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There have been no recent descriptions of the spontaneous conversion of long-standing atrial fibrillation (AF) or flutter (AFl) to sinus rhythm which, in the past, has been associated with rheumatic mitral valve disease and treatment with digoxin. We present 3 contemporary cases, all of whom progressed from AF to slow AFl and then spontaneously converted to slow sinus or junctional rhythm. None of these patients had rheumatic heart disease or were treated with digoxin. In conclusion, we believe that they provide support for the broader view that this uncommon phenomenon is associated with a severe atrial myopathy due to scar and inflammation.

Background— Nonvalvular atrial fibrillation is the most common arrhythmia. Patients with nonvalvular atrial fibrillation are at increased risk of stroke; therefore, we evaluated the efficacy and safety of different approaches to prevent this major complication. Methods and Results— We conducted electronic database searches of phase III randomized controlled trials. The groups were novel oral anticoagulants, Watchman left atrial appendage occlusion device (DEVICE), and warfarin. Efficacy outcomes were stroke or systemic embolism, and all-cause mortality. Safety outcome was major bleeding and procedure-related complications. A subgroup analysis of the elderly population was done. We used random-effects model to compare pooled outcomes and tested for heterogeneity. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed for each outcome. Seven randomized controlled trials (n=73 978) were included. There was a significant difference favoring novel oral anticoagulants for systemic embolism (OR, 0.84; 95% CI, 0.72–0.97; P =0.01), all-cause mortality (OR, 0.89; 95% CI, 0.84–0.94; P P =0.026) compared with warfarin. No difference was seen between DEVICE and warfarin for efficacy end points; however, DEVICE had more complications (OR, 1.85; 95% CI, 1.14–3.01; P =0.012). In the elderly (6 randomized controlled trials, n=30 699), systemic embolism was favored with novel oral anticoagulants over warfarin (OR, 0.77; 95% CI, 0.68–0.87; P ≤0.001). No evidence of significant publication bias was found. Conclusions— Novel oral anticoagulants is superior to warfarin for stroke prevention in nonvalvular atrial fibrillation. This benefit was also observed in the elderly population. DEVICE is a reasonable noninferior alternative to warfarin for stroke prevention, but cautious use is essential given safety concerns.

Endocardial Fibroelastosis (EFE) is caused by avid proliferation of fibroelastic tissue, often associated with atrial fibrillation (AF) and intracardiac thrombus formation. A 68-year-old Nigerian male with medical history significant for AF and right heart failure presented with dizziness. Physical

Different strategies have been evaluated for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). We sought to evaluate the efficacy and safety of different approaches compared to standard therapy with warfarin. We conducted electronic database searches of phase III

Background: The systolic variation of mitral regurgitation (MR) is a pitfall in its quantification. Current recommendations advocate using quantitative echocardiographic techniques that account for this systolic variation. While prior studies have qualitatively described patterns of systolic variation no study has quantified this variation. Methods: This study includes 41 patients who underwent cardiovascular magnetic resonance (CMR) evaluation for the assessment of MR. Systole was divided into 3 equal parts: early, mid, and late. The MR jets were categorized as holosystolc, early, or late based on the portions of systole the jet was visible. The aortic flow and left ventricular stroke volume (LVSV) acquired by CMR were plotted against time. The instantaneous regurgitant rate was calculated for each third of systole as the difference between the LVSV and the aortic flow. Results: The regurgitant rate varied widely with a 1.9-fold, 3.4-fold, and 1.6-fold difference between the lowest and highest rate in patients with early, late, and holosystolic jets respectively. There was overlap of peak regurgitant rates among patients with mild, moderate and severe MR. The greatest variation of regurgitant rate was seen among patients with mild MR. Conclusion: CMR can quantify the systolic temporal variation of MR. There is significant variation of the mitral regurgitant rate even among patients with holosystolic MR jets. These findings highlight the need to use quantitative measures of MR severity that take into consideration the temporal variation of MR.

An86-year-oldwomanwithaknownhistoryofcoronaryarterydisease and a prior percutaneous coronary intervention presented to the emergency department with several episodes of selfresolving chest discomfort occurring at rest. She denied any shortness of breath, palpitations, and diaphoresis. Her home medications included a β-blocker. Her blood pressure was 140/85 mm Hg, and she had an irregular heart rate of 125/min. Figure 1 shows the initial electrocardiogram (ECG) obtained in the emergency department. Question: Does the patient have atrial fibrillation (AF)?