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Objectives: To assess whether daily short-term rhythm strip recordings on top of routine clinical care could increase the atrial fibrillation (AF) detection rate in the hospitalised elderly., Methods: A hand-held device storing a bipolar ECG during 1 min was used for daily rhythm recording in hospitalised elderly patients., Results: During 2 months, all patients admitted to the Department of Geriatric Medicine were screened (n=327). Five patients refused to participate in the study and 70 patients were unable to hold the device due to severe mental (n=46) or motor impairment (n=24). In the remaining 252 patients, 1582 recordings were successfully obtained after 1624 attempts with a median acquisition time of 1 min (min 1, max 9, IQR 1-2 min). The rhythm strips were not reliable interpretable due to artefacts in three patients or an implantable cardiac pulse generator in another 28 patients. Detailed clinical information was available in 214/221 patients. Mean age was 84±6 years. On top of 71 (33%) patients with AF identified by routine clinical care (history, n=64 or de novo detected during current hospitalisation, n=7), review of all rhythm strips identified another 28 patients (13%) with AF. All these patients had a CHA 2 DS 2 VASc score ≥2. A contraindication for anticoagulation was present in only 8/28 (25%) of identified patients., Conclusions: On top of routine clinical care, daily short-term rhythm strip recordings identified another 13% of elderly hospitalised patients with AF, leading to an overall prevalence of 46% in hospitalised patients. This can have significant therapeutic implications with respect to initiation of anticoagulation., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Pulmonary vein reconnection (PVR) still determines recurrences of atrial fibrillation after contact force (CF)-guided pulmonary vein isolation. We studied whether acute PVR (adenosine and waiting time) and late PVR (at repeat) are explained by incomplete transmurality and contiguity within the deployed radiofrequency circle., Methods and Results: We analyzed 42 CF-guided ipsilateral pulmonary vein isolation procedures. For each radiofrequency tag within the circle, we collected data reflecting lesion depth (time of application, power, impedance drop [Δ-Imp], CF, force-time integral [FTI], and ablation index [AI]) and contiguity (automated interlesion distance [ILD]). Ablation line contiguity index (ALCI) was developed as a novel automated algorithm combining depth and contiguity into one single criterion. Each circle was subdivided into 10 segments. For each segment, we determined its weakest link by annotating time min , power min , Δ-Imp min , CF min , FTI min , AI min , ILD max , and ALCI min . Compared with segments without PVR (n=758), PVR segments (n=44) were characterized by lower Δ-Imp min (4.8 versus 7.4 Ω), CF min (8.5 versus 11.8 g), FTI min (351 versus 473 gs), AI min (367 versus 408 arbitrary unit [au]), and higher ILD max (6.8 versus 5.5 mm). ALCI min was significantly lower in segments with PVR (74% versus 104%; P <0.001) and was associated with the highest accuracy to predict durable segments (area under the curve=0.73)., Conclusions: In CF-guided pulmonary vein isolation, PVR is explained by lack of both lesion depth and contiguity within the deployed radiofrequency circle. ALCI, a novel measure combing contiguity and depth, is the most accurate predictor for durable segments. By avoiding weak links in the ablation chain, ALCI-guided ablation is expected to improve success rate of point-by-point radiofrequency ablation., (© 2017 American Heart Association, Inc.)

Background: J waves are the hallmark of both inferolateral early repolarization (ER) and Brugada syndrome. While ajmaline, a class 1a antiarrhythmic drug, accentuates the J wave in Brugada syndrome, its effect on ER is unreported., Objective: To describe the effect of ajmaline on the electrocardiogram in ER., Methods: We analyzed electrocardiograms before and after the administration of intravenous ajmaline (1 mg/kg) in 31 patients with ER, 21 patients with Brugada type 1 electrocardiogram (Br), and 22 controls. ER was defined as J-point elevation of ≥1 mm with QRS slurring or notching in ≥2 inferolateral leads (I, aVL, II, III, aVF, V4-V6)., Results: Ajmaline decreased mean J-wave amplitude in the ER group from 0.2 ± 0.15 mV at baseline to 0.08 ± 0.09 mV (P < .001). The QRS width prolonged significantly in all 3 groups, but the prolongation was significantly less in the ER group (+21 ms) than in the Br group (+36 ms; P < .001) or controls (+28 ms; P = .010). Decrease in mean inferolateral R-wave amplitude was similar in all the groups (ER group -0.14 mV; Br group -0.11 mV; controls -0.13 mV; P = ns), but mean inferolateral S-wave amplitude increased significantly less in the ER group (ER group +0.14 mV; Br group +16 mV; controls +0.20 mV; P < .001)., Conclusions: Ajmaline significantly decreases the J-wave amplitude in ER and prolongs the QRS width significantly less than in patients with Br. This indicates a different pathogenesis for both disorders. The altered terminal QRS vector probably is responsible for the decrease in the J-wave amplitude in ER, although a specific effect of ajmaline on J waves cannot be excluded., (Copyright © 2012 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to assess whether additional ablation in the right atrium (RA) improves termination rate in long-lasting persistent atrial fibrillation (PsAF)., Background: Prolongation of atrial fibrillation (AF) cycle length (CL) measured from the left atrial appendage predicts favorable outcome during catheter ablation of PsAF. However, in some patients, despite prolongation of AF CL in the left atrium (LA) with ablation, AF persists. We hypothesized that this persistence is due to RA drivers, and that these patients may benefit from RA ablation., Methods: In all, 148 consecutive patients undergoing catheter ablation of PsAF (duration 25 +/- 32 months) were studied. AF CL was monitored in both atria during stepwise ablation commencing in the LA. Ablation was performed in the RA when all LA sources in AF had been ablated and an RA-LA gradient existed. The procedural end point was AF termination., Results: Two distinct patterns of AF CL change emerged during LA ablation. In 104 patients (70%), there was parallel increase of AF CL in LA and RA culminating in AF termination (baseline: LA 153 ms [range 140 to 170 ms], RA 155 ms [range 143 to 171 ms]; after ablation: LA 181 ms [range 170 to 200 ms], RA 186 ms [range 175 to 202 ms]). In 24 patients (19%), RA AF CL did not prolong, creating a right-to-left frequency gradient (baseline: LA 142 ms [range 143 to 153 ms], RA 145 ms [range 139 to 162 ms]; after ablation: LA 177 ms [range 165 to 185 ms], RA 152 ms [range 147 to 175 ms]). These patients had a longer AF history (23 months vs. 12 months, p = 0.001), and larger RA diameter (42 mm vs. 39 mm, p = 0.005), and RA ablation terminated AF in 55%. In the remaining 20 patients, biatrial ablation failed to terminate AF., Conclusions: A divergent pattern of AF CL prolongation after LA ablation resulted in a right-to-left gradient, demonstrating that the right atrium is driving AF in approximately 20% of PsAF., (Copyright (c) 2010 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: We postulated that amplitude of fibrillatory (F)-wave in patients with persistent AF would correlate with clinical characteristics and outcome in patients undergoing catheter ablation for AF., Method: Maximal and mean amplitude of F-waves were measured in V1 and lead II in 90 patients prior to ablation for persistent AF. F-wave amplitudes were correlated to clinical, echocardiographic variables, and outcome., Results: F-wave > or = 0.1 mV in lead II and V1 was correlated with younger age and shorter AF history, and in lead II only was correlated with a smaller left atrium. Higher F-wave amplitude at baseline predicted AF termination during ablation. Maximal amplitude of > or = 0.07 mV predicted AF termination by ablation with 82%/79% sensitivity and 68%/73% specificity in V1/lead II respectively. An association between F-wave amplitude and AF recurrence was observed. Forty-three percent of patients with mean f wave amplitude <0.05 in lead V1 had AF recurrence compared to 12% of those with F-wave > or = 0.05 (p = 0.004)., Conclusion: Longer AF duration, older age and larger LA size are associated with fine AF amplitude. High F-wave amplitude predicts procedural termination of arrhyhmia in patients with persistent AF and freedom from AF upon follow-up.

Background: Recent data have shown a high incidence of the early repolarization pattern confined in inferolateral leads in patients with idiopathic ventricular fibrillation., Objectives: The purpose of the present study was to investigate the prevalence and the prognostic significance of the early repolarization pattern in inferolateral leads in patients with Brugada syndrome., Methods: Clinical, genetic, and electrophysiologic data from 290 individuals (223 males, mean age 48.3 +/- 14.2 years) with a spontaneous or drug-induced type 1 electrocardiogram (ECG) pattern of Brugada syndrome and structurally normal hearts were analyzed. Twelve-lead ECGs were evaluated for the presence of early repolarization pattern, which was defined as J-point elevation of at least 0.1 mV from baseline in at least two inferior or lateral leads. Follow-up data were obtained for all subjects., Results: An early repolarization pattern manifested as notched or slurred J-point elevation mainly in lateral leads was observed in 35 subjects (12%). The prevalence of the early repolarization pattern was significantly higher in male subjects (P = .004). During a mean follow-up period of 44.9 +/- 27.5 months, 22 subjects (8%) displayed an arrhythmic event including sudden cardiac death. There were no significant differences regarding spontaneous ECG type of Brugada syndrome, symptoms, family history of sudden cardiac death, and positive genetic test between subjects with and without the early repolarization pattern. The presence of early repolarization pattern was not associated with arrhythmic events during follow-up (Hazard ratio [HR] 1.090; 95% confidence interval 0.349-3.403; P = .882)., Conclusion: The early repolarization pattern in inferolateral leads is not an uncommon finding in Brugada syndrome. In our population, the early repolarization features were not associated with a worse outcome in subjects with Brugada syndrome.

Introduction: During left bundle branch area pacing (LBBAP) lead implantation, intermittent monitoring of unipolar pacing characteristics confirms LBB capture and can detect septal perforation. We aimed to demonstrate that continuous uninterrupted unipolar pacing from an inserted lead stylet (LS) is feasible and facilitates LBBAP implantation. Methods: Thirty patients (mean age 76 ± 14 years) were implanted with a stylet‐driven pacing lead (Biotronik Solia S60). In 10 patients (comparison‐group) conventional implantation with interrupted unipolar pacing was performed, with comparison of unipolar pacing characteristics between LS and connector‐pin (CP)‐pacing after each rotation step. In 20 patients (uninterrupted‐group) performance and safety of uninterrupted implantation during continuous pacing from the LS were evaluated. Results: In the comparison group, LS and CP‐pacing impedances were highly correlated (R2 = 0.95, p <.0001, bias 12 ± 37 Ω) with comparable sensed electrograms and paced QRS morphologies. In the uninterrupted group, continuous LS‐pacing allowed beat‐to‐beat monitoring of impedance and QRS morphology to guide implantation. This resulted in successful LBBAP in all patients, after a mean of 1 ± 0 attempts, with mean threshold 0.81 ± 0.4 V, median sensing 6.5 mV [IQR 4.4–9.5], and mean impedance 624 ± 101 Ω. Positive LBBAP‐criteria were seen in all patients with median paced QRS duration of 120 ms [IQR 112–152 ms] and median pLVAT 73 ms [IQR 68–80.5 ms]. No septal perforation occurred. Conclusion: Unipolar pacing from the LS allows accurate determination of pacing impedance and generates similar paced QRS morphologies and sensed electrograms to CP pacing. Continuous LS pacing allows real‐time monitoring of impedance and paced QRS morphology, which facilitates safe and successful LBBAP lead implantation. [ABSTRACT FROM AUTHOR]

Introduction: Recent studies have characterized drivers in persistent atrial fibrillation using automated algorithm detection with panoramic endocardial mapping by means of basket catheters. We aimed to identify repetitive atrial activation patterns (RAAPs) during ongoing atrial fibrillation (AF) based upon automated annotation of unipolar electrograms (EGMs) recorded with a high‐density regional endocardial contact mapping catheter. Methods: In 14 persistent AF patients, high‐resolution EGMs were recorded for 30 seconds at sequential PentaRay (Biosense Inc) positions covering the entire biatrial surface. All recordings were reviewed off‐line with dedicated software allowing automated annotation of the local activation time of the unipolar fibrillatory EGMs (CARTOFINDER; Biosense Inc). RAAPs were defined as a consistent activation pattern (for ≥3 consecutive beats) of either focal activity with centrifugal spread (RAAPfocal) or rotational activity across the PentaRay splines spanning the AF cycle length (RAAProtational). Results: A total of 498 PentaRay recordings were analyzed (35.6 ± 7.6 per patient). The number of PentaRay recordings displaying RAAP was 9.8 ± 3.1 per patient (range = 3‐15), of which 2.4 ± 2.4 RAAProtational (range = 0‐7), and 7.4 ± 4.4 RAAPfocal (range = 1‐13). 77% of RAAPs portrayed focal firing. The median number of repetitions per 30 second recording was 11 (range = 3‐225) per recording. RAAPs were observed both in the right atrium (RA) (35%) and left atrium (LA) (65%), with the majority being near the left PVs/appendage (35% of all RAAPs) and the superior vena cava/right appendage (23% of all RAAPs). Conclusion: High‐resolution, sequential endocardial EGM‐based mapping allows identification of RAAPs in persistent AF. In our series, focal firing was the most frequently observed pattern. [ABSTRACT FROM AUTHOR]

Role of CS Occlusion for Mitral Isthmus Ablation. Objective: To evaluate the safety and outcomes of mitral isthmus (MI) linear ablation with temporary spot occlusion of the coronary sinus (CS). Background: CS blood flow cools local tissue precluding transmurality and bidirectional block across MI lesion. Methods: In a randomized, controlled trial (CS-occlusion = 20, Control = 22), MI ablation was performed during continuous CS pacing to monitor the moment of block. CS was occluded at the ablation site using 1 cm spherical balloon, Swan-Ganz catheter with angiographic confirmation. Ablation was started at posterior mitral annulus and continued up to left inferior pulmonary vein (LIPV) ostium using an irrigated-tip catheter. If block was achieved, balloon was deflated and linear block confirmed. If not, additional ablation was performed epicardially (power ≤25 W). Ablation was abandoned after ∼30 minutes, if block was not achieved. Results: CS occlusion (mean duration −27 ± 9 minutes) was achieved in all cases. Complete MI block was achieved in 13/20 (65%) and 15/22 (68%) patients in the CS-occlusion and control arms, respectively, P = 0.76. Block was achieved with significantly small number (0.5 ± 0.8 vs 1.9 ± 1.1, P = 0.0008) and duration (1.2 ± 1.7 vs 4.2 ± 3.5 minutes, P = 0.009) of epicardial radiofrequency (RF) applications and significantly lower amount of epicardial energy (1.3 ± 2.4 vs 6.3 ± 5.7 kJ, P = 0.006) in the CS-occlusion versus control arm, respectively. There was no difference in total RF (22 ± 9 vs 23 ± 11 minutes, P = 0.76), procedural (36 ± 16 vs 39 ± 20 minutes, P = 0.57), and fluoroscopic (13 ± 7 vs 15 ± 10 minutes, P = 0.46) durations for MI ablation between the 2 arms. Clinically uneventful CS dissection occurred in 1 patient Conclusions: Temporary spot occlusion of CS is safe and significantly reduces the requirement of epicardial ablation to achieve MI block. It does not improve overall procedural success rate and procedural duration. Tissue cooling by CS blood flow is just one of the several challenges in MI ablation. (J Cardiovasc Electrophysiol, Vol. 23, pp. 489-496, May 2012) [ABSTRACT FROM AUTHOR]

The article discusses the case of a 32-year-old man with a history of symptomatic persistent atrial fibrillation (AF) who was referred for a third catheter ablation procedure. The surface electrocardiogram reveals a consistent biphasic P wave in inferior leads with a pointed positive deflection followed by a late negative deflection. The case illustrates the evaluation of a conduction block created by a linear lesion joining the anterior mitral annulus to the right superior pulmonary vein.

The article presents a case study of an asymtomatic 22-year-old woman diagnosed with accessory pathway (AP) and hypertrophic cardiomyopathy. The patient was subjected to electrophysiology study and a 12-lead electrocardiography (ECG) had been performed which demonstrates sinus rhythm with short PR interval, slurred upstroke and broad QRS duration. It is stated that fasciculoventricular pathways are classified in Mahaim type accessory pathways and are uncommon.