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Background Second-generation cryoballoon ablation is safe and effective in patients with paroxysmal (PAF) and persistent atrial fibrillation (AF). Objective This study aimed to assess the long-term clinical outcomes and freedom from AF in patients undergoing thermal-guided cryoablation without the use of an electrical mapping catheter. Methods All patients who had undergone thermal-guided second-generation cryoablation without electrical mapping between January 2015 and April 2018 at Eastbourne District General Hospital were retrospectively analysed. Success was defined as freedom from atrial arrhythmia lasting >30 s during the follow up period. Results The study included 234 patients with a mean age of 65.3 ± 10.6 years. There were 134 (57.0%) and 100 (42.7%) patients who had PAF and persistent AF respectively. Arrhythmia recurrence occurred in 38 of 134 (28.4%) PAF and 42 of 100 (42.0%) persistent AF patients after mean follow up of 40 ± 9.2 months. The patients with PAF had a significantly greater freedom from arrhythmia than patients with persistent AF (p = .040). The mean procedure time was 55.5 ± 12.2 min and the mean fluoroscopy time was 10.9 ± 4.8 min 73.5% of patients were discharged on the same day. Conclusion Thermal-guided cryoablation is feasible, safe and results in freedom from arrhythmia in the majority of paroxysmal and persistent AF patients in the long term. Randomised controlled trials are required to confirm the findings of this study.

Objective We evaluated pain in leucine-rich glioma inactivated1(LGI1) and contactin-associated protein2(CASPR2)-antibody positive(Ab+) patients, to evaluate clinical associations and pathophysiology of treatable pain syndromes. Methods 108 LGI-Ab+, 33 CASPR2-Ab+, and 6 LGI1/CASPR-Ab+patients were phenotyped. Pain questionnaires were undertaken to identify neuropathic pain using the Douleur Neuropathique(DN4), patient reported outcome measurement information system(PROMIS), and quality of life(EQ5D). Skin biopsies, and serum binding to cell-based assays, sensory neuronal cocultures, and dorsal root ganglion(DRG) cultures were undertaken. Results 39/147 patients described pain, including 17/33 CASPR2-Ab+(52%), 20/108 LGI1-Ab+(19%), and 2 LGI/CASPR2-Ab+patients. Questionnaires completed in 23/39(59%) revealed comparable DN4 scores(p=0.319) with 58% of LGI1-Ab+ and 67% of CASPR2-Ab+patients having neuropathic pain. Patients rated >50% response in 8/30(27%) analgesia trials, versus 20/40(55%) immunotherapy trials(p=0.045). PROMIS ratings were similar between LGI1-Ab+ and CASPR2-Ab+patients at nadir(p=0.662), but showed more improvement following immunotherapy in LGI1-Ab+(p=0.008) than CASPR2-Ab+patients(p=0.125). At follow-up(median 57 months) CASPR2-Ab+patients showed more impairment in mobility(p=0.014), daily activities(p=0.019), and anxiety/depression(p=0.043); and lower overall health(p=0.019) on the EQ5D compared to LGI1-Ab+patients. Intraepidermal nerve fibre density was reduced in 2 LGI1-Ab+ and 1 CASPR2-Ab+patients. Serum immunoglobulin G(IgG) from 6/16 CASPR2-Ab+patients bound to sensory neuronal cocultures compared to 0/14 LGI1-Ab+patients(p=0.019) and 0/12 healthy controls. Serum IgG from 10/16 CASPR2-Ab+patients bound to DRG cultures compared to 1/14 LGI1-Ab+patients(p=0.0024) and 1/12 healthy controls. Conclusion Neuropathic pain may be present in both LGI-Ab+ and CASPR2-Ab+patients, and is immunotherapy responsive. Serum IgG from CASPR2-Ab+patients more frequently bound sensory neurons and dorsal root ganglia, suggesting pathophysiological differences which may underlie the more severe pain in these patients.

Introduction Coronary bifurcation lesions (CBL) constitute a fifth of all coronary lesions and have no optimal method for treatment.(1) Multiple trials were conducted to investigate different modalities of treatment such as drug eluting stents, bioresorbable scaffolds, and dedicated bifurcation stents.(2) There are limited data discussing the clinical outcomes of these trials as most tend to report procedural outcomes.(3) This systematic review aimed to compare clinical outcomes of DBS compared to DES, while excluding bare metal stents and bioresorbable scaffolds.(4) Methods Following the PRISMA guidelines,(5) a systematic data search was conducted including EMBASE, PUBMED, MEDLINE, CINAHL, Cochrane database, TRIP database, and clinicaltrials.gov. Inclusion criteria were for prospective two-arm randomised trials published between the years from 2015 to 2018 comparing DBS and DES exclusively and reported clinical outcomes including cardiac death, myocardial infarction, target lesion revascularisation, and stent thrombosis. Risk of bias was assessed using Cochrane risk of bias assessment tool RoB1.(6) Two reviewers extracted data independently using Microsoft Excel 365 ProPlus. Meta-analysis is performed by restricted maximum-likelihood method comparing relative risks (RR) of clinical outcomes,(7) using MAJOR R pack through Jamovi platform and reported in logarithmic relative risk (Log RR).(8, 9) Results Six trials comparing DBS and DES involving 1914 patients met the inclusion criteria. Most of the studies were conducted in Europe, participants’ ages were DBS: 65.56, DES: 65.18 (p-value = 0.52). Participants of male gender were DBS: 74.9% DES: 77.5% (p-value = 0.44) and patients with smoking history were DBS: 28%, DES: 27.36% (p-value=0.70). Patients who presented with acute coronary syndrome were a fifth of all participants (p-value = 0.74). Around 70% of each arm participants had hypertension, and around 25% suffer from diabetes, as well as smoking. A third of participants had previous myocardial infarction (Table-1). Clinical outcomes were reported for 12 months in all study but one (Genereux et al. – 9 months).(10) There was only one cardiac death in the DBS arm compared to six cardiac deaths in the DES arm. A meta-analysis was performed for MACE (Figure-1), myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularisation (TLR). Major adverse cardiac events (MACE) were 13.3% for DBS and 12.4% for DES with a RR of 1.078 (Log RR = 0.07, p-value = 0.612) (Figure-1 & Table-2). Other measured outcomes showed no superiority for either arms. Conclusion When comparing the one-year clinical outcomes for coronary bifurcation lesions stenting; there was no statistically significant difference between dedicated bifurcation stents and drug eluting stents regarding MACE, CD, MI, TLR, and ST. Conflict of Interest None