (120/203). 54 (45%) of patients had genetic testing ordered prior to their GC visit. There was a significant increase in GCOS score (mean 15.7 points) within 4 weeks post‐GC session (p<.0001) with no significant difference in GCOS change between patients who had genetic testing ordered previously and those attending pre‐test counseling (17.4 ± 18.2 versus. 14.1 ± 16 [p=.35]). Average CAQ score was high at baseline (1.67 ± 0.68), and there was a significant inverse relationship between pre‐GC CAQ score and extent of increase in GCOS score (p=.008) post‐GC. Controlling for baseline anxiety, there was a strong positive relationship between the WAI‐SR score and GCOS change (B = 0.80, 95% CI: 0.43, 1.17, p<.001). These results demonstrate a significant increase in empowerment after GC in ACM patients and that this outcome is not reliant on the ordering of a genetic test but instead sensitive to the quality of the genetic counselor:patient relationship. Genetic counselors can strive to further improve empowerment by focusing on reducing pre‐visit anxiety and alliance building with the patient. [ABSTRACT FROM AUTHOR]

Background: Transesophageal echocardiography (TEE) is variably performed before atrial fibrillation (AF) ablation to evaluate left atrial appendage (LAA) thrombus. We describe our experience with transitioning to the pre‐ablation cardiac computed tomography (CT) approach for the assessment of LAA thrombus during the COVID‐19 pandemic. Methods: We studied consecutive patients undergoing AF ablation at our center. The study cohort was divided into pre‐ versus post‐COVID groups. The pre‐COVID cohort included ablations performed during the 1 year before the COVID‐19 pandemic; pre‐ablation TEE was used routinely to evaluate LAA thrombus in high‐risk patients. Post‐COVID cohort included ablations performed during the 1 year after the COVID‐19 pandemic; pre‐ablation CT was performed in all patients, with TEE performed only in patients with LAA thrombus by CT imaging. The demographics, clinical history, imaging, and ablation characteristics, and peri‐procedural cerebrovascular events (CVEs) were recorded. Results: A total of 637 patients (pre‐COVID n = 424, post‐COVID n = 213) were studied. The mean age was 65.6 ± 10.1 years in the total cohort, and the majority were men. There was a significant increase in pre‐ablation CT imaging from pre‐ to post‐COVID cohort (74.8% vs. 93.9%, p ≤.01), with a significant reduction in TEEs (34.6% vs. 3.7%, p ≤.01). One patient in the post‐COVID cohort developed CVE following negative pre‐ablation CT. However, the incidence of peri‐procedural CVE between both cohorts remained statistically unchanged (0% vs. 0.4%, p =.33). Conclusion: Implementation of pre‐ablation CT‐only imaging strategy with selective use of TEE for LAA thrombus evaluation is not associated with increased CVE risk during the COVID‐19 pandemic. [ABSTRACT FROM AUTHOR]

Background: Data related to electrophysiologic characteristics of atypical atrial flutter (AFL) following atrial fibrillation (AF) ablation and its prognostic value on repeat ablation success are limited. Methods: We studied consecutive patients who underwent a repeat left atrial (LA) ablation procedure for either recurrent AF or atypical AFL, at least 3 months after index AF ablation, between January 2012 and July 2019. The demographics, clinical history, procedural data, complications, and 1‐year arrhythmia‐free survival rates were recorded for each subject after the first repeat ablation. Results: A total of 336 patients were included in our study. Among these 336 patients, 102 underwent a repeat ablation procedure for atypical AFL and 234 underwent a repeat ablation procedure for recurrent AF. The mean age was 63.7 ± 10.7 years, and 72.6% of patients were men. The atypical AFL cohort had significantly higher LA diameters (4.6 vs. 4.4 cm, p =.04) and LA volume indices (LAVi; 85.1 vs. 75.4 ml/m2, p =.03) compared to AF patients at repeat ablation. Atypical AFL patients were more likely to have had index radiofrequency (RF) ablation (as opposed to cryoballoon) than recurrent AF patients (98% vs. 81%, p =.01). Atypical AFLs were roof‐dependent in 35.6% and peri‐mitral in 23.8% of cases. Major complications at repeat ablation occurred in 0.9% of the total cohort. Arrhythmia‐free survival at one year was significantly higher in the recurrent atypical AFL compared to the recurrent AF cohort (75.5 vs. 65.0%, p =.04). Conclusion: In our series, roof‐dependent flutter is the most common form of atypical atrial flutter post AF ablation. Patients developing atypical AFL after index AF ablation have greater LA dimensions than patients with recurrent AF. The success rate of first repeat ablation is significantly higher among patients with recurrent atypical AFL as compared to recurrent AF after index AF ablation. [ABSTRACT FROM AUTHOR]

Background: Premature ventricular contractions (PVCs) may be found in any stage of arrhythmogenic right ventricular cardiomyopathy (ARVC) and have been associated with the risk of sustained ventricular tachycardia (VT). Objective: To investigate the role of PVC ablation in ARVC patients. Methods: We studied consecutive ARVC patients who underwent PVC ablation due to symptomatic high PVC burden. Mean daily PVC burden and antiarrhythmic drug (AAD) use were assessed before and after the procedure. Complete long‐term success was defined as more than 80% reduction in PVC burden off of membrane‐active AADs. Results: Eight patients (37 ± 15 years; 4 males) underwent PVC ablation. The mean daily PVC burden before ablation ranged from 5.4% to 24.8%. A total of 7 (87.5%) patients underwent epicardial ablation. Complete acute elimination of PVCs was achieved in 4 (50%) patients (no complications). The mean daily PVC burden variation ranged from an 87% reduction to a 26% increase after the procedure. Over a median follow‐up of 345 days (range: 182–3004 days), only one (12.5%) patient presented complete long‐term success, and 6 (75%) patients either maintained or increased the need for Class I or Class III AADs. A total of 2 (25%) patients experienced sustained VT for the first time following the ablation procedure, requiring repeat ablation. No death or heart transplantation occurred. Conclusion: PVC ablation was not associated with a consistent reduction of the PVC burden in ARVC patients with symptomatic, frequent PVCs. PVC ablation may be reserved for highly symptomatic patients who failed AADs. Additional investigation is required to improve the efficacy of PVC ablation in ARVC patients. [ABSTRACT FROM AUTHOR]

Introduction: Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes. Methods: The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first‐time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis‐guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3–12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90‐day postablation blanking period. Patients were followed for a period of 12–18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint. Results and Conclusion: The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden. [ABSTRACT FROM AUTHOR]

Introduction: Atrial fibrillation (AF) ablation is successful in 60%–80% of optimal candidates, with many patients requiring repeat procedures. We performed a detailed examination of electrophysiologic findings and clinical outcomes associated with first repeat AF ablations in the era of contact force‐sensing radiofrequency (RF) catheters. Methods: We retrospectively studied patients who underwent their first repeat AF ablations for symptomatic, recurrent AF at our center between 2013 and 2019. All repeat ablations were performed using contact force‐sensing RF catheters. Pulmonary vein (PV) reconnections at repeat ablation and freedom from atrial arrhythmia 1 year after repeat ablation were evaluated. We further assessed these findings based on AF classification at the time of presentation for repeat ablation, index RF versus cryoballoon (CB) ablation, and duration (≥3 versus <3 years) between index and repeat procedures. Results: Among 300 patients, there were 136 (45.3%) who presented for their first repeat ablations in persistent AF. During repeat ablation, at least one PV reconnection was found in 257 (85.6%) patients, while 159 (53%) had three to four reconnections. There was a similar distribution of reconnections among patients with persistent versus paroxysmal AF (mean: 2.7 ± 1.3 vs. 2.9 ± 1.2; p =.341), index RF versus CB ablation (mean: 2.8 ± 1.3 vs. 2.9 ± 1.2; p =.553), and ≥3 versus <3 years between index and repeat procedures (mean: 3.0 ± 1.1 vs. 2.7 ± 1.3; p =.119). At repeat ablation, the PVs were re‐isolated in all patients, and additional non‐PV ablation was performed in 171 (57%) patients. Freedom from atrial arrhythmia at 1‐year follow‐up after repeat ablation was 66%, similar among those with persistent versus paroxysmal AF (65.4% vs. 66.5%; p =.720), index RF versus CB ablation (66.7% vs. 68.9%; p =.930), and ≥3 versus <3 years between index and repeat ablations (64.4% vs. 66.7%; p =.760). Major complications occurred in a total of 4 (1.3%) patients. Conclusion: In a contemporary cohort of patients receiving their first repeat AF ablations using contact force‐sensing RF catheters, PV reconnections were common, and freedom from atrial arrhythmia was 66% at 1‐year follow‐up. The distributions of PV reconnections and rates of freedom from atrial arrhythmia were similar, based on persistent versus paroxysmal AF at presentation for repeat ablation, index RF versus CB ablation, and duration between index and repeat procedures. The incidence of major complications was very low. [ABSTRACT FROM AUTHOR]

Background: The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood. Objectives: To examine short‐ and long‐term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR). Methods: Fifty‐one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature‐tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE). Results: There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long‐term follow‐up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p =.009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p =.001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p =.015. Patients without AF recurrence had no changes in LA functional parameters during follow‐up. The amount of LA LGE at long‐term follow‐up was higher compared to the baseline, however, was significantly less compared to immediately post‐procedure (37 ± 1.9% vs. 47 ± 2.8%; p =.015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = −.59; p <.001). Conclusions: LA function is impaired acutely following AF catheter ablation. However, long‐term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE. [ABSTRACT FROM AUTHOR]

Introduction: Advanced interatrial block (IAB) on a 12‐lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function. Methods/Results: We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P‐wave duration ≥120 ms, and was considered partial if P‐wave was positive and advanced if P‐wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P‐wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m2, P =.010), more LA fibrosis (21.9% vs 13.1%, P =.020), and lower LA maximum strain rate (0.99 vs 1.18, P =.007) than those without. Advanced IAB was independently associated with LA (minimum [P =.032] and fibrosis [P =.009]). P‐wave duration was also independently associated with LA fibrosis (β =.33; P =.049) and LA mechanical dyssynchrony (β = 2.01; P =.007). Conclusion: Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P‐wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony. [ABSTRACT FROM AUTHOR]

Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton‐pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted. Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The VICTORY AF Study was designed to evaluate the risk of the procedure and/or device‐related strokes in patients with PersAF on warfarin undergoing ablation with a phased radiofrequency (RF) system. Methods: The VICTORY AF trial was a prospective, multicenter, single‐arm, investigational study. PersAF patients on vitamin K antagonism without major structural heart disease or history of stroke/transient ischemic attack undergoing phased RF ablation for atrial fibrillation (AF) were included. The primary outcome was the incidence of the procedure and/or device‐related stroke within 30 days of the ablation by a board‐certified neurologist's assessment. The secondary outcomes were an acute procedural success, 6 months effectiveness (defined as the reduction in AF/atrial flutter episodes lasting ≥10 minutes by 48‐hour Holter 6 months postablation) and the number of patients with pulmonary vein (PV) stenosis. Results: A total of 129 (108 PersAF, 21 long‐standing PersAF) patients were treated (mean age: 60.6 ± 7.7; 79.8% male, 54.3% CHA2Ds2‐VASc score ≥ 2). Two nondisabling strokes were reported (1.6%); one before discharge and the second diagnosed at the 30‐day visit. Due to slow enrollment, the study was terminated before reaching the 95% one‐sided upper confidence boundary for stroke incidence. Acute procedural success was 93.8%, and at 6 months, 72.8% of patients demonstrated ≥90% reduction in AF burden, 78.9% were off all antiarrhythmic drugs. There were no patients with PV stenosis of greater than 70%. Conclusions: VICTORY AF demonstrated a 1.6% incidence of stroke in PersAF undergoing ablation with a phased RF system which did not meet statistical confidence due to poor enrollment. The secondary outcomes suggest comparable efficacy to phased RF in the tailored treatment of permanent AF trial. Rigorous clinical evaluation of the stroke risk of new AF ablation technologies as well as restriction to Vitamin K antagonist anticoagulation appears to be unachievable goals in a clinical multicenter IDE trial of AF ablation in the current era. [ABSTRACT FROM AUTHOR]

Background: Pacemaker battery depletion triggers alert for replacement notification and results in automatic reprogramming, which has been shown to be associated with relevant cardiorespiratory symptoms and adverse clinical events. Objective: Determine if electrocardiogram (ECG) pacing features may be predictive of pacemaker battery depletion and clinical risk. Methods: This is an ECG substudy of a cohort analysis of 298 subjects referred for pacemaker generator replacement from 2006 to 2017. Electronic medical record review was performed; clinical, ECG, and pacemaker characteristics were abstracted. We applied two ECG prediction rules for pacemaker battery depletion that are relevant to all major pacemaker manufacturers except Boston Scientific and MicroPort: (1) atrial pacing not at a multiple of 10 and (2) nonsynchronous ventricular pacing not at a multiple of 10, to determine diagnostic sensitivity, specificity, and risk in applicable ECG subjects. Results: We excluded 32 subjects not at replacement notification or duplicate surgeries. Overall, 176 of 266 subjects (66.2%) demonstrated atrial pacing or nonsynchronous ventricular pacing on preoperative ECG. When utilizing both rules, 139 of 176 preoperative ECGs and 12 of 163 postoperative ECGs met criteria for battery depletion yielding reasonable sensitivity (79.0%), high specificity (92.6%), and a positive likelihood ratio of 11.6:1. These rules were associated with significant increase in cardiorespiratory symptoms (P <.001) and adverse clinical events (P <.025). Conclusions: The "Rules of Ten" provided reasonable sensitivity and specificity for detecting replacement notification in pacemaker subjects with an applicable ECG. This ECG tool may help clinicians identify most patients with pacemaker battery depletion at significant clinical risk. [ABSTRACT FROM AUTHOR]

Introduction: Ablation of atrial vagal ganglia has been associated with improved pulmonary vein isolation (PVI) outcomes. Disruption of vagal reflexes results in heart rate (HR) increase. We investigated the association between HR change after PVI and freedom from atrial fibrillation (AF) at 1 year. Methods and Results: Patients who underwent PVI for paroxysmal AF were identified from the Johns Hopkins Hospital AF registry. Electrocardiograms taken pre‐PVI and post‐PVI were used to determine the change in HR. Patients followed‐up at 3, 6, and 12 months. Of 257 patients (66% male, age 59+/‐11 years), 134 (52%) remained free from AF at 1 year. The average HR increased from 60.6 ± 11.3 beats per minute (bpm) pre‐PVI to 70.7 ± 12.0 bpm post‐PVI. Patients with recurrence of AF had lower post‐PVI HR than those who remained free from AF (67.8 ± 0.2 vs 73.3 ± 13.0 bpm; P <.001). The probability of AF recurrence at 1‐year decreased as the change in HR increased (estimated odds ratio [OR], 0.83; 95% confidence interval [CI, 0.74‐0.93]; P = .002). HR increase more than 15 bpm was associated with the lowest odds of AF recurrence (estimated OR, 0.39; 95% [0.17‐0.85]; P = .018) compared to HR decrease. Conclusions: Resting HR was found to increase after PVI. Increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year. [ABSTRACT FROM AUTHOR]

The article focuses on peri‐Direct current cardioversion (DCCV) imaging and anticoagulation practices in patients with left atrial appendage closure devices. Topics discussed include variations in OAC and imaging patterns, predictors of pre- and post-DCCV OAC use and imaging, concerning rates of device-related thrombus (DRT), and the need for further research on optimal anticoagulation strategies in this population.

Aims: The TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) clinical trial compared clinical outcomes using a contact force (CF) sensing ablation catheter (TactiCath) with a catheter that lacked CF measurement. This analysis links recorded events in the TOCCASTAR study and a large claims database, IBM MarketScan®, to determine the economic impact of using CF sensing during atrial fibrillation (AF) ablation. Methods and Results: Clinical events including repeat ablation, use of antiarrhythmic drugs, hospitalization, perforation, pericarditis, pneumothorax, pulmonary edema, pulmonary vein stenosis, tamponade, and vascular access complications were adjudicated in the year after ablation. CF was characterized as optimal if greater than or equal to 90% lesion was performed with greater than or equal to 10 g of CF. A probabilistic 1:1 linkage was created for subjects in MarketScan® with the same events in the year after ablation, and the cost was evaluated over 10 000 iterations. Of the 279 subjects in TOCCASTAR, 145 were ablated using CF (57% with optimal CF), and 134 were ablated without CF. In the MarketScan® cohort, 9811 subjects who underwent AF ablation were used to determine events and costs. For subjects ablated with optimal CF, total cost was $19 271 ± 3705 in the year after ablation. For ablation lacking CF measurement, cost was $22 673 ± 3079 (difference of $3402, P < .001). In 73% of simulations, optimal CF was associated with lower cost in the year after ablation. Conclusion: Compared to ablation without CF, there was a decrease in healthcare cost of $3402 per subject in the first year after the procedure when optimal CF was used. [ABSTRACT FROM AUTHOR]

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited progressive cardiomyopathy characterized by frequent life‐threatening arrhythmias. The diagnosis of ARVC is challenging and is on the basis of a set of major and minor criteria as described by the modified Task Force Criteria (TFC). We report our clinical experience in a series of patients who were misdiagnosed with ARVC and subsequently underwent removal of their implantable cardioverter defibrillator (ICD) after a re‐evaluation at our center. Methods and results: We studied 12 patients who were misdiagnosed with ARVC and had ICD implantation before our assessment. All patients had a repeat evaluation and were scored according to TFC before ICD removal. Cardiac magnetic resonance imaging (CMR) studies performed at outside institutions during the initial evaluation were reported abnormal and classified as meeting major TFC in ninety percent of patients. The most common abnormality reported was fatty infiltration of the right ventricular (RV) free wall and/or presence of focal intra‐myocardial fat in six patients (50%). On re‐evaluation, none of these findings fulfilled the TFC for the diagnosis. Conclusion: This study demonstrated that high dependence on misinterpretation of CMR along with a misunderstanding of the TFC evaluation are the main reasons for the misdiagnosis of ARVC. Despite the updated criteria for almost a decade, this study reminds that the diagnosis of ARVC is complex and hence careful TFC evaluation and consideration of multiple cardiac test results should be the focused approach for clinicians when confronted with suspected ARVC patients. [ABSTRACT FROM AUTHOR]

The article offers information on the abnormalities on cardiac magnetic resonance imaging and arrhythmic events in patients with cardiac sarcoidosis. It analyze cine images to determine regional longitudinal (LS) and radial strain (RS) and also include patients with cardiac sarcoidosis (CS) and cardiac magnetic resonance imaging (CMR).

It is 35 years since the first description of arrhythmogenic right ventricular cardiomyopathy (ARVC) and more than 20 years since the first reports establishing desmosomal gene mutations as a major cause of the disease. Early advances in the understanding of the clinical, pathological and genetic architecture of ARVC resulted in consensus diagnostic criteria, which proved to be sensitive but not entirely specific for the disease. In more recent years, clinical and genetic data from families and the recognition of a much broader spectrum of structural disorders affecting both ventricles and associated with a propensity to ventricular arrhythmia have raised many questions about pathogenesis, disease terminology and clinical management. In this paper, we present the conclusions of an expert round table that aimed to summarise the current state of the art in arrhythmogenic cardiomyopathies and to define future research priorities. [ABSTRACT FROM AUTHOR]

Background: Left atrial appendage (LAA) closure with the Watchman device is increasingly used in patients with nonvalvular atrial fibrillation for stroke prevention. Though clinical trials have shown a similar combined risk of ischemic and hemorrhagic stroke, there is an increased risk of ischemic stroke in patients with a Watchman device compared with anticoagulation. Some ischemic strokes are related to a device‐related thrombus (DRT), which may be attributable to delayed endothelialization of exposed fabric and metal. Methods and Results: Patients undergoing Watchman LAA occlusion between January 2016 and June 2018 were enrolled in a prospective registry. From this cohort, 46 patients who had both transesophageal echocardiogram (TEE) and computed tomography (CT) at 45 days follow‐up were selected for this study. The degree of LAA occlusion and type of leak were assessed by CT and TEE. TEE identified no patients with a significant (>5 mm) peri‐device leak, 27 (58.6%) with nonsignificant peri‐device leak (<5 mm), and 19 (41.4%) with complete occlusion. CT identified contrast in the LAA in 28 (60%) patients. However, in 10 (21.8%) of these patients, contrast entered the LAA through the fabric rather than around the device. No DRT were identified. Conclusion: These data reveal that the Watchman device remains porous 6 weeks after implantation in a substantial percentage of patients, suggesting delayed endothelialization of the device. Cardiac CT may help to differentiate between peri‐device and trans‐fabric leak. Additional studies are required to test whether prolonged anticoagulation in patients with trans‐fabric leak may help to reduce the risk of DRT and ischemic stroke. [ABSTRACT FROM AUTHOR]

Background: Pacemaker patients experience battery depletion that activates pacemaker's alert for replacement notification. Automatic reprogramming at replacement notification can result in loss of rate response and atrioventricular (AV) synchrony. Objective: To determine if relevant symptoms or clinical events may be associated with automatic reprogramming at replacement notification. Methods: Electronic medical record review was undertaken for 298 patients referred for pacemaker generator replacement. Primary endpoints were symptoms or clinical events during replacement notification period. Results: Following elimination of duplicate pacemaker replacements (n = 12), "near‐replacement notification" or "recalled" (n = 15) and pacemakers at "end of life" (n = 5), 266 subjects were included. Three distinct reprogramming cohorts were identified; those with no change (control) in pacing mode (n = 46), those with loss of rate response (n = 154), and those with loss of AV synchrony ± rate response (n = 66). In total, 83 subjects (31.2%) had symptoms with significant differences seen between groups (control = 4.3%, loss of rate response = 26.0%, loss of AV synchrony ± rate response = 62.1%, P < 0.001). Overall, 28 subjects (10.5%) experienced clinical events with significant differences seen between groups (control = 0.0%, loss of rate response = 6.5%, loss of AV synchrony ± rate response = 27.3%, P < 0.001). Conclusions: Automatic reprogramming at replacement notification was associated with significant symptoms in 26% of those who lost rate response and in 62% of those who lost AV synchrony ± rate response. Additionally, 27% of the latter cohort required nonelective clinical care. [ABSTRACT FROM AUTHOR]

An editorial is presented on the more data to motivate hospital volume standards for catheter ablation of atrial fibrillation (AF). Topics inlcude the catheter ablation of AF has emerged as the best treatment option for patients with symptomatic AF, and the not only has it been shown to prevent recurrent AF in most patients but also AF catheter ablation decreases total AF burden and improves patients' quality of life.

Background: Patients go without pacemaker, defibrillator, and cardiac resynchronization therapies (devices) each year due to the prohibitive costs of devices. Objective: We sought to examine data available from studies regarding contemporary risks of reused devices in comparison with new devices. Methods: We searched online indexing sites to identify recent studies. Peer‐reviewed manuscripts reporting infection, malfunction, premature battery depletion, and device‐related death with reused devices were included. The primary study outcome was the composite risk of infection, malfunction, premature battery depletion, and death. Secondary outcomes were the individual risks. Results: Nine observational studies (published 2009–2017) were identified totaling 2,302 devices (2,017 pacemakers, 285 defibrillators). Five controlled trials were included in meta‐analysis (2,114 devices; 1,258 new vs 856 reused). All device reuse protocols employed interrogation to confirm longevity and functionality, disinfectant therapy, and, usually, additional biocidal agents, packaging, and ethylene oxide gas sterilization. Demographic characteristics, indications for pacing, and median follow‐up were similar. There were no device‐related deaths reported and no statistically significant difference in risk between new versus reused devices for the primary outcome (2.23% vs 3.86% respectively, P = 0.807, odds ratio = 0.76). There were no significant differences seen in the secondary outcomes for the individual risks of infection, malfunction, and premature battery depletion. Conclusions: Device reuse utilizing modern protocols did not significantly increase risk of infection, malfunction, premature battery depletion, or device‐related death in observational studies. These data provide rationale for proceeding with a prospective multicenter noninferiority randomized control trial. [ABSTRACT FROM AUTHOR]

Background: Implantable defibrillators (ICD) are an important therapy for arrhythmogenic right ventricular cardiomyopathy (ARVC) patients at high risk of sudden death. Given the high appropriate ICD therapy rate, some have argued that the mere act of implanting an ICD inflates the malignant arrhythmia rate in ARVC. Objective: To report the arrhythmic course of ARVC patients without ICDs at the fulfillment of the 2010 Task Force Criteria and explore predictors of malignant ventricular arrhythmias. Methods: We included 131 definite ARVC patients (age 32 ± 15 years, male 39%, proband 50%) either without ICDs (N  =  47) or receiving an ICD at least 6 months after the fulfillment of the diagnostic criteria. The primary outcome was a composite of cardiac arrest (both resuscitated successfully and unsuccessfully) and sustained ventricular tachyarrhythmias (cycle length< 600 milliseconds, at least 30 seconds or requiring an intervention for termination). Results: At the fulfillment of the diagnostic criteria, ICDs were not recommended to 59 (45%) patients and declined by 22 (17%) patients. Forty (31%) patients were not recognized as having ARVC by the treating physicians. Over 8 (interquartile interval: 3–12) years, 38 (29%) patients had primary outcomes (8 cardiac arrests [3 died] and 30 sustained ventricular arrhythmias) while not having ICDs. The 1‐year and 5‐year event‐free survival was 92% and 72%. Spontaneous sustained ventricular arrhythmias, cardiac syncope, men, proband, and inducibility in electrophysiology study were significantly associated with the primary outcome. Conclusion: In a contemporary cohort, a considerable risk of malignant arrhythmias existed in ARVC when ICDs were not implanted. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Prior studies identified a relationship between epicardial bipolar and endocardial unipolar voltage. Whether the relationship is valid with smaller multielectrode mapping catheters has not been reported. We explored the association of right ventricular (RV) endocardial unipolar voltage mapping with epicardial bipolar voltage mapping using a multielectrode mapping catheter. Methods: Electrograms from patients who underwent multielectrode endocardial and epicardial RV electroanatomical mapping during ablation procedures were analyzed. Each endocardial mapping point was matched to the corresponding nearest epicardial point. The correlation between unipolar endocardial voltage and epicardial bipolar voltage was determined. The optimal unipolar threshold to detect epicardial low voltage (< 1.0 mV) and dense scar (0.5 mV) was calculated. Results: A total of 4,895 points were analyzed. There was a significant correlation between endocardial unipolar and epicardial bipolar voltage (Spearman rho  =  0.499, P  =  < 0.001). The extent of the correlation was inversely associated with wall thickness. The receiver operator characteristic analysis of endocardial unipolar voltage predicting epicardial bipolar voltage of < 1.0 mV and < 0.5 showed an area under the curve of 0.769 and 0.812, respectively. The endocardial unipolar voltage that had the highest sensitivity and specificity in detecting epicardial bipolar voltage of < 1.0 mV and < 0.5 mV was 3.3 mV (70.3% sensitivity, 70.3% specificity), and 2.8 mV (sensitivity 73.8%, specificity 73.3%), respectively. Conclusion: Epicardial low voltage of the RV can be assessed by unipolar endocardial voltage using small multielectrode catheters. The strength of the association was inversely correlated with the wall thickness. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Catheter ablation is common for patients with symptomatic, drug‐refractory atrial fibrillation (AF). Obesity is a known risk factor for incident AF. The impact of obesity on AF ablation outcomes is incompletely understood. We sought to determine the impact of elevated body mass index (BMI) on pulmonary vein isolation (PVI) procedural outcomes and associated complications. Methods and results: We evaluated patients undergoing PVI from 2001 to 2015, dividing them into four groups: normal weight (BMI ≥ 18.5 to < 25), overweight (BMI ≥ 25 to < 30), obese (BMI > 30 to < 40), and morbidly obese (BMI ≥ 40). Demographic and procedural characteristics, complications, and ablation outcomes were compared among groups. A total of 701 patients (146 time‐matched controls, 227 overweight, 244 obese, and 84 morbidly obese) with complete demographic, procedural, and follow‐up data were included. Increasing BMI correlated positively with HTN, OSA, CHA2DS2‐VASC score, and persistent AF (P ≤ 0.001 for all associations). Radiofrequency application time and intraprocedural heparin dose increased with BMI (P ≤ 0.001). Arrhythmia recurrence at 1 year was 39.9% in controls, while higher in all high‐BMI groups (overweight, 51.3%; obese, 57%; morbidly obese, 58.1 %; P  =  0.007 for all versus controls). Impact of BMI on AF recurrence was not seen in persistent AF patients. Complication rates across groups were similar. Conclusions:  AF recurrence after catheter ablation is higher in overweight, obese, and morbidly obese patients comparing to normal‐weight controls, driven primarily by outcomes differences in paroxysmal AF patients. Complications were not associated with increased BMI. [ABSTRACT FROM AUTHOR]

The article discusses a paper by C. Rajyaguru and colleagues on the assessment of hospital web sites in the U.S which provide information on the management of atrial fibrillation (AF). Topics mentioned include the factors that contributed to the increase in the incidence of AF around the world, a description of AF based on the knowledge of an electrophysiology community, and the analysis of data about the complications and success rate of ablative technology for the treatment of AF.

Introduction Epicardial ablation is becoming an important part of management in patients with ventricular tachycardia (VT). Posterior epicardial access via the Sosa or needle-in-needle (NIN) approach for epicardial VT ablation is considered to be the method of choice for most electrophysiologists. Anterior epicardial access as an alternative technique has recently been proposed, but there are limited data about its safety, efficacy, and the rate of immediate complications. In this study, we report our experience with anterior epicardial access between 2009 and 2016. Methods Between 2009 and June 2016, 100 consecutive patients underwent epicardial VT ablation using an anterior approach. The success rate, epicardial bleeding, and other complications related to the epicardial access in these patients were compared to the previously reported rate of complications in patients whom epicardial access was performed using the NIN or Sosa techniques. Results Anterior epicardial access was obtained successfully in 100% of patients in the first attempt. The success rate of the anterior approach was comparable with the reported success rate of the NIN technique (100% vs. 100%, P value not significant) but better than the Sosa technique (100% vs. 94%, P = 0.012). None of the patients in the anterior approach series suffered from significant pericardial bleeding (defined as greater than 80 mL of blood loss), RV puncture/damage, or need for an emergent cardiac surgery. Conclusion An anterior epicardial approach is feasible and appears to have an acceptable safety profile in comparison with other epicardial approaches. [ABSTRACT FROM AUTHOR]

All contemporary pacemakers undergo automatic reprogramming upon reaching elective replacement indication due to battery depletion. The majority of such reprogramming will result in changes to both pacing mode and pacing rate. The exact software reprogramming varies considerably among pacemaker manufacturers and may even vary among models of the same manufacturer. Accordingly, it is essential for healthcare providers managing pacemaker patients to have a detailed understanding of the automatic reprogramming seen at elective replacement indication as well as their potential physiological and clinical consequences. [ABSTRACT FROM AUTHOR]