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Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a multicentre international project initiated to implement remote care delivery for patients with atrial fibrillation (AF) through teleconsultations supported by an on-demand photoplethysmography (PPG)-based heart rate/rhythm monitoring app. Purpose The current sub-study of the TeleCheck-AF project aimed to provide the first real-world dataset on feasibility and patient experience of this standardized mobile health (mHealth) infrastructure in the clinical setting of follow-up after catheter ablation. Methods This sub-study included consecutive patients in each centre who have undergone catheter ablation. In the post-ablation period, at the 3-, 6- or 12-month visit, patients were provided with the app and were instructed to perform 60-second heart rate/rhythm recordings three times daily and in case of symptoms for seven consecutive days prior to teleconsultation. Recurrences of AF were documented by PPG-based app (FibriCheck®). Motivation was defined as number of days in which the expected number of measurements (≥three/day) were performed per number of days over the entire prescription period. Adherence was defined as number of performed measurements per number of expected measurements over the entire prescription period. Patients’ experience was based on a survey sent to each patient via e-mail. Results Data from 588 patients (median age 63 [56-70] years, 39% female) from eight centres from six European countries were analysed. Patients with both optimal motivation (100%) and adherence (≥100%) constituted 158 (29%) of the study population and had more often previously undergone an ablation for AF (77% vs 62%), P=0.005) and had a higher number of AF PPG recordings (mean 1.9 vs 0.8, P=0.017). The app gave patients a safe feeling (70%) and automated reminders were useful (68%). Patients agreed that the app was easy to use (97%), easy to install (89%) and that they would like to use the app in the future (70%). In 95 (16%) patients, AF was detected by the app. There was no statistically significant difference between patients with (vs without) app-based detected AF, except a higher prevalence of prescribed three or more cardiovascular drugs (65% vs 53%, P=0.032) and beta-blockers (64% vs 52%, P=0.033). Patients with (vs without) app-based detected AF had higher optimal adherence (66% vs 41%, P Conclusion The TeleCheck-AF approach is feasible and associated with high adherence as well as motivation to use the app and with optimal patient experience. Whether this approach can replace conventional rhythm follow-up after catheter ablation required further study.

Funding Acknowledgements Type of funding sources: None. Purpose Sleep-disordered breathing (SDB) is prevalent in up to 50% of patients undergoing atrial fibrillation (AF) ablation. Currently, it remains unclear whether all AF patients should be systematically screened for SDB, or whether pre-selection of patients requiring screening can be improved. We aimed 1) to assess the accuracy of the STOP-Bang screening questionnaire as a tool for detecting SDB in patients scheduled for AF ablation; and 2) to develop a refined, AF-specific version of the STOP-Bang to improve pre-selection. Methods Consecutive patients scheduled for AF ablation without a previous history of SDB and/or SDB screening were included. Patients were digitally referred to the previously described Virtual-SAFARI SDB screening and management pathway1 including a home sleep test using polygraphy. An apnoea-hypopnoea-index (AHI) of ≥15 was interpreted as moderate-to-severe SDB. The accuracy of the STOP-Bang questionnaire (Snoring, Tiredness, Observed apneas, blood Pressure, BMI ≥35 kg/m², Age, Neck circumference, and Gender) was evaluated. Logistic regression was used to assess characteristics within and outside the STOP-Bang questionnaire associated with moderate-to-severe SDB. These characteristics were used to refine the STOP-Bang specifically for AF patients. Results Of 206 included patients, 51% was diagnosed with moderate-to-severe SDB. The STOP-Bang questionnaire performed poorly in detecting SDB, with an area under the receiver operating characteristic curve (AUROC) of 0.647 (0.573-0.721). AF-specific refinement of the STOP-BANG resulted in the BOSS-GAP score. Therein, tiredness and neck circumference were removed, while body mass index with cut-off point ≥27 kg/m² and previous stroke or transient ischaemic attack were added. The BOSS-GAP questionnaire performed better with an AUROC of 0.738 (0.672-0.805) in the overall population. Conclusion The STOP-Bang questionnaire showed limited value when used as a pre-selection tool for SDB screening. The refined, AF-specific BOSS-GAP questionnaire demonstrated slightly improved, but still limited accuracy in identifying AF patients with SDB. Whether questionnaires bring an advantage in pre-selection for SDB screening compared to structural screening in patients with AF, requires further study.

Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a digital care pathway, which consists of a structured teleconsultation ("Tele") preceded by an app-based on-demand heart rate and rhythm monitoring infrastructure ("Check") and the consecutive integration of the app-derived findings in a comprehensive atrial fibrillation (AF) management. Purpose To evaluate changes in healthcare utilisation and declarable care products during the implementation of the TeleCheck-AF approach in a Dutch AF-clinic. Methods Healthcare provided to patients in the Netherlands is based on a diagnosis-treatment combination (Dutch: DBC). Once a patient visits the hospital, a treatment trajectory is opened, which contains the DBC care product. The DBC care products contain diagnostic and therapeutic performances for a certain diagnosis as well as information about reimbursement and are weighted in light (≤ € 200), medium (€ 300-500) and heavy (≥ € 600) depending on the performed diagnostic tests. Patients with AF who were treated with both a conventional approach in 2019 (standard care) and by the TeleCheck-AF approach in 2020 in a Dutch AF-clinic, were compared in this prospective case-crossover analysis. Healthcare utilisation in terms of numbers and modes of outpatient contacts (teleconsultation vs face-to-face), number of emergency department (ED) presentations, use of diagnostic resources (i.e. ECG, Holter) and related reimbursement were analysed. A patient experience survey which encompassed five questions regarding use of the app and patient satisfaction with the remote heart rate and rhythm control was performed. Results Ninety-one patients with AF from a Dutch AF-clinic (median age 68 years; 43% women) were analysed. Within the conventional approach in 2019, 113 face-to-face consultations and 1 teleconsultation were performed. After the implementation of TeleCheck-AF in 2020 the number of face-to-face consultations reduced by 53% and teleconsultations increased by 2900%. While 151 ECGs and 42 Holter-ECGs were performed within the conventional approach, the number of ECGs in the TeleCheck-AF approach decreased by 48% and number of Holters decreased by 35%. ED presentations did not differ significantly in the conventional compared to TeleCheck-AF approach (22 vs 17). Patients’ satisfaction within the TeleCheck-AF approach was high. The change in healthcare utilisation in TeleCheck-AF treated patients resulted in a mutation in declarable care products weights (towards light weighted DBC) and associated reimbursement. Conclusion The implementation of TeleCheck-AF was associated with a change in health care utilisation which resulted in a disproportional drop in reimbursement by health insurances due to a shift in declarable care products weights. Results of this analysis were basis to design a new reimbursement code for the TeleCheck-AF approach in the Netherlands.

Funding Acknowledgements Type of funding sources: None. Background TeleCheck-AF is a novel remote on-demand mobile health (mHealth) infrastructure supporting teleconsultations. During the COVID-19 pandemic, social media (SoMe) communication on Twitter contributed to the rapid dissemination and implementation of this health care innovation into 41 European hospitals by using the hashtag #TeleCheckAF. Purpose To (1) analyze the SoMe Twitter network behind #TeleCheckAF, (2) describe the communities and behavioral groups within the network and (3) to determine the opinion leaders and influencers. Methods Publicly available data on actors and interactions within the #TeleCheckAF SoMe network was collected by web-scraping from the platform Twitter. This included all public tweets that used the hashtag #TeleCheckAF including their meta-data. Based on this, a node list (Twitter accounts) and an edge list (ties between accounts) as well as a social network were created. The position of an actor in the network and an actor’s opinion leadership was analyzed with the help of centrality measures (i.e. degree centrality, closeness centrality, betweenness centrality). Communities, or groups of nodes that were highly connected to each other, were further assessed by a modularity algorithm. Behavioral groups were analyzed based on participation in the healthcare innovation TeleCheck-AF (active participation) and dissemination of #TeleCheckAF on Twitter. Three behavioral groups were defined: Diffusers (dissemination but no active participation), adopters (no dissemination but active participation) and communicative adopters (dissemination and active participation). Results The network consisted of 413 086 nodes and 636 502 edges. 287 actors within the SoMe Twitter network behind #TeleCheckAF, who were either diffusers, adopters or communicative adopters, were further analyzed. Twenty-two different communities and 20 opinion leaders were identified. Peaks in Twitter activity could be temporally related to (inter-,)national virtual conferences, where results on TeleCheck-AF were presented. Two official European Society of Cardiology (ESC) Twitter handles and two Twitter handles of ESC SoMe supervisors and ESC Journal SoMe editors were among the group of opinion leaders reflecting the effect of the ESC SoMe promotion strategy. Overall, not only professionals directly involved in the TeleCheck-AF project, but also different other stakeholders such as allied health professionals or health technology companies were represented within the network. Conclusion The SoMe network behind #TeleCheckAF showed a wide dissemination involving a broad spectrum of healthcare professionals and was accelerated by the official ESC Twitter handles. Social network analysis created a helpful insight into the mechanisms behind innovation dissemination within social media. Future research could further analyze the difssemination process using e.g. hazard modeling and investigate the evolution of the network and behaviors over time.

Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and atherosclerosis often coexist due to a shared risk profile. Prior to an AF ablation, computed tomography (CT) scans are routinely performed to assess pulmonary vein anatomy. Often coronary plaques are described as incidental findings. According to current guidelines, patients with coronary plaques on CT are classified as being at very high risk of developing cardiovascular atherosclerotic events, potentially resulting in a redefinition of treatment targets for comorbidities. Purpose This study estimated individual 10-year risks of developing atherosclerotic cardiovascular disease (CVD) events according to the 2021 ESC guideline on CVD prevention before and after the integration of CT-derived coronary plaque information in the risk assessment of AF patients scheduled for catheter ablation. Methods Consecutive AF patients scheduled for catheter ablation were included in the ISOLATION registry (NCT04342312). Patients were excluded from this subanalysis if no preprocedural CT was performed. Each patient was classified as being at low-to-moderate, high, or very high risk of developing CVD in the coming 10 years according to the 2021 ESC guideline on CVD prevention (Figure 1). This classification was based on previous CVD, chronic kidney disease, diabetes mellitus, or the Systematic Coronary Risk Estimation 2 (SCORE2) or SCORE2-Older Persons (SCORE2-OP) risk estimation. The impact of pre-AF ablation CTs on CVD risk was assessed by comparing risk classifications excluding and including information on coronary plaques on CT. Results A total of 1022 patients (age 64 ±9, 664 [65%] male, 686 [67%] paroxysmal AF) was included. Overall CVD risk was high, with 86% of patients at a high (n=190, 19%) or very high (n=693, 68%) 10-year risk of developing CVD events. Coronary plaques were observed in 59% (n=606) of pre-AF ablation CTs. Integration of the CT-derived information on coronary plaques resulted in reclassification of 364 patients (36%) towards the very high risk category (Figure 2). Previous CVD events were observed in 161 very high risk patients (16%). Conclusion In AF patients scheduled for catheter ablation, integration of the information on coronary plaques derived from the pre-AF ablation CT resulted in reclassification of one in three patients towards the very high risk category, which impacted treatment targets for lipid levels and blood pressure.

Funding Acknowledgements Type of funding sources: None. Background In patients with atrial fibrillation (AF), expiratory airflow limitation adds to overall morbidity and may impair the response to heart rhythm control strategies. Purpose We aimed to determine the prevalence of expiratory airflow limitation in patients scheduled for AF ablation and evaluated whether routine preprocedural cardiac analyses can detect occult lung disease. Methods Consecutive AF patients scheduled for catheter ablation were systematically screened for expiratory airflow limitation with handheld (micro)spirometry devices. As part of routine preprocedural care, patients underwent cardiac computed tomographic angiography (cCTA), transthoracic echocardiography and respiratory polygraphy. Qualitative analyses of cCT was performed for emphysema, airway abnormalities and lymphadenopathy. Sleep apnea severity and nocturnal desaturation were derived from polygraphy. Multivariate logistic regression was performed to assess if routinely preprocedural studies were associated with expiratory airflow limitation. Results (Micro)spirometry was performed in 110 consecutive patients and expiratory airflow limitation was detected in 25% of patients (previously unknown in 24 of 28 patients; Figure 1). Patients with expiratory airflow limitation more often presented with pulmonary abnormalities on cCTA, such as mild-to-severe emphysema (odds ratio [OR] 4.2, 95% confidence interval [CI] 1.12-15.1, p < 0.05), lymphadenopathy (OR 3.6, 95% CI 1.1-11.3, p < 0.05) and bronchial wall thickening (OR 2.6, 95% CI 1.0-6.5, p < 0.05; Figure 2). The negative predictive value of the absence of pulmonary abnormalities on cCTA to identify patients with normal lung function was 85%. Polygraphy-derived sleep apnea status and nocturnal desaturation was less severe in patients with expiratory airflow limitation compared to patients with normal lung function (32% vs 48% moderate-to-severe sleep apnea, p = 0.23; oxygen desaturation index 3.0 [2.4-6.5] vs. 6.7 [3.4-11.4], p = 0.03). Echocardiography data did not differ between patients with compared to patients without expiratory airflow limitation. Conclusions Spirometry detected expiratory airflow limitation in 25% of patients scheduled for AF ablation. Routine preprocedural cCTA includes pulmonary features which may help in triage referral for formal pulmonary assessment.

Funding Acknowledgements Type of funding sources: Public grant(s) – EU funding. Main funding source(s): a.o. The European Union (ITN Network Personalize AF: Personalized Therapies for Atrial Fibrillation: a translational network, grant number 860974; MAESTRIA: Machine Learning Artificial Intelligence Early Detection Stroke Atrial Fibrillation, grant number 965286). Background/Introduction Noninvasive quantification of electrophysiological properties of the atria is increasingly used for outcome prediction in atrial fibrillation (AF) patients. Data on the added value of ECG parameters to predict AF recurrences in patients undergoing AF ablation are scarce. Purpose To investigate the predictive performance of clinical and echocardiographic characteristics as well as features extracted from extended surface electrocardiogram (extECG) recordings for AF recurrences in patients after AF ablation. Methods ISOLATION is a prospective, observational, multicenter registry of patients scheduled for AF catheter ablation, including cryoballoon and radiofrequency ablation. 178 patients (66.4%) patients used anti arrhythmic drugs at baseline. Clinical characteristics and results of routine blood tests were collected. In addition, an extECG was recorded (12 additional leads, 5 minutes recording) before ablation to analyze P-wave characteristics. The main study endpoint was ablation success after 12 months, defined as freedom from any episode of documented atrial arrhythmia after the blanking period recorded on holter or ECG. Results Currently, 627 of 650 scheduled patients have been included. In total, 268 patients completed the 1-year follow-up. 190 patients (70.9%) had paroxysmal AF and 75 patients (28.0%) had persistent AF. Median age was 65±9 years, 38.1% were female. 46 patients (17.2%) had a recurrence of AF after 12 months [figure 1]. Univariate analysis showed that higher age (64 years vs. 69 years, p=0.023, Mann-Whitney U-test), lower P-wave mean area (4.402 mV vs. 3.567 mV, p=0.034) and lower P-wave mean amplitude (0.087 mV vs. 0.081 mV, p=0.033), were associated with a higher recurrence rate of AF [figure 2]. However, multivariate analysis showed no significant independent prognostic factors so far. Conclusion Our first results show that patients with AF recurrences after catheter ablation are older, show lower P-wave mean area and lower P-wave mean amplitude. We need to wait for the completion of follow-up in more patients, before we can determine the predictive value of P-wave parameters derived from extECGs for the prediction of AF recurrence and to identify predictive factors with more subtle effects on risk for AF recurrences.

Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities. Purpose This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation. Methods This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure >130 mmHg and/or diastolic blood pressure >80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of >15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients). Results Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3]. Conclusions Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality. Funding Acknowledgement Type of funding sources: None.