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We present a patient with acute heart failure and new onset atrial fibrillation secondary to giant cell myocarditis with lone atrial involvement. The diagnosis was managed with cardiac magnetic resonance and confirmed by interventionally guided biopsy. In the future, diagnosis could be managed noninvasively for this rare entity as the gold standard. (Level of Difficulty: Advanced.), Graphical abstract

A retained intracardiac catheter fragment left in situ for 2 years was incidentally found in a patient presenting with worsening heart failure and atrial fibrillation. This case describes the diagnostic evaluation of this rare event, with successful endovascular retrieval and resolution of his symptoms. (Level of Difficulty: Advanced.), Central Illustration

Transcatheter mitral valve replacement carries a risk of left ventricular outflow tract obstruction associated with mortality. We present a case of left ventricular outflow tract obstruction that resolved spontaneously when chords to the anterior mitral leaflet were found to have ruptured. (Level of Difficulty: Advanced.), Central Illustration

INTRODUCTION AND OBJECTIVES: This article reports the results of the 2020 Spanish Catheter Ablation Registry, a year marked by the SARS-CoV-2 pandemic. METHODS: Data were collected retrospectively through completion and return of a specific form by the participating centers. RESULTS: Data from 97 centers (67 public, 30 private) were analyzed. A total of 15 169 ablation procedures were reported with a mean of 155 ± 117 and a median [interquartile range] of 115 [62-227]. Because of the SARS-CoV-2 pandemic, both procedures and participating centers markedly decreased (-3380 procedures, -18%) and there were 5 centers less than in 2019. The most common procedure continued to be atrial fibrillation ablation (4513; 30%), well ahead of the remaining substrates, followed by ablation of the cavotricuspid isthmus (3188; 21%), and intranodal re-entry tachycardia (2808; 18%). Ablation of these 3 substrates continued to form the bulk of the procedures. The total success rate was slightly lower than in previous years (88%) with a similar complication rate (n = 309; 2%) and mortality (n = 7; 0.04%). A total of 243 procedures were performed in pediatric patients (1.6%). CONCLUSIONS: The Spanish Catheter Ablation Registry systematically and continuously reflects the national trajectory, which, in 2020, was markedly affected by the SARS-CoV-2 pandemic. Although slightly lower than in previous years, the success rate remained high, with a low complication rate.

Aneurysms of the left atrial appendage (LAA) are rare entities that often require surgical intervention. We demonstrate multimodality imaging features of a giant LAA aneurysm, with a focus on 3-dimensional blood flow dynamics by using 4-dimensional-flow cardiac magnetic resonance. (Level of Difficulty: Advanced.), Graphical abstract

In a patient with long-standing persistent atrial fibrillation, elimination of an epicardial connection between the right-sided pulmonary venous carina and the right atrium during catheter ablation resulted in intra-atrial conduction injuries in the presence of advanced atrial remodeling. (Level of Difficulty: Advanced.), Central Illustration

Cardiovascular disease and cancer are the 2 leading causes of death worldwide. Emerging evidence suggests common mechanisms between cancer and cardiovascular disease, including atrial fibrillation and atherosclerosis. With advances in cancer therapies, screening, and diagnostics, cancer-specific survival and outcomes have improved. This increase in survival has led to the coincidence of cardiovascular disease, including atrial fibrillation and atherosclerosis, as patients with cancer live longer. Additionally, cancer and cardiovascular disease share several risk factors and underlying pathophysiologic mechanisms, including inflammation, cancer-related factors including treatment effects, and alterations in platelet function. Patients with cancer are at increased risk for bleeding and thrombosis compared with the general population. Although optimal antithrombotic therapy, including agent choice and duration, has been extensively studied in the general population, this area remains understudied in patients with cancer despite their altered thrombotic and bleeding risk. Future investigation, including incorporation of cancer-specific characteristics to traditional thrombotic and bleeding risk scores, clinical trials in the cancer population, and the development of novel antithrombotic and anti-inflammatory strategies on the basis of shared pathophysiologic mechanisms, is warranted to improve outcomes in this patient population., Central Illustration, Highlights • Cancer and cardiovascular disease increasingly coexist, and patients with cancer are often undertreated. • Cancer and cardiovascular disease share common pathophysiology, including inflammation. • Thrombosis and bleeding risk scores often underperform in patients with cancer and cardiovascular disease. • Inclusion of cancer status in cardiovascular trials and risk scores may improve cardiovascular outcomes.

Objectives This study sought to describe expected changes in a mirror-image prone electrocardiogram (ECG) compared with normal supine, including a range of cardiac conditions. Background Unwell COVID-19 patients are at risk of cardiac complications. Prone ventilation is recommended but poses practical challenges to acquisition of a 12-lead ECG. The effects of prone positioning on the ECG remain unknown. Methods 100 patients each underwent 3 ECGs: standard supine front (SF); prone position with precordial leads attached to front (PF); and prone with precordial leads attached to back in a mirror image to front (PB). Results Prone positioning was associated with QTc prolongation (PF 437 ± 32 ms vs. SF 432 ± 31 ms; p, Central Illustration

Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by the extracellular deposition of amyloid fibrils in the myocardium. Although cardiac amyloidosis patients primarily present with heart failure symptoms, arrhythmias and conduction system disease are frequently encountered. Atrial fibrillation (AF) is observed in up to 70% of patients at the time of diagnosis, and patients typically have controlled ventricular rates caused by concomitant conduction system disease. Thromboembolic risk is particularly high in patients with CA and AF, and left atrial thrombi have been observed even in the absence of clinically diagnosed AF. Atrioventricular nodal and infra-Hisian disease are common, and permanent pacemakers are frequently required. The use of implantable cardioverter-defibrillators in this population is controversial. This review summarizes the published data and therapeutic strategies surrounding arrhythmias and conduction system disease with the goal of aiding clinicians managing the clinical complexities of CA., Central Illustration, Highlights • Cardiac arrhythmias and conduction system disease are common in CA. • Management of AF is complicated by difficulty in maintaining sinus rhythm and thromboembolic complications. • Atrioventricular nodal and infra-Hisian disease are common, and the optimal choice of device is controversial. • Prospective studies are required to establish optimal management strategies for arrhythmias and conduction disease.

Pulmonary vein isolation (PVI) using cryoballoon causes acute tissue edema of the osteal region of the pulmonary veins and the left atrium. In two cases combining PVI with an implantation of a left atrial appendage closure device led to malsizing of the device, device shouldering, and a paraprosthetic residual flow. (Level of Difficulty: Advanced.), Central Illustration

Routine electrocardiogram in a middle-aged man with left ventricular hypertrophy showed sinus rhythm, a short PR interval, and delta wave, confirming ventricular pre-excitation. Pre-excitation was fixed after a premature atrial complex and in atrial fibrillation, features diagnostic of a fasciculo-ventricular pathway. Genetic testing confirmed a diagnosis of hypertrophic cardiomyopathy. (Level of Difficulty: Intermediate.), Central Illustration

Background Patients with cancer are more likely to develop nonvalvular atrial fibrillation (NVAF). Currently there are no definitive clinical trials or treatment guidelines for NVAF patients with concurrent cancer. Objectives This subgroup analysis of the ARISTOPHANES study compared the risk of stroke/systemic embolism (stroke/SE) and major bleeding (MB) among NVAF patients with active cancer who were prescribed non–vitamin K antagonist oral anticoagulants (NOACs) or warfarin. Methods A retrospective observational study was conducted in NVAF patients with active cancer who newly initiated apixaban, dabigatran, rivaroxaban, or warfarin from January 1, 2013, through September 30, 2015, with the use of Medicare and 4 U.S. commercial claims databases. Cox models were used to estimate the risk of stroke/SE and MB in the pooled propensity score–matched cohorts. Results A total of 40,271 patients were included, with main cancer types of prostate (29%), female breast (17%), genitourinary (14%), and lung (13%). Compared with warfarin, apixaban was associated with a lower risk of stroke/SE (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.45-0.78) and MB (HR: 0.58; 95% CI: 0.50-0.68); dabigatran and rivaroxaban had similar risks of stroke/SE (dabigatran: HR: 0.88 [95% CI: 0.54-1.41]; rivaroxaban: HR: 0.82 [95% CI: 0.62-1.08]) and MB (dabigatran: HR: 0.76 [95% CI: 0.57-1.01]; rivaroxaban: HR: 0.95 [95% CI: 0.85-1.06]). Risks of stroke/SE and MB varied among NOAC-NOAC comparisons, while consistent treatment effects were seen for all treatment comparisons across key cancer types. Conclusions Among this cohort of NVAF patients with active cancer, the risk of stroke/SE and MB varied among oral anticoagulants and were consistent across cancer types., Central Illustration

We describe the case of a 73-year-old woman presenting with heart failure, a degenerating bioprosthetic mitral valve, and severely dilated left atrium, and highlight the role of multimodality imaging in planning transseptal transcatheter mitral valve-in-valve implantation. (Level of Difficulty: Advanced.), Central Illustration

Tumoral obstruction is a small, but broadly defined, category of pulmonary hypertension that encompasses microvascular tumor emboli, tumor thrombotic microangiopathy, and macrovascular tumor obstruction within the pulmonary circulation. We present 4 patients with solid tumors, severe pre-capillary pulmonary hypertension, right ventricular failure, and pulmonary veno-occlusive–like disease. (Level of Difficulty: Advanced.), Central Illustration

Objective COVID-19 patients may develop coagulopathy which is associated with poor prognosis and high risk of thrombosis. The objective of this work was to evaluate the prevalence of deep venous thrombosis of lower limbs (DVT) through ultrasonography in patients infected with COVID-19 admitted to hospital in conventional units with 5 days monitoring. The secondary objective was to determine if D-dimer levels body mass index (BMI) and C-reactive ; protein (CRP) were associated with DVT. Materials and Methods 72 patients with a mean age of 65±12.3 years infected with COVID-19 were admitted to three conventional units at our institution ,28 patients were women. A COVID-19 diagnosis was made by transcriptase polymerase chain reaction by means of nasopharyngeal swab or by chest computer tomography (CT) without iodine contrast media. Demographics ,co-morbidities characteristics and laboratory parameters were collected . A preventive anticoagulation treatment was established on admission with low molecular weight heparin (LMWH) . A complete venous duplex ultrasound (DU) test of lower limbs was performed on Day (D) 0 and D5 .A pulmonary CT angiograms with iodine contrast media (CTPA) was required when was ; suspected pulmonary embolism (PE). Results On D0 the DU showed acute DVT in seven patients (9.75%).A CTPA was performed in 12 patients (16.65%) ,3 of whom with an acute PE (25 %). On D0 acute DVT was not significantly associated with CRP (mean 101±98.6 in the group without DVT versus 67.6±58.4 mg/l p=0.43) or BMI ( 27.7 ±5.04 versus 28.1 ± 2.65 Kg/m2 p=0.54 ).However we found a significant association between acute DVT and D-dimer levels (1536±2347 versus 9652 ±10205 ng/ml p, In 72 patients admitted to standard hospital wards with COVID-19 pneumonia screening duplex ultrasound (DU) found 9.7% had DVT on admission and 15.6% without DVT on admission had and examined with DU on day 5 had developed DVT despite preventative anticoagulation justifying DU screening in non-ICU hospitalized patients with COVID-19 pneumonia.

We describe a zero-fluoroscopy ablation of a left atrial re-entry tachycardia in a patient with a previous atrial fibrillation ablation procedure. The critical isthmus was demonstrated to use an epicardial connection via the ligament of Marshall after failed endocardial and epicardial ablation along the mitral isthmus line. (Level of Difficulty: Intermediate.), Central Illustration

A patient underwent left atrial appendage occlusion due to recurrent stroke despite new oral anticoagulant therapy. The patient later presented with severe acute mitral regurgitation secondary to occluder device migration, which was retrieved percutaneously from the descending aorta via the femoral artery. Mitral surgical repair was required and successfully performed. (Level of Difficulty: Intermediate.), Central Illustration

Ventricular fibrillation is a life-threatening arrhythmia that can result in sudden cardiac death and almost always requires emergency electrical defibrillation. This paper presents a unique case of a 74-year-old woman with spontaneous termination of a 2-min 13-s ventricular fibrillation episode without organization before termination. (Level of Difficulty: Advanced.), Central Illustration

This case illustrates the incomplete protection of surgical ligation of left atrial appendage and maze procedure at the time of mitral valve replacement against thromboembolic complications and recurrence of atrial fibrillation. The utility of surgical left atrial appendage ligation as stroke prophylaxis and identification of selected high-risk subjects are reviewed. (Level of Difficulty: Intermediate.), Central Illustration

Background Patients with cancer have an increased risk of atrial fibrillation (AF). However, there is a paucity of information regarding the association between cancer type and risk of AF. Objectives This study sought to evaluate the risk of AF according to the type of cancer. Methods We enrolled 816,811 patients who were diagnosed with cancer from the Korean National Health Insurance Service database between 2009 and 2016. Age- and sex-matched noncancer control subjects (1:2; n = 1,633,663) were also selected. Newly diagnosed AF was identified based on the type of cancer. Results During a median follow-up of 4.5 years, AF was newly diagnosed in 25,356 patients with cancer (6.6 per 1,000 person-years). In multivariable Fine and Gray’s regression analysis, cancer was an independent risk factor for incident AF (adjusted subdistribution hazard ratio [aHR]: 1.63; 95% confidence interval [CI]: 1.61 to 1.66). Multiple myeloma showed a higher association with incident AF (aHR: 3.34; 95% CI: 2.98 to 3.75). Esophageal cancer showed the highest risk among solid cancers (aHR: 2.69; 95% CI: 2.45 to 2.95), and stomach cancer showed the lowest association with AF risk (aHR: 1.27; 95% CI 1.23 to 1.32). Conclusions Although patients with cancer were found to have a higher risk of AF, the impact on AF development varied by cancer type., Central Illustration

The presence of left atrial thrombus is a contraindication to cardioversion or catheter ablation in patients with atrial fibrillation, due to the increased risk of systemic thromboembolism. Management of this situation includes changes in the anticoagulation regimen and repeat imaging tests. Accurate diagnosis of left atrial appendage thrombus is therefore essential but can sometimes be challenging. Multiple imaging modalities may sometimes be required in the setting of anatomical variations of the left atrial appendage and surrounding structures. We present the case of a patient awaiting ablation for atypical atrial flutter, who underwent a transthoracic echocardiogram that showed an echodense, mobile structure within the vicinity of the left atrial appendage, suggesting a possible thrombus. A cardiac CT demonstrated the image to correlate with an epicardial fat pad within the transverse sinus.

Embolization of a device in patients undergoing percutaneous left atrial appendage closure is an uncommon complication. We present an illustrative case of successful percutaneous retrieval of an embolized LAmbre device (Lifetech Scientific, Shenzhen, China) that was achieved with a combination of a snaring technique and forceps grasping and by using a steerable guiding catheter. (Level of Difficulty: Advanced.), Central Illustration

Objective To evaluate the effectiveness and safety of totally thoracoscopic ablation (TTA) in patients with left ventricular (LV) dysfunction for treatment of atrial fibrillation (AF) refractory to antiarrhythmic drug (AAD) therapy. Methods Between January 2012 and December 2018, 31 patients underwent TTA with drug-refractory AF and preoperative left ventricular ejection fraction (LVEF), Video Abstract

Background Association between clinical effect and serum concentration of amiodarone (AMI) and its active metabolite desethylamidarone (DEA) in patients after surgical ablation (SA) of atrial fibrillation (AF) has not yet been studied. Aims We wanted to find a correlation between AMI and DEA serum concentration and maintaining sinus rhythm (SR) after SA of AF. Methods Sixty eight patients with AF who had undergone surgical ablation between 2014 and 2017 were included in a single-centre, prospective, observational study. Maintaining of SR was evaluated by standard 12-lead ECG and 24-hour Holter ECG monitoring at months 1, 3, 6 and 12 following surgery. Therapeutic monitoring of AMI and DEA concentrations was done to optimize therapy and adverse effects were followed up. Results We have noticed a high success rate in maintaining of SR (overall 83%). The median of serum concentration of AMI was 0.81 mg/L (range 0.16–2.35 mg/L) and DEA 0.70 mg/l (range 0.19–2.63 mg/L). No significant differences were found in the serum concentratration of AMI, DEA or DEA/AMI concentratration ratios between patients with SR and persistent supraventricular tachyarrhythmia except on the second outpatient visit. We observed significant correlation between serum concentration of DEA and thyroid-stimulating hormone elevation. Conclusion We confirmed the efficacy of AMI and DEA at the measured serum concentrations. However, analysis of these concentrations alone cannot replace assessment of the clinical response for treatment. Establishment of individual AMI (and DEA) concentrations at which the optimal therapeutic response is achieved seems to be advantageous. Therapeutic monitoring of AMI and DEA is helpful in personalised pharmacotherapy after SA of AF.

A patient with known obstructive hypertrophic cardiomyopathy developed worsening left ventricular outflow tract obstruction, severe mitral regurgitation, and apical ballooning leading to cardiogenic shock, a combination in which treatment of each component could worsen the others. Emergency veno-arterial extracorporeal membrane oxygenation, levosimendan, and noradrenaline transiently restored adequate systemic perfusion and gas exchange. Surgical myectomy offered a more definitive solution. (Level of Difficulty: Intermediate.), Graphical abstract

Differential diagnosis of wide complex tachycardia in patients taking anti-arrhythmic can be challenging. Conventional ECG diagnostic criteria are poorly specific and should be applied with caution. Patients who develop life-threatening arrhythmias after flecainide infusion should be screened for Brugada Syndrome, especially if concomitant sinus node dysfunction is present. (Level of Difficulty: Intermediate.), Central Illustration

ST-segment elevation is a dreadful finding in the emergency department because it is often associated with myocardial infarction and demands a prompt and definitive treatment. However, the clinical and echocardiographic assessment of a patient with electrocardiographic changes trumps any electrocardiology expert and should always lead to a clinical decision. (Level of Difficulty: Intermediate.), Central Illustration

Transseptal access for atrial fibrillation ablation can be challenging in the presence of iatrogenically modified interatrial septum. We report the first described transseptal left atrial access for atrial fibrillation ablation in the presence of an investigational interatrial shunt device, performed in a patient with heart failure with preserved ejection fraction. (Level of Difficulty: Intermediate.), Graphical abstract

A 62-year-old male with symptomatic persistent atrial fibrillation underwent radiofrequency catheter ablation. During exchange of the saline irrigation bag, the patient developed sudden hypotension and bradycardia and was found to have a massive air embolism. Air was successfully aspirated with catheters, and the patient did not suffer any permanent sequelae. (Level of Difficulty: Intermediate.), Graphical abstract

An 86-year-old man with paroxysmal atrial fibrillation on flecainide, a class IC antiarrhythmic, presented with cardiac arrest. The patient had extremely wide QRS complexes with inconsistent pacemaker capture on electrocardiography. Due to cardiac failure and renal failure, the patient developed progressive flecainide toxicity, which led to pacemaker failure, and ultimately, death. (Level of Difficulty: Beginner.), Central Illustration

Objective To investigate the impact of limiting the definition of post-coronary artery bypass graft (CABG) atrial fibrillation (AF) to AF/flutter requiring treatment—as in the Society of Thoracic Surgeons' (STS) database— on the association with survival. Patients and Methods We assessed in-hospital incidence of post-CABG AF in 7110 consecutive isolated patients with CABG without preoperative AF at 4 hospitals (January 1, 2004 to December 31, 2010). Patients with ≥1 episode of post-CABG AF detected via continuous in-hospital electrocardiogram (ECG)/telemetry monitoring documented by physicians were assigned to the following: Group 1, identified as having post-CABG AF in STS data and Group 2, not identified as having post-CABG AF in STS data. Patients without documented post-CABG AF constituted Group 3. Survival was compared via a Cox model, adjusted for STS risk of mortality and accounting for site differences. Results Over 7 years’ follow-up, 16.0% (295 of 1841) of Group 1, 18.7% (79 of 422) of Group 2, and 7.9% (382 of 4847) of Group 3 died. Group 2 had a significantly greater adjusted risk of death than both Group 1 (hazard ratio [HR]: 1.16; 95% confidence interval [CI], 1.02 to 1.33) and Group 3 (HR: 1.94; 95% CI, 1.69 to 2.22). Conclusions The statistically significant 16% higher risk of death for patients with AF post-CABG missed vs captured in STS data suggests treatment and postdischarge management should be investigated for differences. The historical misclassification of “missed” patients as experiencing no AF in the STS data weakens the ability to observe differences in risk between patients with and without post-CABG AF. Therefore, STS data should not be used for research examining post-CABG AF.

Background Atrial fibrillation (AF) is a common cardiovascular complication affecting patients with cancer, but management strategies are not well established. Objectives The purpose of this retrospective cohort study was to evaluate cross-sectional patterns of anticoagulation (AC) use in patients with cancer with AF or atrial flutter (AFL) on the basis of their risk for stroke and bleeding. Methods Patients with cancer and electrocardiograms showing AF or AFL performed at Moffitt Cancer Center in either the inpatient or outpatient setting were included in this retrospective analysis. We described percentages of AC prescription by stroke and bleeding risk, as determined by individual CHA2DS2-VASc and HAS-BLED scores, respectively. Multivariable logistic regression evaluated clinical variables independently associated with anticoagulant prescription. Results The prevalence of electrocardiography-documented AF or AFL was 4.8% (n = 472). The mean CHA2DS2-VASc score was 2.8 ± 1.4. Among patients with CHA2DS2-VASc scores ≥2 and HAS-BLED scores, Central Illustration

A patient with a left atrial appendage occlusion device underwent mitral valve replacement. Later, the patient developed a left atrial thrombosis with thromboembolic myocardial infarction caused by a dislocation of the occlusion device. Exclusion of the device and non–device-based appendage occlusion may have prevented the patient from experiencing postoperative complications (Level of Difficulty: Intermediate.)., Graphical abstract, A patient with a left atrial appendage occlusion device underwent mitral valve replacement. Later, the patient developed a left atrial thrombosis…

Highlights • Serious cardiac arrhythmias may be the consequence of direct effects of COVID-19 infection, but also the outcome of the deleterious effects of systemic illness and the adverse proarrhythmic reactions to drugs employed in the treatment of this pandemic • Drug combinations, especially of QT-prolonging agents, can lead to higher arrhythmogenicity, compared with single drug therapies • Furthermore, critically ill COVID-19 patients often have comorbidities that can trigger life-threatening ventricular arrhythmias, while acute myocardial injury increases the prevalence of arrhythmias • ECG and QTc monitoring and taking appropriate measures are of critical importance to prevent, detect and manage cardiac arrhythmias in COVID-19 patients • Contactless monitoring and telemetry for inpatients, especially those admitted to the ICU, as well as for outpatients needing continued management, has recently been facilitated by implementing digital health monitoring tools, As the coronavirus 2019 (COVID-19) pandemic marches unrelentingly, more patients with cardiac arrhythmias are emerging due to the effects of the virus on the respiratory and cardiovascular (CV) systems and the systemic inflammation that it incurs, and also as a result of the proarrhythmic effects of COVID-19 pharmacotherapies and other drug interactions and the associated autonomic imbalance that enhance arrhythmogenicity. The most worrisome of all arrhythmogenic mechanisms is the QT prolonging effect of various anti-COVID pharmacotherapies that can lead to polymorphic ventricular tachycardia in the form of torsade des pointes and sudden cardiac death. It is therefore imperative to monitor the QT interval during treatment; however, conventional approaches to such monitoring increase the transmission risk for the staff and strain the health system. Hence, there is dire need for contactless monitoring and telemetry for inpatients, especially those admitted to the intensive care unit, as well as for outpatients needing continued management. In this context, recent technological advances have ushered in a new era in implementing digital health monitoring tools that circumvent these obstacles. All these issues are herein discussed and a large body of recent relevant data are reviewed.

Atrial fibrillation (AF) is a triggered rhythm, and ablation of the trigger is a common strategy for rhythm control. We describe a patient with symptomatic AF who was found to have episodes of AF triggered by premature ventricular complexes, likely by retrograde atrioventricular nodal conduction. (Level of Difficulty: Beginner.), Graphical abstract

Conduction delay in the right ventricular outflow tract as manifested in the electrocardiogram constitutes a high-risk predictor of ventricular arrhythmias in patients with Brugada syndrome. We present a case with a right QRS axis between –90° and ±180°. This feature has never been reported in the context of Brugada syndrome. (Level of Difficulty: Advanced.), Graphical abstract

We report the case of a 70-year-old woman with hypertrophic obstructive cardiomyopathy, who was admitted because of severe heart failure and cardiogenic shock and mechanical support requiring extracorporeal membrane oxygenation. She recovered well by percutaneous transluminal septal myocardial ablation under the extracorporeal membrane oxygenation support and was discharged without complications. (Level of Difficulty: Advanced.), Graphical abstract

A 68-year-old Caucasian man with a history of Waldenstrom macroglobulinemia (WM) on treatment with ibrutinib for 2 years presented with syncope. He had no prior cardiovascular history or risk factors. On the day of presentation, he had an episode of dizziness followed by a sudden loss of

Background Early studies suggest that coronavirus disease 2019 (COVID-19) is associated with a high incidence of cardiac arrhythmias. SARS-CoV-2 infection may cause injury to cardiac myocytes and increase arrhythmia risk. Objective To evaluate the risk of cardiac arrest and arrhythmias including incident atrial fibrillation (AF), bradyarrhythmias, and nonsustained ventricular tachycardia (NSVT) in a large urban population hospitalized for COVID-19. We also evaluated correlations between the presence of these arrhythmias and mortality. Methods We reviewed the characteristics of all COVID-19 patients admitted to our center over a 9-week period. Throughout hospitalization, we evaluated the incidence of cardiac arrests, arrhythmias and in-patient mortality. We also used logistic regression to evaluate age, sex, race, body mass index, prevalent cardiovascular disease, diabetes, hypertension, kidney disease and ICU status as potential risk factors for each arrhythmia. Results Among 700 patients (mean age 50±18 years, 45% men, 71% African American, and 11% received ICU care), there were 9 cardiac arrests, 25 incident AF events, 9 clinically significant bradyarrhythmias, and 10 NSVTs. All cardiac arrests occurred among patients admitted to the ICU. In addition, admission to the ICU was associated with incident AF (OR 4.68 [95% CI 1.66 – 13.18]) and NSVT (OR 8.92 [95% CI 1.73 – 46.06]) after multivariable adjustment. Also, age and incident AF (OR 1.05 [95% CI 1.02 – 1.09]); and prevalent heart failure and bradyarrhythmias (OR 9.75 [95% CI 1.95 – 48.65]) were independently associated. Only cardiac arrests were associated with acute, in-hospital mortality. Conclusion Cardiac arrests and arrhythmias are likely the consequence of systemic illness and not solely the direct effects of COVID-19 infection., Graphical abstract

A 75-year-old man was admitted for repeat ablation of atrial fibrillation. At 30 min after infusion of 3.5 ml of ethanol into the vein of Marshall, inferior ST-segment elevation with coronary arterial vasospasm was observed. This is the first report of coronary vasospasm after chemical ablation of the vein of Marshall. (Level of Difficulty: Intermediate.), Graphical abstract, A 75-year-old man was admitted for repeat ablation of atrial fibrillation. At 30 min after infusion of 3.5 ml of ethanol into the vein of Marshall, inferior…

Several registries and quality improvement initiatives have focused on assessing and improving secondary prevention of CVD in India. While the Treatment and Outcomes of Acute Coronary Syndromes in India (CREATE), Indian Heart Rhythm Society-Atrial Fibrillation (IHRS-AF), and Trivandrum Heart Failure (THF) registries are limited to collecting data, the Tamil Nadu-ST-Segment Elevation Myocardial Infarction (TN-STEMI) program was aimed at examining and improving access to revascularization after an ST-elevation myocardial infarction (STEMI). The Acute Coronary Syndromes: Quality Improvement in Kerala (ACS-QUIK) study recruited hospitals from the Kerala ACS registry to assess a quality improvement kit for patients with ACS while the Practice Innovation and Clinical Excellence India Quality Improvement Program (PIQIP) provides valuable data on outpatient CVD quality of care. Collaborative efforts between health professionals are needed to assess further gaps in knowledge and policy makers to utilize new and existing data to drive policy-making.

Introduction Conflicting results regarding the impact of left common pulmonary vein (LCPV) on clinical outcome of atrial fibrillation (AF) ablation with cryoballoon technology have been reported. Methods We systematically searched PubMed and Cochrane library for articles that compared the arrhythmia recurrence rate after cryoballoon ablation between patients with normal pattern PVs and patients with LCPV. Studies of first ablation for persistent and paroxysmal AF using the 28 mm Arctic Front Advance, Medtronic cryoballoon (CB-A) reporting clinical success rates at a mean follow-up of ≥12 months were included. Data were analyzed by applying a random effects model. Results A total of 5 studies with a total of 1178 patients met our predefined inclusion criteria. After a mean follow-up of 18.4 months, the overall success rate of CB-A ablation among patients with persistent and paroxysmal AF was 57%; in the LCPV group the success rate was 46% and in the normal anatomical pattern group it was 61%. No significant heterogeneity was noted among the studies (I2 = 35.8%; Q (df = 3) = 6.23 p-value = 0.18). Arrhythmia recurrence after CB-A ablation was not statistically significant between the two groups (LogOR 0.24; 95% CI [-0.16-0.63]; p-value = 0.23). No significant difference in PNI was observed between the two groups (p-value = 0.693). Conclusion The presence of LCPV does not affect the long-term outcome of paroxysmal and persistent atrial fibrillation ablation with 28 mm CB-A compared to normal left PVs pattern.

A 70-year-old woman presented with aphasia caused by acute infarction in the left middle cerebral artery. Cardiac investigation revealed progressively increasing mobile mass in the left atrial appendage over 2 months (from 9 to 15 mm). Decision was made to proceed with mass resection, and pathological evaluation confirmed Masson tumor. (Level of Difficulty: Advanced.), Graphical abstract

Cardiac tamponade is a life-threatening complication during left atrial appendage (LAA) closure. We report a 77-year-old woman who underwent a transseptal puncture for LAA closure with the Watchman device that was complicated by tamponade. This was successfully treated with the deployment of a Cardioform 25-mm septal occluder device. (Level of Difficulty: Intermediate.), Graphical abstract, Cardiac tamponade is a life-threatening complication during left atrial appendage (LAA) closure. We report a 77-year-old woman who underwent a transseptal…

Progressive conduction system disease affects patients with transthyretin cardiac amyloidosis, often requiring permanent pacing as the His-Purkinje system is affected. We present a case of left bundle branch pacing in a patient with transthyretin cardiac amyloidosis and infra-Hisian conduction disease with a favorable improvement in cardiac function and stable pacing thresholds. (Level of Difficulty: Intermediate.), Graphical abstract, Progressive conduction system disease affects patients with transthyretin cardiac amyloidosis, often requiring permanent pacing as the His-Purkinje…

Asynchronous activation of the endo-epicardium plays an important role in persistence of atrial fibrillation. So far, endo-epicardial asynchrony has only been demonstrated in the human right atrium. Our data provides the first evidence for existence of a considerable degree of endo-epicardial asynchrony in the human left atrium. (Level of Difficulty: Advanced.), Graphical abstract, Asynchronous activation of the endo-epicardium plays an important role in persistence of atrial fibrillation. So far, endo-epicardium has only been…

A 50-year-old man presented with general fatigue on exertion. Investigations revealed tachycardia-induced cardiomyopathy induced by Wolff-Parkinson-White syndrome and atrial fibrillation. He was successfully treated with catheter ablation. Cardiac magnetic resonance imaging revealed that delayed enhancement throughout the left ventricle disappeared within 2 months after ablation. (Level of Difficulty: Beginner.), Graphical abstract, A 50-year-old man presented with general fatigue on exertion. Investigations revealed tachycardia-induced cardiomyopathy caused by Wolff-Parkinson-White…

This is the first report demonstrating persistence and distortion of electrical activity in the left atrial appendage 5 years after endovascular occlusion with a Watchman device. Electrical conduction is impaired providing an arrhythmogenic substrate for atrial tachyarrhythmias. Localized inflammation may result in structural and electrical remodeling in these patients. (Level of Difficulty: Intermediate.), Graphical abstract, This is the first report demonstrating persistence and distortion of electrical activity in the left atrial appendage 5 years after endovascular…

A 46-year-old man developed chronic thromboembolic pulmonary hypertension and atrial fibrillation after acute pulmonary embolism. He was found incidentally to have an isolated secundum atrial septal defect, as well as a homozygous mutation for the plasminogen activator inhibitor-1 gene. He was successfully treated with pulmonary endarterectomy and atrial septal defect repair. He has continued to do well on a regimen of dabigatran. (Level of Difficulty: Beginner.), Graphical abstract, A 46-year-old man developed chronic thromboembolic pulmonary hypertension and atrial fibrillation after acute pulmonary embolism. He was found…