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Background: Even after atrial fibrillation (AF) catheter ablation, many patients still experience relevant symptom burden. The objective of the MENTAL AF trial was to determine whether app-based mental training (MT) during the 3 months following pulmonary vein isolation reduces AF-related symptoms., Methods and Results: Patients scheduled for pulmonary vein isolation were enrolled and randomized 1:1 to either app-based MT or usual care. Of 174 patients, 76 in the MT and 75 in the usual care group were included in the final analysis. The intervention was delivered by a daily 10-minute app-based MT. The primary outcome was the intergroup difference of the mean AF6 sum score, an AF-specific questionnaire, during the 3-month study period. Secondary outcomes included quality-of-life measures such as the AFEQT (Atrial Fibrillation Effect on Quality of Life). Mean age (SD) was 61 (8.7) years and 61 (41%) were women. The mean AF6 sum score over the study period was 8.9 (6.9) points in the MT group and 12.5 (10.1) in the usual care group ( P =0.011). This referred to a reduction in the AF6 sum score compared with baseline of 75% in MT and 52% for usual care ( P <0.001). The change in the AFEQT Global Score was 22.6 (16.3) and 15.7 (22.1), respectively; P =0.026., Conclusions: MENTAL AF showed that app-based MT as an adjunctive treatment tool following pulmonary vein isolation was feasible. App-based MT was found to be superior to standard care in reducing AF-related symptom burden and improving health-related quality of life., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04067427.

Aims: High-power-short-duration (HPSD) ablation is an effective treatment for atrial fibrillation but poses risks of thermal injuries to the oesophagus and vagus nerve. This study aims to investigate incidence and predictors of thermal injuries, employing machine learning., Methods and Results: A prospective observational study was conducted at Leipzig Heart Centre, Germany, excluding patients with multiple prior ablations. All patients received Ablation Index-guided HPSD ablation and subsequent oesophagogastroduodenoscopy. A machine learning algorithm categorized ablation points by atrial location and analysed ablation data, including Ablation Index, focusing on the posterior wall. The study is registered in clinicaltrials.gov (NCT05709756). Between February 2021 and August 2023, 238 patients were enrolled, of whom 18 (7.6%; nine oesophagus, eight vagus nerve, one both) developed thermal injuries, including eight oesophageal erythemata, two ulcers, and no fistula. Higher mean force (15.8 ± 3.9 g vs. 13.6 ± 3.9 g, P = 0.022), ablation point quantity (61.50 ± 20.45 vs. 48.16 ± 19.60, P = 0.007), and total and maximum Ablation Index (24 114 ± 8765 vs. 18 894 ± 7863, P = 0.008; 499 ± 95 vs. 473 ± 44, P = 0.04, respectively) at the posterior wall, but not oesophagus location, correlated significantly with thermal injury occurrence. Patients with thermal injuries had significantly lower distances between left atrium and oesophagus (3.0 ± 1.5 mm vs. 4.4 ± 2.1 mm, P = 0.012) and smaller atrial surface areas (24.9 ± 6.5 cm2 vs. 29.5 ± 7.5 cm2, P = 0.032)., Conclusion: The low thermal lesion's rate (7.6%) during Ablation Index-guided HPSD ablation for atrial fibrillation is noteworthy. Machine learning based ablation data analysis identified several potential predictors of thermal injuries. The correlation between machine learning output and injury development suggests the potential for a clinical tool to enhance procedural safety., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Low-voltage areas (LVAs) found during left atrial (LA) electroanatomical mapping are increasingly targeted by radiofrequency catheter ablation (RFCA) on top of pulmonary vein isolation to improve arrhythmia-free survival in patients with atrial fibrillation (AF). However, pre-procedural prediction of LVAs remains challenging. The purpose of the present study was to describe the association between parameters of LA function and dimensions, respectively, derived from pre-procedural cardiovascular magnetic resonance (CMR) imaging, and the presence of LVAs on LA voltage mapping., Methods and Results: Patients who underwent first-time RFCA for paroxysmal or persistent AF and who were in stable sinus rhythm during pre-procedural CMR imaging were included in this study. Cardiovascular magnetic resonance-derived parameters of LA function and dimensions were calculated. Low-voltage areas were defined as areas with bipolar voltage amplitudes of ≤0.5 mV on electroanatomical mapping. In total, 259 consecutive patients were included in this analysis. Low-voltage areas were found in 25 of 259 patients (9.7%). Compared with those without LVAs, patients with LVAs were significantly older, were more likely to be female, had a higher CHA2DS2-VASc score, had larger LA volumes, and had a lower LA total emptying fraction (TEF). In multivariate analysis, only LA TEF [odds ratio (OR) 0.885, 95% confidence interval (CI) 0.846-0.926, P < 0.001] and the CHA2DS2-VASc score (OR 1.507, 95% CI 1.115-2.038, P = 0.008) remained independently associated with the presence of LVAs., Conclusion: Left atrial TEF and the CHA2DS2-VASc score were independently associated with the presence of LVAs found during LA electroanatomical mapping. These findings may help to improve pre-procedural prediction of pro-arrhythmogenic LVAs and to improve peri-procedural patient management., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Aims: Same-day discharge (SDD) following catheter ablation (CA) of atrial fibrillation (AF) was already introduced in selected facilities in Europe, but a widespread implementation has not yet succeeded. Data on patients' perspectives are lacking. Therefore, we conducted a survey to address patients' beliefs towards SDD and identify variables that are associated with their evaluation., Methods and Results: As part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing left atrial CA for AF were asked to participate in the survey consisting of a study-specific questionnaire, the AF knowledge scale, and pre-defined patient-reported outcome measures. The study cohort was stratified based on SDD willingness, and a logistic regression analysis was used to identify predictors for patients' valuation. Between 26 July 2021 and 01 July 2022, 256 of 376 screened patients consented to study participation of whom 248 (mean age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%), and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, expressed concerns included uncertainties with occurring complaints (50.6%), the insufficient recognition (47.8%), and treatment (48.9%) of complications. European Heart Rhythm Association class at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not., Conclusion: We provide a detailed survey expressing patients' beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Early detection of atrial fibrillation (AF) could improve patient outcomes. P-wave duration (PWD) and interatrial block (IAB) are known predictors of new-onset AF and could improve selection for AF screening. This meta-analysis reviews the published evidence and offers practical implications., Methods: Publication databases were systematically searched, and studies reporting PWD and/or morphology at baseline and new-onset AF during follow-up were included. IAB was defined as partial (pIAB) if PWD≥120 ms or advanced (aIAB) if the P-wave was biphasic in the inferior leads. After quality assessment and data extraction, random-effects analysis calculated odds ratio (OR) and confidence intervals (CI). Subgroup analysis was performed for those with implantable devices (continuous monitoring)., Results: Among 16,830 patients (13 studies, mean 66 years old), 2,521 (15%) had new-onset AF over a median of 44 months. New-onset AF was associated with a longer PWD (mean pooled difference: 11.5 ms, 13 studies, p < 0.001). The OR for new-onset AF was 2.05 (95% CI: 1.3-3.2) for pIAB (5 studies, p = 0.002) and 3.9 (95% CI: 2.6-5.8) for aIAB (7 studies, p < 0.001). Patients with pIAB and devices had higher AF-detection risk (OR: 2.33, p < 0.001) than those without devices (OR: 1.36, p = 0.56). Patients with aIAB had similarly high risk regardless of device presence. There was significant heterogeneity but no publication bias., Conclusion: Interatrial block is an independent predictor of new-onset AF. The association is stronger for patients with implantable devices (close monitoring). Thus, PWD and IAB could be used as selection criteria for intensive screening, follow-up or interventions., (Copyright © 2023 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Aims: To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend remote monitoring (RM) of device-detected atrial high-rate episodes (AHREs) and progression of arrhythmia duration along pre-specified strata (6 min…<1 h, 1 h…<24 h, ≥ 24 h). We used the MATRIX registry data to assess the capability of a single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (DX ICD system) to follow this recommendation in patients with standard indication for single-chamber ICD., Methods and Results: In 1841 DX ICD patients with daily automatic RM transmissions, electrograms of first device-detected AHREs per patient in each duration stratum were adjudicated, and the corresponding positive predictive values (PPVs) for the detections to be true atrial arrhythmia were calculated. Moreover, the incidence and progression of new-onset AF was assessed in 1451 patients with no AF history. A total of 610 AHREs ≥6 min were adjudicated. The PPV was 95.1% (271 of 285) for episodes 6min…<1 h, 99.6% (253/254) for episodes 1 h…<24 h, 100% (71/71) for episodes ≥24 h, or 97.5% for all episodes (595/610). The incidence of new-onset AF was 8.2% (119/1451), and in 31.1% of them (37/119), new-onset AF progressed to a higher duration stratum. Nearly 80% of new-onset AF patients had high CHA2DS2-VASc stroke risk, and 70% were not on anticoagulation therapy. Age was the only significant predictor of new-onset AF., Conclusion: A 99.7% detection accuracy for AHRE ≥1 h in patients with DX ICD systems in combination with daily RM allows a reliable guideline-recommended screening for subclinical AF and monitoring of AF-duration progression., Competing Interests: Conflict of interest: D.T. is a consultant of Boston Scientific and has received research grants from Biotronik and Boston Scientific. M.A. has received speaker fees and conducts research sponsored by Biotronik. J.M. is an investigator in the Bio|Stream.HF study sponsored by Biotronik. I.D. has received speaker fees from Biotronik and Boston Scientific and conducts research sponsored by Abbott, Biotronik, Boston Scientific, and Medtronic. T.T. is an employee of Biotronik. The other authors declare no competing interests., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Cardiovascular magnetic resonance (CMR) imaging allows to combine pulmonary perfusion measurements and pulmonary venous angiography during a single-session examination with both imaging modules representing the basis for accurate diagnosis and therapeutic stratification of pulmonary vein (PV) stenosis. The present study investigated the clinical utility of dynamic pulmonary perfusion imaging integrated into a comprehensive CMR protocol for the evaluation of patients with suspected PV stenosis., Methods: 162 patients with clinically suspected PV stenosis after catheter ablation of atrial fibrillation underwent a combined single-session CMR examination (cardiac cine imaging, dynamic pulmonary perfusion, and three-dimensional PV angiography). CMR angiography was used for visual grading of PV stenoses; dynamic pulmonary perfusion imaging was evaluated per lung lobe visually and quantitatively., Results: All PV stenosis ≥90% showed a visible perfusion deficit of the corresponding lung lobe (60/60, 100%) while all PVs with luminal narrowing <50% exhibited normal pulmonary perfusion (680/680, 100%). However, every third 70-89% stenosis showed a normal pulmonary perfusion (10/31, 32%) while every fourth 50-69% PV stenosis was associated with hypoperfusion of the corresponding lung lobe (9/39, 23%). For quantitative pulmonary perfusion measurements, ROC analysis demonstrated high discriminatory power regarding PV stenosis detection with the highest AUC values for time-to-peak enhancement (cut-off value, 8.5 s)., Conclusions: The combination of CMR angiography and CMR pulmonary perfusion allowed for assessment of the anatomical degree of PV stenosis and its hemodynamic impact on the pulmonary parenchymal level. Thus, the proposed comprehensive CMR protocol provided an efficient diagnostic work-up of patients with suspected PV stenosis., Competing Interests: Declaration of Competing Interest The authors have no relevant financial or non-financial interests to disclose., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aims: Atrial fibrillation (AF) is a global health problem with high morbidity and mortality. Catheter ablation (CA) can reduce AF burden and symptoms, but AF recurrence (AFr) remains an issue. Simple AFr predictors like P-wave duration (PWD) could help improve AF therapy. This updated meta-analysis reviews the increasing evidence for the association of AFr with PWD and offers practical implications., Methods and Results: Publication databases were systematically searched and cohort studies reporting PWD and/or morphology at baseline and AFr after CA were included. Advanced interatrial block (aIAB) was defined as PWD ≥ 120 ms and biphasic morphology in inferior leads. Random-effects analysis was performed using the Review Manager 5.3 and R programs after study selection, quality assessment, and data extraction, to report odds ratio (OR) and confidence intervals. : Among 4175 patients in 22 studies, 1138 (27%) experienced AFr. Patients with AFr had longer PWD with a mean pooled difference of 7.8 ms (19 studies, P < 0.001). Pooled OR was 2.04 (1.16-3.58) for PWD > 120 ms (13 studies, P = 0.01), 2.42 (1.12-5.21) for PWD > 140 ms (2 studies, P = 0.02), 3.97 (1.79-8.85) for aIAB (5 studies, P < 0.001), and 10.89 (4.53-26.15) for PWD > 150 ms (4 studies, P < 0.001). There was significant heterogeneity but no publication bias detected., Conclusion: P-wave duration is an independent predictor for AF recurrence after left atrium ablation. The AFr risk is increasing exponentially with PWD prolongation. This could facilitate risk stratification by identifying high-risk patients (aIAB, PWD > 150 ms) and adjusting follow up or interventions., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background and Objective: Cardiac tamponade during ablation procedures is a life-threatening complication. While the incidence and management of tamponade in atrial fibrillation ablation have been extensively described, the data on tamponade during ventricular ablations are very limited. The purpose of this study is to shed light on the incidence, typical perforation sites, and optimal management as observed through real-life data in a tertiary referral center for ventricular ablation., Methods and Results: Consecutive patients with structural heart disease undergoing ventricular tachycardia ablation from 2008-2020 were analyzed. Of the 1078 patients undergoing 1287 ventricular ablation procedures, 20 procedures (1.5%) were complicated by cardiac tamponade. In all but one patient, the tamponade was treated with emergent pericardial drainage, while nine patients eventually underwent surgical repair. The perforation occurred during transseptal or subxiphoid puncture in six patients, during ventricle mapping in two patients, and during ablation in five patients (predominantly basal left ventricle). Steam pop as definite perforation cause could only be established in two patients. Regardless of the management of the complication, all patients survived to discharge., Conclusion: Cardiac tamponade during ventricular ablation occurred in 1.5% of the procedures. In nine patients cardiac repair was necessary. Perforation was mostly associated with subxiphoid puncture or ablation of the basal left ventricle., (© 2022 The Authors. The Journal of World Intellectual Property published by John Wiley & Sons Ltd.)

Background: Pulmonary vein (PV) stenosis represents a rare but serious complication following radiofrequency ablation of atrial fibrillation with a comprehensive diagnosis including morphological stenosis grading together with the assessment of its functional consequences being imperative within the relatively narrow window for therapeutic intervention. The present study determined the clinical utility of a combined, single-session cardiovascular magnetic resonance (CMR) imaging protocol integrating pulmonary perfusion and PV angiographic assessment for pre-procedural planning and follow-up of patients referred for interventional PV stenosis treatment., Methods: CMR examinations (cine imaging, dynamic pulmonary perfusion, three-dimensional PV angiography) were performed in 32 consecutive patients prior to interventional treatment of PV stenosis and at 1-day and 3-months follow-up. Degree of PV stenosis was visually determined on CMR angiography; visual and quantitative analysis of pulmonary perfusion imaging was done for all five lung lobes., Results: Interventional treatment of PV stenosis achieved an acute procedural success rate of 90%. Agreement between visually evaluated pulmonary perfusion imaging and the presence or absence of a ≥ 70% PV stenosis was nearly perfect (Cohen's kappa, 0.96). ROC analysis demonstrated high discriminatory power of quantitative pulmonary perfusion measurements for the detection of ≥ 70% PV stenosis (AUC for time-to-peak enhancement, 0.96; wash-in rate, 0.93; maximum enhancement, 0.90). Quantitative pulmonary perfusion analysis proved a very large treatment effect attributable to successful PV revascularization already after 1 day., Conclusion: Integration of CMR pulmonary perfusion imaging into the clinical work-up of patients with PV stenosis allowed for efficient peri-procedural stratification and follow-up evaluation of revascularization success., (© 2022. The Author(s).)

Competing Interests: Conflict of interest: none declared.

Purpose: Subjective estimation of recurrence after atrial fibrillation ablation is an important tool in clinical use. The aim of this study is to evaluate (1) if the subjective complexity of an atrial fibrillation ablation procedure is correlated with rhythm stability and (2) if the subjective prognosis of the operator has a predictive value., Methods: We prospectively enrolled patients admitted for ablation of atrial fibrillation. Two scores were given immediately after the procedure by the operator: the complexity and the prognosis scores. With routine follow-ups, we tried to evaluate the correlation between the subjective scores and measured outcome., Results: The study population included 611 patients (63 ± 10 years, 37% females, 61% persistent AF). During follow-up (FU) (median 24, IQR 7-36 months), recurrences occurred in 44% patients. Both scores (prognosis and complexity) correlated significantly with age, persistent AF, LA diameter, procedural characteristics, and recurrences. On multivariable analysis, complexity (OR 1.304, 95%CI 1.016-1.675, p = 0.037) and prognosis (OR 1.443, 95%CI 1.080-1.982, p = 0.013) scores remained significant predictors for arrhythmia recurrences. On ROC analysis, both scores showed significant predictive value for rhythm outcomes after catheter ablation (AUC 0.599 and 0.613, both p < 0.001 for complexity and prognosis scores, respectively)., Conclusions: Complexity and prognosis scores are significant predictors for arrhythmia recurrences after AF catheter ablations and even independent when competing with simple risk factors., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Catheter ablation of atrial fibrillation (AF) is the most effective rhythm control strategy and its role in the treatment of AF patients has been strengthened by recent guidelines. An increasing AF prevalence and the resulting demands on interventional electrophysiology call for improved resource allocation through both technical innovations and streamlined workflows and patient pathways. Same-day discharge is already established in the context of other electrophysiological interventions; however, its broad implementation in the practice of AF ablation is pending for several reasons, despite the fact that the body of evidence is growing and the majority of reports propagate early discharge to be feasible and safe under certain conditions. This review article is intended to provide an overview of the existing data, classify these into the specific study context, and to show limitations and open questions., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The quantity of data produced and captured in medicine today is unprecedented. Technological improvements and automation have expanded the traditional statistical methods and enabled the analysis of Big Data. This has permitted the discovery of new associations with a granularity that was previously hidden to human eyes. In the first part of this review, the authors would like to provide an overview of basic Machine Learning (ML) principles and techniques in order to better understand their application in recent publications about cardiac arrhythmias. In the second part, ML-enabled advances in disease detection and diagnosis, outcome prediction, and novel disease characterization in topics like electrocardiography, atrial fibrillation, ventricular arrhythmias, and cardiac devices are presented. Finally, the limitations and challenges of applying ML in clinical practice, such as validation, replication, generalizability, and regulatory issues, are discussed. More carefully designed studies and collaborations are needed for ML to become feasible, trustworthy, accurate, and reproducible and to reach its full potential for patient-oriented precision medicine., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Aims: Evidences suggest that recurrent atrial fibrillation (AF) is associated with left atrial (LA) remodelling. The goal of this study is to establish a method for assessment of LA remodelling and find predictors for the development of AF., Methods and Results: This prospective study included patients without a history of AF who were evaluated using pulsed-wave tissue Doppler imaging (PW-TDI). P-wave onset to A'-wave (PA' interval) was measured at the septal, lateral, anterior, and inferior mitral annulus. Abnormal LA activation pattern was defined as an upward LA activation over the coronary sinus and delayed activation anterior. Left atrial asynchrony was measured as (i) the difference between the septal and lateral PA' interval (DLS) and (ii) the standard deviation of all four PA' intervals (SD4-PA'). The follow-up for AF recurrence (AF+) was based on symptoms and 7-day Holter electrocardiograms. Ninety-eight patients (mean age 58 ± 15 years, 47% female) were included. During a follow-up of 28 ± 9 months, AF was documented in 10%. More pronounced LA asynchrony was observed in AF+ group: DLS (AF+) 39 ± 16 vs. DLS (AF-) 20 ± 11 ms; P < 0.001, and SD4-PA' (AF+) 18.6 ± 6.4 vs. SD4-PA' (AF-) 11.7 ± 4.2 ms; P < 0.001. Abnormal LA activation was frequently observed in AF+ patients: 60% vs. 27%; P = 0.033. Electrocardiogram sign of Bachmann's bundle block (BBB) was associated with prolongation of SD4-PA': SD4-PA' (BBB+) vs. SD4-PA' (BBB-) = 18 ± 6 vs. 13 ± 4.5 ms; P = 0.007., Conclusions: More pronounced LA asynchrony and abnormal LA activation pattern were associated with new-onset AF., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Atrial fibrillation (AF) will become one of the biggest challenges in cardiovascular medicine in the near future. Attempting an improvement in future patient care calls explicitly for the screening of subclinical AF. Digital health solutions implementing communication technologies for the collection and analysis of digitally assessable data will most likely serve this need. Several new rapidly developing methods were introduced in the past decade. Although the vast majority still require scientific validation, the body of evidence is growing and several randomized controlled trials are planned. This review aims to give an overview of current technologies with a specific focus on mobile health (mHealth) and appraise their value with regard to the available scientific data., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

The term "atrial remodeling" is used to describe the electrical, mechanical, and structural changes associated with the presence of an arrhythmogenic substrate for atrial fibrillation. Rhythm control therapy may slow down or even reverse progressive atrial remodeling. Atrial remodeling has long been recognized as an important predictor of clinical outcomes and therapeutic success, but recent advances have highlighted its clinical relevance and revealed the implications of specific anatomical changes such as atrial asymmetry or shape. This has opened the path to computational precision medicine that captures these data in detail and combines them with other factors, to provide patient-specific solutions. The goal of precision medicine lies in improving clinical outcomes, reducing costs, and avoiding unnecessary procedures. In this article, we review the history of atrial remodeling and we summarize the insights from our research on anatomical atrial remodeling and its association with rhythm outcomes after catheter ablation. Finally, we present recent advances in the field, reflecting the beginning of a new technological era that will enable us to improve patient care by personalized patient-specific medicine., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Atrial fibrillation (AF) leads to remodeling characterized by changes in both size and shape of the left atrium (LA). Here we aimed to study the effect of hypertrophic cardiomyopathy (HCM) on the pattern of LA remodeling in AF-patients. HCM-patients (n = 23) undergoing AF ablation (2009-2012) were matched and compared with 125 Non-HCM patients from our prospective registry. Pre-procedural CT data were analyzed (EnSite Verismo, SJM, MN) to determine the maximal sagittal (anterior-posterior, AP), coronal (superior-inferior, SI and transversal, TV) dimensions and the sphericity index (LAS). Volume (LAV) was rendered after appendage (LAA) and pulmonary vein (PV) exclusion. A cutting plane, between PV ostia/LAA and parallel to the posterior wall, divided LAV into anterior- (LA-A) and posterior-LA (LA-P) parts. The ratio LA-A/LAV was defined as asymmetry index (ASI). HCM patients had a wider inter-ventricular septum and a smaller LV than Non-HCM patients. LA volume (LAV 166 ± 72 vs. 130 ± 36 ml, p = 0.03) and LA diameters were significantly larger in HCM patients. Anterior volume (LA-A: 112 ± 48 vs. 83 ± 26 ml, p < 0.001) differed significantly between groups, whereas the posterior volume LA-P (55 ± 28 vs. 47 ± 13 ml, p = 0.23) and LAS (75% vs. 78%, p = 0.089) was similar in both groups. As a result, ASI was significantly higher (67 ± 6 vs. 63 ± 6%, p = 0.01) in HCM than in Non-HCM patients. In conclusion, LA remodeling in patients with AF and HCM is characterized by asymmetric dilatation, driven by an anterior rather than a posterior dilatation. This can be characterized by three-dimensional imaging and could be used as surrogate of advanced atrial remodeling.

Aims: Several reports indicate lower rates of emergency admissions in the cardiovascular sector and reduced admissions of patients with chronic diseases during the Coronavirus SARS-CoV-2 (COVID-19) pandemic. The aim of this study was therefore to evaluate numbers of admissions in incident and prevalent atrial fibrillation and flutter (AF) and to analyse care pathways in comparison to 2019., Methods: A retrospective analysis of claims data of 74 German Helios hospitals was performed to identify consecutive patients hospitalized with a main discharge diagnosis of AF. A study period including the start of the German national protection phase (13 March 2020 to 16 July 2020) was compared to a previous year control cohort (15 March 2019 to 18 July 2019), with further sub-division into early and late phase. Incidence rate ratios (IRRs) were calculated. Numbers of admission per day (A/day) for incident and prevalent AF and care pathways including readmissions, numbers of transesophageal echocardiogram (TEE), electrical cardioversion (CV), and catheter ablation (CA) were analysed., Results: During the COVID-19 pandemic, there was a significant decrease in total AF admissions both in the early (44.4 vs. 77.5 A/day, IRR 0.57 [95% confidence interval (CI) 0.54-0.61], P < 0.01) and late (59.1 vs. 63.5 A/day, IRR 0.93 [95% CI 0.90-0.96], P < 0.01) phases, length of stay was significantly shorter (3.3 ± 3.1 nights vs. 3.5 ± 3.6 nights, P < 0.01), admissions were more frequently in high-volume centres (77.0% vs. 75.4%, P = 0.02), and frequency of readmissions was reduced (21.7% vs. 23.6%, P < 0.01) compared to the previous year. Incident AF admission rates were significantly lower both in the early (21.9 admission per day vs. 41.1 A/day, IRR 0.53 [95% CI 0.48-0.58]) and late (35.5 vs. 39.3 A/day, IRR 0.90 [95% CI 0.86-0.95]) phases, whereas prevalent admissions were only lower in the early phase (22.5 vs. 36.4 A/day IRR 0.62 [95% CI 0.56-0.68]), but not in the late phase (23.6 vs. 24.2 A/day IRR 0.97 [95% CI 0.92-1.03]). Analysis of care pathways showed reduced numbers of TEE during the early phase [34.7% vs. 41.4%, odds ratio (OR) 0.74 [95% CI 0.64-0.86], P < 0.01], but not during the late phase (39.9% vs. 40.2%, OR 0.96 [95% CI 0.88-1.03], P = 0.26). Numbers of CV were comparable during early (40.6% vs. 39.7%, OR 1.08 [95% CI 0.94-1.25], P = 0.27) and late (38.6% vs. 37.5%, OR 1.06 [95% CI 0.98-1.14], P = 0.17) phases, compared to the previous year, respectively. Numbers of CA were comparable during the early phase (21.6% vs. 21.1%, OR 0.98 [95% CI 0.82-1.17], P = 0.82) with a distinct increase during the late phase (22.9% vs. 21.5%, OR 1.05 [95% CI 0.96-1.16], P = 0.28)., Conclusion: During the COVID-19 pandemic, AF admission rates declined significantly, with a more pronounced reduction in incident than in prevalent AF. Overall AF care was maintained during early and late pandemic phases with only minor changes, namely less frequent use of TEE. Confirmation of these findings in other study populations and identification of underlying causes are required to ensure optimal therapy in patients with AF during the COVID-19 pandemic., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: To develop quality indicators (QIs) that may be used to evaluate the quality of care and outcomes for adults with atrial fibrillation (AF)., Methods and Results: We followed the ESC methodology for QI development. This methodology involved (i) the identification of the domains of AF care for the diagnosis and management of AF (by a group of experts including members of the ESC Clinical Practice Guidelines Task Force for AF); (ii) the construction of candidate QIs (including a systematic review of the literature); and (iii) the selection of the final set of QIs (using a modified Delphi method). Six domains of care for the diagnosis and management of AF were identified: (i) Patient assessment (baseline and follow-up), (ii) Anticoagulation therapy, (iii) Rate control strategy, (iv) Rhythm control strategy, (v) Risk factor management, and (vi) Outcomes measures, including patient-reported outcome measures (PROMs). In total, 17 main and 17 secondary QIs, which covered all six domains of care for the diagnosis and management of AF, were selected. The outcome domain included measures on the consequences and treatment of AF, as well as PROMs., Conclusion: This document defines six domains of AF care (patient assessment, anticoagulation, rate control, rhythm control, risk factor management, and outcomes), and provides 17 main and 17 secondary QIs for the diagnosis and management of AF. It is anticipated that implementation of these QIs will improve the quality of AF care., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Background: Cardiac resynchronization therapy (CRT) is widely used in atrial fibrillation (AF) patients and could impact rhythm stability., Hypothesis: We aimed to identify predictors of sinus rhythm (SR) stability or AF progression in a real-word cohort of CRT-AF patients., Methods: From 330 consecutive implantable cardioverter-defibrillator implantations due to ischemic or dilated cardiomyopathy, 65 (20%) patients with AF history (paroxysmal, n = 32) underwent a CRT implantation with an atrial electrode and were regularly followed every 4-6 months. Rhythm restoration was attempted for most AF patients based on symptoms, biventricular pacing (BP), and lack of thrombi., Results: After 33 months, 18 (28%) patients progressed to permanent mode switch (MS≥99%) and 20 (31%) patients had stable SR (MS < 1%). Logistic regression showed that history of persistent AF (OR: 8.01, 95%CI: 2.0-31.7, p = .003) is associated with higher risk of permanent MS. In persistent AF patients, a bigger left atrium (OR: 1.2 per mm, 95%CI: 1.03-1.4, p = .025) and older age (OR: 1.15 per life-year, 95%CI: 1.01-1.3, p = .032) were predictors of future permanent MS. Paroxysmal AF at implantation (OR: 5.96, 95%CI: 1.6-21.9, p = .007) and increased BP (OR: 1.4 per 1%, 95%CI: 1.05-1.89, p = .02) were associated with stable SR. In persistent AF patients, stable SR correlated with higher BP (98 ± 2 vs. 92 ± 8%, p < .001)., Conclusion: In patients with AF undergoing CRT implantation, persistent AF, LA dilatation and advanced age relate to future permanent MS (AF), whereas high BP promotes SR stability. These findings could facilitate the management of CRT-AF patients and guide therapy in order to maximize its effect on rhythm., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Background: To achieve high image quality of cardiovascular magnetic resonance (CMR) pulmonary vein (PV) angiography prior catheter ablation in patients with atrial fibrillation, optimal timing of the angiographic sequence during contrast agent passage is important. The present study identified influential cardiovascular parameters for prediction of contrast agent travel time., Methods: One hundred six consecutive patients underwent a CMR examination including three-dimensional (3D) contrast-enhanced PV angiography with real-time bolus tracking prior to catheter ablation. Correct scan timing was characterized by relative signal enhancement measurements in the pulmonary artery, left atrium (LA), and ascending aorta. Furthermore, left- and right-ventricular function, left- and right-atrial dimensions, presence of mitral or tricuspid insufficiencies, and main pulmonary artery diameter were determined., Results: The highest relative signal enhancement in LA demonstrated optimal scan timing. Contrast agent travel time showed wide variability (range: 12-42 s; mean: 18 ± 4 s). On univariate analysis, most cardiovascular parameters correlated with contrast agent travel time while on multivariate analysis left- and right-ventricular function remained the only independent predictors, but overall a poor fit to the data (adjusted R2, 27.5%) was found., Conclusions: Contrast agent travel time was mainly influenced by left- and right-ventricular function but prediction models poorly fitted the data. Thus, 3D PV angiography prior to PV ablation procedures necessitates real-time assessment, with visual determination of individual contrast agent passage time to ensure consistently high CMR image quality.

Background: The aim of the current study was to analyze the impact of single versus double transseptal puncture (TSP) for atrial fibrillation (AF) ablation., Methods: Consecutive patients undergoing AF ablation were prospectively included in the AF ablation registry and were analyzed according to single versus double TSP., Results: A total of 478 patients (female 35%, persistent AF 67%) undergoing AF ablation between 01/2014 and 09/2014 were included. Single TSP was performed in 202 (42%) patients, double TSP in 276 (58%) patients. Age, gender, body mass index, CHA2DS2-VASc score, left ventricular ejection fraction and operator experience (experienced operator defined as ≥ 5 years of experience in invasive electrophysiology) were equally distributed between the two groups. Repeat procedures (re-dos) were more frequently performed using single TSP access (p < 0.001). Left atrial (LA) diameter was larger in patients with double TSP (p = 0.001). Procedure duration in single TSP was identical to double TSP procedures (p = 0.823). Radiation duration was similar between the two groups (p = 0.217). There were 49 (10%) patients with complications after catheter ablation. There were no differences between complication rates and TSP type (p = 0.555). Similarly, recurrence rates were comparable between both TSP groups (p = 0.788)., Conclusions: There was no clear benefit of single or double TSP in AF ablation.

Background: The beneficial effect of remote ischemic preconditioning (RIP) on electrophysiological parameters resulting in lower inducibility and sustainability of atrial fibrillation (AF) in patients with paroxysmal AF has been recently demonstrated in a randomized trial. However, the potential clinical impact of RIP on persistent AF (CAF) has not been investigated. Therefore, we designed a randomized trial set in a setting of electrical cardioversion (CV) of early onset CAF., Aim: The aim of the study is to answer the following questions: I) Does RIP have impact on rate of spontaneous conversion into sinus rhythm (SR) within 24 h after first RIP intervention? II) Does RIP have the potential to improve the acute outcome of CV following a standardized protocol?, Methods: The presented study is a two-armed randomized, placebo-controlled, double-blinded, multi-center trial in a cohort of 588 patients with early onset CAF referred for electrical CV. The patients will undergo 3 sessions (immediately after randomization, the following morning, and directly before scheduled CV 24 h after randomization) of either RIP intervention or a sham procedure. The primary outcome of the study, i.e. documentation of SR 24 h after randomization as well secondary outcome i.e. stable SR first CV without usage of anti-arrhythmic drugs will be documented by 12-lead surface electrocardiography., Conclusion: Previously observed positive effect of RIP on atrial electrophysiology might be also implemented in a clinical setting of CV and therefore simplified and improve patient treatment., (Copyright © 2020. Published by Elsevier Ltd.)

Background: Identifying patients with advanced left atrial (LA) remodeling before catheter ablation (CA) of atrial fibrillation (AF) is crucial., Hypothesis: This study aimed to identify echocardiographic parameters associated with changes in anatomy and conduction properties of the left atrium (LA)., Methods: We examined 75 AF patients prior to CA and measured the intervals from the P-wave-onset to four mitral annulus sites by pulsed-wave tissue Doppler imaging (PW-TDI). Patients were grouped to an upward U-pattern (delayed anterior activation) and a downward D-pattern (earliest LA activation anterior). CT-data were used to measure the LA volume (LAV). LAV was divided into anterior- (LA-A) and posterior-parts by a plane, parallel to the posterior wall and between the veins and the appendage, to calculate the asymmetry index (ASI = LA-A/LAV)., Results: Patients with U-pattern (n = 66) had a higher ASI (65 ± 6 vs. 61 ± 3%, p = .014), older age (61 ± 11 vs. 51 ± 11 years, p = .03) and more diastolic dysfunction (71 vs. 22%, p = .008) Multivariate regression showed that age (OR 1.1 per year, CI 1.007-1.199) and diastolic dysfunction (OR 6.36, CI 1.132-35.7, p = .036) were independent predictors of the U-pattern. Diastolic dysfunction (B 4.49, CI 1.61-7.37, p = .003) was the only independent predictor of ASI in linear regression analysis., Conclusion: AF patients with a U-pattern have an increased LA asymmetry. Diastolic dysfunction is a common cause of this LA activation and remodeling. Therefore, detection of a U-pattern signifies patients with advanced AF and may facilitate selection for an appropriate ablation strategy., (© 2020 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

In clinical practice, atrial fibrillation (AF) is known as the most common sustained arrhythmia. Therefore, identification of individuals at risk of AF development/recurrence or its associated complications has emerged as a hot topic in the field of cardiology. Recently, several biomarkers have been introduced to predict AF and its consequences; however, use of biomarkers in AF management has not been highly recommended by guidelines yet. While utilization of natriuretic peptides (NPs) including brain (B-type) NPs (BNPs) in heart failure management has been well established, their use in relation to AF has not been fully understood. Accordingly, this review article aimed at presenting an overview of the role of NPs in predicting AF development/recurrence as well as its complications and making suggestions for their use in management of patients with AF in clinical settings.

Objective: Atrial fibrillation or atrial flutter (AF) and heart failure (HF) often go hand in hand and, in combination, lead to an increased risk of death compared with patients with just one of both entities. Sex-specific differences in patients with AF and HF are under-reported. Therefore, the aim of this study was to investigate sex-specific catheter ablation (CA) use and acute in-hospital outcomes in patients with AF and concomitant HF in a retrospective cohort study., Methods: Using International Statistical Classification of Diseases and Related Health Problems and Operations and Procedures codes, administrative data of 75 hospitals from 2010 to 2018 were analysed to identify cases with AF and HF. Sex differences were compared for baseline characteristics, right and left atrial CA use, procedure-related adverse outcomes and in-hospital mortality., Results: Of 54 645 analysed cases with AF and HF, 46.2% were women. Women were significantly older (75.4±9.5 vs 68.7±11.1 years, p<0.001), had different comorbidities (more frequently: cerebrovascular disease (2.4% vs 1.8%, p<0.001), dementia (5.3% vs 2.2%, p<0.001), rheumatic disease (2.1% vs 0.8%, p<0.001), diabetes with chronic complications (9.7% vs 9.1%, p=0.033), hemiplegia or paraplegia (1.7% vs 1.2%, p<0.001) and chronic kidney disease (43.7% vs 33.5%, p<0.001); less frequently: myocardial infarction (5.4% vs 10.5%, p<0.001), peripheral vascular disease (6.9% vs 11.3%, p<0.001), mild liver disease (2.0% vs 2.3%, p=0.003) or any malignancy (1.0% vs 1.3%, p<0.001), underwent less often CA (12.0% vs 20.7%, p<0.001), had longer hospitalisations (6.6±5.8 vs 5.2±5.2 days, p<0.001) and higher in-hospital mortality (1.6% vs 0.9%, p<0.001). However, in the multivariable generalised linear mixed model for in-hospital mortality, sex did not remain an independent predictor (OR 0.96, 95% CI 0.82 to 1.12, p=0.579) when adjusted for age and comorbidities. Vascular access complications requiring interventions (4.8% vs 4.2%, p=0.001) and cardiac tamponade (0.3% vs 0.1%, p<0.001) occurred more frequently in women, whereas stroke (0.6% vs 0.5%, p=0.179) and death (0.3% vs 0.1%, p=0.101) showed no sex difference in patients undergoing CA., Conclusions: There are sex differences in patients with AF and HF with respect to demographics, resource utilisation and in-hospital outcomes. This needs to be considered when treating women with AF and HF, especially for a sufficient patient informed decision making in clinical practice., Competing Interests: Competing interests: GH is receiving grants through the Leipzig Heart Institute from Boston Scientific (Boston Scientific Corporation, Marlborough, Massachusetts, USA) and Abbott/St. Jude Medical (Abbott Laboratories, Chicago, Illinois, USA), no personal payments are to declare. JT is receiving personal fees from Medtronic (Medtronic plc, Minneapolis, Minnesota, USA). The other authors state that there is no conflict of interest., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: As health systems around the world increasingly look to measure and improve the value of care that they provide to patients, being able to measure the outcomes that matter most to patients is vital. To support the shift towards value-based health care in atrial fibrillation (AF), the International Consortium for Health Outcomes Measurement (ICHOM) assembled an international Working Group (WG) of 30 volunteers, including health professionals and patient representatives to develop a standardized minimum set of outcomes for benchmarking care delivery in clinical settings., Methods and Results: Using an online-modified Delphi process, outcomes important to patients and health professionals were selected and categorized into (i) long-term consequences of disease outcomes, (ii) complications of treatment outcomes, and (iii) patient-reported outcomes. The WG identified demographic and clinical variables for use as case-mix risk adjusters. These included baseline demographics, comorbidities, cognitive function, date of diagnosis, disease duration, medications prescribed and AF procedures, as well as smoking, body mass index (BMI), alcohol intake, and physical activity. Where appropriate, and for ease of implementation, standardization of outcomes and case-mix variables was achieved using ICD codes. The standard set underwent an open review process in which over 80% of patients surveyed agreed with the outcomes captured by the standard set., Conclusion: Implementation of these consensus recommendations could help institutions to monitor, compare and improve the quality and delivery of chronic AF care. Their consistent definition and collection, using ICD codes where applicable, could also broaden the implementation of more patient-centric clinical outcomes research in AF., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Ablation is a widely used therapy for atrial fibrillation (AF); however, arrhythmia recurrence and repeat procedures are common. Studies examining surrogate markers of genetic susceptibility to AF, such as family history and individual AF susceptibility alleles, suggest these may be associated with recurrence outcomes. Accordingly, the aim of this study was to test the association between AF genetic susceptibility and recurrence after ablation using a comprehensive polygenic risk score for AF., Methods: Ten centers from the AF Genetics Consortium identified patients who had undergone de novo AF ablation. AF genetic susceptibility was measured using a previously described polygenic risk score (N=929 single-nucleotide polymorphisms) and tested for an association with clinical characteristics and time-to-recurrence with a 3 month blanking period. Recurrence was defined as >30 seconds of AF, atrial flutter, or atrial tachycardia. Multivariable analysis adjusted for age, sex, height, body mass index, persistent AF, hypertension, coronary disease, left atrial size, left ventricular ejection fraction, and year of ablation., Results: Four thousand two hundred seventy-six patients were eligible for analysis of baseline characteristics and 3259 for recurrence outcomes. The overall arrhythmia recurrence rate between 3 and 12 months was 44% (1443/3259). Patients with higher AF genetic susceptibility were younger ( P <0.001) and had fewer clinical risk factors for AF ( P =0.001). Persistent AF (hazard ratio [HR], 1.39 [95% CI, 1.22-1.58]; P <0.001), left atrial size (per cm: HR, 1.32 [95% CI, 1.19-1.46]; P <0.001), and left ventricular ejection fraction (per 10%: HR, 0.88 [95% CI, 0.80-0.97]; P =0.008) were associated with increased risk of recurrence. In univariate analysis, higher AF genetic susceptibility trended towards a higher risk of recurrence (HR, 1.08 [95% CI, 0.99-1.18]; P =0.07), which became less significant in multivariable analysis (HR, 1.06 [95% CI, 0.98-1.15]; P =0.13)., Conclusions: Higher AF genetic susceptibility was associated with younger age and fewer clinical risk factors but not recurrence. Arrhythmia recurrence after AF ablation may represent a genetically different phenotype compared to AF susceptibility.

Background: The role of atrial arrhythmia inducibility as an endpoint of catheter ablation of atrial fibrillation (AF) has been a controversial subject in many studies. Our goal is to evaluate the significance of inducibility, the impact of multiple sites or protocols of stimulation or the change in inducibility status in a prospective study including patients with AF undergoing first catheter ablation., Methods: We studied 170 consecutive patients with AF (62.9% paroxysmal) undergoing catheter ablation. All patients underwent two separate stimulation protocols before and after the ablation from the coronary sinus ostium and the left atrial appendage: burst pacing at 300, 250, 200 milliseconds (or until refractoriness) for 10 seconds and ramp decrementing from 300 to 200 milliseconds in increments of 10 milliseconds every three beats for 10 seconds. Inducibility was defined as any sustained AF or organized atrial tachycardia (AT) lasting >30 seconds., Results: We had AF/AT inducibility in 55 patients at baseline compared to 36 following ablation. After a mean of 41, 3 months follow-up, 115 patients were free of AF. Inducibility before or after the ablation or change in inducibility status did not influence AF recurrence. There were no significant differences regarding paroxysmal or persistent patients with AF., Conclusions: Non-inducibility of atrial arrhythmia or change in inducibility status following pulmonary vein (PV) isolation and substrate modification are not associated with long-term freedom from recurrent arrhythmia. Therefore, the use of induction of an endpoint in AF ablation is limited., (© 2020 Wiley Periodicals, Inc.)

Background: Myeloperoxidase (MPO), secreted by neutrophils under inflammatory conditions, is elevated in atrial fibrillation (AF). MPO may be involved in atrial remodeling that underpins AF progression characterized by a switch from paroxysmal to persistent AF and the formation of low-voltage areas (LVA). MPO levels are modulated by renin-angiotensin system antagonists (RAS-A), commonly used to treat AF comorbidities, and are associated with reduced AF incidence, implicating a potential link., Objective: We investigated MPO levels in progressing AF in peripheral and left atrial (LA) blood and analyzed a potential effect of RAS-A., Methods: Samples of AF patients were collected from the femoral vein and the LA during catheter ablation (n = 121) and at follow-up (n = 23). No-AF probands (n = 37) served as controls. MPO was determined using commercial ELISA., Results: MPO levels were significantly increased in AF patients compared to controls (median, 27.7 ng/ml (IQR 14.3-66.6) versus 12.6 (IQR 9.9-17.7), p < 0.001), without differences between clinical AF progression phenotypes. MPO concentration was tenfold higher in LA than periphery (279.2 ng/ml (IQR 202.2-342.9) versus 27.7 ng/ml (IQR 14.3-65.9), p < 0.001). MPO remained increased at midterm follow-up irrespective of rhythm outcome. RAS-A was associated with significantly lower peripheral (22.2 ng/ml (IQR 12.7-48.2) versus 37.1 ng/ml (IQR 18.2-85.2), p < 0.05) MPO levels in AF patients., Conclusion: The pro-fibrotic enzyme MPO is generally elevated in AF patients irrespective of AF type, the presence of LVA or midterm rhythm outcome. Our data suggest that MPO may directly originate from the LA. RAS-A decrease peripheral MPO levels in AF patients.

Background: Thermolesions are a dangerous complication of atrial fibrillation (AF) ablation. We aimed to assess the reasons for thermolesions and the effect of esophageal position on recurrences., Methods: The study included consecutive patients undergoing AF catheter ablation at Heart Center Leipzig between January and September 2014. We collected data of esophagus localization, temperature, endoscopy, and follow-up., Results: The study included 645 patients into analyses. A total of 626 (97.2%) received a temperature probe. Esophageal position was categorized: (A) behind left pulmonary veins, (B) left ostial, (C) in the middle of left atrium, (D) right ostial, and (E) behind right pulmonary veins. The most frequent esophageal position was B-C (n = 201, 32.1%), followed by B (n = 161, 25.7%), and C (n = 147, 23.5%). The temperature was highest in A-B positions (42.04°C) and in D-E positions (41.70°C). There was a significant correlation between the endoscopically detected esophageal lesions (EDEL) and the esophageal position (r² = -.115, P = .004) and the esophageal temperature (r² = .162, P = .000), but not with body mass index (BMI) (r² = -.016, P = .688). Additional substrate modification in the left atrium resulted in significantly higher esophageal temperatures (P < .001) and more frequent EDEL (P = .049). An EDEL was found in 15 patients (2.3% of all patients, 5.6% of patients receiving endoscopy). Of those, the median esophageal temperature was 41.8°C (interquartile range [IQR]: 41.2-42.4). Neither esophageal position nor temperature during ablation was associated with arrhythmia recurrences (both P > .400)., Conclusions: EDEL depended on the esophageal position and temperature, but not on BMI. Esophageal position and intraluminal temperature during ablation had no effect on recurrences., (© 2019 Wiley Periodicals, Inc.)

Introduction: The aim of this study was to describe and illustrate the technique of performing interatrial septum biopsy and to demonstrate its use for direct histological substrate characterization in atrial fibrillation (AF)., Methods and Results: Biopsies were performed in four patients who underwent AF catheter ablation. Bipal 7 bioptome was directed through a steerable sheath directly onto the septum. Fluoroscopic views as well as echocardiography-guided techniques were utilized to confirm that the tip was oriented towards the interatrial septum. The bioptome was then placed on the right atrial (RA) septum and maneuvered to obtain the specimens (at least 1 mm in size) from the posterior septal region of the RA, adjacent to the fossa ovalis. Bioptome placement and sample acquisition were successful in all patients at the first attempt. No patient developed any minor or major complications during the procedure and hospital stay. All the biopsy specimens had proper qualities for histological assessments and revealed a variety of pathologies including fibrosis, inflammation, and fatty infiltration., Conclusion: Atrial septum biopsies could be safely performed guided by fluoroscopy and transesophageal echocardiography. The obtained specimens allowed for a detailed localized substrate characterization which is of great interest in AF., (© 2019 Wiley Periodicals, Inc.)

Introduction: Atrial fibrillation (AF) has been recognised as the most prevalent sustained arrhythmia. Recently, a growing body of evidence has suggested that AF might be involved in the progression of cognitive impairment (CIM), potentially extending into types of dementia. Accordingly, the purpose of the present study was to summarise the findings of investigations examining association between AF and cognitive function as well as highlighting the possible causes of discrepancy between the findings and reviewing the probable mechanisms of CIM in patients affected with AF., Methods: A systematic search in the literature was conducted in the databases of PubMed, Scopus, Cochrane Library, and Google Scholar with no language restrictions, using specified search terms to identify studies published between 1 January 1990 and 1 April 2018. Then, study designs, participant information, diagnostic approaches used for cognitive assessments, and incidence/prevalence rates of CIM and/or dementia were assessed., Results: Out of the initial 2,364 articles retrieved, a total number of 40 studies were selected for data collection. Most studies had suggested a significant relationship between AF and CIM. In this regard, cerebral hypo-perfusion, altered cerebral blood flow, cerebral micro-bleeds, micro-emboli, vascular inflammation, cerebral small vessel diseases, vascular inflammation, and genetic factors were considered as the possible mechanisms of CIM in patients suffering from AF. It seemed that differences in study settings and designs, variations of diagnostic tools for CIM and AF, as well as underlying conditions such as age groups, concurrent chronic diseases, and therapeutic interventions for AF might be amongst probable factors justifying the diversity of findings across the selected articles., Conclusion: Although evidence is much more directed towards an association between AF and CIM, the role of AF in CIM needs to be confirmed in-depth via longer prospective and cohort studies at larger scales using accurate neuropsychological and cognitive function assessments. Moreover, the mechanisms involved in the relationship between AF and Alzheimer's disease (AD) require further studies. To conclude, the effect of different therapeutic strategies of AF on CIM should be investigated in more clinical trials., (Copyright © 2019 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Atrial fibrillation (AF) remains the most relevant arrhythmia with a prevalence of 2%. The treatment options are either highly invasive and cost-intensive or limited by potential side effects or insufficient efficacy. However, no direct means of prevention that could reduce the burden of AF have been tested., Objective: The purpose of this study was to determine whether remote ischemic preconditioning (RIPC) has an impact on inducibility and sustainability of AF., Methods: A total of 146 patients with paroxysmal AF undergoing electrophysiology study were randomized to receive either RIPC, performed by short episodes of forearm ischemia, or sham intervention (clinicaltrials.gov identifier: NCT02779660). Effective refractory periods, conduction times, velocities, and conduction delays measured were analyzed by pacing from the coronary sinus (CS). End points of the study were the inducibility and sustainability of AF after prespecified rapid pacing sequences., Results: RIPC significantly reduces the inducibility (odds ratio 0.35; 95% confidence interval 0.17-0.71; P = .003) and sustainability (odds ratio 0.36; 95% confidence interval 0.16-0.81; P = .01) of AF. Furthermore, it decreased dispersion of atrial refractory periods (16.0 ± 14.0 ms vs 22.7 ± 19.0 ms; P = .021) as well as atrial conduction delays (49.2 ± 19.6 ms vs 56.2 ± 22.5 ms; P = .049 for proximal CS and 42.4 ± 16.6 ms vs 49.8 ± 22.2 ms; P = .029 for distal CS). In the whole cohort, longer atrial conduction delay (57.6 ± 22.2 ms vs 50.0 ± 20.5 ms; P = .044) and slower conduction velocity (1.74 ± 0.3 mm/ms vs 1.93 ± 0.5 mm/ms; P = .006) were associated with inducibility of AF whereas a wider dispersion of effective refractory periods (25.9 ± 18.3 ms vs 15.7 ± 11.6 ms; P = .028) maintained AF episodes., Conclusion: RIPC reduces the inducibility and sustainability of AF, which is possibly mediated by changes in electrophysiological properties of the atria. It may be used as a simple noninvasive procedure to reduce AF burden., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The significance of the inducibility of atrial fibrillation (AF) after pulmonary vein isolation (PVI) in patients with AF remains disputable and polarizing. Therefore, we investigated the prognostic value of the inducibility of AF on long-term outcome after PVI in patients without low-voltage left atrial (LA) substrate., Methods: Two hundred forty-five patients (mean age 59+/-9years, 72% male) without LA low-voltage areas (defined as electrogram amplitudes <0.5 mV) undergoing first PVI procedure were included in the study. Following successful PVI, inducibility was assessed by burst pacing from coronary sinus with a cycle length (CL) of 300, 250, and 200 ms or the shortest CL resulting in 1:1 atrial capture. During the follow-up period of up to 3 years, the rhythm outcome was monitored by serial 7-days Holter electrocardiogram., Results: AF was induced in 38 patients (16%). Atypical atrial flutter was observed in six patients (2%), while typical flutter in three cases (1%). Within the first 3 months, early recurrence was diagnosed in 39 patients (16%), while late recurrence was detected in 58 patients (24%) after a mean AF free survival of 28 ± 1 months. While there was no impact on early recurrence, AF inducibility affected long-term recurrence (31 ± 1 vs 23 ± 3 months; P = .001). In multivariate analysis, AF inducibility (hazard ratio [HR] 2.14; 95% confidence interval [CI], 1.03-4.45; P = .041) and persistent type of AF (HR 2.17; 95%CI, 1.06-4.47; P = .034) were associated with late AF recurrence., Conclusion: In patients without low-voltage substrate undergoing PVI, AF inducibility is a significant predictor of long-term outcome. The pathomechanisms of this phenomenon must be further studied to be addressed by additional treatment., (© 2019 Wiley Periodicals, Inc.)

Aims: To determine the clinical utility of a combined single-session cardiovascular magnetic resonance (CMR) imaging protocol integrating adenosine stress perfusion and three-dimensional pulmonary vein angiography for stratification of atrial fibrillation (AF) patients referred for pulmonary vein isolation (PVI) and complaining about chest pain syndromes., Methods and Results: The preprocedural CMR examination (adenosine stress perfusion, late gadolinium enhancement, and three-dimensional pulmonary vein angiography) was performed in 357 consecutive AF patients with chest pain syndromes referred for PVI. Stress perfusion results were used for stratification: ischaemia positive patients underwent invasive coronary angiography, ischaemia negative patients underwent PVI, and follow-up/outcome data were collected (combined primary endpoint of cardiac death/non-fatal myocardial infarction). The integrated CMR protocol had a high success rate (356/357, 99.7%), a short total examination duration (<30 min in all patients), and delivered high-quality three-dimensional pulmonary vein angiography in all patients undergoing PVI (324/324, 100%). Variants of pulmonary vein anatomy were identified in 33% of all patients (117/357). Stress positivity (28/356, 8%) had a high positive predictive value for identification of obstructive coronary artery disease (86%), while stress negativity carried a low short-term event rate following PVI (cumulative 1-year event-free survival rate, 99.6%)., Conclusion: Combined single-session CMR as a routine diagnostic workup for AF patients with chest pain syndromes prior to PVI proved to represent a time-efficient and effective stratification tool., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Aims: Arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) still remain an important management issue. Recently, the APPLE score had been introduced to predict rhythm outcomes within 12 months after catheter ablation, while the simple MB-LATER score was developed for the prediction of very late recurrence of AF (VLRAF) occurring after 12 months. The aim of this study was to compare APPLE and MB-LATER scores in predicting VLRAF., Methods and Results: The study population included arrhythmia-free patients within first 12 months after first radiofrequency catheter ablation from The Heart Center Leipzig AF Ablation Registry. The APPLE [one point for Age >65 years, Persistent AF, imPaired eGFR <60 mL/min/1.73 m2, Left atrial (LA) diameter ≥43 mm, EF <50%] and MB-LATER scores [one point for Male gender, Bundle branch block or QRS >120 ms, LA diameter ≥47 mm, AF Type (persistent AF), Early Recurrence <3 months] were calculated before and 3 months after ablation, respectively. We followed 482 patients {age 61 [interquartile range (IQR) 54-68] years, 66% males, 32% persistent AF} for median 40 (IQR 35-50) months. There were 184 patients (38.3%) with arrhythmia recurrences within 13-60 months after ablation. On multivariate analysis, APPLE [odds ratio (OR) 1.517, 95% confidence interval (CI) 1.244-1.850, P < 0.001] and MB-LATER (OR 1.437, 95% CI 1.211-1.705, P < 0.001) scores and diabetes mellitus (OR 2.214, 95% CI 1.353-3.625, P = 0.002) were significantly associated with arrhythmia recurrences. Receiver operating characteristic curve analyses demonstrated moderate prediction for both scores [area under the curve (AUC) 0.607, P < 0.001 for APPLE score, AUC 0.604, P < 0.001 for MB-LATER]., Conclusion: Prediction of VLRAF is similar for both APPLE and MB-LATER scores. A better score remains still a clinical unmet need., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.)

Background: Rivaroxaban is a non-vitamin K oral anticoagulant and has been approved for prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). Current labeling recommends 20 mg once a day (q.d.) as a standard dose and a reduced dose of 15 mg q.d. in patients with renal impairment., Hypothesis: The aim of this study was to analyze the adherence to current labeling concerning initial rivaroxaban dosing and to determine whether potential lack of such adherence is medically justified., Methods: Patients with AF initiated on rivaroxaban between January 1, 2016 and January 31, 2017, were identified in the Heart Center Leipzig database. Health records were screened to identify prescribed rivaroxaban dose, presence or absence of renal impairment, patient characteristics, further dosing-relevant diagnoses and co-medication with antiplatelet drugs and non-vitamin K oral anticoagulants (NOACs)., Results: We identified a total of 378 consecutive patients. In 282 cases (74.6%), rivaroxaban was prescribed in a standard dose and in 96 (25.4%) in a reduced dose. Out of 96 patients receiving a reduced dose, 50 (52.1%) did not meet labeling criteria for dose reduction. In uni- and multivariate regression analysis, estimated glomerular filtration rate (eGFR) (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.12-0.95, P = .04) was the only independent predictor of rivaroxaban underdosage., Conclusions: In clinical practice, rivaroxaban dosing is frequently incoherent with labeling. In this study, rivaroxaban was often administered underdosed. Potentially inappropriate dose reduction was significantly associated with eGFR, the same factor that is used as criterion for dose adjustment., (© 2019 The Authors. Clinical Cardiology published by Wiley Periodicals, Inc.)

Increased morbidity and mortality in atrial fibrillation (AF) are related to the pro-fibrotic, pro-thrombotic, and pro-inflammatory processes that underpin the disease. High-density lipoproteins (HDL) have anti-inflammatory, anti-oxidative, and anti-thrombotic properties. Functional impairment of HDL may, therefore, associate with AF initiation or progression. We studied indices of HDL quality and quantity of AF patients and healthy controls, including HDL-particle number, HDL cholesterol, apolipoprotein (apo) A-I levels, serum amyloid A (SAA) content and HDL-cholesterol efflux capacity, and paraoxonase activity of apoB-depleted serum. Serum samples were collected from AF patients (n = 91) before catheter ablation and from age- and sex-matched control subjects (n = 54). HDL-cholesterol efflux capacity was assessed in a validated assay using [ 3 H]-cholesterol-labeled J774 macrophages. Lecithin-cholesterol acyltransferase (LCAT) and paraoxonase activities were assessed using fluorometric assays, SAA levels were determined by ELISA, and total and subclass HDL-particle number was assessed by nuclear magnetic resonance spectroscopy. ApoA-I levels were determined by immunoturbidimetry. HDL-cholesterol efflux capacity, HDL-particle number, apoA-I levels, and LCAT activity were markedly reduced in AF patients when compared to healthy individuals (all p < 0.001), whereas HDL-associated paraoxonase activity and SAA content were not altered (p = 0.578, p = 0.681). Notably, cholesterol efflux capacity, HDL-particle number, apoA-I levels as well as LCAT activity recovered following restoration of sinus rhythm (all p < 0.001). We identified marked alterations in HDL function, HDL maturation, and HDL-particle number in AF patients. Assessing HDL-particle number and function in AF may be used as a surrogate marker of AF onset and progression and may help identifying patients at high risk.

The prediction of arrhythmia recurrences after catheter ablation of atrial fibrillation (AF) remains challenging. The aim of current analysis was to investigate the time-dependent prediction of arrhythmia recurrences after AF catheter ablation during long-term follow-up. The study included 879 patients (61 ± 10 years; 64% males; 39% persistent AF) undergoing first AF catheter ablation. Rhythm outcomes were documented using 7-days Holter monitoring. The APPLE score (Age, Persistent AF, imPaired eGFR, Left atrium (LA), EF) was calculated at baseline, while MB-LATER score (Male gender, Bundle branch block, LA, AF Type, Early Recurrences) 3 months after ablation. The median follow-up time was 37 months [95%CI 35;39]. ERAF and LRAF occurred in 45% and 64%, respectively. On multivariable analysis, ERAF (HR 2.095, 95%CI 1.762-2.490, p < 0.001) was strongly associated with LRAF. The APPLE (HR 1.385, 95%CI 1.276-1.505, p < 0.001) and MB-LATER (HR 1.326, 95%CI 1.239-1.419, p < 0.001) scores significantly predicted LRAF during follow-up. On the ROC analysis, APPLE (AUC 0.640, 95%CI 0.602-0.677, p < 0.001) and MB-LATER (AUC 0.654, 95%CI 0.616-0.691, p < 0.001) demonstrated moderate prediction. Summarizing, ERAF was the strongest predictor for LRAF in time-dependent manner. The APPLE and MB-LATER scores demonstrated moderate prediction of arrhythmia recurrences during long term follow-up.

Background: Stage of platelet activation is an important modulator of stroke risk associated with atrial fibrillation (AF). However, factors determining such activation status of thrombocytes in patients with AF are still not well studied., Methods and Results: We enrolled 83 patients (mean age 61 ± 10 years, 61% male, mean CHA 2 DS 2 -VASc 2.1 ± 1.4) with paroxysmal (75%) or persistent (25%) AF admitted for catheter ablation. Blood samples were collected directly from the left atrium (LA) and platelet activation status was measured by means of flow cytometric assessment in whole blood and light transmission aggregometry (LTA) in unstimulated and Thrombin-receptor-activated-peptide-6 (TRAP-6)-stimulated platelet rich plasma. In flow cytometry, we measured fractions of platelet microparticles and aggregates as well as P-selectin expression on platelets' surfaces. LTA findings are expressed as maximal aggregation (MA), primary slope (PS) and area under curve (AUC). Cardiac anatomy has been assessed by means of echocardiography and magnetic resonance imaging. Left atrial appendage (LAA) volume, but not LAA morphology nor morphological and functional parameters describing LA, was significantly correlated with increased pre-activation of platelets (R = 0.224, p = 0.043) and consecutive reduced response to TRAP-6 (R = 0.231, p = 0.037) measured by P-selectin expression in flow cytometry. Similarly, a reduced response to TRAP-6 in patients with larger LAA volume (PS: R = -0.240; p = 0.042; AUC: R = -0.244; p = 0.035; MA: R = -0.270; p = 0.019) as well as with heart failure (PS 54.75 vs 71.45, p = 0.026) was observed in LTA., Conclusion: In patients with AF, LAA volume correlates with extent of platelet activation status, this effect is aggravated in patients with heart failure., (Copyright © 2018. Published by Elsevier B.V.)

Background: Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). It is currently unclear if routine screening for PVS by imaging (echocardiography, computed tomography) is clinically meaningful and if there is a correlation between PVS and the electroanatomical mapping system (EAMS) used for the ablation procedure. It was therefore investigated in the current single center experience., Methods: All patients from January 2004 to December 2016 with the diagnosis of PVS after interventional ablation of AF by radiofrequency were retrospectively analyzed. From 2004 to 2007, transesophageal echocardiography was routinely performed as screening for RFA-acquired PVS (group A). Since 2008, diagnostics were only initiated in cases of clinical symptoms suggestive for PVS (group B)., Results: The overall PVS rate after interventional RFA for AF of the documented institution is 0.72% (70/9754). The incidence was not influenced by screening: group A had a 0.74% PVS rate and group B a 0.72% rate (NS). Referred to as the EAMS, there were significant differences: 20/4229 (0.5%) using CARTO®, 48/4510 (1.1%) using EnSite®, 1/853 (0.1%) using MediGuide®, and 1/162 (0.6%) using Rhythmia®. Since 2009, no significant difference between technologies was found., Conclusions: The present analysis of 9754 procedures revealed 70 cases of PVS. The incidence of PVS is not related to screening but to the application of different EAMS. Possible explanations are technological backgrounds (magnetic vs. electrical), learning curves, operator experience, and work-flow differences. Furthermore, incorporation of new technologies seems to be associated with higher incidences of PVS before workflows are optimized.

Aims: Results of catheter based interventional treatment for pulmonary vein stenosis (PVS) following radiofrequency ablation (RFA) for atrial fibrillation remain suboptimal. Surgical repair may represent an alternative therapy, though long-term results have not been thoroughly investigated., Methods and Results: We retrospectively assessed all patients in our centre undergoing surgical repair for radiofrequency-induced PVS. Data regarding surgical technique, clinical outcome, and rate of pulmonary vein (PV) restenosis were collected and analysed. Between 2004 and 2016, the rate for PVS resulting from RFA for atrial fibrillation in our institution was 0.79% (76/9633). During this period, five male patients with multiple PVS (3 ± 1) underwent surgical repair of a total of 13 symptomatic PVS. Surgery was performed in a standard setting under cardiopulmonary bypass. Stenotic veins were incised longitudinally followed by a patch augmentation plasty using either bovine pericard (n = 7) or polytetrafluoroethylene (PTFE) patches (n = 5). Localization of incision was on the anterior side of the PV only (n = 8) or on both the anterior and posterior sides (n = 4). In one PVS lesion, mechanical dilatation was sufficient. Long-term follow-up after 60 ± 69 months revealed an average restenosis rate of 38%. Restenosis was defined as narrowing >70%. All patients reported clinical improvement of symptoms at follow-up., Conclusion: Even in the era of wide circumferential lesions, PVS still occurs. While surgical PV patch plasty represents a valuable treatment option, restenosis remains an issue during follow-up. Nevertheless, surgical repair achieves highly acceptable long-term results for RFA-acquired PVS. Hence, it should be routinely discussed as a therapeutic option in cases with multiple PVS.