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ObjectivesWe aimed to determine the safety and efficacy of pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients with impaired left ventricular (LV) systolic function.BackgroundTo date, PVI has been performed primarily in patients with normal LV function. Yet, many AF patients have impaired LV systolic function. The outcomes of PVI in patients with impaired LV systolic function are unknown.MethodsWe included 377 consecutive patients undergoing PVI between December 2000 and January 2003. Ninety-four patients had impaired LV function (ejection fraction [EF]

Background: Left atrial flutter following atrial fibrillation (AF) ablation is increasingly common and difficult to treat. We evaluated the safety and efficacy of ablation of the anteroseptal line connecting the right superior pulmonary vein (RSPV) to the anteroseptal mitral annulus (MA) for the treatment of perimitral flutter (PMF). Methods: We systematically studied patients who were previously treated with AF ablation and who presented to the electrophysiology laboratory with atrial tachyarrhythmias between January 2000 and July 2010. The diagnosis of PMF was confirmed by activation mapping and/or entrainment. After re-isolation of any recovered pulmonary vein, a linear radiofrequency (RF) ablation was performed on the line that connected the RSPV to the anteroseptal MA. In this analysis, we included only patients who were treated with an anteroseptal line for their PMF. Results: Ablation was performed at the anteroseptal line in 27 PMF patients (63±13 years; 9 women) who had undergone prior ablation for paroxysmal (n=3) or persistent (n=24) AF, using electroanatomic activation mapping (70% CARTO, 30% NavX). The anteroseptal ablation line was effective in 22/27 (81.5%) patients in the acute-care setting. Termination of AF to sinus rhythm occurred in 15/22 (68.2%) patients, and 7/22 (31.8%) patients׳ AF converted to another right or left atrial flutter. At the 6-month follow-up, 20% of patients demonstrated recurrent left atrial tachyarrhythmia. Only one patient required repeat ablation, and the remaining patients׳ condition was controlled with antiarrhythmic medications. No major procedural complications or heart block occurred. Conclusion: Ablation at the left atrial anteroseptal line is safe and efficacious for the treatment of PMF. Unlike ablation at the traditional mitral isthmus line, ablation at the left atrial anteroseptal line does not require ablation in the coronary sinus.

Summary Background The neutrophil to lymphocyte ratio (NLR) is associated with increased risk of cardiovascular morbidity and mortality. We aimed to assess the association between NLR and first episode of stroke in patients with atrial fibrillation. Methods Using the computerized database of the largest HMO in Israel, we identified a cohort of adults, aged 20 years or older, with atrial fibrillation diagnosed before 1 January 2012. Eligible subjects had no prior stroke or TIA, were not on anticoagulants at baseline, and had at least one blood cell count performed in 2011. The cohort (32 912 subjects) was followed for the first event of stroke or TIA until 31 December 2012. Results Overall 981 subjects developed stroke during a follow-up of 30 961 person-years (stroke rate, 3.17 per 100 person-years). The incidence rate of stroke increased across NLR quartiles: 2.27, 2.72, 3.26 and 4.54 per 100 person-years, respectively. Cox proportional hazard regression analysis adjusting for the individual CHA2DS2-VASc score risk factors showed that, compared with the lowest NLR quartile, the HR for stroke was 1.11 (95% CI, 0.91–1.35), 1.25 (1.03–1.51) and 1.56 (1.29–1.88) for the second, third and highest quartile, respectively. On stratified analysis, NLR refined the risk of stroke across all CHA2DS2-VASc score strata. Adding NLR to the CHA2DS2-VASc score increased the AUC from 0.627 (95% CI, 0.612–0.643) to 0.635 (0.619–0.651) (P = 0.037). Conclusions The neutrophil to lymphocyte ratio is directly associated with the risk of stroke in patients with atrial fibrillation. Future studies are needed to replicate these findings.

Essentials CHADS2 and CHA2DS2-VASc scores are used to predict stroke in atrial fibrillation (AF). These scores were calculated for a large cohort from the largest healthcare provider in Israel. The risk of stroke gradually increased with an increase in the scores in individuals without AF. Both scores have a relatively high performance for stroke prediction in individuals without AF. Click to hear Prof. Lowe's perspective on Arterial Thrombosis, Pathogenesis and Epidemiology SummaryBackground CHADS2 and CHA2DS2-VASc are validated scores used to predict stroke in patients with atrial fibrillation (AF). We aimed to examine the performance of these scores in predicting stroke in individuals without AF. Methods Using the computerized database of the largest HMO in Israel, we identified all not-anticoagulated adults, aged 50 years or older on 1 January 2012. The cohort was followed for the occurrence of stroke or transient ischemic attack (TIA) until 31 December 2014. Results Of 1 053 871 individuals without AF at baseline, 34 215 developed stroke/TIA during a follow-up of 3 014 002 person-years (stroke/TIA incidence rate, 1.14 per 100 person-years). The incidence rate of stroke/TIA increased in a graded manner with increasing CHADS2 score: 0.36, 0.89, 1.89, 2.96, 4.31, 5.37 and 6.62 per 100 person-years for CHADS2 scores of 0 to 6 points, respectively (P < 0.001). Results were similar for the CHA2DS2-VASc score. A similar graded increasing trend in the stroke/TIA incidence rate was observed in a cohort of 46 657 patients with AF at baseline; however, stroke/TIA rates were higher in each score stratum compared with the rates of individuals without AF. The area under the receiver operating characteristic curve was 0.718 (95% CI, 0.715–0.721) and 0.714 (0.711–0.717) for CHADS2 and CHA2DS2-VASc scores, respectively, in individuals without AF, and 0.606 (0.598–0.614) and 0.610 (0.602–0.618), respectively, in individuals with AF. Conclusions CHADS2 and CHA2DS2-VASc scores have a relatively high performance for prediction of stroke/TIA in individuals without AF, which is comparable to their performance in patients with AF.

Dofetilide is indicated for pharmacological cardioversion and maintenance of sinus rhythm (SR) in patients with symptomatic atrial fibrillation or flutter. Though most patients achieve SR during the drug loading, there is no evidence to guide the most appropriate next clinical steps for those that