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Background: Atrial fibrillation (AF) and heart failure (HF) frequently coexist and can be challenging to treat. Pharmacologically based rhythm control of AF has not proven to be superior to rate control. Ablation-based rhythm control was compared with rate control to evaluate if clinical outcomes in patients with HF and AF could be improved. Methods: This was a multicenter, open-label trial with blinded outcome evaluation using a central adjudication committee. Patients with high-burden paroxysmal (>4 episodes in 6 months) or persistent (duration Results: From December 1, 2011, to January 20, 2018, 411 patients were randomly assigned to ablation-based rhythm control (n=214) or rate control (n=197). The primary outcome occurred in 50 (23.4%) patients in the ablation-based rhythm-control group and 64 (32.5%) patients in the rate-control group (hazard ratio, 0.71 [95% CI, 0.49–1.03]; P =0.066). Left ventricular ejection fraction increased in the ablation-based group (10.1±1.2% versus 3.8±1.2%, P =0.017), 6-minute walk distance improved (44.9±9.1 m versus 27.5±9.7 m, P =0.025), and NT-proBNP demonstrated a decrease (mean change –77.1% versus –39.2%, P P =0.0036), as did the AF Effect on Quality of Life score (least-squares mean difference of 6.2 [95% CI, 1.7–10.7]; P =0.0005). Serious adverse events were observed in 50% of patients in both treatment groups. Conclusions: In patients with high-burden AF and HF, there was no statistical difference in all-cause mortality or HF events with ablation-based rhythm control versus rate control; however, there was a nonsignificant trend for improved outcomes with ablation-based rhythm control over rate control. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01420393.

The globe is currently in the midst of a COVID-19 pandemic, resulting in significant morbidity and mortality. This pandemic has placed considerable stress on health care resources and providers. This document from the Canadian Association of Interventional Cardiology- Association Canadienne de Cardiologie d'intervention, specifically addresses the implications for the care of patients in the cardiac catheterization laboratory (CCL) in Canada during the COVID-19 pandemic. The key principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients and staff and maintaining the overall health care resources. As the COVID-19 pandemic evolves, procedures will be increased or reduced based on the current level of restriction to health care services. Although some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. We believe the framework and recommendations in this document will provide crucial guidance for clinicians and policy makers on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates.

BACKGROUND Cardiovascular disease (CVD) is a leading cause of hospitalization and death around the world. The prevalence of CVD is increasing and, therefore, development and investigation of effective programs to help people better self-manage their CVD and prevent secondary complications are needed. OBJECTIVE In this paper, we report on a protocol to evaluate Healing Circles—an evidence-based and patient-informed peer support mobile health program designed to facilitate self-management and support patients in their recovery from and management of CVD. We hypothesize that individuals with CVD who use Healing Circles will experience greater improvements to their self-management ability than individuals receiving usual care. METHODS In this single-blinded (assessor) randomized controlled trial, 250 community-living individuals with CVD will be randomized on a 1:1 basis to either Healing Circles or Usual Care. The primary outcome of self-management will be measured using the Health Education Impact Questionnaire version 3.0. Secondary outcomes include self-efficacy with chronic disease management, health-related quality of life, health resource use and costs, and electronic health literacy. Measurements will be taken at the baseline and every 6 months for 24 months. RESULTS The study started recruitment in September 2017. Individuals are currently being recruited for participation, and existing participants are currently on follow-up. Measurements will be taken every 6 months until the study end, which is anticipated in December 2019. CONCLUSIONS Healing Circles is a novel program aimed toward improving self-management through peer support. Given our real-world study design, our findings will be readily translatable into practice. If the results support our hypothesis, it will indicate that Healing Circles is an effective intervention for improving self-management and reducing health care use. CLINICALTRIAL ClinicalTrials.gov NCT03159325; https://clinicaltrials.gov/ct2/show/NCT03159325 (Archived by WebCite at http://www.webcitation.org/74DvxVKUd) INTERNATIONAL REGISTERED REPOR DERR1-10.2196/12322

Introduction: The combination of head-up tilt and incremental lower body negative pressure has shown promise in the diagnosis of orthostatic hypotension and neurocardiogenic syncope, although prior methodologies limited conclusions as to the reproducibility of the test. The aim of this study was to assess the efficacy and reproducibility of a protocol combining tilt and stages of incremental lower body negative pressure. Methods and Results: Ten volunteers (6 men and 4 women; mean age 21 ± 1 years) participated in the study, which was composed of three sessions, 1 month apart, each consisting of 60° tilt followed by lower body suction in incremental levels of −10 mmHg for 5 minutes at each level. The primary outcome variable was the time to presyncope. Secondary variables were the levels of heart rate, blood pressure, cerebral blood flow, and end-tidal CO2 at each level of the test. Presyncope could be achieved in all subjects. The mean times to presyncope were 24.6 ± 1.4 minutes, 26.2 ± 1.8 minutes, and 31.8 ± 1.6 minutes and were not different across tests (P = 0.3). Intrasubject variability was assessed by determining the mean average deviation from the mean, which was 3.2 ± 2.0 minutes. Changes in heart rate, blood pressure, end-tidal CO2, and cerebral blood flow were consistent with repeat testing. Conclusion: Lower body negative pressure combined with head-up tilt in a staged protocol can safely and reliably induce presyncope in all normal subjects tested. The test is a potent and reproducible investigational tool for inducing hypotension and transient cerebral hypoperfusion. (J Cardiovasc Electrophysiol, Vol. 14, pp. 920-924, September 2003)

The aim of this study was to demonstrate the feasibility of providing spatially matched, 3-dimensional (3D) myocardial scar and coronary imaging for the purpose of fused volumetric image display in patients undergoing cardiac resynchronization therapy (CRT) or coronary artery revascularization (CAR).Clinical success in coronary vascular-based interventions is mitigated by the presence of scar in related myocardium. Pre-procedural fused volumetric imaging of both myocardial scar and coronary vasculature may benefit pre-procedural planning and patient selection in populations referred for CRT or CAR.A total of 55 studies were performed in patients referred for either CRT (n = 42) or CAR (n = 13). Coronary-enhanced and scar-enhanced imaging was performed on a 3-T cardiac magnetic resonance scanner using the same cardiac-gated, 3D, free-breathing cardiac magnetic resonance technique during and 20 minutes following slow gadolinium infusion. Matched image datasets were fused and volume-rendered to simultaneously display coronary anatomy and myocardial scar. Visual scoring of coronary artery, coronary vein, and myocardial scar image quality (score 0 to 4) was performed. The clinical impact of imaging was also scored using a physician survey.Mean age was 57 ± 14 years. Combined 3D coronary and scar imaging was successful in 49 studies (89%). A quality score ≥ 2 was obtained for 97% of proximal- and mid-coronary artery and vein segments. The mean quality score of 3D scar imaging was 2.8 ± 1.0 and was scored as ≥ 2 in 86% of patients with myocardial scar. All patients with a scar quality score ≥ 2 achieved successful image fusion. Transmural scar was present below ≥ 1 planned target vessel in 9 patients (39%) planned for CRT and 8 patients (62%) planned for CAR. Physician surveys demonstrated incremental clinical impact in 67% of patients.Three-dimensional myocardial scar and coronary imaging with fused volumetric display is clinically feasible and may be valuable for the planning of vascular-based interventions when regional myocardial scar is pertinent to therapeutic success.

Background: Torsades de pointes (TdP) is a well known arrhythmic sequela in congenital and acquired long QT syndromes (LQTS). Less frequently, bradyarrhythmias are associated with QT prolongation and TdP. Although some observations have been made on the predictors of TdP in bradyarrhythmias, there is limited data on cellular mechanisms or genetic predisposition to bradycardia-induced TdP. Methods: In a retrospective case-control study, we identified 11 patients who were referred with CHB and TdP. Comprehensive assessment was performed in these patients, including, history, examination, ECG parameters (baseline, in CHB and pre-TdP) and genetic testing of repolarization related ion channel genes. 33 control patients with CHB and no TdP were selected for comparison of ECG parameters. All patients received either a pacemaker or implantable cardioverter defibrillator, with outpatient follow-up. Results: Four out of 11 patients with CHB and TdP had a genetic mutation identified involving ion channels responsible for cardiac repolarization (36%), involving hERG (n=3) and SCN5A (n=1). The key observations were that Tpeak to Tend interval was significantly longer in patients with a genetic abnormality at baseline, in CHB and pre-TdP (see Table 1 ). Compared to controls, patients who had TdP complicating CHB had significantly longer QTc and Tpeak to Tend intervals in CHB. Conclusion: TdP in the setting of CHB appears to identify patients who have an underlying genetic predisposition to reduced repolarization reserve. In particular, the terminal phase of repolarization (Tpeak to Tend) appears to be a marker for patients who have a cardiac ion channel abnormality. Given these findings, genetic testing should be considered in patients with TdP in the setting of CHB.

Patients with syncope of unknown etiology (SUE) after electrophysiologic (EP) studies are said to have a good prognosis but often suffer from recurrent disability. Syncopal episodes are often too infrequent for conventional ambulatory monitoring (AM) techniques to detect. We implanted a long term subcutaneous monitoring device (Medtronic, Inc.) in 14 patients (m age 57 ± 21 yrs) with 7.3 ± 4.6 previous syncopal episodes and negative AM, head up tilt (HUT) and EP studies. The pacemaker-shaped device has 2 electrodes 3.2 cm. apart and is able to record 7.5 or 15 minutes of continuous ECG signal in a circular buffer, which is triggered by magnet application by the patient or partner. The data are then retrievable by telemetry. Eight patients had structural heart disease. Eleven patients developed recurrent syncope 4.1 ± 4.3 months after implantation. The etiology of syncope was bradycardic in 5 (sinus arrest in 3, complete heart block in 2), tachyarrhythmic in 2 (Supraventricular tachycardia in 1, ventricular tachycardia in 1), and non-arrhythmic in 4 (vasodepressor in 2, hemodynamic in 1, and psychogenic in 1). No further episodes of syncope have occurred over 10.3 ± 7.6 months follow-up after successful therapy was implemented in all 11 patients. The remaining 3 patients have not had recurrent syncope over a mean of 8.7 months and continue to be followed. Conclusions We conclude that patients with SUE after negative investigations have a broad spectrum of etiologies, with bradycardia being the most common. The etiology of syncope is often not apparent from clinical variables. An implantable “loop recorder” is useful for making a diagnosis when episodes are too infrequent for standard ambulatory monitoring techniques.