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AIM: The 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation and the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Leadless pacemakers have provided new treatment modalities that can be especially useful in patients with complex cardiac anatomy and contraindications toward other pacemaker approaches. The Aveir™ single-chamber (VR) leadless pacemaker (LP) (Abbott Laboratories, Chicago, IL) is a recently approved device that can be placed in the right ventricle for patients with bradycardia. In this case, we present a novel use for the device through placement in the atrium to control atrial flutter in a patient with a hypoplastic right ventricle.

Introduction: The reduction of fluoroscopic exposure during catheter ablation of supraventricular arrhythmias is widely adopted by experienced electrophysiology physicians with a relatively short learning curve and is becoming the standard of care in many parts of the world. While observational studies in the United States and some parts of Western Europe have evaluated the minimal fluoroscopic approach, there are scarce real‐world data for this technique and the generalizability of outcomes in other economic regions. Method: The AALARA study is a prospective, observational, multicenter, and multinational open‐label study. Patients were recruited from 13 countries across Central Eastern Europe, North and South Africa, the Middle East, and the CIS (Commonwealth of Independent States), with different levels of operator expertise using minimal fluoroscopic exposure techniques. Data on radiation exposure, procedural success, complications, recurrence, and quality of life changes were collected and analyzed. Result: A total of 680 patients were enrolled and followed for 6 months. The majority were ablation naïve with the commonest arrhythmia ablated being typical AVNRT (58%) followed by Atrial Flutter (23%). Zero fluoroscopy exposure was observed in almost 90% of the cases. Fluoroscopy was most commonly used during the ablation phase of the procedure. We observed a high acute success rate (99%), a low complication rate (0.4%), and a 6‐month recurrence rate of 3.8%. There was a significant improvement in the patient's symptoms and quality of life as measured by patient global assessment. Conclusion: The routine use of a 3D mapping system during right‐sided ablation was associated with low radiation exposure and associated with high acute success rate, low complications, and recurrence rate along with significant improvement in quality of life. The data confirm the reproducibility of this approach in real‐world settings across different healthcare systems, and operator experience supporting this approach to minimize radiation exposure without compromising efficacy and safety. Trial Registration: NCT04716270 [ABSTRACT FROM AUTHOR]

Background: Atrioventricular block (AVB) is common in the elderly and therefore considered to be a degenerative disease of the cardiac conduction system. However, there exist other etiologies contributing to AVB in young patients. This study aimed to determine the etiologies in patients aged before 60 years receiving their first pacemaker implantation for AVB in China. Methods and Results: Medical records and diagnostic tests of AVB patients were reviewed to identify the etiologies between 2010 and 2021 at Guangdong Provincial People's Hospital. Eight hundred and twenty‐six patients (median age 47 years; 47.9% males) were included. The etiologies were identified in 336 (40.7%) cases, including complications to cardiac surgery (n = 190 [23.0%]), myocarditis (n = 57 [6.9%]), myocardial infarction (n = 25 [3.0%]), complications to catheter‐based interventional procedures (n = 21 [2.5%]) and others (n = 43 [5.2%]). AVB caused by myocardial infarction was more common in men (5.8% vs. 0.5%, p <.001), while women received pacing treatment earlier (48 vs. 46 years, p =.019). Men were more likely to suffer from dilated cardiomyopathy (6.6% vs. 2.1%, p =.001) and atrial fibrillation/flutter (23.0% vs. 12.8%, p <.001). The number of first pacemaker implantation increased with age especially among patients with unclear etiologies. Conclusion: The etiology of AVB was only determined in approximately 40% of patients receiving their first pacemaker implantation aged before 60 years. The predominance of AVB with unknown etiology and potential gender differences warrants further studies. [ABSTRACT FROM AUTHOR]

Background: Implantable loop recorder (ILR) allows rhythm‐monitoring up to 3 years. They are recommended in patients with recurrent syncope and for the detection of atrial fibrillation (AF) in patients with cryptogenic thromboembolic events. AF and syncope occur more often in elderly patients. However, data in this cohort is limited. Methods and results: All patients ≥ 80 years undergoing ILR‐implantation between 2011 and 2022 in our center were included. Permanent pacemaker implantation (PPI) and oral anticoagulation due AF were defined as primary endpoints. Forty‐five patients ≥ 80 years were included, 33 because of recurrent syncope and 12 because of suspected AF. The average follow up (FU) was 17.6 months. Overall in 22 patients, ILR‐implantation led to a therapeutic consequence (48.9%). In the 12 patients who underwent ILR‐implantation for detection of AF, AF was detected in nine patients (75%). In the 33 elderly patients who received ILR‐implantation after syncope, 11 underwent PPI during FU (33.3%). One patient accidentally removed the ILR himself via the implantation‐wound, and no other ILR‐related complications were observed. Conclusion: ILR are effective and safe in elderly patients. AF was often found in patients with suspected AF, especially in patients after catheter ablation of only documented atrial flutter (AFlu). PPI‐rate was high in patients with recurrent syncope and ILR‐implantation. Further investigations are necessary to determine whether PPI may be considered in elderly patients with syncope even in the absence of a bifascicular block. [ABSTRACT FROM AUTHOR]

Background: Ablation techniques have evolved greatly with advances in high-density 3D mapping systems over the last few years. Some patients develop atypical atrial flutter (AAFL) after pulmonary vein isolation (PVI). The data regarding follow-up after AAFL ablation as well as predictors of arrhythmia recurrence are lacking. This analysis aims to report procedure success rates and establish predictors of long-term success. Methods and Results: This retrospective cohort study included 45 patients (median age: 69 years; 40% female) who qualified for their first AAFL after PVI. The procedures were performed with the use of conventional ablation-index-guided ThermoCool Smarttouch SF and QDOT MICRO catheters. Freedom from arrhythmia recurrence was used as a primary end point. After 52 weeks of follow-up, 60% of patients suffered from arrhythmia recurrence, but over 70% of the studied cohort reported symptom improvement. In multivariate analysis, class I antiarrhythmics prescription (HR = 0.24 [95% CI 0.06–0.94], p = 0.04) was associated with the lack of arrhythmia recurrence during the follow-up, while cardioversion during procedure was associated with increased risk of arrhythmia recurrence (HR = 7.05 [95% CI 2.09–23.72], p = 0.002). Conclusions: Long-term success of AAFL ablation procedures is not satisfactory despite improvement in symptoms. Class I antiarrhythmics prescription at the discharge contributes to higher chances of sinus rhythm maintenance, whereas cardioversion during the procedure is related to increased risk of arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

Purpose: To assess associations between atrial fibrillation/atrial flutter (AF) and ocular parameters and diseases. Methods: The population‐based Ural Eye and Medical Study (UEMS) and the Ural Very Old Study (UVOS) included 4894 individuals (age: 40+ years) and 835 individuals (age: 85+ years), respectively. Results: In the UEMS, AF prevalence (80/4894; 1.6%; 95% CI: 1.3, 2.0) increased from 1/1029 (0.1%) in the age group of 40 to <50 years to 29/619 (4.7%) and 12/159 (7.5%) in the age groups of 70 to <80 years and 80+ years, respectively. Higher AF prevalence correlated with older age (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), urban region of habitation (OR: 1.08; 95% CI: 1.04, 1.12; p < 0.001), higher prevalence of cardiovascular disease/stroke (OR: 2.50; 95% CI: 1.32, 4.72; p < 0.001) and lower prevalence of neck pain (OR: 0.35; 95% CI: 0.14, 0.85; p = 0.02), higher serum concentration of bilirubin (OR: 1.03; 95% CI: 1.02, 1.05; p < 0.001) and lower prothrombin index (OR: 0.96; 95% CI: 0.93, 0.99; p = 0.003), higher stage of arterial hypertension (OR: 1.52; 95% CI: 1.01, 2.28; p = 0.04) and higher ankle‐brachial index (OR: 22.1; 95% CI: 4.45, 1.10; p < 0.001). In that model, AF prevalence was not associated with ocular parameters such as intraocular pressure (p = 0.52), retinal nerve fibre layer thickness (p = 0.70), refractive error (p = 0.13), axial length (p = 0.14), nuclear cataract degree (p = 0.50) and prevalence (p = 0.40), cortical cataract degree (p = 0.43) and presence (p = 0.17), lens pseudoexfoliation (p = 0.58), status after cataract surgery (p = 0.38), age‐related macular degeneration prevalence (p = 0.63), open‐angle glaucoma presence (p = 0.90) and stage (p = 0.55), angle‐closure glaucoma prevalence (p = 0.99) and stage (p = 0.99), diabetic retinopathy prevalence presence (p = 0.37) and stage (p = 0.32), and myopic macular degeneration (p = 0.98). In the UVOS, similar results were obtained. Conclusions: In these multi‐ethnic populations from Russia, AF prevalence was not associated with any major ocular disease and may not play a major role in the pathogenesis of these disorders. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusion The impact of repeated atrial fibrillation (AF) ablations on left atrial (LA) mechanical function remains uncertain, with limited long‐term follow‐up data.This retrospective study involved 108 AF patients who underwent two catheter ablations with cardiac magnetic resonance imaging (MRI) done before and 3 months after each of the ablations from 2010 to 2021. The rate of change in peak longitudinal atrial strain (PLAS) assessed LA function. Additionally, a sub‐study of 36 patients who underwent an extra MRI before the second ablation, gave us an additional time segment to evaluate the basis of change in PLAS.In the two‐ablation, three MRI sub‐study 1, the PLAS percent change rate was similar before and after the first ablation (r11 = −0.9 ± 3.1%/year, p = 0.771). However, the strain change rate from postablation 1 to postablation 2 was significantly worse (r12 = −23.7 ± 4.8%/year, p < 0.001). In the sub‐study 2 with four MRIs, all three rates were negative, with reductions from postablation 1 to pre‐ablation 2 (r22 = −13.3 ± 2.6%/year, p < 0.001) and from pre‐ablation 2 to postablation 2 (r23 = −8.9 ± 3.9%/year, p = 0.028) being significant.The present study suggests that the more ablations performed, the more significant the decrease in the postablation mechanical function of the LA. The natural progression of AF (strain change from postablation 1 to pre‐ablation 2) had a greater negative influence on LA mechanical function compared to the second ablation itself suggesting that second ablation in patients with recurrence after first ablation is an effective strategy even from the LA mechanical function aspect. [ABSTRACT FROM AUTHOR]

The article discusses the author's experience participating in an Ironman event in Austria at the age of 66, highlighting the challenges faced due to illness and poor weather during training. The text delves into the physiological aspects of endurance performance, including issues like dehydration, glycogen depletion, and cardiac arrhythmias. The author reflects on the mental and physical demands of the event, emphasizing the importance of adaptability and perseverance in completing the race. The article also touches on the implications of aging, fitness, and endurance training on overall health and well-being. [Extracted from the article]

The question of optimal timing for catheter ablation of atrial fibrillation (AF) to achieve best outcomes remains a crucial clinical issue. As AF occurs less frequently in younger patients, data regarding Diagnosis-to-Ablation Time (DAT) is especially limited in patients under the age of 55 years with persistent AF. We therefore analyzed the temporal relationship between initial AF presentation and timing of catheter ablation in this cohort. We conducted a retrospective single-centre study of patients ≤ 55 years with persistent AF who underwent first-time catheter ablation at our center. The cohort was divided into patients that underwent catheter ablation after diagnosis of persistent AF within a DAT of ≤ 12 months and patients with a DAT of > 12 months. A total of 101 patients (median age 51 years; female n = 19 (18.8%)) with persistent AF were included. Ablation was performed within 12 months ("early DAT") in 51 patients and > 12 months ("late DAT") in 50 patients. Pulmonary vein isolation was performed using high-power short-duration (HPSD) radiofrequency ablation. Median DAT was 5 months (1–12 months) in the early ablation group and 36 months (13–240 months) in the late ablation group. The median follow-up was 11.3 months (0.03–37.1 months). The rate of any atrial arrhythmia recurrence after a 30-day blanking period was significantly lower in the early DAT group (13/51 patients; 25.5%) as compared to the late DAT group (26/50 patients; 52.0%) (log rank test; p = 0.003). Catheter ablation performed > 12 months after the initial AF diagnosis was an independent predictor for the occurrence of any atrial arrythmia (OR: 2.58; (95%-CI: 1.32–5.07). Early first-time catheter ablation (DAT ≤ 12 months) in patients ≤ 55 years with persistent AF is associated with a significantly lower rate of arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

The European Heart Journal presents innovative approaches to managing recurrent atrial fibrillation, aortic dilation, and Brugada syndrome. Articles discuss the role of diet in preventing cardiovascular diseases, the use of induced pluripotent stem cells in cardiovascular drug development, and the application of artificial intelligence in clinical medicine. A clinical trial in China shows that the traditional Chinese medicine SSYX reduces recurrent atrial tachyarrhythmias post-catheter ablation. Another study introduces the AORTA Gene score for detecting and stratifying ascending aortic dilation. Additionally, research reveals the presence of anti-NaV1.5 autoantibodies in Brugada syndrome patients, suggesting an immunopathogenic component beyond genetic factors. The articles aim to advance precision medicine in cardiovascular care. [Extracted from the article]

Background and Aims Despite advances in technology and techniques, the recurrence rate of persistent atrial fibrillation (AF) following catheter ablation remains high. The Shensong Yangxin (SSYX) capsule, a renowned traditional Chinese medicine formula, is used in the treatment of cardiac arrhythmias. This trial aimed to investigate whether the SSYX can improve clinical outcomes in patients who have undergone catheter ablation for persistent AF. Methods A multi-centre, randomized, double-blind, placebo-controlled clinical trial was conducted at 66 centres in China among 920 patients with persistent AF undergoing first ablation. Participants were randomized to oral SSYX, 1.6 g (.4 g/granule) thrice daily (n = 460), or matched placebo (n = 460) for 12 months. The primary endpoint was recurrent atrial tachyarrhythmias lasting for ≥30 s following a blanking period of 3 months. Secondary endpoints included time to first documented atrial tachyarrhythmias, AF burden, cardioversion, stroke/systemic embolism, changes in echocardiographic parameters, and quality-of-life (QoL) score. Analyses were performed according to the intention-to-treat principle. Results A total of 920 patients underwent randomization (460 assigned to SSYX group and 460 assigned to placebo group). During the follow-up of 12 months, patients assigned to SSYX had a higher event-free rate from recurrent atrial tachyarrhythmias when compared with the placebo group (12-month Kaplan–Meier event-free rate estimates, 85.5% and 77.7%, respectively; hazard ratio,.6; 95% confidence interval.4–.8; P =.001). Patients assigned to receive SSYX had a better QoL score at 12 months compared to those randomized to placebo. There was no significant difference in the incidence of serious adverse events between the two groups. Conclusions Treatment with SSYX following radiofrequency catheter ablation for persistent AF reduced the incidence of recurrent atrial tachyarrhythmias and led to clinically significant improvements in QoL during a 12-month follow-up in a Chinese population. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion New‐onset atrial fibrillation or flutter (NOAF) is a common arrhythmia in adult intensive care unit (ICU) patients. Intravenous amiodarone is one of the most used anti‐arrhythmic drugs, despite its risk of inducing acute amiodarone‐induced pulmonary toxicity (APT). We aimed to outline the body of evidence on acute APT in ICU patients with NOAF.We performed a systematic search using the population, intervention, comparison, and outcome (PICO) approach. We included studies of adults admitted to the ICU, who developed NOAF during their ICU stay, were treated with amiodarone, and reported on acute APT, irrespective of research design. The CASE guidelines were applied to evaluate the quality of the included studies, and study results are reported in accordance with the preferred reporting items for systematic reviews and meta‐analyses.No randomised controlled trials or observational studies were identified. Nine case reports and one retrospective case series of fatal outcomes in ICU patients treated with amiodarone for NOAF constituted the evidence base. The quality of the included studies was high with a mean of 10 (range 8–12) of the 13 CASE guideline criteria fulfilled. The studies included a total of 16 critically ill adults who was diagnosed with acute APT after a mean of 9 days (range 2–20 days) following initiation of amiodarone with a mean total dose of amiodarone of 4553 mg (range 1100–13,500 mg) predominantly administrated intravenously. Three out of nine patients in the case reports died in the ICU during the amiodarone treatment. No long‐term follow‐up was conducted for the survivors.Acute APT in adult ICU patients treated with amiodarone for NOAF is poorly described and is based on a total of 16 reported cases. Additional studies assessing the safety of amiodarone in critically ill adults with NOAF in the ICU is warranted. [ABSTRACT FROM AUTHOR]