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Atrial fibrillation (AF) is part of a vicious cycle that includes multiple cardiovascular risk factors and comorbidity which can promote atrial remodelling and AF progression. Most AF-related risk factors—hypertension, diabetes, sleep apnoea, obesity and sedentary lifestyle—are in essence modifiable which may prevent AF development. Treatment of associated cardiovascular conditions may prevent both symptoms and future cardiovascular events. For advanced forms of symptomatic AF refractory to lifestyle management and optimal medication, invasive ablation therapies have become a cornerstone. Although electrical trigger isolation from the pulmonary veins is reasonably effective and safe, more potent energy sources including high output-short duration radiofrequency, ultra-low cryo-energy, and electroporation, as well as more sophisticated arrays, balloons, and lattice-tipped catheter tools, are on their way to eliminate existing pitfalls and simplify the procedure. Electroanatomical navigation and mapping systems are becoming available to provide real-time information on ablation lesion quality and the critical pathways of AF in the individual patient to guide more extensive ablation strategies that may enhance long-term outcome for freedom of advanced AF. Surgical techniques, either stand-alone or concomitant to structural cardiac repair, hybrid, or convergent, with novel less invasive access options are developing and can be helpful in situations unsuitable for catheter ablation.

Background Ablation therapy is widely used as a treatment of atrial fibrillation (AF) and is associated with 3.6% minor and major complications in the Netherlands. Mortality following AF ablation is rare, but has been reported 0.46% in the United States in recent literature. We hypothesize that in the Netherlands, where AF ablation is performed in high volume centres only, 30-day mortality rate is low. Purpose To describe 30-day mortality in the Netherlands after AF ablation. Methods In the Netherlands Heart Registration, all 16 Dutch ablation centres participate and 14 out of 16 centres reported AF ablation outcomes using predefined variables for quality purposes. The number of reported procedures per centre was on average 236/year [range, 33–593], where 87.5% of the centres perform >150 AF ablations per year. All patients who underwent AF ablation were eligible for this analysis irrespective of ablation method used, or whether it was the first or a redo AF ablation. 30-day mortality was derived from, the municipal death registration, and individually checked by each participating ablation centre. No further analysis was available on the cause of death. Results In total, 20,230 patients who underwent AF ablation between 01-01-2013 and 31-12-2018 were included. The majority of patients were male (68%), mean age was 60.9±9.8 years, mean body mass index was 27.3±4.2kg/m2, and the average CHA2DS2VASc score was 1.6±1.3. Reduced left ventricular (LV) ejection fraction ( Conclusion Patients undergoing AF ablation in the Netherlands mainly presented with paroxysmal AF. In a setting where AF ablation is performed in high volume centres only, such as the Netherlands, 30-day mortality is very low after AF ablation. Funding Acknowledgement Type of funding source: None

Background Severely enlarged left atrial (LA) volume is associated with a considerable ineffective outcome of ablation for atrial fibrillation (AF). Therefore, in patients with AF and a giant atrial volume catheter ablation is not recommended. However, thoracoscopic AF ablation is being performed in patients with AF and giant LA, but with unknown efficacy. Purpose To determine efficacy of thoracoscopic AF ablation in patients with AF and a giant LA. Methods Patients underwent thoracoscopic AF ablation (paroxysmal AF) plus additional left atrial ablations (persistent AF) and were prospectively followed. Giant LA was defined as left atrial volume index (LAVI)≥50 ml/m2, outcome was also assessed for LAVI≥55 ml/m2. Follow-up was performed with ECGs and 24-hour Holters every three months. After a 3-month blanking period, all AADs were discontinued. Primary outcome was recurrence of any atrial tachycardia ≥30 sec during one year of follow-up. Results Between 2008–2017, 357 patients underwent thoracoscopic AF ablation. At baseline, giant LA was diagnosed in 72 (20.2%) patients (mean LAVI: 59.5±9.6 ml/m2), while 285 (79.8%) had a smaller left atrium (mean LAVI: 36.3±7.8 ml/m2), p Kaplan-Meier analysis of AF recurrence i Conclusion Thoracoscopic AF ablation is an effective therapy in patients with a giant LA. Thoracoscopic AF ablation may therefore be a feasible treatment for patients with a giant LA.

Purpose To evaluate the proportion of patients in whom parameters that define the diagnosis of HFpEF and HFmrEF persist versus normalize upon elimination of AF. Background Atrial fibrillation (AF) and heart failure with preserved or mid-range ejection fraction (HFpEF or HFmrEF) concur in many patients. Distinction between these two diagnoses remains challenging as one can cause or exacerbate the other. Adequate patient selection for invasive AF treatment is crucial to improve rhythm outcome. Methods Patients underwent thoracoscopic ablation, consisting of pulmonary vein isolation (PVI) alone or PVI with additional lines in the case of persistent AF. Patients were prospectively followed-up. HFmrEF or HFpEF was defined as left ventricular ejection fraction (LVEF) ≥40% or ≥50% respectively and N-terminal prohormone of brain natriuretic peptide (NT-proBNP) levels >125 pg/ml. Patients who remained free from AF, or any atrial tachycardia of more than 30 seconds, at 6 months postoperatively, were included in this study. Patients with AF recurrences during this period were excluded. The primary outcome was the change of NT-proBNP at 6 month follow-up. Results From 2008 to 2017, 92 patients undergoing thoracoscopic AF ablation fulfilled the aforementioned criteria and were included. Of these patients, mean age was 61±8 years and 66 (72%) were male. Median NT-proBNP was 366 pg/ml (128–2916) and mean LVEF was 53±7%. Thirty (35%) patients had a LVEF of 40–49%. Six months after elimination of AF, NT-proBNP was Figure 1. NT-proBNP alterations after thoracoscopic AF ablation from baseline to 6 month follow-up. A. Patients with normalization of NT-proBNP. B. Patients with unchanged high levels of NT-proBNP. Conclusion In 28% of patients the diagnostic criteria of HFpEF/HFmrEF are caused by AF and normalize upon elimination of AF with thoracoscopic ablation.

Background Many adult congenital heart disease (ACHD) patients are at risk of sudden cardiac death (SCD). An implantable cardioverter-defibrillator (ICD) may prevent SCD, but the evidence for primary prevention indications is still unsatisfactory. Study Design PREVENTION-ACHD is a prospective study with which we aim to prospectively validate a new risk score model for primary prevention of SCD in ACHD patients, as well as the currently existing guideline recommendations. Patients are screened using a novel risk score to predict SCD as well as current ICD indications according to an international Consensus Statement. Patients are followed up for two years. The primary endpoint is the occurrence of SCD and sustained ventricular arrhythmias. The Study was registered at ClinicalTrials.gov (NCT03957824). Conclusion PREVENTION-ACHD is the first prospective study on SCD in ACHD patients. In the light of a growing and aging population of patients with more severe congenital heart defects, more robust clinical evidence on primary prevention of SCD is urgently needed. Electronic supplementary material The online version of this article (10.1007/s12471-019-1297-3) contains supplementary material, which is available to authorized users.

Background: Eight-mm ablation catheters are widely used in cavotricuspid isthmus ablation (CTI) for treatment of right sided atrial flutter. However a high success rate, these large ablation tips comes with adisadvantage of lower resolution of fractionated signals. Purpose:The aim of this study was to evaluate the additional diagnostic value of the electrograms recorded from mini electrodes (MEs) in an 8-mm ablation catheter tip during CTI. Methods: CTI-Ablation procedures were compared retrospectively in two groups, namely, group A: The Abbott Safire 8-mm tip with a 3D mapping system (n =37) and group B: The Boston Scientific MiFi IntellaTip XP 8-mm tip without a 3D mapping system (n=13). We analyzed acute procedural success, ablation characteristics and recurrence rate at one-year follow-up. Electrograms from MEs were analyzed right before the onset of the critical ablation application that resulted in acute CTI-block. We determined whether these ME electrograms had additional diagnostic value in addition to of the 8-mm tip derivedelectrogram. Results: At the onset of the critical ablation application, the MEs had an important additional value in 3 out of 13 cases as local signals were sensed on the MEs that were not recorded by the 8-mm tip electrode. In 2cases the ME did not show local electrograms although the ablation was still effective. Acute procedural and long-Term success were observed in all patients. No differences were found in time to bidirectional block, procedure time or fluoroscopic exposure. Conclusions: Our data show that signals recorded from the MEs had additional diagnostic value, but only in a small percentage of the patients. We did not observe, although omitting 3D-mapping in the ME group, any difference between groups with regard to procedural or ablation characteristics during CTI-Ablation.

Background: Timely detection of atrial fibrillation (AF) in implantable cardioverter defibrillator (ICD) patients is clinically important for prevention of AF-related complications and inappropriate shocks. Patients with coronary artery disease (CAD) and a dual or triple chamber ICD show a high incidence of device-detected AF. Whether CAD patients with a single chamber ICD carry a similar risk for device-detected AF remains unknown. Study design: The INDICO AF trial is an investigator-initiated, multicentre, observational study evaluating the incidence of subclinical AF (SCAF) in CAD patients who will receive a single chamber ICD as primary prevention for sudden cardiac death (SCD). Fifty patients will receive a single chamber ICD with an integrated RR interval based AF detection algorithm. In combination with remote monitoring, rhythm data will be collected monthly. The primary endpoint is the incidence of SCAF at 1 year of follow-up; secondary endpoints include time until 10 and 20% of the patients have a first episode of SCAF. All patients in whom SCAF is detected will be invited for an outpatient visit and will receive adequate anticoagulation treatment when appropriate according to the CHA2DS2-VASc score and current guidelines. Conclusion: The INDICO AF trial will quantify the incidence of SCAF in patients with an ICD and CAD. The study will underscore the clinical value of SCAF detection in single chamber ICD patients using remote patient monitoring and may improve patient care. This trial is registered at trialregister.nl with trial NTR6910.

Aims The subcutaneous implantable cardioverter-defibrillator (S-ICD) and leadless pacemaker (LP) are evolving technologies that do not require intracardiac leads. However, interactions between these two devices are unexplored. We investigated the feasibility, safety, and performance of combined LP and S-ICD therapy, considering (i) simultaneous device-programmer communication, (ii) S-ICD rhythm discrimination during LP communication and pacing, and (iii) post-shock LP performance. Methods and results The study consists of two parts. Animal experiments : Two sheep were implanted with both an S-ICD and LP (Nanostim, SJM), and the objectives above were tested. Human experience : Follow-up of one S-ICD patient with bilateral subclavian occlusion who received an LP and two LP (all Nanostim, SJM) patients (without S-ICD) who received electrical cardioversion (ECV) are presented. Animal experiments : Simultaneous device-programmer communication was successful, but LP-programmer communication telemetry was temporarily lost (2 ± 2 s) during ventricular fibrillation (VF) induction and 4/54 shocks. Leadless pacemaker communication and pacing did not interfere with S-ICD rhythm discrimination. Additionally, all VF episodes ( n = 12/12), including during simultaneous LP pacing, were detected and treated by the S-ICD. Post-shock LP performance was unaltered, and no post-shock device resets or dislodgements were observed (24 S-ICD and 30 external shocks). Human experience : The S-ICD/LP patient showed adequate S-ICD sensing during intrinsic rhythm, nominal, and high-output LP pacing. Two LP patients (without S-ICD) received ECV during follow-up. No impact on performance or LP dislodgements were observed. Conclusion Combined LP and S-ICD therapy appears feasible in all animal experiments ( n = 2) and in one human subject. No interference in sensing and pacing during intrinsic and paced rhythm was noted in both animal and human subjects. However, induced arrhythmia testing was not performed in the patient. Defibrillation therapy did not seem to affect LP function. More data on safety and performance are needed.

Atrial fibrillation (AF) is the most common arrhythmia and its prevalence and incidence increase with age, but also with cardiovascular morbidity, such as hypertension, diabetes, vascular and valvular disease and heart failure. Indeed, in patients with implantable cardioverter defibrillators (ICD), who usually have one or more of these predisposing factors, a history of AF was present in 33 % [1]. In this patient group AF can be symptomatic for example by causing palpitations, dyspnoea and fatigue, but can also worsen heart failure and lead to inappropriate ICD discharges. The electrophysiological substrate of persistent AF is heterogeneous, but the fact that the arrhythmia does not terminate spontaneously, as paroxysmal AF does, and may require cardioversion, triggers the impression that the substrate is more advanced in this type of AF. This is evidenced by more left atrial fibrosis, dilated atria and lower intracardial electrogram amplitudes in persistent versus paroxysmal AF [2, 3]. Despite the fact that pharmacological cardioversion is recommended as the first-line treatment option in patients with recent-onset AF [4], electrical cardioversion (ECV) is highly efficacious in restoring sinus rhythm in patients with AF, and performed on a daily basis in most hospitals. Patients with ICDs in this respect form an interesting subgroup, while they carry their cardioverter subcutaneously or under the pectoral muscle. Indeed, it was shown in a population of patients with cardiac resynchronisation therapy that internal cardioversion was associated with 82 % of restoration of sinus rhythm [5]. Aside from the demonstration of feasibility, the efficacy seems somewhat lower than conventional, external ECV and the question arises whether internal defibrillation should be implemented into clinical practice. In this issue of the Netherlands Heart Journal Limantoro et al. describe the efficacy of internal cardioversion using the ICD in all-comers with persistent AF [6]. They show a disappointingly low cardioversion rate of 33 % among the 27 patients with persistent AF in whom internal cardioversion was attempted. Patients with failed internal cardioversion subsequently underwent external electrical cardioversion, which was effective in all of the patients. Interestingly, looking further into the characteristics of the patients who failed internal cardioversion, Limantoro et al. report that those patients had significantly larger left atrial volumes (146 ± 44 ml vs. 99 ± 36 ml), a longer total AF history (40 (5–75) vs. 2 (0–17) months) and shorter right atrial cycle length (169 (152–183) ms vs. 227 (186–255) ms), as recorded from the atrial lead of the ICD. The investigators suggest that the atrial substrate, as clinically assessed with these parameters, negatively affects the atrial defibrillation threshold for internal cardioversion of AF, which is supported by the even lower efficacy of 10 % of subsequent internally delivered shocks. Furthermore, they describe that three out of four (75 %) patients with a dual-coil ICD had successful internal cardioversion. On the other hand, only 28 % of 23 patients with a single-coil ICD were cardioverted internally, demonstrating that internal cardioversion was particularly ineffective in this group. Therefore, they emphasise the importance of patient selection: Patients with a short history of AF and small atria may be suitable for internal cardioversion, but patients with more structurally remodelled atria should rather directly undergo external cardioversion to achieve sinus rhythm. As of today, we do not know whether the three parameters mentioned above are sufficient to determine the extent of atrial substrate remodelling in these patients. It can be hypothesised that the amount of fibrosis, which is very hard to determine echocardiographically (although atrial fibrosis is associated with left atrial size), may have an important contribution to the atrial defibrillation threshold. Potentially, there is an unrecognised group of patients with remodelled atria who are not detected with these three parameters and in whom internal cardioversion may be evenly unsuccessful. It is tempting to seek the characteristics of the atrial substrate as a determinant of internal cardioversion success, but against the background of the data that Limantaro et al. describe, the most important question is why internal cardioversion should be considered in ICD patients at all. One reason could be that external cardioversion could damage the device. There are indeed older case reports on broken implanted rhythm devices after direct current shocks requiring replacement of the device [7]. Generally, it is advised to place the paddles of the external defibrillator in an anteroposterior manner to avoid current flow through the device causing device and/or electrode dysfunction. With external cardioversion being performed almost daily in most cardiac care units, shock paddles could theoretically be misplaced and cause damage to the ICD. However, Manegold et al. [8] showed that using the appropriate (antero-posterior) paddle position, external cardioversion for AF is safe and effective in patients with implanted rhythm devices and no device or lead dysfunction was reported in any of their patients. Another advantage could be that less shock energy is required with internal cardioversion as compared with ECV, but the clinical interpretation thereof is unclear. It seems simple logic that more shocks are worse than fewer, and that the first shock should be aimed at restoring sinus rhythm in as many patients as possible. Other sources of potential adverse effects associated with cardioversion include the risk of thromboembolic complications, for which the use of anticoagulants is clearly defined in the guidelines [4] and complications associated with the use of general anaesthesia. These factors, however, are present to the same extent in patients being cardioverted internally as externally. The use of general anaesthesia, and therefore the presence of an anaesthesiologist at the site, as described by Limantaro et al., and conform the current clinical practice in most centres, importantly limits the potential benefits of internal cardioversion. Additionally, for internal cardioversion an ICD technician is needed to program the ICD and apply the internal shock. The requirement of the presence of several professionals in performing the procedure can be a logistic disadvantage of internal cardioversion and result in significantly higher costs. Finally, as Limantoro et al. discuss, extra shocks performed with an implantable cardioverter defibrillator may have a negative impact on battery lifetime. Battery depletion is the major cause of ICD replacement, which is associated with higher risks for the patient [9]. Moreover, saving battery lifetime will reduce the number of ICD generator changes, maybe not on the level of the individual patient, but certainly on a population level. Consequently, saving battery lifetime is expected to reduce complications and costs. This is especially true in patients with frequent recurrences of AF, something that is not uncommon in persistent AF. Hence, battery depletion has to be taken into account when considering internal cardioversion. Taking the above argumentation into account Limantoro et al. raise the justified question if internal cardioversion should be the preferred treatment of choice in patients with an ICD. As a conclusion from the disappointingly low efficacy rate for internal cardioversion, they answer that question with ‘no’ and they have indeed discontinued this practice in their own hospital. Internal cardioversion seems to have no significant advantages over external cardioversion. Determining the atrial substrate of AF, although scientifically very interesting for a better understanding the disease, may therefore be futile when choosing the cardioversion strategy in patients with an ICD and persistent AF. It may be, however, of importance to find parameters that can determine patients in whom atrial remodelling is advanced and who will experience frequent recurrences, despite cardioversion. Since ECV was eventually successful in all the patients in the study by Limantoro et al., this determination may be relevant for patient prognosis, but not for cardioversion success. The goal of cardioversion in patients with AF is restoration of sinus rhythm, while applying the least number of shocks. Apart from the patients with recent-onset AF, in whom pharmacological cardioversion is applied, the results of the study by Limantoro et al. point us in the direction of applying external cardioversion as treatment of choice for persistent AF, whether the patient carries an ICD or not.

Endocardial catheter ablation for cardiac arrhythmias has emerged as a powerful treatment over the last decades. Supraventricular tachycardias such as for example AV nodal re-entrant tachycardias, circus movement tachycardias making use of an accessory bundle and right-sided, cavotricuspid dependent atrial flutters can be treated with a success rate close to 100 %. However, with the emerging technology, the field is widening and more complex arrhythmias are being treated, with a less robust outcome and endpoint. The arrhythmogenic substrate may not always be confined to or modifiable via an endocardial approach. For ventricular arrhythmias in the setting of dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy (ARVC), previous myocardial infarction or myocardial storage disorders, an epicardial substrate may be crucial for arrhythmia perpetuation, and consequently an epicardial approach may be warranted for ablation. Epicardial procedures are usually performed after failed endocardial ablation, their number is steadily growing, and in experienced hands these procedures appear efficacious and safe [1, 2]. Damage to the coronary vessels is a potential complication of epicardial mapping radiofrequency ablation. To prevent this, (repeated) coronary angiography can be performed, which adds to the radiation burden. Alternatively, scar anatomy and coronary vasculature can be imaged using cardiac MRI. Navigation systems such as the CARTO system may facilitate epicardial mapping by merging imaging techniques with the electroanatomical map, in which critical structures can be further annotated [3]. Furthermore, they may assist in reducing radiation exposure to both the operator and the patient. Anatomical barriers associated with epicardial ablation include problematic pericardial access through a subxiphoid approach, puncture of the right ventricle in 10–14 %, and potential manoeuvrability problems in case of adhesions within the pericardium [4]. Indeed, it was shown that epicardial ablation was associated with a failure percentage of the procedure of 10–11 %, of which 75–87 % due to pericardial adhesions after cardiac surgery [1, 4]. In this issue of the Netherlands Heart Journal, Abraham et al. present three patients, all under general anaesthesia, where a magnetic navigating system (MNS) was used to complement epicardial mapping and ablation [5]. The first patient is a 78-year-old man with episodes of ventricular tacycardia from an inferior myocardial infarction scar. The second patient is a 50-year-old man with symptomatic, idiopathic premature ventricular complexes, arising from an epicardial site close to the left main stem coronary artery. A third patient had a left lateral accessory pathway, of which the insertion site could not be determined with an endocardial approach because of perimitral block after previous ablations. In this specific case, endocardial ablation was employed after localisation of the bypass tract was confirmed epicardially. Hence, these three patients form an atypical population for epicardial ablation. Abraham et al. confirm that MNS can be used for epicardial mapping, as has been demonstrated by others [1, 6]. However, several issues remain unsolved and may be the subject of further studies. First, the most important motivation to employ an MNS is the reduction of radiation for both the operator and the patient. In the three patients that Abraham et al. describe, the amount of radiation is considerable, 46 min on average, with a cumulative fluoroscopy time up to 84 min in patient 3. Additionally, in this study, repeat coronary angiograms were performed after every radiofrequency ablation application, which is not specific for MNS-guided ablation, but does not add to reduction of radiation exposure either. Although the authors state that in the literature the amount of radiation using MNS is less than using conventional mapping, [4, 6] this statement holds true for their two ventricular arrhythmia cases only and cannot be substantiated without a head-to-head comparison. Similarly, it is not indicated that epicardial mapping is less time-consuming than conventional catheter mapping. The use of dedicated multi-electrode catheters such as the Pentaray catheter, for example, may even be associated with a more rapid, higher resolution, mapping procedure, although this also has to be proven in a clinical comparison. Thirdly, it remains open to debate whether MNS provides a better epicardial tissue contact. One might even speculate that manoeuvrability within the pericardial space is even less efficient than manual catheter ablation, since the pericardium itself may possess a random resistance to the mapping catheter. Finally, it remains to be solved whether truly difficult epicardial cases, such as after cardiothoracic surgery, can be handled more easily using MNS than with conventional techniques. Indeed, of the failed epicardial access cases reported earlier, the vast majority were related to postoperative pericardial adhesions [1, 4]. It could be argued that such adhesions would need careful dissection using steerable sheaths, as has been demonstrated previously, [7] and that MNS is of little added value here. Again, studies comparing different techniques are so far lacking. Furthermore, patients who underwent coronary bypass grafting were excluded from most studies on epicardial ablation because of the risk of damaging coronary grafts. However, this patient group may represent the true last frontier for epicardial mapping and ablation, and potentially MNS could be of use in this patient group. Abraham et al. modestly conclude that magnetic navigation for epicardial mapping and ablation may offer benefits, but that more cases are required to actually prove this. Apart from the conclusion that magnetic epicardial navigation can be done, we must await further data to be able to understand the specific indication for this technique in epicardial mapping and ablation of arrhythmias.

This editorial refers to ‘Minimal invasive surgery for atrial fibrillation: an updated review’ by M. La Meir et al ., on page 170–182 and ‘Circumferential pulmonary vein isolation: wait or stop early after initial successful pulmonary vein isolation?’ by D. Bansch et al ., on page 183–188 Circumferential pulmonary vein isolation (PVI) is the current treatment of choice for drug refractory symptomatic atrial fibrillation (AF). Although PVI is safe, recurrences of AF may occur, and are almost always associated with reconnection of one or more pulmonary veins.1 Therefore, there is consensus that complete isolation of all the pulmonary veins is the cornerstone of the ablation procedure. However, we can never be sure that the PVs remain isolated over time, because myocardial oedema might cause acute but reversible conduction block. Additionally, the decision to plan a redo procedure depends on recurrent AF, and not on reconnection of the pulmonary veins. Pratola et al. 2 showed in 20 asymptomatic patients undergoing electrophysiological evaluation after successful PVI that reconnection of one or more PVs was present in as many as 62.5%, and voltage abatement was not complete around 60% of PVs. Remarkably, these rates did not differ from 10 patients undergoing a redo ablation because of recurrent AF, who served as control. In other words, the durability and meaning of acute conduction block during PVI are questionable. One could argue that waiting long enough for acute reconnection to appear would allow treatment of any reconnection of the pulmonary veins, and confer a better outcome, and there are data supporting this strategy.3 The questions how long a wait is worth waiting for, and whether that …

Atrial fibrillation (AF) is the most common chronic arrhythmia, and its incidence and prevalence are expected to double within the forthcoming decades [1–3]. Currently, approximately 250,000 patients have AF in the Netherlands, corresponding to a prevalence of 5.5% in patients older than 55 years [4]. The vast majority of those patients can effectively be treated with pharmacological rate or rhythm control. However, there is a small subset of patients that remains severely symptomatic despite treatment with class 1 or 3 antiarrhythmic drugs. For those patients, an invasive approach can be indicated [5, 6]. Historically, this means either a classic Cox-Maze 3 operation or a catheter isolation of the pulmonary veins. The Maze operation, although associated with impressive success rates in some centres, has been abandoned as stand-alone procedure because of its surgical complexity and the requirement of cardiopulmonary bypass. Catheter ablation for atrial fibrillation is less invasive and is being performed by an increasing number of operators and centres. The procedure has a lower efficacy, particularly in patients with persistent AF or an enlarged left atrium. Moreover, patients are frequently not free of AF after a single procedure, and more than one procedure might therefore be required. In a recent meta analysis, the single procedure success of catheter ablation for AF was 57%, which rose to 71% after multiple procedures in selected patients [7]. The 5-year freedom of AF rates from Bordeaux, one of the most esteemed AF ablation centres in the world, were 29% after a single procedure (40% after one year), which increased to 63% after up to 7 procedures [8]. The volume of the number of catheter ablations for AF in comparison with the number of patients with AF is limited: approximately 2200 catheter ablations for AF were performed in the Netherlands in 2010 (exact data from two centres missing, S.A.I.P. Trines, personal communication), accounting for less than 1% of the number of patients with AF [4]. Bearing this in mind, a thoracoscopic surgical approach toward pulmonary vein isolation was developed in an effort to combine the efficacy reported with surgical ablation with a less invasive approach. There are several small studies showing the feasibility and safety of thoracoscopic pulmonary vein isolation, and a recent systematic review demonstrates that absence of AF recurrence (without the use of antiarrhythmic drugs) is 79% in paroxysmal AF and 69% in persistent AF after a single procedure in the studies published so far [9]. The number of patients and the number of studies are low, but there also seems to be a tendency toward better outcomes when the procedures are performed in a hybrid fashion, that is, by a surgeon and electrophysiologist together. Data from Maastricht and from our own hospital show that in a mixed population of patients with paroxysmal and persistent AF 83 and 86%, respectively, are free of AF without the use of antiarrhythmic drugs one year after the procedure [9–11]. This suggests that a hybrid procedure, where the ablation lines are controlled for conduction block during the procedure, is associated with less AF recurrence. Thoracoscopic or minimal invasive surgery for AF has not been established in the Guidelines as a ‘reasonable alternative’ for either antiarrhythmic drugs or catheter ablation, which might be due to the limited availability of published evidence. The most recent European Society of Cardiology (ESC) Guidelines for AF award a 2B recommendation for stand-alone minimally invasive surgery for AF only for patients with a previously failed catheter ablation [5]. The 2007 Heart Rhythm Society (HRS)/European Heart Rhythm Association (EHRA)/European Cardiac Arrhythmia Society (ECAS) Consensus provides three recommendations: surgery for AF can be considered in patients with a failed catheter ablation, in those with a contraindication for catheter ablation and in patients with a preference for surgery [6]. Therefore, investigators from Nieuwegein and Barcelona conducted the FAST study, a two-centre randomised trial, which was published in the first 2012 issue of Circulation. [12] The study included 124 patients (81% male, mean age 56 years) with a previously failed catheter ablation (67%) or with enlarged atria (>40 mm in the presence of hypertension, or >45 mm without hypertension, 33%). Patients were randomised to a redo catheter ablation or to a totally thoracoscopic surgical ablation, which consisted of pulmonary vein isolation with a bipolar clamp device with or without the addition of left atrial lines, constructed anatomically with a bipolar cooled rail device at the discretion of the operator. Exclusion criteria included left atrium size >65 mm, left ventricular ejection fraction

Implantable cardioverter defibrillators (ICDs) are an established therapy for the prevention of sudden cardiac death. Since the 1990s multiple primary and secondary prevention trials, such as AVID, MADIT-I and II and SCD-HeFT, have demonstrated a significant reduction in mortality in patients with ischaemic and non-ischaemic cardiomyopathy, especially in survivors of ventricular arrhythmias causing haemodynamic compromise. Today, expanding indications, mainly for prophylactic device implantation, cause a steep growth of ICD implantations worldwide [1]. However, not all patients eligible for prophylactic ICD therapy are likely to experience ICD therapy, and therefore benefit, within a reasonable time horizon. Assessment of multiple risk factors can more clearly identify patients at risk in whom ICD efficacy may be different from what was demonstrated in the large randomised ICD trials. In this issue of the Netherlands Heart Journal Wijers et al. [1] present an extensive real-world clinical study in which they sought to determine in which patients sudden cardiac death was actually prevented with ICD implantation. They demonstrate that 21 % of the 1075 patients receiving an ICD between 2006 and 2011 (61 % primary prevention) received appropriate shocks during a median follow-up of 31 months. They report that ischaemic cardiomyopathy, an LVEF ≤25 % and male gender were independently associated with appropriate shock therapy. Also, they find that 14 % of the patients implanted with an ICD died during a 31-month follow-up, of whom 9.7 % did not receive prior appropriate therapy and 4.7 % died within the first year after ICD implantation. Predictors for mortality are, however, quite similar to the predictors for appropriate shocks [1]. ICD efficacy in terms of survival rather than in terms of appropriate therapy may therefore be questioned in high-risk subgroups of patients with multiple risk factors in whom the short-term risk of nonarrhythmic death may predominate despite ICD therapy. These risk factors are defined by Goldenberg et al. [2] as >3 of the following: NYHA class >II, age >70 years, impaired renal function, QRS duration >120 ms or atrial fibrillation. Conversely, there are also low-risk subgroups consisting of patients without any risk factors who actually have a very low annualised need for truly lifesaving therapy [2]. While the presumed benefit of ICDs is reflected in the indications for ICD implantation in the guidelines, which are predominantly based on the ICD efficacy, the associated harm (such as inappropriate shocks and implant and long-term complications) receives less attention. Multiple studies demonstrate that the inappropriate shock rate in the general ICD population is approximately 3 % per year, and higher numbers are reported in patients with a history of atrial fibrillation and, generally younger, patients with inherited or congenital heart diseases [3, 4]. This number of inappropriate shocks can safely and substantially be reduced by contemporary ICD programming, which Wijers et al. likewise suggest as an explanation for the low inappropriate shock rate in their study. ICD-related complications are reported in 5 % of the ICD patients per year and complication rates may increase with multiple lead and device replacements [3]. ICD patients are exposed to both implantation-related complications such as pneumothorax and heart perforation and long-term complications such as vein occlusions and consequences of lead fractures [3, 4]. Despite advances in ICD system design and manufacturing, devices remain imperfect. Failures of lead design, such as with the Sprint Fidelis and Riata lead, can lead to inappropriate sensing due to electrical noise with resultant inappropriate shocks. Complication rates are, however, not consequently reported in the large randomised ICD trials and appear to be a suppositious child, while substantially contributing to the morbidity and even mortality of ICD patients. Moreover, ICD therapy may lead to a psychological burden. Studies consistently show impairments in health status and quality of life in ICD patients, with an elevated risk for anxiety and depression in up to 30 % of the patients. ICDs exacerbate psychological distress and the experience of one or more ICD shocks further negatively affects quality of life [5]. Finally, ICD therapy is expensive to society, with high costs at implantation. Earlier studies demonstrate a reasonable cost-effectiveness for prophylactic ICD therapy [6]. However, patient comorbidities affect long-term prognosis which might limit the cost-effectiveness whereas more extensive risk stratification could increase the effectiveness further. With increasing burden on health care budgets it should be questioned from a society perspective whether ICD therapy in patients who are less likely to benefit from ICD therapy is preferable. Hence, when judging the price of ICD therapy, ICD-related adverse events, ICD-related psychological distress and cost-effectiveness need to be taken into account. This however, does not imply that prophylactic ICDs should not be implanted in patients in whom the indication can be debated, because the severity of the chance of sudden cardiac death may outweigh the chance of harm. An inappropriate shock or ICD-related complication may then be considered an acceptable, minor complication of ICD therapy in the context of prevention of sudden cardiac death, particularly in patients with concurrent appropriate shock therapy. However, patients with ICD harm but without appropriate shocks obviously pay the price for ICD therapy. Evolving technology may continuously change the balance between benefit and harm. This notwithstanding, risk taking is essential to success in any goal where the stakes are high. A patient-tailored risk stratification for a better benefit-harm equilibrium seems currently underdeveloped but certainly needed; and Wijers et al. should therefore be commended on clarifying which patients have the most benefit of their ICD [1].

The implantable cardioverter defibrillator (ICD) has significantly improved survival in patients with an increased risk of sudden cardiac death (SCD). The wearable cardioverter defibrillator (WCD) is an alternative to the ICD in patients with a transient ICD indication or those in whom an ICD temporarily cannot be implanted. We describe here the technical details of the WCD and report three patients who were treated with a WCD in an outpatient setting. The WCD allowed the cardiac condition of two patients to improve to such an extent that permanent ICD implantation was deemed unnecessary. This new form of therapy may result in significant cost reduction, avoidance of unnecessary ICD implantation, and increased patient satisfaction.

Sudden cardiac death resulting from lethal ventricular arrhythmias forms a major cause of mortality. The implantable cardioverter defibrillator (ICD) has been shown to reduce mortality in patients who survived cardiac arrest, who experienced a previous myocardial infarction and have a diminished left ventricular ejection fraction (LVEF), or who have a dilated cardiomyopathy and an LVEF. This has been demonstrated and verified in several randomised trials, and has subsequently entered the guidelines (1). Consequently, the implantation rate of ICDs has increased exponentially worldwide over the last decade. A case can be made that this conveys an enormous success of medical technology to improve quality and quantity of life. Indeed, it was recently reported that there were fewer cases of ventricular fibrillation encountered during out-of-hospital cardiac arrest between 2005–2008, compared with the time frame 1995–1997, which could be explained in part (33 %) by the increased number of ICD carriers among subjects vulnerable for sudden death.(2) However, ICDs only protect against ventricular arrhythmia-induced cardiac arrest, and the question arises whether some ICD candidates may not have too many life-threatening comorbid conditions to have the chance to experience gain in life expectancy from ICD implantation. Therefore, Goldenberg et al. performed a post hoc analysis of the MADIT 2 trial, and proposed a simple and easily applicable clinical model of five risk factors associated with the usefulness of ICD therapy.(3;4) They showed that a risk score model including: 1) age above 70 years, 2) renal insufficiency (defined as blood urea nitrogen >26 mg/dl), 3) atrial fibrillation, 4) NYHA class >2 and 5) a QRS complex >120 msec on the ECG was able to predict clinical benefit of ICD implantation. In their analysis, ICD implantation was futile in patients with none of these risk factors, as no events urging ICD therapy occurred. The curve of ICD benefit was U shaped, however, and on its right side were patients with 3 or more risk factors. These patients had no benefit from ICD therapy, because they died from other than arrhythmic causes such as advanced heart failure. Hence, optimal benefit from the ICD was gained in the patient group with more than 0 but less than 3 risk factors. It is suggested that within the population of patients conforming to the inclusion criteria of the randomised ICD trials, or conforming to the guidelines, patient selection may potentially be further optimised to select those patients who will really experience net benefit from the ICD. Despite the elegance and simplicity of their model, the criteria proposed by Goldenberg et al. have not found their way into the guidelines yet. One of the possible explanations for this is that the clinical decision to abstain from ICD therapy can be difficult, and that ICDs are readily implanted when the patient’s life expectancy is estimated to be more than 1 year. Estimating life expectancy may be complex at the bedside, but a very similar set of risk factors, namely age ≥75 years, estimated glomerular filtration rate (eGFR) ≤30 ml/min/1.73 m2 and LVEF ≤20 % was recently reported to be associated with 2.5, 13.2 and 46.3 % mortality within the first year after primary prevention ICD implantation for ≤1, 2 and 3 risk factors respectively.(3) Another explanation could be that many patients eligible for ICD therapy are beyond the age of 75 at the time the indication is set, which would, according to the Goldenberg criteria, directly put them at least into the intermediate risk category, and seemingly prevent the need for further risk stratification. Given the fact that many ICD recipients are old, the question whether advanced age is a (relative) contraindication for ICD implantation is eminent, but the efficacy of ICD therapy in the elderly remains largely unknown. In this issue of the Netherlands Heart Journal, Anne et al. investigated the validity of the Goldenberg risk factors (QRS >120 msec, NYHA class >2, atrial fibrillation, defined as at least one documented episode, and renal failure, defined as eGFR