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OBJECTIVE: A subset of patients with atrial fibrillation (AF) presents without established AF risk factors and normal left ventricular (LV) systolic function, called idiopathic AF (IAF). Traditionally, echocardiography derived LV dimensions and ejection fraction (EF) are used to exclude LV dysfunction in IAF, but their sensitivity is limited. Our objective is to evaluate the presence of subtle alterations in LV function despite normal LVEF in patients with IAF compared to healthy controls, using speckle-tracking echocardiography (STE) based global longitudinal strain (GLS).METHODS: Standard transthoracic echocardiography was performed in 80 patients with IAF and 129 healthy controls. Patients with overt cardiac disease as well as known established AF risk factors were excluded. STE analysis was performed to assess GLS of the LV, and left atrial strain (LAS).RESULTS: LVEF was normal and comparable between patients with IAF and healthy controls (63 ± 4% for both groups; p = 0.801). Mean GLS was within normal limits for both groups but statistically significantly more negative in patients with IAF (-20.6 ± 2.5% vs. -19.7 ± 2.5%; p = 0.016), however not when indexed for ventricular cycle length (p = 0.784). No differences in LA volume or non-indexed LAS were seen in patients with IAF compared to healthy controls.CONCLUSIONS: In this selected group of IAF patients, STE did not detect any overt LV or LA dysfunction compared to healthy controls. Thus, IAF occurred in these patients not only in the absence of established AF risk factors but also without evidence of ventricular or atrial dysfunction.

Background Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients referred for atrial fibrillation (AF) catheter ablation (CA). Currently, it remains unclear how to improve pre-selection for SDB screening in patients with AF. Aim We aimed to (1) assess the accuracy of the STOP-Bang screening questionnaire for detection of SDB within an AF population referred for CA; (2) derive a refined, AF-specific SDB score to improve pre-selection. Methods Consecutive AF patients referred for CA without a history of SDB and/or SDB screening were included. Patients were digitally referred to the previously implemented Virtual-SAFARI SDB screening and management pathway including a home sleep test. An apnoea–hypopnoea index (AHI) of ≥ 15 was interpreted as moderate-to-severe SDB. Logistic regression analysis was used to assess characteristics associated with moderate-to-severe SDB to refine pre-selection for SDB screening. Results Of 206 included patients, 51% were diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (95% Confidence-Interval (CI) 0.573–0.721). AF-specific refinement resulted in the BOSS-GAP score. Therein, BMI with cut-off point ≥ 27 kg/m2 and previous stroke or transient ischaemic attack (TIA) were added, while tiredness and neck circumference were removed. The BOSS-GAP score performed better with an AUROC of 0.738 (95% CI 0.672–0.805) in the overall population. Conclusion AF-specific refinement of the STOP-Bang questionnaire moderately improved detection of SDB in AF patients referred for CA. Whether questionnaires bring benefits for pre-selection of SDB compared to structural screening in patients with AF requires further studies. Trial registration number ISOLATION was registered NCT04342312, 13-04-2020. Graphical Abstract

Excessive drinking has detrimental effects on the cardiovascular system. Atrial fibrillation (AF) following alcohol binge drinking, also named "holiday heart syndrome", is well established. However, even chronic lower levels of alcohol intake may also increase AF risk. In this review article, we aim to provide a comprehensive overview of the epidemiology and pathophysiology by which alcohol may be responsible for AF and discuss whether alcohol abstinence is required for optimal rhythm control as well as to maintain sinus rhythm in patients with AF. The pathophysiological mechanisms responsible for the relationship between alcohol consumption and AF may include both direct and chronic effects increasing AF-burden. Acute effects may include arrhythmogenic changes (such as shortening in atrial refractoriness, slowing in conduction velocity and increased atrial ectopy) and an autonomic imbalance. Chronic changes contributing to the development of an arrhythmogenic substrate involve atrial structural and functional remodeling process due to atrial dilatation, elevated pressures and fibrosis formation. Additionally, alcohol consumption contributes to developing concomitant AF risk factors such as obesity, sleep-disordered breathing, and hypertension. Alcohol abstinence is associated with a reduction in AF-recurrence and overall burden and moreover improves AF-risk factor development such as obesity, hypertension, sleep apnea and AF-related consequences such as stroke. In conclusion, alcohol consumption is associated with atrial arrhythmia and a wide range of cardiovascular comorbidities. Although further evidence is needed, current knowledge indicates that there might not be a safe level of alcohol consumption which is not increasing AF-risk.

Background: Sleep is fragmented by brief arousals, and excessive arousal burden has been linked to increased cardiovascular (CV) risk, but mechanisms are poorly understood. Research Question: Do arousals trigger cardiac ventricular repolarization lability that may predispose people to long-term cardiovascular mortality? Study Design and Methods: This study analyzed 407,541 arousals in the overnight polysomnograms of 2,558 older men in the Osteoporotic Fractures in Men sleep study. QT and RR intervals were measured beat-to-beat starting 15 s prior to arousal onset until 15 s past onset. Ventricular repolarization lability was quantified by using the QT variability index (QTVi). Results: During 10.1 ± 2.5 years of follow-up, 1,000 men died of any cause, including 348 CV deaths. During arousals, QT and RR variability increased on average by 5 and 55 ms, respectively, resulting in a paradoxical transient decrease in QTVi from 0.07 ± 1.68 to –1.00 ± 1.68. Multivariable Cox proportional hazards analysis adjusted for age, BMI, cardiovascular and respiratory risk factors, sleep-disordered breathing and arousal, diabetes, and Parkinson disease indicated that excessive QTVi during arousal was independently associated with all-cause and CV mortality (all-cause hazard ratio, 1.20 [95% CI, 1.04-1.38; P = .012]; CV hazard ratio, 1.29 [95% CI, 1.01 -1.65; P = .043]). Interpretation: Arousals affect ventricular repolarization. A disproportionate increase in QT variability during arousal is associated with an increased all-cause and CV mortality and may reflect ventricular repolarization maladaptation to the arousal stimulus. Whether arousal-related QTVi can be used for more tailored risk stratification warrants further study, including evaluating whether arousal suppression attenuates ventricular repolarization lability and reduces subsequent mortality. Clinical Trial Registration: ClinicalTrials.gov; No.: NCT00070681; URL: www.clinicaltrials.gov

Aims The aim of this TeleCheck-AF sub-analysis was to evaluate motivation and adherence to on-demand heart rate/rhythm monitoring app in patients with atrial fibrillation (AF). Methods and results Patients were instructed to perform 60 s app-based heart rate/rhythm recordings 3 times daily and in case of symptoms for 7 consecutive days prior to teleconsultation. Motivation was defined as number of days in which the expected number of measurements (≥3/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period. Data from 990 consecutive patients with diagnosed AF [median age 64 (57–71) years, 39% female] from 10 centres were analyzed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 28% of the study population and had a lower percentage of recordings in sinus rhythm [90 (53–100%) vs. 100 (64–100%), P < 0.001] compared with others. Older age and absence of diabetes were predictors of both optimal motivation and adherence [odds ratio (OR) 1.02, 95% coincidence interval (95% CI): 1.01–1.04, P < 0.001 and OR: 0.49, 95% CI: 0.28–0.86, P = 0.013, respectively]. Patients with 100% motivation also had ≥100% adherence. Independent predictors for optimal adherence alone were older age (OR: 1.02, 95% CI: 1.00–1.04, P = 0.014), female sex (OR: 1.70, 95% CI: 1.29–2.23, P < 0.001), previous AF ablation (OR: 1.35, 95% CI: 1.03–1.07, P = 0.028). Conclusion In the TeleCheck-AF project, more than one-fourth of patients had optimal motivation and adherence to app-based heart rate/rhythm monitoring. Older age and absence of diabetes were predictors of optimal motivation/adherence.

Background: In patients with chronic kidney disease (CKD), atrial fibrillation (AF) is highly prevalent and represents a major risk factor for stroke and death. CKD is associated with atrial proarrhythmic remodeling and activation of the sympathetic nervous system. Whether reduction of the sympathetic nerve activity by renal denervation (RDN) inhibits AF vulnerability in CKD is unknown. Methods: Left atrial (LA) fibrosis was analyzed in samples from patients with AF and concomitant CKD (estimated glomerular filtration rate [eGFR], 2 ) using picrosirius red and compared with AF patients without CKD and patients with sinus rhythm with and without CKD. In a translational approach, male Sprague Dawley rats were fed with 0.25% adenine (AD)-containing chow for 16 weeks to induce CKD. At week 5, AD-fed rats underwent RDN or sham operation (AD). Rats on normal chow served as control. After 16 weeks, cardiac function and AF susceptibility were assessed by echocardiography, radiotelemetry, electrophysiological mapping, and burst stimulation, respectively. LA tissue was histologically analyzed for sympathetic innervation using tyrosine hydroxylase staining, and LA fibrosis was determined using picrosirius red. Results: Sirius red staining demonstrated significantly increased LA fibrosis in patients with AF+CKD compared with AF without CKD or sinus rhythm. In rats, AD demonstrated LA structural changes with enhanced sympathetic innervation compared with control. In AD, LA enlargement was associated with prolonged duration of induced AF episodes, impaired LA conduction latency, and increased absolute conduction inhomogeneity. RDN treatment improved LA remodeling and reduced LA diameter compared with sham-operated AD. Furthermore, RDN decreased AF susceptibility and ameliorated LA conduction latency and absolute conduction inhomogeneity, independent of blood pressure reduction and renal function. Conclusions: In an experimental rat model of CKD, RDN inhibited progression of atrial structural and electrophysiological remodeling. Therefore, RDN represents a potential therapeutic tool to reduce the risk of AF in CKD, independent of changes in renal function and blood pressure.

AimTo propose a standardized workflow for 3D-electroanatomical mapping guided pulmonary vein isolation in pigs.Materials and methodsDanish female landrace pigs were anaesthetized. Ultrasound-guided puncture of both femoral veins was performed and arterial access for blood pressure measurement established. Fluoroscopy- and intracardiac ultrasound-guided passage of the patent foramen ovale or transseptal puncture was performed. Then, 3D-electroanatomical mapping of the left atrium was conducted using a high-density mapping catheter. After mapping all pulmonary veins, an irrigated radiofrequency ablation catheter was used to perform ostial ablation to achieve electrical pulmonary vein isolation. Entrance- and exit-block were confirmed and re-assessed after a 20-min waiting period. Lastly, animals were sacrificed to perform left atrial anatomical gross examination.ResultsWe present data from 11 consecutive pigs undergoing pulmonary vein isolation. Passage of the fossa ovalis or transseptal puncture was uneventful and successful in all animals. Within the inferior pulmonary trunk 2–4 individual veins as well as 1–2 additional left and right pulmonary veins could be cannulated. Electrical isolation by point-by-point ablation of all targeted veins was successful. However, pitfalls including phrenic nerve capture during ablation, ventricular arrhythmias during antral isolation close to the mitral valve annulus and difficulties in accessing right pulmonary veins were encountered.ConclusionFluoroscopy- and intracardiac ultrasound-guided transseptal puncture, high-density electroanatomical mapping of all pulmonary veins and complete electrical pulmonary vein isolation can be achieved reproducibly and safely in pigs when using current technologies and a step-by-step approach.

Contains fulltext : 283519.pdf (Publisher’s version ) (Open Access) BACKGROUND: The assessment of symptom-rhythm correlation (SRC) in patients with persistent atrial fibrillation (AF) is challenging. Therefore, we performed a novel mobile app-based approach to assess SRC in persistent AF. METHODS: Consecutive persistent AF patients planned for electrical cardioversion (ECV) used a mobile app to record a 60-s photoplethysmogram (PPG) and report symptoms once daily and in case of symptoms for four weeks prior and three weeks after ECV. Within each patient, SRC was quantified by the SRC-index defined as the sum of symptomatic AF recordings and asymptomatic non-AF recordings divided by the sum of all recordings. RESULTS: Of 88 patients (33% women, age 68 ± 9 years) included, 78% reported any symptoms during recordings. The overall SRC-index was 0.61 (0.44-0.79). The study population was divided into SRC-index tertiles: low (

Introduction Sodium-glucose co-transporter 2 (SGLT2) inhibitors have cardiovascular protective properties in addition to the metabolic effects and represent a cornerstone of treating patients with chronic heart failure (CHF). We hypothesised that empagliflozin reduces tissue sodium content in patients with CHF. Methods In a double-blind, randomised (2:1), placebo-controlled, parallel-group, clinical trial, 74 patients with NYHA class II–III CHF and an ejection fraction of 49% or less received empagliflozin 10 mg once daily or placebo for 3 months. In each patient, tissue sodium content of the lower leg was assessed non-invasively by sodium-MRI (23Na-MRI) at baseline, after 1 and 3 months of treatment. Results After 1 and 3 months treatment with empagliflozin (n = 48), a significant decrease in skin sodium content was observed (1 month: 22.8 ± 6.1 vs. 21.6 ± 6.0 AU, p = 0.039; 3 months: 22.9 ± 6.1 vs. 21.6 ± 6.1 AU, p = 0.013), while there was no change in muscle sodium and muscle water content. In direct comparison, the change in skin sodium content between baseline and 3 months was − 1.3 ± 3.5 AU in the empagliflozin group versus 0.6 ± 3.5 AU in the placebo group (p for between-group difference = 0.022). No significant difference regarding change in muscle sodium and in muscle water content was observed after 3 months treatment between the two groups. Conclusion This trial showed a significant decrease in skin sodium content after 1 and 3 months of treatment with empagliflozin. The decrease in skin sodium content may reflect a decrease in subclinical micro-oedema or/and in non-osmotic bound tissue sodium, both reported to impair left ventricular function. Trial registration number NCT03128528 (http://www.clinicaltrials.gov). Trial registration date 25th April 2017.

The current classification of atrial fibrillation (AF) is mainly focused on the clinical presentation according to the duration of AF episodes and the mode of termination, which incompletely reflect the severity and progressive nature of the underlying atrial disease. In this review article, "atrial cardiomyopathy" is discussed as a new concept in AF pathophysiology. Electrogram-, imaging-, and biomarker-derived measures and parameters to assess atrial cardiomyopathy, which will likely impact how AF is clinically classified and managed in the future, are presented.Die aktuelle Klassifikation von Vorhofflimmern (VHF) basiert hauptsächlich auf der klinischen Präsentation unter Berücksichtigung der Dauer einzelner VHF-Episoden und der Art, wie eine VHF-Episode spontan endet. Dies beschreibt allerdings den Schweregrad und den progressiven Charakter der zugrunde liegenden atrialen Erkrankung nicht ausreichend. Im vorliegenden Übersichtsbeitrag wird die „atriale Kardiomyopathie“ als ein neues Konzept der Pathophysiologie von VHF diskutiert. Wir stellen elektrogramm-, bildgebungs- und biomarkerbasierte Parameter für die Beurteilung der atrialen Kardiomyopathie vor, die in der Zukunft wahrscheinlich die klinische Klassifikation und Behandlung von VHF beeinflussen werden.

Introduction: Sleep-disordered breathing (SDB) is present in 21–74% of all patients with atrial fibrillation (AF). Treatment of SDB by positive airway pressure may help to prevent recurrence of AF after electrical cardioversion and help to improve AF ablation success rates in non-randomized studies. Areas covered: In this review, the current understanding of the atrial arrhythmogenic pathophysiology of SDB is summarized, and diagnostic and therapeutic challenges in AF patients are discussed. Current international recommendations are presented, and a comprehensive literature search is undertaken. Expert opinion: AF patients with SDB rarely report SDB-related symptoms such as daytime sleepiness. Therefore, systematic home sleep testing evaluation should be considered for all patients eligible for rhythm control strategy. A close interdisciplinary collaboration between the electrophysiologist/cardiologist, nurses and sleep-specialists are required for the management of SDB in AF patients. An arrhythmia-orientated assessment of SDB may better quantify SDB-related AF risk in an individual patient and may help to better guide targeted and personalized SDB treatment in AF patients as a component of rhythm and symptom control strategies. Finally, randomized controlled trials are needed to confirm the relationship between SDB and AF, and the benefits of routine testing and treatment of SDB in AF patients.

Aims Oesophageal fistula represents a rare but dreadful complication of atrial fibrillation catheter ablation. Data on its incidence, management, and outcome are sparse. Methods and results This international multicentre registry investigates the characteristics of oesophageal fistulae after treatment of atrial fibrillation by catheter ablation. A total of 553 729 catheter ablation procedures (radiofrequency: 62.9%, cryoballoon: 36.2%, other modalities: 0.9%) were performed, at 214 centres in 35 countries. In 78 centres 138 patients [0.025%, radiofrequency: 0.038%, cryoballoon: 0.0015% (P < 0.0001)] were diagnosed with an oesophageal fistula. Peri-procedural data were available for 118 patients (85.5%). Following catheter ablation, the median time to symptoms and the median time to diagnosis were 18 (7.75, 25; range: 0–60) days and 21 (15, 29.5; range: 2–63) days, respectively. The median time from symptom onset to oesophageal fistula diagnosis was 3 (1, 9; range: 0–42) days. The most common initial symptom was fever (59.3%). The diagnosis was established by chest computed tomography in 80.2% of patients. Oesophageal surgery was performed in 47.4% and direct endoscopic treatment in 19.8% and conservative treatment in 32.8% of patients. The overall mortality was 65.8%. Mortality following surgical (51.9%) or endoscopic treatment (56.5%) was significantly lower as compared to conservative management (89.5%) [odds ratio 7.463 (2.414, 23.072) P < 0.001]. Conclusion Oesophageal fistula after catheter ablation of atrial fibrillation is rare and occurs mostly with the use of radiofrequency energy rather than cryoenergy. Mortality without surgical or endoscopic intervention is exceedingly high.

BACKGROUND: Obstructive sleep apnea (OSA) creates a complex substrate for atrial fibrillation (AF), which is refractory to many clinically available pharmacological interventions. We investigated atrial antiarrhythmogenic properties and ventricular electrophysiological safety of small-conductance Ca2+ -activated K+ (SK)-channel inhibition in a porcine model for obstructive respiratory events.METHODS: In spontaneously breathing pigs, obstructive respiratory events were simulated by intermittent negative upper airway pressure (INAP) applied via a pressure device connected to the intubation tube. INAP was applied for 75 s, every 10 min, three times before and three times during infusion of the SK-channel inhibitor AP14145. Atrial effective refractory periods (AERP) were acquired before (pre-INAP), during (INAP) and after (post-) INAP. AF-inducibility was determined by a S1S2 atrial pacing protocol. Ventricular arrhythmicity was evaluated by heart rate adjusted QT-interval duration (QT-paced) and electromechanical window (EMW) shortening.RESULTS: During vehicle infusion, INAP transiently shortened AERP (pre-INAP: 135 ± 10 ms vs. post-INAP 101 ± 11 ms; p = .008) and increased AF-inducibility. QT-paced prolonged during INAP (pre-INAP 270 ± 7 ms vs. INAP 275 ± 7 ms; p = .04) and EMW shortened progressively throughout INAP and post-INAP (pre-INAP 80 ± 4 ms; INAP 59 ± 6 ms, post-INAP 46 ± 10 ms). AP14145 prolonged baseline AERP, partially prevented INAP-induced AERP-shortening and reduced AF-susceptibility. AP14145 did not alter QT-paced at baseline (pre-AP14145 270 ± 7 ms vs. AP14145 268 ± 6 ms, p = .83) or QT-paced and EMW-shortening during INAP.CONCLUSION: In a pig model for obstructive respiratory events, the SK-channel-inhibitor AP14145 prevented INAP-associated AERP-shortening and AF-susceptibility without impairing ventricular electrophysiology. Whether SK-channels represent a target for OSA-related AF in humans warrants further study.

BACKGROUND: To identify the association between comorbidities and left atrial (LA) and right atrial (RA) function in patients with paroxysmal atrial fibrillation (AF).METHODS: This is a cross-sectional study. Speckle-tracking echocardiography was performed in 344 patients with paroxysmal AF at baseline, and available in 298 patients after 1-year follow-up. The number of comorbidities (hypertension, diabetes mellitus, coronary artery disease, body mass index >25 kg/m2, age > 65 years, moderate to severe mitral valve regurgitation and kidney dysfunction (estimated glomerular filtration rate RESULTS: Mean age of the patients was 58 (SD 12) years and 137 patients were women (40%). Patients with a higher number of comorbidities had larger LA volumes (p for trend CONCLUSIONS: In patients with paroxysmal AF, individual and combined comorbidities are related to lower LA and RA strain. In patients with few comorbidities, impairment in atrial function progresses during one year of follow-up. Whether comorbidity management prevents or reverses decrease in atrial function warrants further study.

Little data exists on electrogram sensing in current generation of miniaturized insertable cardiac monitors (ICMs).To compare the sensing capability of ICM with different vector length: Medtronic Reveal LINQ (~40 mm) vs. Biotronik Biomonitor III (BM-III, ~70 mm).De-identified remote monitoring transmissions from n = 40 patients with BM-III were compared with n = 80 gender and body mass index (BMI)-matched patients with Reveal LINQ. Digital measurement of P- and R-wave amplitude from calibrated ICM electrograms was undertaken by 3 investigators independently. Further, we evaluated the impact of BMI and gender on P-wave visibility.Patients in both groups were well matched for gender and BMI (53% male, mean BMI 26.7 kg/m2, both p = NS). Median P- and R-wave amplitude were 97%56% larger in the BM-III vs. LINQ [0.065 (IQR 0.039-0.10) vs. 0.033 (IQR 0.022-0.050) mV, p .0001;0.78 (IQR 0.52-1.10) vs. 0.50 (IQR 0.41-0.89) mV, p = .012 respectively). The P/R-wave ratio was 36% greater with the BM-III (p .001). The 25th percentile of P-wave amplitude for all 120 patients was .026 mV. Logistic regression analysis showed BM-III was more likely than LINQ to have P-wave amplitude ≥.026 mV (OR 7.47, 95%CI 1.965-29.42, p = .003), and increasing BMI was negatively associated with P-wave amplitude ≥.026 mV (OR 0.84, 95%CI 0.75-0.95, p = .004). However, gender was not significantly associated with P-wave amplitude ≥.026 mV (p = .37).The longer ICM sensing vector of BM-III yielded larger overall P- and R- wave amplitude than LINQ. Both longer sensing vector and lower BMI were independently associated with greater P-wave visibility.

The present article reviews the state of the art of machine learning algorithms for the detection, prediction, and management of atrial fibrillation (AF), as well as of the development and evaluation of artificial intelligence (AI) in cardiology and beyond. Today, AI detects AF with a high accuracy using 12-lead or single-lead electrocardiograms or photoplethysmography. The prediction of paroxysmal or future AF currently operates at a level of precision that is too low for clinical use. Further studies are needed to determine whether patient selection for interventions may be possible with machine learning.In diesem Beitrag wird der aktuelle Stand von Algorithmen des maschinellen Lernens zur Erkennung, Vorhersage und Behandlung von Vorhofflimmern zusammengefasst, zudem werden die Entwicklung und Prüfung von künstlicher Intelligenz in der Kardiologie und anderen Bereichen dargelegt. Nach heutigem Stand lässt sich Vorhofflimmern mithilfe künstlicher Intelligenz in 12-Kanal- oder 1‑Kanal-Elektrokardiogrammen bzw. in Photoplethysmogrammen zuverlässig erkennen. Die Vorhersage von paroxysmalem oder neu auftretendem Vorhofflimmern hat die für den klinischen Einsatz erforderliche Genauigkeit noch nicht erreicht. Weitere Studien sind notwendig, um zu untersuchen, ob auf Basis des maschinellen Lernens eine Patientenselektion für Interventionen möglich ist.

Funding Acknowledgements Type of funding sources: None. Aim Although mobile health tools using photoplethysmography (PPG) technology have been validated for the detection of atrial fibrillation (AF), their utility for heart rate assessment during AF remains unclear. Therefore, we aimed to evaluate the accuracy of continuous PPG-based heart rate assessment during AF. Methods Persistent AF patients were provided with Holter electrocardiography (ECG) (for ≥24 hours) simultaneously with a PPG-equipped smartwatch. Both the PPG-based smartwatch and Holter ECG automatically and continuously monitored patients’ heart rate/rhythm. ECG and PPG recordings were synchronised and divided into 1-minute segments from which a PPG-based and an ECG-based average heart rate estimation were extracted. Results In total, 47,661 simultaneous ECG and PPG 1-minute heart rate segments were analysed in 50 patients (34% women, age 73±8 years). The agreement between ECG-determined and PPG-determined heart rate was high (root-mean-squared error [RMSE]: 4.7 bpm). Heart rate estimated using PPG was accurate within ±10% in 93.7% of the corresponding ECG-derived heart rate segments. PPG-based heart rate estimation was more often accurate during night- (97%) than during day-time (91%, P Conclusions During persistent AF, continuous PPG-based heart rate assessment is feasible and shows high accuracy compared to Holter ECG. Motion and recording quality among other PPG-derived covariates did not introduce a systematic and correctable bias in the heart rate assessment.

Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a multicentre international project initiated to implement remote care delivery for patients with atrial fibrillation (AF) through teleconsultations supported by an on-demand photoplethysmography (PPG)-based heart rate/rhythm monitoring app. Purpose The current sub-study of the TeleCheck-AF project aimed to provide the first real-world dataset on feasibility and patient experience of this standardized mobile health (mHealth) infrastructure in the clinical setting of follow-up after catheter ablation. Methods This sub-study included consecutive patients in each centre who have undergone catheter ablation. In the post-ablation period, at the 3-, 6- or 12-month visit, patients were provided with the app and were instructed to perform 60-second heart rate/rhythm recordings three times daily and in case of symptoms for seven consecutive days prior to teleconsultation. Recurrences of AF were documented by PPG-based app (FibriCheck®). Motivation was defined as number of days in which the expected number of measurements (≥three/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period. Patients’ experience was based on a survey sent to each patient via e-mail. Results Data from 588 patients (median age 63 [56-70] years, 39% female) from eight centres from six European countries were analysed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 158 (29%) of the study population and had more often previously undergone an ablation for AF (77% vs 62%), P=0.005) and had a higher number of AF PPG recordings (mean 1.9 vs 0.8, P=0.017). The app gave patients a safe feeling (70%) and automated reminders were useful (68%). Patients agreed that the app was easy to use (97%), easy to install (89%) and that they would like to use the app in the future (70%). In 95 (16%) patients, AF was detected by the app. There was no statistically significant difference between patients with (vs without) app-based detected AF, except a higher prevalence of prescribed three or more cardiovascular drugs (65% vs 53%, P=0.032) and beta-blockers (64% vs 52%, P=0.033). Patients with (vs without) app-based detected AF had higher optimal adherence (66% vs 41%, P Conclusion The TeleCheck-AF approach is feasible and associated with high adherence as well as motivation to use the app and with optimal patient experience. Whether this approach can replace conventional rhythm follow-up after catheter ablation required further study.

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): This work is part of Personalize AF. This project received funding from the European Union’s Horizon 2020 research and innovation programme under the Marie Skłodowska-Curie grant agreement No 860974, This work was also supported by the Swiss National Supercomputing Centre (CSCS), project s1074. Introduction Detecting and targeting the most dominant drivers of atrial fibrillation (AF) might improve the outcome of AF ablation procedures. We hypothesize that dominant drivers entrain their vicinity in a temporally and spatially stable manner resulting in local as well as adjacent repetitive activation patterns. Purpose We present a novel approach to detect the most dominant drivers of AF based on driver repetitiveness and the degree to which they entrain their vicinity. Methods We retrospectively analyzed a dataset of high-density bi-atrial sequential mapping in ablation-naive persistent AF patients (n=13, 30s recording per site). Candidate drivers (focal activity or re-entry) were detected based on local activation time analysis of unipolar electrograms. Focal activity was defined as radial spread of activation, re-entry as a circular activation sequence on at least 4 splines of the mapping catheter that covered >50% of the AF cycle length. As a measure of driver stability, we determined the driver's local repetitiveness (in % of recording). As a measure of driver-associated entrainment, we determined the directionally coherent repetitiveness of adjacent recordings within 30 mm (Figure 1). Following our hypothesis, most dominant drivers can be recognized by their high local and directional coherent adjacent repetitiveness. Results A total of 459 recordings were analyzed (35±5 per patient). We detected 130 focal activities (10±3 per patient) and 42 re-entries (4±2 per patient) in total. The spatial distribution of all drivers is shown in Figure 2 (blue bars). Focal activities were more repetitive than re-entries (Figure 2, median [IQR] 3.2% [1.9%, 5.6%] vs. 1.8% [1.8%, 2.2%], p Conclusion In this abstract we present a novel methodology to detect the most dominant drivers of AF. Using this method, we found that some (but not all) patients have temporally and spatially stable drivers that are able to entrain their vicinity.

Funding Acknowledgements Type of funding sources: None. Purpose Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients undergoing atrial fibrillation (AF) ablation. Currently, it remains unclear whether all AF patients should be systematically screened for SDB, or whether pre-selection of patients requiring screening can be improved. We aimed 1) to assess the accuracy of the STOP-Bang screening questionnaire as a tool for detecting SDB in patients scheduled for AF ablation; and 2) to develop a refined, AF-specific version of the STOP-Bang to improve pre-selection. Methods Consecutive patients scheduled for AF ablation without a previous history of SDB and/or SDB screening were included. Patients were digitally referred to the previously described Virtual-SAFARI SDB screening and management pathway1 including a home sleep test using polygraphy. An apnoea-hypopnoea-index (AHI) of ≥15 was interpreted as moderate-to-severe SDB. The accuracy of the STOP-Bang questionnaire (Snoring, Tiredness, Observed apneas, blood Pressure, BMI ≥35 kg/m², Age, Neck circumference, and Gender) was evaluated. Logistic regression was used to assess characteristics within and outside the STOP-Bang questionnaire associated with moderate-to-severe SDB. These characteristics were used to refine the STOP-Bang specifically for AF patients. Results Of 206 included patients, 51% was diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (0.573-0.721). AF-specific refinement of the STOP-BANG resulted in the BOSS-GAP score. Therein, tiredness and neck circumference were removed, while body mass index with cut-off point ≥27 kg/m² and previous stroke or transient ischaemic attack were added. The BOSS-GAP questionnaire performed better with an AUROC of 0.738 (0.672-0.805) in the overall population. Conclusion The STOP-Bang questionnaire showed limited value when used as a pre-selection tool for SDB screening. The refined, AF-specific BOSS-GAP questionnaire demonstrated slightly improved, but still limited accuracy in identifying AF patients with SDB. Whether questionnaires bring an advantage in pre-selection for SDB screening compared to structural screening in patients with AF, requires further study.

Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a digital care pathway, which consists of a structured teleconsultation ("Tele") preceded by an app-based on-demand heart rate and rhythm monitoring infrastructure ("Check") and the consecutive integration of the app-derived findings in a comprehensive atrial fibrillation (AF) management. Purpose To evaluate changes in healthcare utilisation and declarable care products during the implementation of the TeleCheck-AF approach in a Dutch AF-clinic. Methods Healthcare provided to patients in the Netherlands is based on a diagnosis-treatment combination (Dutch: DBC). Once a patient visits the hospital, a treatment trajectory is opened, which contains the DBC care product. The DBC care products contain diagnostic and therapeutic performances for a certain diagnosis as well as information about reimbursement and are weighted in light (≤ € 200), medium (€ 300-500) and heavy (≥ € 600) depending on the performed diagnostic tests. Patients with AF who were treated with both a conventional approach in 2019 (standard care) and by the TeleCheck-AF approach in 2020 in a Dutch AF-clinic, were compared in this prospective case-crossover analysis. Healthcare utilisation in terms of numbers and modes of outpatient contacts (teleconsultation vs face-to-face), number of emergency department (ED) presentations, use of diagnostic resources (i.e. ECG, Holter) and related reimbursement were analysed. A patient experience survey which encompassed five questions regarding use of the app and patient satisfaction with the remote heart rate and rhythm control was performed. Results Ninety-one patients with AF from a Dutch AF-clinic (median age 68 years; 43% women) were analysed. Within the conventional approach in 2019, 113 face-to-face consultations and 1 teleconsultation were performed. After the implementation of TeleCheck-AF in 2020 the number of face-to-face consultations reduced by 53% and teleconsultations increased by 2900%. While 151 ECGs and 42 Holter-ECGs were performed within the conventional approach, the number of ECGs in the TeleCheck-AF approach decreased by 48% and number of Holters decreased by 35%. ED presentations did not differ significantly in the conventional compared to TeleCheck-AF approach (22 vs 17). Patients’ satisfaction within the TeleCheck-AF approach was high. The change in healthcare utilisation in TeleCheck-AF treated patients resulted in a mutation in declarable care products weights (towards light weighted DBC) and associated reimbursement. Conclusion The implementation of TeleCheck-AF was associated with a change in health care utilisation which resulted in a disproportional drop in reimbursement by health insurances due to a shift in declarable care products weights. Results of this analysis were basis to design a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, and grant support from Medtronic to the institution. MHJPF was funded by a grant from the Karen Elise Jensen Foundation. JCN was supported by a grant from the Novo Nordisk Foundation Background Atrial fibrillation (AF) has been associated with adverse events and constitutes a significant, global healthcare challenge. Paucity exists on the occurrence of brady- and ventricular tachyarrhythmias. Purpose The aim of this predefined sub-analysis of the Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilization in the progression of AF (RACE V) study was to examine the prevalence of brady- and tachyarrhythmias using continuous rhythm monitoring in patients with paroxysmal self-terminating AF (PAF). Methods We identified 417 patients with PAF and at least two years of follow-up in RACE V; 25 patients with pacemakers at baseline were excluded. All remaining patients (n=392) received an implantable loop recorder and performed daily automated and weekly manual transmissions. Throughout follow-up, all detected episodes of tachycardia ≥182 BPM (cycle length ≤330ms) of ≥24 beats, bradycardia ≤30 BPM (cycle length ≥2000ms) of ≥12 beats, and pauses ≥5 seconds were adjudicated by three cardiologists. Results Over 1,272 patient years of continuous rhythm monitoring, we validated 1,940 episodes in 175 patients with paroxysmal self-terminating PAF (45%); 106 (27%) patients experienced AF or atrial flutter (AFL) with a rapid rate, pauses ≥5 seconds or bradycardias ≤30 BPM occurred in 47 (12%) patients (figure 1), and in 22 (6%) patients, both rapid AF/AFL and bradyarrhythmias were observed. No sustained ventricular tachycardias occurred. In the multivariable analysis, age >70 years (HR 2.4, 95% CI 1.4-3.9), longer PQ interval (HR 1.9, 1.1-3.1), CHA2DS2-VASc score ≥2 (HR 2.2, 1.1-4.5), and treatment with verapamil or diltiazem (HR 0.4, 0.2-1.0) were significantly associated with bradyarrhythmia episodes. For tachyarrhythmia episodes, age >70 years was associated with a significantly lower tachyarrhythmia risk (HR 0.4, 95% CI 0.2-0.7) in the multivariable analysis. Conclusions In a cohort exclusive to patients with self-terminating PAF, severe bradyarrhythmia episodes or AF/AFL with rapid ventricular rates occurred in 45% of patients. Our data highlight a higher than anticipated bradyarrhythmia risk in PAF.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Stockholm County Council, the Swedish Heart & Lung Foundation Introduction Atrial fibrillation (AF) is associated with an increased risk of stroke, which may be reduced through timely and adequate treatment initiation. Consequently, early detection of AF is important. In a recent European Heart Rhythm Association practical guide on the use of digital devices, systematic screening for AF of those ≥75 years is recommended. Purpose To 1) evaluate adherence and adherence consistency to a handheld electrocardiography (ECG)-based device for AF screening and 2) evaluate factors associated with optimal adherence and adherence consistency. Methods In STROKESTOP I and II, half of the 75- and 76-year old population in up to two regions in Sweden were invited to an AF screening program. Participants without previously known AF and without AF during baseline visit, were asked to perform 30-seconds recordings using a handheld ECG-based device for a period of two weeks twice daily in STROKESTOP I and four times a day in STROKESTOP II. Adherence was defined as the number of recordings performed per number of recordings that were asked from the participant over the entire screening period. Adherence consistency was defined as full screening days, i.e. the number of screening days on which the asked number of recordings was performed. Since baseline date was excluded from analysis, the total screening period consisted of 13 days. Results In total, 6436 participants from STROKESTOP I (3585 females (55.7%)) and 3712 participants from STROKESTOP II (2218 females (59.8%)) were included in the current analysis. Median adherence was 100% [92-100%] and 90% [75-98%] in STROKESTOP I and II, respectively. The median number of full screening days was 12 [11-13] in STROKESTOP I and 8 [3-11] in STROKESTOP II. In STROKESTOP I, female sex, region of inclusion, income in 1st to 3rd quartile and no university or college education were factors independently associated with both optimal adherence and adherence consistency (Figure 1). In addition, no previous stroke or transient ischemic attack and the use of beta blockers were associated with optimal adherence, whereas no diabetes and low alcohol index were associated with optimal adherence consistency. In STROKESTOP II, socioeconomic factors were not available at the time of the current analysis. Other associations (female sex, absence of diabetes) were comparable to STROKESTOP I. Conclusions In this screening program for AF, median adherence was optimal in case of twice daily measurements, and nearly optimal in case of measurements four times a day. Several demographic and socioeconomic factors, as well as low alcohol index and the absence of diabetes and previous stroke were associated with optimal adherence and/or adherence consistency.

Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a novel remote on-demand mobile health (mHealth) infrastructure supporting teleconsultations. During the COVID-19 pandemic, social media (SoMe) communication on Twitter contributed to the rapid dissemination and implementation of this health care innovation into 41 European hospitals by using the hashtag #TeleCheckAF. Purpose To (1) analyze the SoMe Twitter network behind #TeleCheckAF, (2) describe the communities and behavioral groups within the network and (3) to determine the opinion leaders and influencers. Methods Publicly available data on actors and interactions within the #TeleCheckAF SoMe network was collected by web-scraping from the platform Twitter. This included all public tweets that used the hashtag #TeleCheckAF including their meta-data. Based on this, a node list (Twitter accounts) and an edge list (ties between accounts) as well as a social network were created. The position of an actor in the network and an actor’s opinion leadership was analyzed with the help of centrality measures (i.e. degree centrality, closeness centrality, betweenness centrality). Communities, or groups of nodes that were highly connected to each other, were further assessed by a modularity algorithm. Behavioral groups were analyzed based on participation in the healthcare innovation TeleCheck-AF (active participation) and dissemination of #TeleCheckAF on Twitter. Three behavioral groups were defined: Diffusers (dissemination but no active participation), adopters (no dissemination but active participation) and communicative adopters (dissemination and active participation). Results The network consisted of 413 086 nodes and 636 502 edges. 287 actors within the SoMe Twitter network behind #TeleCheckAF, who were either diffusers, adopters or communicative adopters, were further analyzed. Twenty-two different communities and 20 opinion leaders were identified. Peaks in Twitter activity could be temporally related to (inter-,)national virtual conferences, where results on TeleCheck-AF were presented. Two official European Society of Cardiology (ESC) Twitter handles and two Twitter handles of ESC SoMe supervisors and ESC Journal SoMe editors were among the group of opinion leaders reflecting the effect of the ESC SoMe promotion strategy. Overall, not only professionals directly involved in the TeleCheck-AF project, but also different other stakeholders such as allied health professionals or health technology companies were represented within the network. Conclusion The SoMe network behind #TeleCheckAF showed a wide dissemination involving a broad spectrum of healthcare professionals and was accelerated by the official ESC Twitter handles. Social network analysis created a helpful insight into the mechanisms behind innovation dissemination within social media. Future research could further analyze the difssemination process using e.g. hazard modeling and investigate the evolution of the network and behaviors over time.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and atherosclerosis often coexist due to a shared risk profile. Prior to an AF ablation, computed tomography (CT) scans are routinely performed to assess pulmonary vein anatomy. Often coronary plaques are described as incidental findings. According to current guidelines, patients with coronary plaques on CT are classified as being at very high risk of developing cardiovascular atherosclerotic events, potentially resulting in a redefinition of treatment targets for comorbidities. Purpose This study estimated individual 10-year risks of developing atherosclerotic cardiovascular disease (CVD) events according to the 2021 ESC guideline on CVD prevention before and after the integration of CT-derived coronary plaque information in the risk assessment of AF patients scheduled for catheter ablation. Methods Consecutive AF patients scheduled for catheter ablation were included in the ISOLATION registry (NCT04342312). Patients were excluded from this subanalysis if no preprocedural CT was performed. Each patient was classified as being at low-to-moderate, high, or very high risk of developing CVD in the coming 10 years according to the 2021 ESC guideline on CVD prevention (Figure 1). This classification was based on previous CVD, chronic kidney disease, diabetes mellitus, or the Systematic Coronary Risk Estimation 2 (SCORE2) or SCORE2-Older Persons (SCORE2-OP) risk estimation. The impact of pre-AF ablation CTs on CVD risk was assessed by comparing risk classifications excluding and including information on coronary plaques on CT. Results A total of 1022 patients (age 64 ±9, 664 [65%] male, 686 [67%] paroxysmal AF) was included. Overall CVD risk was high, with 86% of patients at a high (n=190, 19%) or very high (n=693, 68%) 10-year risk of developing CVD events. Coronary plaques were observed in 59% (n=606) of pre-AF ablation CTs. Integration of the CT-derived information on coronary plaques resulted in reclassification of 364 patients (36%) towards the very high risk category (Figure 2). Previous CVD events were observed in 161 very high risk patients (16%). Conclusion In AF patients scheduled for catheter ablation, integration of the information on coronary plaques derived from the pre-AF ablation CT resulted in reclassification of one in three patients towards the very high risk category, which impacted treatment targets for lipid levels and blood pressure.

Funding Acknowledgements Type of funding sources: Other. Main funding source(s): Stockholm County Council, the Swedish Heart & Lung Foundation Introduction Screening for atrial fibrillation (AF) in older adults and high-risk patients may be beneficial in preventing clinical outcomes such as stroke. Studies on clinical outcomes in screening-detected AF have highlighted difficulties in getting the population at highest risk to participate in screening programs. Whether the risk of clinical outcomes differs among individuals depending on the level of adherence to the screening program instructions, is currently unknown. Purpose To explore associations between different levels of adherence consistency of and adherence to systematic screening, consisting of measurements using a handheld ECG device, and clinical outcomes. Methods Half of all 75- and 76-year old inhabitants of two Swedish regions were invited to participate in an AF screening program (STROKESTOP I study). Participants in whom AF was not diagnosed previously or during the baseline visit, were asked to perform 30-seconds recordings using a handheld ECG device twice daily for a period of two weeks. The total screening period consisted of 13 days. Adherence was defined as the total number of recordings performed divided by the total number of recordings asked, whereas adherence consistency was defined as the number of screening days on which the asked number of recordings was performed. Based on the thresholds when 90% of AF cases were detected, the participants were divided into low ( Results In total, 6436 participants (3585 females (55.7%)) were included in the analysis. Participants with low adherence consistency were at higher risk of ischemic stroke (hazard ratio (HR) 1.7 (95% confidence interval (CI) 1.2-2.3), p=0.001), systemic embolism (HR 1.7 (1.3-2.4), p= Conclusion Low adherence and adherence consistency in systematic screening for AF were associated with a higher risk of adverse cardiovascular and cerebral outcomes.

Funding Acknowledgements Type of funding sources: None. Background In patients with atrial fibrillation (AF), expiratory airflow limitation adds to overall morbidity and may impair the response to heart rhythm control strategies. Purpose We aimed to determine the prevalence of expiratory airflow limitation in patients scheduled for AF ablation and evaluated whether routine preprocedural cardiac analyses can detect occult lung disease. Methods Consecutive AF patients scheduled for catheter ablation were systematically screened for expiratory airflow limitation with handheld (micro)spirometry devices. As part of routine preprocedural care, patients underwent cardiac computed tomographic angiography (cCTA), transthoracic echocardiography and respiratory polygraphy. Qualitative analyses of cCT was performed for emphysema, airway abnormalities and lymphadenopathy. Sleep apnea severity and nocturnal desaturation were derived from polygraphy. Multivariate logistic regression was performed to assess if routinely preprocedural studies were associated with expiratory airflow limitation. Results (Micro)spirometry was performed in 110 consecutive patients and expiratory airflow limitation was detected in 25% of patients (previously unknown in 24 of 28 patients; Figure 1). Patients with expiratory airflow limitation more often presented with pulmonary abnormalities on cCTA, such as mild-to-severe emphysema (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.12-15.1, p < 0.05), lymphadenopathy (OR 3.6, 95% CI 1.1-11.3, p < 0.05) and bronchial wall thickening (OR 2.6, 95% CI 1.0-6.5, p < 0.05; Figure 2). The negative predictive value of the absence of pulmonary abnormalities on cCTA to identify patients with normal lung function was 85%. Polygraphy-derived sleep apnea status and nocturnal desaturation was less severe in patients with expiratory airflow limitation compared to patients with normal lung function (32% vs 48% moderate-to-severe sleep apnea, p = 0.23; oxygen desaturation index 3.0 [2.4-6.5] vs. 6.7 [3.4-11.4], p = 0.03). Echocardiography data did not differ between patients with compared to patients without expiratory airflow limitation. Conclusions Spirometry detected expiratory airflow limitation in 25% of patients scheduled for AF ablation. Routine preprocedural cCTA includes pulmonary features which may help in triage referral for formal pulmonary assessment.

Funding Acknowledgements Type of funding sources: None. Background Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The gold-standard test for HFpEF diagnosis remains invasive assessment of left ventricular end-diastolic pressures but noninvasive diagnostic scoring systems have been developed to aid accurate diagnosis. However, the diagnosis of HFpEF in patients with AF is more difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Purpose To compare the guidelines and scoring systems for HFpEF diagnosis in patients with AF, and to indicate the most relevant clinical and echocardiographic parameters supporting the diagnosis of HFpEF in an AF cohort. Methods Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Clinical characteristics and transthoracic echocardiography examination was collected at baseline visit. The European Society of Cardiology (ESC) guidelines from 2016 and 2021 as well as scoring systems (HFA-PEFF and H2FPEF scores) were used to diagnose HFpEF. In the H2FPEF score, patients with AF alone, score of 3, were assessed as group with the low risk for HFpEF (instead of intermediate risk according to the H2FPEF score), as all enrolled patients had AF. Multiple logistic regression was performed to find optimal parameters predicting HFpEF, that was defined as diagnosis of HFpEF according to all following scores: ESC guidelines from 2016 and 2021 and high risk in HF2FPEF and HF-PEFF scores. Results We analysed 325 patients (median age 65 [59-72], 36% women). Considerable differences were observed in HFpEF diagnoses when stratifying patients according to ESC 2016 and ESC 2021 guideline definitions; the percentage of HFpEF patients reduced from 55% (n=180) to 28% (n=90). The agreement of HF2PEF score relative to HFA-PEFF score was 46% (n=25/55), 54% (n=115/213) and 35% (n=20/57) of patients regarding low, intermediate and high risk for HFpEF, respectively. Overall, 5.8% of patients (n=19) had HFpEF (Figure 1). These 19 patients were older (median age 70 vs 65, p Conclusions The differences in HFpEF definition in the guidelines and various scoring systems lead to considerable difference in stratification of HFpEF in AF patients. In our population, just 5.8% of AF patients were diagnosed with HFpEF regarding ESC guidelines and high risk for HFpEF in scoring systems.

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): a.o. The European Union (ITN Network Personalize AF: Personalized Therapies for Atrial Fibrillation: a translational network, grant number 860974; MAESTRIA: Machine Learning Artificial Intelligence Early Detection Stroke Atrial Fibrillation, grant number 965286). Background/Introduction Noninvasive quantification of electrophysiological properties of the atria is increasingly used for outcome prediction in atrial fibrillation (AF) patients. Data on the added value of ECG parameters to predict AF recurrences in patients undergoing AF ablation are scarce. Purpose To investigate the predictive performance of clinical and echocardiographic characteristics as well as features extracted from extended surface electrocardiogram (extECG) recordings for AF recurrences in patients after AF ablation. Methods ISOLATION is a prospective, observational, multicenter registry of patients scheduled for AF catheter ablation, including cryoballoon and radiofrequency ablation. 178 patients (66.4%) patients used anti arrhythmic drugs at baseline. Clinical characteristics and results of routine blood tests were collected. In addition, an extECG was recorded (12 additional leads, 5 minutes recording) before ablation to analyze P-wave characteristics. The main study endpoint was ablation success after 12 months, defined as freedom from any episode of documented atrial arrhythmia after the blanking period recorded on holter or ECG. Results Currently, 627 of 650 scheduled patients have been included. In total, 268 patients completed the 1-year follow-up. 190 patients (70.9%) had paroxysmal AF and 75 patients (28.0%) had persistent AF. Median age was 65±9 years, 38.1% were female. 46 patients (17.2%) had a recurrence of AF after 12 months [figure 1]. Univariate analysis showed that higher age (64 years vs. 69 years, p=0.023, Mann-Whitney U-test), lower P-wave mean area (4.402 mV vs. 3.567 mV, p=0.034) and lower P-wave mean amplitude (0.087 mV vs. 0.081 mV, p=0.033), were associated with a higher recurrence rate of AF [figure 2]. However, multivariate analysis showed no significant independent prognostic factors so far. Conclusion Our first results show that patients with AF recurrences after catheter ablation are older, show lower P-wave mean area and lower P-wave mean amplitude. We need to wait for the completion of follow-up in more patients, before we can determine the predictive value of P-wave parameters derived from extECGs for the prediction of AF recurrence and to identify predictive factors with more subtle effects on risk for AF recurrences.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): We acknowledge the support from the Netherlands Cardiovascular Research Initiative: an initiative with support of the Dutch Heart Foundation, CVON 2014-9: Reappraisal of Atrial Fibrillation: interaction between hyperCoagulability, Electrical remodelling, and Vascular destabilisation in the progression of AF (RACE V). Unrestricted grant support from Medtronic Trading NL B.V. Background Atrial fibrillation (AF) progression is associated with morbidity and mortality. Both comorbidities and symptom severity are pillars in the ABC treatment pathway as proposed by the ESC guidelines. Interaction between comorbidities, symptom severity and AF progression seems evident, but evidence is lacking. Aims The aim of the present study is to investigate whether the number of comorbidities is related with severity of AF symptoms, and whether AF symptom severity is associated with AF progression in patients with paroxysmal AF. Methods Patients Underwent extensive phenotyping at baseline and received continuous rhythm monitoring with an implantable loop recorder during follow-up. We studied the relation between comorbidities, AF symptom severity [quantified with the Toronto AF Severity Scale (AFSS)], and AF progression in patients with paroxysmal AF included in the RACE V study. Multivariate regression analysis was performed to study the association between comorbidities and AFSS tertiles, and the association between AF progression and AFSS tertiles. Results Of 417 paroxysmal AF patients, AFSS questionnaires at baseline were available in 403 patients (97%). Mean age was 65 (IQR 58-71) years, 174 (43%) were women. 132 patients (33%) reported a low score [score 0–2; lowest tertile (T1)], 129 patients (32%) reported a moderate score [score 3–7; middle tertile (T2)], and 142 (35%) reported a high score [score 8–35; highest tertile (T3)]. Patients with the most severe symptoms were older, more often women, more often had coronary artery disease, kidney dysfunction, and a higher body mass index (BMI). The number of comorbidities [defined as hypertension, heart failure, age >65 years, diabetes mellitus; coronary artery disease, BMI >25kg/m2, moderate or severe mitral valve regurgitation and kidney dysfunction (estimated glomerular rate (eGFR) Conclusions In paroxysmal AF, multimorbidity was associated with symptom severity and AF progression. However, symptom severity was not associated with AF progression.

Funding Acknowledgements Type of funding sources: None. Introduction Chronic obstructive pulmonary disease (COPD) is a well-recognized risk factor for atrial fibrillation (AF) and negatively impacts symptom burden and AF rhythm control treatment. Nevertheless, there are currently no guideline recommendations or practical guides about whether or not and how to screen for COPD. Purpose To describe the implementation of an integrated screening and management pathway for COPD in patients with diagnosed AF, into the existing pre-ablation work-up embedded in an AF outpatient clinic infrastructure. Methods Unselected consecutive AF patients scheduled for catheter ablation were prospectively screened for airflow limitation using handheld (micro)spirometry devices. Patients with a forced expiratory volume (FEV) in one second (FEV1)/FEV in six seconds ratio of ≤0.73 or a FEV1/forced vital capacity ratio of Results In total, 232 patients (median age 66 [59-71], 31.9% female, 33.6% self-reported dyspnoea) were included in this screening and management pathway. Screening (micro)spirometry yielded interpretable results in 88.8% of patients. Airflow limitation was observed in 47 patients (20.3%) of whom 29 (12.5%) opted for referral to the pulmonologist and 17 (7.3%) received a final diagnosis of chronic respiratory disease, either COPD or asthma (11 newly diagnosed). The majority of these 17 patients (70.6%) scored high on the CAT (score ≥10), whereas 14 (82.4%) had a moderate-to-highly increased risk of COPD based on the RHSQ (score ≥16.5). Conclusions A COPD care pathway can successfully be embedded in an existing AF patient clinic infrastructure, using (micro)spirometry and remote analysis of results. Although all patients chose to perform handheld (micro)spirometry, only 60% of those in whom referral was advised opted for referral. Preselection of patients based on respiratory symptoms as well as increasing patient involvement might increase patient acceptance for respiratory analysis, and requires further research.

Funding Acknowledgements Type of funding sources: None. Background Catheter ablation (CA) has been established as an effective therapeutic option to achieve rhythm control in patients with atrial fibrillation (AF). However, AF recurrence occurs in approximately 45% of the patients undergoing CA. The association between AF recurrence after CA and left atrial (LA) strain, which is a surrogate marker of LA mechanical dysfunction already appearing before the enlargement of the LA, remains less clear. Aim The purpose of this study was to evaluate the association between LA function assessed by strain echocardiography and AF recurrence after CA. Methods This sub-study of ISOLATION (NCT04342312), involved consecutive patients with paroxysmal or persistent AF scheduled for first cryoballoon or radiofrequency CA. Clinical characteristics and echocardiography examination were collected at baseline visit before CA. Patients were followed for 12 months. Follow-up consisted of outpatient visits and heart rhythm monitoring (48 day Holter, 12-lead electrocardiogram, 7 day photoplethysmography-based rhythm app) at 3, 6, and 12 months. Results We analyzed 312 patients (median age 65, 36% women). More than half (52%; n=162) underwent radiofrequency CA and 84 (27 %) had AF recurrence within one year follow-up. No statistically significant differences in baseline characteristic were observed between patients with and without recurrent AF, expect higher prevalence of persistent AF prior to CA in patients with recurrence of AF (75% vs. 46%, p Conclusions LA function assessed by LA strain is associated with AF recurrence after CA, even in patients with non-dilated LA. Whether integration of results derived from systematic preprocedural LA strain analysis into patients’ selection strategies may help to identify patients profiting from CA required further study.

Objectives: Photoplethysmography (PPG) is an established technology for detecting pulse rate and pulse wave irregularities. However, whether temporal variations in pulse wave amplitudes, reflecting a combination of acute hemodynamic or autonomic responses to changes in overall vascular function, carry prognostic information remains unclear. To quantify nocturnal temporal pulse wave amplitude (PWA) attenuations and evaluate its association with long-term cardiovascular (CV) events in a large, racially diverse sample of men and women. Methods: Temporal PWA attenuations were determined based on the slopes between the upper and lower envelopes of PPGs derived from overnight polysomnography of 1957 participants (899 men, 1058 women, mean age 68.2 ± 9.1 years) of the Multi-Ethnic Study of Atherosclerosis. The nocturnal PWA attenuation index was defined as the cumulative duration of all PWA attenuation events relative to total sleep duration. Results: Nocturnal PWA attenuation index was greater in men than in women by almost 13% (16.3 ± 8.9% vs. 14.4 ± 7.9%, p < 0.001). The nocturnal PWA attenuation index was highest in Chinese-American participants (17.9 ± 9.2%) and lowest in African-Americans (13.5 ± 8.1%). During a median follow-up of 4.9 years, 94 CV events occurred. In multivariable Cox proportional hazard analysis adjusted for typical confounders, the nocturnal PWA attenuation index

Aims The recent 4S-AF (scheme proposed by the 2020 ESC AF guidelines to address stroke risk, symptom severity, severity of AF burden and substrate of AF to provide a structured phenotyping of AF patients in clinical practice to guide therapy and assess prognosis) scheme has been proposed as a structured scheme to characterize patients with atrial fibrillation (AF). We aimed to assess whether the 4S-AF scheme predicts AF progression in patients with self-terminating AF. Methods and results We analysed 341 patients with self-terminating AF included in the well-phenotyped Reappraisal of Atrial Fibrillation: Interaction between HyperCoagulability, Electrical remodelling, and Vascular Destabilization in the Progression of AF (RACE V) study. Patients had continuous monitoring with implantable loop recorders or pacemakers. AF progression was defined as progression to persistent or permanent AF or progression of self-terminating AF with >3% burden increase. Progression of AF was observed in 42 patients (12.3%, 5.9% per year). Patients were given a score based on the components of the 4S-AF scheme. Mean age was 65 [interquartile range (IQR) 58–71] years, 149 (44%) were women, 103 (49%) had heart failure, 276 (81%) had hypertension, and 38 (11%) had coronary artery disease. Median CHA2DS2-VASc (the CHA2DS2–VASc score assesses thromboembolic risk. C, congestive heart failure/left ventricular dysfunction; H, hypertension; A2, age ≥ 75 years; D, diabetes mellitus; S2, stroke/transient ischaemic attack/systemic embolism; V, vascular disease; A, age 65–74 years; Sc, sex category (female sex)) score was 2 (IQR 2–3), and median follow-up was 2.1 (1.5–2.6) years. The average score of the 4S-AF scheme was 4.6 ± 1.4. The score points from the 4S-AF scheme did not predict the risk of AF progression [odds ratio (OR) 1.1 95% CI 0.88–1.41, C-statistic 0.53]. However, excluding the symptoms domain, resulting in the 3S-AF (4S-AF scheme without the domain symptom severity, only including stroke risk, severity of AF burden and substrate of AF) scheme, predicted the risk of progression (OR 1.59 95% CI 1.15–2.27, C-statistic 0.62) even after adjusting for sex and age. Conclusions In self-terminating AF patients, the 4S-AF scheme does not predict AF progression. The 3S-AF scheme, excluding the symptom domain, may be a more appropriate score to predict AF progression. Trial registration numbers Clinicaltrials.gov NCT02726698 for RACE V

AimsAtrial fibrillation (AF) progression is associated with adverse outcome, but the role of the circadian or diurnal pattern of AF onset remains unclear. We aim to assess the association between the time of onset of AF episodes with the clinical phenotype and AF progression in patients with self-terminating AF.Methods and resultsThe Reappraisal of AF: Interaction Between Hypercoagulability, Electrical Remodelling, and Vascular Destabilization in the Progression of AF study included patients with self-terminating AF who underwent extensive phenotyping at baseline and continuous rhythm monitoring with an implantable loop recorder (ILR). In this subanalysis, ILR data were used to assess the development of AF progression and the diurnal pattern of AF onset: predominant (>80%) nocturnal AF, predominant daytime AF, or mixed AF without a predominant diurnal AF pattern. The median follow-up was 2.2 (1.6–2.8) years. The median age was 66 (59–71) years, and 117 (42%) were women. Predominant nocturnal (n = 40) and daytime (n = 43) AF onset patients had less comorbidities compared to that of mixed (n = 195) AF patients (median 2 vs. 2 vs. 3, respectively, P = 0.012). Diabetes was more common in the mixed group (12% vs. 5% vs. 0%, respectively, P = 0.031), whilst obesity was more frequent in the nocturnal group (38% vs. 12% vs. 27%, respectively, P = 0.028). Progression rates in the nocturnal vs. daytime vs. mixed groups were 5% vs. 5% vs. 24%, respectively (P = 0.013 nocturnal vs. mixed and P = 0.008 daytime vs. mixed group, respectively).ConclusionIn self-terminating AF, patients with either predominant nocturnal or daytime onset of AF episodes had less associated comorbidities and less AF progression compared to that of patients with mixed onset of AF.Clinical trial registrationNCT02726698

Background and aims Chronic obstructive pulmonary disease (COPD) is present in 13% of atrial fibrillation (AF) patients. In patients diagnosed with both AF and COPD, we aimed to assess overall mortality risk and its association with temporal sequence in AF and COPD diagnosis. Methods This nationwide study assessed all patients aged 18–85 years diagnosed with both COPD and AF between 1999 and 2018 in Denmark. Three groups were defined according to the temporal sequence of diagnosis: COPD diagnosed at least 6 months before AF (COPD-First), AF diagnosed at least 6 months before COPD (AF-First) and COPD, and AF diagnosed within a 6-months’ time frame (AF∼COPD). Results We included 62 806 patients (75.0 years; 56.5% males). After 5 years of follow-up, 31 494 (50.1%) died. Mortality was highest in the COPD-First group (COPD-First: 52.8%; AF-First: 46.0%; AF∼COPD 50.6%). In a multivariable Cox-regression model adjusted for age, sex, type 2 diabetes, history of acute myocardial infarction, hypertension, heart failure, dyslipidemia, cancer, chronic kidney disease, and stroke, the AF∼COPD group (HR 1.19, 95% CI 1.16–1.23; P Conclusion Patients with concomitant AF and COPD had a very poor prognosis and the temporal sequence in diagnosis was differentially associated with prognosis, where a COPD diagnosis preceding an AF diagnosis was accompanied with a higher mortality risk compared with a COPD diagnosis following an AF diagnosis.

BackgroundIn patients who underwent pneumonectomy, pulmonary vein isolation for atrial fibrillation by catheter ablation may be complicated by the anatomical alterations caused by the surgical intervention. Pre- and peri-procedural imaging can visualize and guide the procedure to assure safety and procedural success.Case summaryThis case series describes different imaging and ablation strategies in three cases from three different ablation centres with the unusually challenging and complex anatomical conditions in patients following lobectomy or pneumonectomy.DiscussionPulmonary vein isolation in patients with previous pulmonary resection was feasible by both radiofrequency and cryocatheter ablation despite the anatomical alterations caused by the surgery. Pre- and peri-procedural imaging by cardiac computed tomography and transoesophageal echocardiography contributed to an increased understanding of the complex anatomical substrate.

BACKGROUND Obstructive sleep apnea is associated with increased risk of sudden cardiac death.OBJECTIVE The purpose of this study was to elucidate changes in ventricular repolarization and electromechanical interaction during obstructive respiratory events simulated by intermittent negative upper airway pressure (INAP) in pigs. We also investigated the effect of a reduced repolarization reserve in drug-induced long QT (LQT) following INAP-induced changes in ventricular repolarization.METHODS In sedated spontaneously breathing pigs, 75 seconds of INAP was applied by a negative pressure device connected to the endotracheal tube. Ventricular electromechanical coupling was determined by the electromechanical window (EMW) before (preINAP), during (INAP), and after INAP (post-INAP). Incidence rates of premature ventricular contractions (PVCs) were measured respectively. A drug-induced LQT was modeled by treating the pigs with the hERG1 Mocker dofetilide (DOE).RESULTS Whereas QT interval increased during and decreased after INAP (pre-INAP: 273 +/- 5 ms; INAP 281 +/- 6 ms; post-INAP 254 +/- 9 ms), EMW shortened progressively throughout INAP and post-INAP periods (pre-INAP 81 +/- 4 ms; post-INAP 44 +/- 7 ms). DOF shortened EMW at baseline. Throughout INAP, EMW decreased in a comparable fashion as before DOF (pre-INAP/+DOF 61 +/- 7 ms; post-INAP/+DOF 14 +/- 9 ms) but resulted in shorter absolute EMW levels. Short EMW levels were associated with increased occurrence of PVCs (pre-INAP 7 +/- 2 ms vs post-INAP 26 +/- 6 ms; P = .02), which were potentiated in DOF pigs (pre-INAP/+DOF 5 +/- 2 ms vs post-INAP/+DOF 40 +/- 8 ms; P = .006). Administration of atenolol prevented post-INAP EMW shortening and decreased occurrence of PVCs.CONCLUSION Transient dissociation of ventricular electromechanical coupling during simulated obstructive respiratory events creates a dynamic ventricular arrhythmogenic substrate, which is sympathetically mediated and aggravated by drug-induced LQT.

This editorial refers to 'Attaining sinus rhythm mediates improved outcome with early rhythm control therapy of atrial fibrillation: the EAST-AFNET 4 trial', by L. Eckardt et al., https://doi.org/10.1093/eurheartj/ehac471.[GRAPHICS].

Heart rhythm 18(3), 455-464 (2021). doi:10.1016/j.hrthm.2020.10.011, Published by Elsevier, New York, NY [u.a.]

Aims There is a paucity of epidemiological evidence on alcohol and the risk of bradyarrhythmias. We thus characterized associations of total and beverage-specific alcohol consumption with incident bradyarrhythmias using data from the UK Biobank. Methods and results Alcohol consumption reported at baseline was calculated as UK standard drinks (8 g alcohol)/week. Bradyarrhythmia events were defined as sinus node dysfunction (SND), high-level atrioventricular block (AVB), and permanent pacemaker implantations. Outcomes were assessed through hospitalization and death records, and dose–response associations were characterized using Cox regression models with correction for regression dilution bias. We studied 407 948 middle-aged individuals (52.4% female). Over a median follow-up time of 11.5 years, a total of 8 344 incident bradyarrhythmia events occurred. Increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Beer and cider intake were associated with increased bradyarrhythmia risk up to 12 drinks/week; however, no significant associations were observed with red wine, white wine, or spirit intake. When bradyarrhythmia outcomes were analysed separately, a negative curvilinear was observed for total alcohol consumption and risk of SND, but no clear association with AVB was observed. Conclusion In this predominantly White British cohort, increasing total alcohol consumption was not associated with an increased risk of bradyarrhythmias. Associations appeared to vary according to the type of alcoholic beverage and between different types of bradyarrhythmias. Further epidemiological and experimental studies are required to clarify these findings.

Although previous studies have demonstrated a U-shaped relationship between alcohol and sudden cardiac death (SCD), there is a paucity of evidence on the role of alcohol specifically on incident ventricular arrhythmias (VAs).The purpose of this study was to characterize associations of total and beverage-specific alcohol consumption with incident VA and SCD using data from the UK Biobank.Alcohol consumption reported at baseline was calculated as UK standard drinks (8 g of alcohol) per week. Outcomes were assessed through hospitalization and death records. Alcohol consumption was modeled as restricted cubic splines in multivariate Cox regression models and corrected for regression dilution bias.We studied 408,712 middle-aged individuals (52.1% female) over a median follow-up time of 11.5 years. A total of 1733 incident VA events and 2044 SCDs occurred. For incident VA, no clear association was seen with total alcohol consumption. Although consumption of greater amounts of spirits was associated with increased VA risk, no other significant beverage-specific associations were observed. For SCD, a U-shaped association was seen for total alcohol consumption, such that consumption of26 drinks per week was associated with lowest risk. Consumption of greater amounts of beer, cider, and spirits was potentially associated with increasing SCD risk, whereas increasing red and white wine intake was associated with reduced risk.In this predominantly white cohort, no association of total alcohol consumption was observed with VA, whereas a U-shaped association was present for SCD. Additional studies utilizing accurately defined VA and SCD events are required to provide further insights into these contrasting findings.

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are two cardiovascular conditions that often coexist. Strain phases of both the left and right atria are more impaired in paroxysmal AF patients with HFpEF than those without HFpEF in spite of comparable global longitudinal strain of the left ventricle. Atrial function may differentiate paroxysmal AF patients with HFpEF from those without HFpEF.

Aims To systematic review and meta-analyse the association and mechanistic links between atrial fibrillation (AF) and cognitive impairment. Methods and results PubMed, EMBASE, and Cochrane Library were searched up to 27 March 2021 and yielded 4534 citations. After exclusions, 61 were analysed; 15 and 6 studies reported on the association of AF and cognitive impairment in the general population and post-stroke cohorts, respectively. Thirty-six studies reported on the neuro-pathological changes in patients with AF; of those, 13 reported on silent cerebral infarction (SCI) and 11 reported on cerebral microbleeds (CMB). Atrial fibrillation was associated with 39% increased risk of cognitive impairment in the general population [n = 15: 2 822 974 patients; hazard ratio = 1.39; 95% confidence interval (CI) 1.25–1.53, I2 = 90.3%; follow-up 3.8–25 years]. In the post-stroke cohort, AF was associated with a 2.70-fold increased risk of cognitive impairment [adjusted odds ratio (OR) 2.70; 95% CI 1.66–3.74, I2 = 0.0%; follow-up 0.25–3.78 years]. Atrial fibrillation was associated with cerebral small vessel disease, such as white matter hyperintensities and CMB (n = 8: 3698 patients; OR = 1.38; 95% CI 1.11–1.73, I2 = 0.0%), SCI (n = 13: 6188 patients; OR = 2.11; 95% CI 1.58–2.64, I2 = 0%), and decreased cerebral perfusion and cerebral volume even in the absence of clinical stroke. Conclusion Atrial fibrillation is associated with increased risk of cognitive impairment. The association with cerebral small vessel disease and cerebral atrophy secondary to cardioembolism and cerebral hypoperfusion may suggest a plausible link in the absence of clinical stroke. PROSPERO CRD42018109185.

Background Left bundle branch area pacing (LBBAP) has recently been introduced as a physiological pacing technique with synchronous left ventricular activation. It was our aim to evaluate the feasibility and learning curve of the technique, as well as the electrical characteristics of LBBAP. Methods and results LBBAP was attempted in 80 consecutive patients and electrocardiographic characteristics were evaluated during intrinsic rhythm, right ventricular septum pacing (RVSP) and LBBAP. Permanent lead implantation was successful in 77 of 80 patients (96%). LBBAP lead implantation time and fluoroscopy time shortened significantly from 33 ± 16 and 21 ± 13 min to 17 ± 5 and 12 ± 7 min, respectively, from the first 20 to the last 20 patients. Left bundle branch (LBB) capture was achieved in 54 of 80 patients (68%). In 36 of 45 patients (80%) with intact atrioventricular conduction and narrow QRS, an LBB potential (LBBpot) was present with an LBBpot to onset of QRS interval of 22 ± 6 ms. QRS duration increased significantly more during RVSP (141 ± 20 ms) than during LBBAP (125 ± 19 ms), compared to 130 ± 30 ms without pacing. An even clearer difference was observed for QRS area, which increased significantly more during RVSP (from 32 ± 16 µVs to 73 ± 20 µVs) than during LBBAP (41 ± 15 µVs). QRS area was significantly smaller in patients with LBB capture compared to patients without LBB capture (43 ± 18 µVs vs 54 ± 21 µVs, respectively). In patients with LBB capture (n = 54), the interval from the pacing stimulus to R‑wave peak time in lead V6 was significantly shorter than in patients without LBB capture (75 ± 14 vs 88 ± 9 ms, respectively). Conclusion LBBAP is a safe and feasible technique, with a clear learning curve that seems to flatten after 40–60 implantations. LBB capture is achieved in two-thirds of patients. Compared to RVSP, LBBAP largely maintains ventricular electrical synchrony at a level close to intrinsic (narrow QRS) rhythm.