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Arrhythmia is a significant clinical modifier in COVID-19 patient outcomes. Currently, data on arrhythmia and ECG characteristics in COVID-19 from lower middle-income countries are limited.COVID-19 was confirmed by polymerase chain reaction testing of a nasopharyngeal sample. All clinical records were systematically evaluated to obtain demographic characteristics and medical comorbidities. The ECG was recorded on admission, in-hospital, and at discharge.Total documented arrhythmia events account for 22% of patients, comprising 6% of new-onset arrhythmia and 16% of existing arrhythmia. Atrial fibrillation is the most common arrhythmia. The ECG changes were a decrease in heart rate (91 ± 22 vs. 83 ± 20,The incidence of arrhythmias in COVID-19 patients at COVID-19 referral hospitals in Indonesia is 22%. Atrial fibrillation is the most common arrhythmia in COVID-19 patients. Prolongation of QRS duration from admission to discharge was related to the occurrence of new-onset arrhythmia. The in-hospital HR of 85 bpm or higher increased the risk of death.

Atrial fibrillation (AF) is the most common rhythm disorder seen in doctors' offices and emergency departments (EDs). In both settings, an AF holistic pathway including anticoagulation or stroke avoidance, better symptom management, and cardiovascular and comorbidity optimization should be followed. However, other considerations need to be assessed in the ED, such as haemodynamic instability, the onset of AF, the presence of acute heart failure and pre-excitation. Although the Advanced Cardiovascular Life Support guidelines (European Society of Cardiology guidelines, Acute Cardiac Care Association/European Heart Rhythm Association position statements) and several recent AF publications have greatly assisted physicians in treating AF with rapid ventricular response in the ED, further practical clinical guidance is required to improve physicians' skill and knowledge in providing the best treatment for patients. Herein, we combine multiple strategies with supporting evidence-based treatment and experiences encountered in clinical practice into practical stepwise approaches. We hope that the stepwise algorithm may assist residents and physicians in managing AF in the ED.

Background: Studies have shown that cardiac arrhythmias may occur in up to 44% of patients with severe coronavirus disease 2019 (COVID-19) and has been associated with an increased risk of death. This systematic review and meta-analysis aimed to evaluate the incidence of cardiac arrhythmias in patients with COVID-19 and their implications on patient prognosis. Methods: We performed a systematic literature search from PubMed, SCOPUS, Europe PMC, Cochrane Central Databases, and Google Scholar + Preprint Servers. The primary endpoint of the study was poor outcomes including mortality, severe COVID-19, and the need for ICU care. Results: A total of 4 studies including 784 patients were analyzed. The incidence of arrhythmia in patients with COVID-19 was 19% (9–28%; I2: 91.45). Arrhythmia occurred in 48% (38–57%; I2: 48.08) of patients with poor outcome and 6% (1–12%; I2: 85.33%) of patients without poor outcome. Patients with COVID-19 experiencing arrhythmia had an increased risk of poor outcome (RR 7.96 [3.77, 16.81], p

Introduction This systematic review and meta‐analysis aimed to assess the latest evidence on the use of renal denervation (RDN) + pulmonary vein isolation (PVI) compared to PVI alone for treating atrial fibrillation (AF) with hypertension. Methods A systematic literature search from several electronic databases was performed up until January 2020. The primary outcome was AF recurrence defined as AF/atrial flutter (AFL)/atrial tachycardia (AT) ≥30 seconds at 12‐month follow‐up and the secondary outcome was procedure‐related complications. Results There were 568 subjects from five studies. AF recurrence was 90/280 (32.1%) in the RDN + PVI group and 142/274 (51.8%) in the PVI group. RDN + PVI was associated with a lower incidence of AF recurrence (RR 0.62 [0.51, 076], P, There were 568 subjects from 5 studies. RDN+PVI was associated with a lower incidence of AF recurrence compared to PVI alone (RR 0.62 [0.51, 0.76], p

Atrial fibrillation (AF), the most prevalent arrhythmic disease, tends to foster thrombus formation due to hemodynamic disturbances, leading to severe disabling and even fatal thromboembolic diseases. Meanwhile, patients with AF may also present with acute coronary syndrome (ACS) and coronary artery disease (CAD) requiring stenting, which creates a clinical dilemma considering that majority of such patients will likely receive oral anticoagulants (OACs) for stroke prevention and require additional double antiplatelet treatment (DAPT) to reduce recurrent cardiac events and in-stent thrombosis. In such cases, the gentle balance between bleeding risk and atherothromboembolic events needs to be carefully considered. Studies have shown that congestive heart failure, hypertension, age ≥ 75 years (doubled), diabetes mellitus, and previous stroke or transient ischemic attack (TIA; doubled)–vascular disease, age 65 to 74 years, sex category (female; CHA2DS2-VASc) scores outperform other scoring systems in Asian populations and that the hypertension, abnormal renal/liver function (1 point each), stroke, bleeding history or predisposition, labile international normalized ratio (INR), elderly (>65 years), drugs/alcohol concomitantly (1 point each; HAS-BLED) score, a simple clinical score that predicts bleeding risk in patients with AF, particularly among Asians, performs better than other bleeding scores. A high HAS-BLED score should not be used to rule out OAC treatment but should instead prompt clinicians to address correctable risk factors. Therefore, the current review attempted to analyze available data from patients with nonvalvular AF who underwent stenting for ACS or CAD and elaborate on the direct-acting oral anticoagulant (DOAC) and antiplatelet management among such patients. For majority of the patients, “triple therapy” comprising OAC, aspirin, and clopidogrel should be considered for 1 to 6 months following ACS. However, the optimal duration for “triple therapy” would depend on the patient's ischemic and bleeding risks, with DOACs being obviously safer than vitamin-K antagonists.

Introduction Ablating the slow pathway (SP) is the superior treatment for atrioventricular nodal reentrant tachycardia (AVNRT) with a low complication rate. However, the ablation of the SP could result in either complete elimination or modification of the SP. We aimed to investigate whether the duration of AH jump pre-ablation associated with the outcome of elimination of SP. Methods We included 56 patients with typical AVNRT (slow-fast), 20 males and 36 females, aged 44.2 ± 15.1 years. Slow pathway ablation was performed using classical approach. Univariate and multivariate analysis was performed for potential predictors of SP elimination. Results Typical AVNRT was inducible in all patients. Post-ablation, non-inducibility of AVNRT was obtained in all 56 (100%) patients, with SP elimination in 33 (61%) patients and SP modification in 23 (39%) patients. Patients with SP elimination had significantly longer AH jump than patients with SP modification. Cox regression analysis showed that AH jump duration was the independent predictor of SP elimination, in which every 20 ms increase in AH jump duration was associated with 1.30 higher rate of SP elimination. Furthermore, ROC curve analysis indicated that the AH jump duration of ≥100 ms had 6.14 times higher probability for complete elimination of the SP with a sensitivity of 79%, specificity of 70%, PPV of 79% and NPV of 70%. Conclusions AH jump duration pre-ablation is associated with complete elimination of slow pathway during AVNRT ablation.

Background: Serum galectin-3, a circulating biomarker of fibrosis, has been associated with atrial remodelling. Recent studies investigating serum galectin-3 and AF recurrence post-ablation have shown mixed results. We aimed to analyze the latest evidence on the association between serum galectin-3 and AF recurrence after catheter ablation. Methods: We performed a comprehensive search on topics that assesses serum galectin-3 and AF recurrence post-ablation up until August 2019. Results: There were 597 patients from seven studies. The mean difference of serum galectin-3 was similar in both AF recurrence and non AF recurrence group (mean difference 0.78 ng/mL [-0.56, 2.13]; p = 0.25; I2: 69%. Upon removal of a study in sensitivity analysis, the serum galectin-3 became higher in AF recurrence group (mean difference 1.41 ng/mL [0.47, 2.34], p = 0.003; I2: 17%). Serum galectin-3 was associated with a higher risk for AF recurrence (HR 1.25 [1.01, 1.55]; p = 0.04; I2: 76%). Upon removal of a study in sensitivity analysis, HR became 1.45 [1.07, 1.96], p = 0.02; I2: 47%. Meta-analysis of adjusted HR demonstrated that high serum galectin-3 independently predicts AF recurrence (HR 1.15 [1.02, 1.29], p

Background Diagnosis‐to‐ablation time (DTAT) has been postulated to be one of the predictors of atrial fibrillation (AF) recurrence, and it is a “modifiable” risk factor unlike that of many electrocardiographic or echocardiographic parameters. This development may change our consideration for ablation. In this systematic review and meta‐analysis, we aim to analyze the latest evidence on the importance of DTAT and whether they predict the AF recurrence after catheter ablation. Methods We performed a comprehensive search on topics that assess diagnosis‐to‐ablation time (DTAT) and AF recurrence from inception up until August 2019 through PubMed, EuropePMC, Cochrane Central Database, and http://ClinicalTrials.gov. Results There was a total of 3548 patients from six studies. Longer DTAT was associated with increased risk for AF recurrence in all studies included. Meta‐analysis of these studies showed that DTAT had a hazard ratio (HR) of 1.19 [1.02, 1.39], P = .03; I 2: 92% for AF recurrence. Upon sensitivity analysis by removing a study, HR became 1.24 [1.16, 1.32], P 3 years had HR 1.73 [1.54, 1.93], P 6 years to, Diagnosis‐to‐ablation time >3 years is associated with the increased risk of atrial fibrillation recurrence after catheter ablation.

Background Radiofrequency ablation (RFA) has become therapeutic modality with high success rate for outflow tract ventricular arrhythmia (OTVA). Determining the origin of OTVA before ablation is important to choose the appropriate approach, avoiding multiple complications, and saving fluoroscopy time. ECG-based criteria is a method that has been widely used to predict the origin of OTVA, but it oftenly has inconsistent diagnostic value. Previous study showed that aortoseptal angulation by echocardiography might be beneficial to predict the origin of OTVA. We need to validate the result in a prospective manner. Objective To validate the association between aortoseptal angulation measurements by echocardiography and OTVA origin. Methods A validation of diagnostic study involving patients VTs/PVCs with the ECG’s morphology of LBBB and inferior axis who underwent RFA therapy. An echocardiography examination was held before RFA therapy. Aortoseptal angulation is measured on parasternal long axis (PLAX)view to measure the angle between the aortic root and interventricular septum. The origin of OTVA was determined by mapping during RFA. Results There were 41 subjects with a mean age of 44.7±12.6 years. Majority of subjects were patients with right OTVA (n = 34, 82.9%). The mean aortoseptal angulation of the left OTVA 127.2±2.8 was significantly smaller than the right OTVA 136.7±5.7(p Conclusion This validation study proved that aortoseptal angulation measurement by echocardiography

Aims To investigate the correlation between circadian variation of idiopathic ventricular arrhytmia (IVA) and left ventricular (LV) intrinsic systolic function. Methods This cross sectional study included 67 patients with IVA originated from ventricular outflow tract. All patients underwent 24-hour Holter monitoring and speckle tracking echocardiography examinations. The circadian variation of IVA burden and global longitudinal strain (GLS) were determined and statistical analysis was conducted to evaluate their correlation. Results A total 31 patients (46.3%) had impaired LV systolic function by GLS (-15.1% + 1.8% vs -21.3% + 2.0%; p = 9% (OR = 6.81, 95%CI 1.35-34.41, p = 0.020), and male gender (OR = 14.4, CI 95%=2.02-101.1, p = 0.004). Conclusion This study is the first to show that lack of circadian variation of IVA is associated with impaired LV systolic function by GLS. The finding of this study suggested that chronotherapy of antiarrhytmia medication may prevent the development of LV dysfunction.

In this paper, the Asia Pacific Heart Rhythm Society (APHRS) sought to provide practice guidance on AF screening based on recent evidence, with specific considerations relevant to the Asia-Pacific region. A key recommendation is opportunistic screening for people aged ≥65 years (all countries), with systematic screening to be considered for people aged ≥75 years or who have additional risk factors (all countries).

The prevalence of stroke in Indonesia increased overtime. CS ranges from 15 to 40% from all ischemic strokes. Finding the etiology of ischemic stroke is important to prevent recurrence. AF is predicted as the etiology behind CS. The current recommendation only supports short period of ECG monitoring. However, studies have shown that a higher detection rate can be achieved with longer duration of monitoring. ICM, a diagnostic tool with the highest detection rate, is still considered cost-effective when the calculation takes into account the QALY gained. Digital health tools such as handheld devices and smartwatch ECG have revolutionized the screening of AF however it is still considered as pre-diagnostic and verification is needed to confirm the rhythm generated.

Purpose: During medical residency programs, physicians develop their professional identities as specialists and encounter high expectations in terms of achieving competencies. The responsibilities of medical trainees include caring for patients, balancing work with personal life, and weathering stress, depression, and burnout. Formal academic mentoring programs strive to ease these burdens. The coronavirus disease 2019 (COVID-19) pandemic has altered the trainee–academic mentor relationship, and solutions are needed to address these challenges. The present study aimed to evaluate the formal academic mentoring process through trainees’ perceptions and expectations of formal mentoring programs during COVID-19 in Indonesian cardiology residency programs.Methods: This cross-sectional study used a self-administered online questionnaire to capture trainees’ perceptions and expectations regarding academic mentoring programs in 3 cardiology residency programs in Indonesia from October to November 2020. The questionnaire was developed before data collection. Perceptions of the existing mentoring programs were compared with expectations.Results: Responses were gathered from 169 out of 174 residents (response rate, 97.3%). Most trainees reported having direct contact with COVID-19 patients (88.82%). They stated that changes had taken place in the mode and frequency of communication with their academic advisors during the pandemic. Significant differences were found between trainees’ perceptions of the existing mentoring programs and their expectations for academic mentoring programs (P

Background Left atrial appendage (LAA) closure device is an alternative to anticoagulants for stroke prevention in selected atrial fibrillation (AF) patients. The LAA device implantation is safe with short period of learning curve. The standard implantation technique warrants a transesophageal echocardiography (TEE) guided and general anesthesia. In region of Asia Pacific as well as Indonesia, both TEE and general anesthesia are not always available in district hospital. We studied the safety and efficacy of Amplatzer Cardiac Plug (ACP) implantation guided by fluoroscopy only and without general anesthesia. Methods Consecutive nonvalvular AF patients with CHA2DS2VASc score of ≥2 and HASBLED score of ≥3 are participated. Patients requiring long‐life anticoagulant for any other indication are excluded. The choice of implanted first or second‐generation ACP is that with excess size of 2‐4 mm of measured landing zone diameter. Results Twenty‐five subjects were implanted ACP by means fluoroscopy only (Group A) and 28 subjects using standard technique group (Group B). The median AF duration was 36 months (6‐276 months) and majority of patients (49%) are having permanent AF. The mean CHA2DS2VASc score is 3.9 ± 1.63. Successful implantation of ACPs was 96% in both groups. Nonfatal pericardial effusion occurred in three patients. During 75 weeks of follow‐up period, there were no significant differences of stroke event and death between groups. Conclusion ACP implantation guided with fluoroscopy only is feasible and safe.

Intravascular lipomas are rare occurrences, especially in major vessels. This tumour is composed of adipocytes in a fibrous capsule that has a slow growth rate and usually shows no symptoms. There were only eight reports in the literature regarding intravascular lipoma located in the superior vena cava.A 54-year-old man had episodes of supraventricular tachycardia and atrial flutter for over a year. Preoperative radiological findings showed a giant mass that arose from the superior vena cava to the right atrium and a biopsy catheter showed that there were no signs of malignancy. The patient then underwent surgery through median sternotomy and the mass was extirpated on the highest part of the stalk that could be reached. The patient was stable and remained to show no symptoms or evidence of residual mass or stalk in 2 years follow-up.The surgical approach in excising lipoma in SVC should be considered wisely with the support of adequate preoperative diagnosis. Since lipoma is a very slow-growing tumour, extensive manipulation that could increase surgical technique difficulty or postoperative morbidity and mortality is not necessary.

Background: Atrioventricular (AV) block is a threatening condition that caused sudden loss of consciousness and death, notably if happened to aircraft pilot will compromise the reliability of flight operations and safety. Cardiac arrhythmia is well known as one of the main disqualifier for loss of flying license, and discriminating between benign and potentially significant rhythm abnormalities remains a challenge. The present case describes the electrophysiological feature of a high-grade AV block in an aircraft pilot. Case illustration: A 60-year-old male worked as commercial aircraft pilot presented with asymptomatic high-grade AV block during inflight Holter monitoring. He had never experienced any remarkable symptoms nor history of near syncope, but had a history of percutaneous coronary intervention (PCI) with one stent at left circumflex (LCx) coronary artery. Electrophysiology (EP) study revealed AH interval of 105 ms, HV interval of 50 ms, AV node effective refractory period of 280 ms and Weckenbach point of 330 ms, suggesting a normal EP study. Stimulation with atrial pacing and ATP showed prolongation of AH interval without changes in HV interval, showing the presence of a supra-Hisian AV node dysfunction. The highly demanding physiological environment in aircraft elucidate the likelihood of vagotonic cause of his condition and pacemaker implantation was not warranted. Conclusion: Atrioventricular (AV) block is an AV conduction disorder that can manifests in various symptoms and severity. Electrophysiology study is considered as a modality to locate the site of block that allows the avoidance of unnecessary permanent pacing and the appropriate prophylactic pacing.

Objective: To investigate the association between hypertension and outcome in patients with Coronavirus Disease 2019 (COVID-19) pneumonia. Methods: We performed a systematic literature search from several databases on studies that assess hypertension and outcome in COVID-19. Composite of poor outcome, comprising of mortality, severe COVID-19, acute respiratory distress syndrome (ARDS), need for intensive care unit (ICU) care and disease progression were the outcomes of interest. Results: A total of 6560 patients were pooled from 30 studies. Hypertension was associated with increased composite poor outcome (risk ratio (RR) 2.11 (95% confidence interval (CI) 1.85, 2.40), p < 0.001; I2, 44%) and its sub-group, including mortality (RR 2.21 (1.74, 2.81), p < 0.001; I2, 66%), severe COVID-19 (RR 2.04 (1.69, 2.47), p < 0.001; I2 31%), ARDS (RR 1.64 (1.11, 2.43), p = 0.01; I2,0%, p = 0.35), ICU care (RR 2.11 (1.34, 3.33), p = 0.001; I2 18%, p = 0.30), and disease progression (RR 3.01 (1.51, 5.99), p = 0.002; I2 0%, p = 0.55). Meta-regression analysis showed that gender ( p = 0.013) was a covariate that affects the association. The association was stronger in studies with a percentage of males < 55% compared to ⩾ 55% (RR 2.32 v. RR 1.79). Conclusion: Hypertension was associated with increased composite poor outcome, including mortality, severe COVID-19, ARDS, need for ICU care and disease progression in patients with COVID-19.

Funding Acknowledgements National Cardiovascular Center Harapan Kita Hospital Background Right ventricular dysfunction is the worst mortality predictor in pulmonary arterial hypertension (PAH). Recent animal PAH studies have demonstrated the benefit of partial fatty acid inhibitor such as trimetazidine in improving right ventricular function. Therefore, we hypothesize that trimetazidine can improve right ventricular ejection fraction (RVEF) in PAH patients. Purpose Investigating the effect of trimetazidine on right ventricle function in PAH patients. Methods We conducted 3 months randomized double blind placebo controlled trial on PAH patients at outpatient clinic in National Cardiovascular Center Harapan Kita Hospital Indonesia. Those who fulfilled the inclusion criteria will be randomized into trimetazidine or placebo group for 3 months on top of their standard PAH regime. Clinical and cardiovascular magnetic resonance imaging (CMR) parameters will be evaluated before and after 3 months therapy. The primary outcome of this study is the differences of RVEF from CMR. Results We randomly enrolled 26 PAH patients equally to receive placebo or trimetazidine for 3 months on top of their standard PAH regime. Total of 10 patients in each group was able to finish the study. There was significant improvement of RVEF in trimetazidine group 3.78 + 1.5% compared to placebo 2.76 + 1.6% (p 0.008, CI 1.96 to 10.96). Furthermore, we also observed improvement of functional capacity in trimetazidine group 0.24 + 0.09 compared to placebo -0.44 + 0.16 (p 0.002, CI 0.28 s/d 1.08). Conclusions Trimetazidine therapy for 3 months on top of standard PAH regime significantly improve RVEF and functional capacity in PAH patients. Abstract P194 Figure. Effect of trimetazidine on RV function

Background : Brugada syndrome is an inherited disease characterized by an increased risk of sudden cardiac death owing to ventricular arrhythmias in the absence of structural heart disease. It has been reported that this syndrome is more prevalent in South-East Asia than in Western countries. Furthermore, genetic studies showed important contributions of several gene mutations to the phenotype of BrS. These suggest that ethnic difference play significant roles in the pathogenesis of BrS. In addition, ICD implantation remains the cornerstone management with a low rate of appropriate shocked. Therefore, it is important to investigate patients’ characteristics for risk stratification. Our objective to investigate the clinical, electrocardiography (ECG) and electrophysiological characteristics that can be used as predictor of appropriate shock due to ventricular arrhythmia (VA) in Indonesian patients with BrS. Methods : We analyse data from Brugada syndrome registry at National Cardiovascular Centre Harapan Kita since January 2013. Total 22 patients were included. Characteristics of BrS that we analysed were baseline characteristics (age and sex), Clinical finding (syncope, cardiac arrest), ECG finding (spontaneous type 1 or drug induced) and Electrophysiology study result (inducible VA and RV ERP). We also added some new ECG characteristic (S wave in lead 1, S wave duration in V1, Fragmented QRS, Junction ST elevation and early repolarization pattern in infero-lateral) to be analysed. Our end point are appropriate shock during ICD interrogation for those who have been implanted an ICD, and documented VA for those who didn’t receive ICD. Result : We found high incidence of appropriate ICD’s shock in our population (50% in our study vs 5-11.5% in real world). Predictors of appropriate shock and documented VA are history of syncope (p = 0.045; OR 2.57 [1.44-4.59]), spontaneous type-1 ECG (p = 0.005) and right ventricular effective refractory period (RV ERP) of

Introduction Patients with atrial fibrillation (AF) for >48 hours who are a candidate for cardioversion should have transesophageal echocardiography (TEE) performed to exclude left atrial thrombus (LAT) that may cause systemic thromboembolism upon conversion to sinus rhythm. However, TEE facilities were limited, especially in developing countries. Case illustration A 50 years-old man presented with exertional dyspnea and palpitation for 72 hours prior to admission. Electrocardiography showed AF with a ventricular rate of 140x/minute. Cardioversion was decided to be the best approach. This patient has an AF >48 hours of onset, hence, LAT should be excluded by the use of TEE. Unfortunately, there was no TEE facility nearby. Discussion Upon comprehensive search on the use of D-Dimer assay to exclude the LAT in AF patients, we found seven studies showed increased D-dimer level in those with left atrial thrombus. In 4 studies, AUC was > 0.70, sensitivity and specificity varied from 75.9% to 89% and 73.1% to 95% respectively. However, there is no single cut-off point, due to the heterogeneity of cut-off points. Conclusion D-dimer assay combined with other variables of atrial thrombus exclusion score is valuable in excluding LAT. Previously, weeks of anticoagulation is more advisable before attempting cardioversion in the absence of nearby TEE facilities. With current evidence, a low D-dimer and ATE score of 0 is safe for cardioversion.

Background: Data on the optimal therapeutic international normalized ratio (INR) for non-valvular and valvular atrial fibrillation (AF) in Indonesia is currently unavailable. Therefore, we designed the Indonesian Registry on Atrial Fibrillation (OneAF) registry in order to seek a safe and beneficial range of INR in Indonesian patients with non-valvular and valvular AF. Methods/design: The OneAF registry is a nationwide collaboration of the Indonesian Heart Rhythm Society (InaHRS) enrolling all hospitals with cardiac electrophysiologists in Indonesia. It is a prospective, multicentre, nationwide, observational study aiming to recruit non-valvular and valvular AF patients in Indonesia. The registry was started in January 2020 with a planned 2 years of recruitment. There are 2 respondents for this registry: non-cohort and cohort respondents. Non-cohort registry respondents are AF patients at hospitals who fulfill inclusion and exclusion criteria but did not consent for a 24 month follow up. Whereas patients who consented for a 24 month follow up were included as cohort registry respondents. Key data collected includes basic sociodemographic information, symptoms and signs, medical history, results of physical examination and laboratory test, details of diagnostics and treatment measures and events. Results: Currently, a total of 1568 respondents have been enrolled in the non-cohort registry, including 1065 respondents with non-valvular AF (67.8%) and 503 respondents with valvular AF (32.2%). We believe that the OneAF registry will provide insight into the regional variability of anticoagulant treatment for AF, the implementation of rhythm/rate control approaches, and the clinical outcomes concerning cardiocerebrovascular events. Trial registration: Registered at clinicaltrials.gov (NCT04222868).

Left atrial appendage (LAA) dimensions have been shown as an independent predictor of higher risk for stroke in AF patients. Little data exist on the outcomes after LAA closure in patients with nonvalvular atrial fibrillation (NVAF) who have relatively bigger LAA size. This study aims to evaluate the results associated with LAA closure with the Amplatzer cardiac plug (ACP, AGA, St. Jude Medical, Minneapolis, MN) in bigger LAA size. A total of 25 patients with NVAF underwent LAA closure with the ACP device. All patients received short-term (up to 3 months) dual-antiplatelet therapy (clopidogrel and aspirin) after the procedure and aspirin only thereafter. A transesophageal echocardiography was performed in all patients at the 3- and 6-month follow-ups. No patient was lost to follow-up (≥ 12 months in all patients). The mean age, CHA 2 DS 2 -VASc score, and HAS-BLED score were 66.2 ± 8.79 years; 3.2 ± 1.46 and 2.4 ± 1.0, respectively. The average sizes of the LAA landing zone and ostium were 23.08 ± 5.0 and 24.9 ± 4.4 mm, respectively. The procedure was successful in 23 (92%) patients and was canceled in 2 (8%) patients due to huge LAA dimensions. In 56% of the patients “pull and release” technique is needed to appropriately implant the ACP. During a mean follow-up of 12 months, no cases of periprocedural stroke and no mortality were observed. In patients with NVAF at high risk of cardioembolic events and big LAA size, LAA closure using the ACP device is safe and effective.

Background: Twiddler syndrome is an infrequent but potentially dangerous complication of device therapy for dysrhythmias. This syndrome results from manipulation of implanted pulse generator by the patient, leading to traction and subsequent lead dislodgement. It can also occur spontaneously. It has been increasingly reported with pacemaker or implantable cardioverter-defibrillators (ICDs). In this reports, we describe two patients with Twiddler syndrome with substantial retraction of their lead who denied any manipulation of their device.Case Illustration: The first patient was a 56 year-old man with single-chamber ICD due to dilated cardiomyopathy (DCM) with congestive heart failure and severe systolic left ventricular dysfunction (ejection fraction 18%). The dislodged lead causing rhythmical twitching of left pectoral muscles and abdominal pulsations. The second patient was a 69 year-old man with dual-chamber pacemaker due to total atrioventricular block with normal systolic left ventricular function (ejection fraction 70%). It manifested as dyspnea on effort, and he also underwent pacemaker implantation. They underwent primary devices implantation at April 2016 and reposition of generators and its leads in December 2016. The first and second patients denied of manipulating the generator of ICD or pacemaker and rotated their left arm and right arm, respectively, after implantation.Summary: Other unconscious arm abduction during sleep or increased muscular activity of the shoulder and arm might have led to repetitive motions within the pocket and dislodge the device. Adequate individualized patient and family education and regular evaluation every 6 month of the leads position with fluoroscopy or chest X-ray is advisable.