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Navzer D Sachinvala,1 Angeline Stergiou,2 Duane E Haines3,4 1Retired, US Department of Agriculture-Agricultural Research Service, New Orleans, LA 70124, USA; 2Department of Medicine, Fairfield Medical Center, Lancaster, OH 43130, USA; 3Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA; 4Department of Neurobiology and Anatomy, The University of Mississippi Medical Center, Jackson, MS 39216, USA Abstract: In this report, we discuss the case of an multiple sclerosis (MS) patient, age 62, who learned to attain and sustain euthymia despite his ailments. He has Ehlers Danlos Syndrome (EDS), asthma, MS, urticaria, and major depression (MD). Despite thriving limitations, the patient is an accomplished scientist, who struggled for > twelve years to emerge from being confined to bed and wheel chair with MS, to walking with crutches, scuba diving, writing manuscripts, and living a positive life. Through former educators, he reacquired problem-solving habits to study the literature on his illnesses; keep records; try new therapies; and use pharmaceutical, nutritional, physical, and psychological methods to attain euthymia. With this inculcation, years later, he discovered that dimethyl fumarate (DMF) suppressed inflammation, cramping, urticaria, and asthma; and the combination of bupropion, S-adenosylmethionine (SAMe), vitamin-D3 (vit-D3), yoga, and self-hypnosis relieved MD. Then, after a 14-month respite, the patient, discovered that he had adult onset craniopharyngioma: a benign, recurring, epithelial tumor that grows from vestigial embryonic tissue (Rathke’s pouch) which formed the anterior pituitary. The tumor grows aggressively and causes surrounding tissue and function losses. It caused headaches, disorientation, bitemporal vision loss, among other problems. To emerge from this conundrum, the patient employed his relearned habits; the above antidepressant cocktail (bupropion, SAMe, and vit-D3); and with 30 fractionated stereotactic radiation treatments shrank his tumor and gained relief. This is a single case, and methods we discovered serendipitously may not work for other chronically ill patients. Consequently, we want to encourage such patients and their physicians to discuss their experiences in peer-reviewed domains so readers may acquire new perspectives that help individualize their care, and have productive contented lives. Keywords: craniopharyngioma, euthymia, dimethyl fumarate, bupropion, S-adenosylmethionine, vitamin D3

Background: Ablation of the left atrium and pulmonary veins antrum (PVAI) can be an effective treatment of atrial fibrillation (AF). However, there is discrepancy in the literature regarding the effect extensive ablation has on left atrial (LA) function. We sought to evaluate the effect that AF ablation procedures has on global and regional wall motion as assessed by cardiovascular magnetic resonance imaging (MRI).Methods: Consecutive patients undergoing PVAI had cardiac MRI performed preablation and 3 months post ablation. Patients included paroxysmal (n = 16) and persistent/permanent (n = 13). In addition, 12 volunteers underwent cardiac MRI to provide a control population. LA transport function was assessed by obtaining cyclical change indices, total percent emptying, LA stroke volume indices, and LA active percent emptying. Using chordal segment analysis and radial motion of the left atrium, regional motion was assessed throughout the LA emptying cycle.Results: All four PVs were isolated for all patients. Imaging revealed a significant reduction in LA volumes in AF patients post-PVAI. In the subset of patients with persistent AF, post-PVAI improvements were seen in global (p < 0.01) and regional LA functions (p = 0.01). In the paroxysmal AF patients, post-PVAI measurements revealed decreases in LA transport function (p = 0.02) as well as diminished regional function in the LA lateral wall (p = 0.02). The paroxysmal AF patients had global and regional LA functions comparable to the normal volunteers prior to ablation; however, these were significantly diminished post ablation.Conclusion: Extensive ablation during PVAI causes mild deterioration in LA function. However, in patients with a high burden of AF, it appears that the positive remodeling that occurs with rhythm restoration outweighs any negative effects of ablation. [ABSTRACT FROM AUTHOR]

Abstract Background In the context of finite health resources, encouraging self-management of chronic conditions is important. Indeed, it is a key priority in the UK. An increasing number of self-management programmes are becoming available. However, patients may not always choose to participate in them. Some will prefer a more directed or medically orientated treatment. The acceptability of self-management programmes for patients suffering from chronic pain is an important issue. Few measures exist that examine the process of change to a self-management approach. The Pain Stages of Change Questionnaire (PSOCQ) was evaluated for this purpose in the present study. Hypotheses were centred around criterion and construct validity of the PSOCQ. Methods A sample of pain patients was surveyed about their interest in participating in a lay-led self-management programme ('the Expert Patients Programme'). In addition, participants completed two psychometric measures: the Pain Stages of Change Questionnaire (PSOCQ) together with the Chronic Pain Acceptance Questionnaire (CPAQ). This is the first study as far as we are aware to examine these two scales together. The psychometric properties of the PSOCQ were examined. Analyses focused on the associations between the PSOCQ scores and interest in participating in the self-management programme. Further associations were examined between the PSOCQ and the Chronic Pain Acceptance Questionnaire. Results The results demonstrated qualified support for the PSOCQ, in particular the Contemplation sub-scale. There was a significant positive association between interest and likelihood of joining the self-management programme and contemplation scores. The action and maintenance sub-scales appeared to be measuring a unitary dimension. The associations between the PSOCQ and the Chronic Pain Acceptance Questionnaire were in the directions predicted. The limitations of the study were discussed. Conclusion The results showed some support for the PSOCQ as a potentially useful tool in assessing who may or may not be likely to join a self-management course.

The genesis of cardiac arrhythmia can be grouped into 3 common mechanisms: abnormal automaticity, triggered activity, and re-entry. Alteration of automaticity, triggered activity, conduction, and/or refractoriness of myocardial tissue by drugs will perturb and often prevent the occurrence of arrhythmias. Ranolazine is a novel agent approved in the United States for antianginal therapy. The potential of ranolazine as an antiarrhythmic drug stems from observation of its ability to modify multiple ionic currents in cardiac cells responsible for generation of the action potential. In contrast to currently available antiarrhythmic drugs, ranolazine is well tolerated and has few side effects. Small clinical trials suggest that ranolazine may have a role in the treatment of patients with non-ST-elevation acute coronary syndrome, atrial fibrillation, long QT syndromes, and sinus node dysfunction. [ABSTRACT FROM AUTHOR]

Background: We sought to evaluate the anatomic and functional lesion development over time at different atrial sites immediately following delivery of pulsed field ablation (PFA)., Methods: Using a porcine model, PFA ablations were performed in the superior vena cava (SVC), right atrial lateral wall (RA), left atrial appendage (LAA), and right superior pulmonary vein (RSPV) using four different PFA profiles. Mapping was done sequentially in 5-20-min increments up to 280-min post lesion delivery for low voltage area (LVA) assessment and conduction velocity. Lesion characteristics were noted with voltage mapping immediately post ablation and at the serial time points., Results: In 9 animals, 33 sites were ablated. None of the four different profiles across all sites showed any statistical difference on acute lesion formation or persistence. Higher tissue contact was observed in the SVC and RSPV and lower tissue contact was observed in the LAA and RA locations. Higher contact areas were noted to have higher density electroanatomic low voltage area (LVA) (12/14 vs 5/18, p = 0.01) and larger lesions on gross pathology (2 /14 vs 6/16, p = 0.01) compared to lower contact areas. Lesion regression occurred in 16/33 sites. Sustained lesions were significantly more prevalent in higher versus lower contact sites (65% vs 38%, p = 0.037)., Conclusion: The development of significant and durable lesions for PFA in a porcine model appears to be dependent on tissue proximity and contact., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Transcatheter aortic valve replacement (TAVR) carries a risk of high-grade AV block requiring cardiac implantable electronic device (CIED) implantation, which has been associated with a higher mortality rate. However, the outcomes of TAVR in patients with preexisting CIEDs are not well understood. We conducted a retrospective analysis of consecutive patients who underwent TAVR from December 2014 to December 2019 at our institution. Patients were categorized into 3 groups: preexisting CIED pre-TAVR (group 1), CIED implanted within 30 days after TAVR (group 2), and no CIED implanted (group 3). Cox proportional hazard was conducted to determine the primary end point of all-cause mortality. A total of 366 patients were included, of whom 93 (25.4%), 51 (13.9%), and 222 (60.7%) comprised group 1, 2, and 3, respectively. The median follow-up time was 2.3 years. The all-cause mortality rate was higher in group 1 than group 2 (hazard ratio [HR] 2.60, 95% confidence interval [CI] 1.09 to 6.18, p = 0.03) and group 3 (HR 1.96, 95% CI 1.24 to 3.08, p = 0.004). On the multivariate analysis, there was no statistically significant difference in mortality among the groups (group 1 vs group 2: HR 1.95, 95% CI 0.70 to 5.44, p = 0.20 and group 1 vs group 3: HR 1.27, 95% CI 0.66 to 2.43, p = 0.47). Preoperative hemoglobin ≤12 g/100 ml was an independent predictor of all-cause mortality (HR 1.75, 95% CI 1.10 to 2.80, p = 0.02). Group 1 had a higher 1 year congestive heart failure readmission rate (29%) than group 2 (17.6%) and group 3 (8.1%; p <0.0001). In conclusion, there was no difference in the adjusted long-term survival based on the CIED grouping. However, patients with preexisting CIEDs had higher all-cause mortality and 1-year congestive heart failure readmission rates owing to their higher co-morbidity burden, irrespective of their Society of Thoracic Surgeons score. This can be taken into account for preoperative risk stratification., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to declare., (Copyright © 2023. Published by Elsevier Inc.)

Background: Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds after pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; ClinialTrials.gov Identifier: NCT04198701). AA burden may be a more clinically meaningful endpoint., Objective: The purpose of this study was to determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and health care utilization (HCU) after PFA., Methods: Patients underwent 24-hour Holter monitoring at 6 and 12 months and weekly, and symptomatic transtelephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of (1) percentage of AA on total Holter time; or (2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM., Results: Freedom from all AAs varied by >20% when differing monitoring strategies were used. PFA resulted in zero burden in 69.4% of paroxysmal atrial fibrillation (PAF) and 62.2% of persistent atrial fibrillation (PsAF) patients. Median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (P <.01)., Conclusion: The ≥30-second AA endpoint is dependent on the monitoring protocol used. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU., (Copyright © 2023 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Ablation strategies remain poorly defined for persistent atrial fibrillation (AF) patients with recurrence despite intact pulmonary vein isolation (PVI). As the ability to perform durable PVI improves, the need for advanced mapping to identify extra-PV sources of AF becomes increasingly evident. Multiple mapping technologies attempt to localize these self-sustained triggers and/or drivers responsible for initiating and/or maintaining AF; however, current approaches suffer from technical limitations. Electrographic flow (EGF) mapping is a novel mapping method based on well-established principles of optical flow and fluid dynamics. It enables the full spatiotemporal reconstruction of organized wavefront propagation within the otherwise chaotic and disorganized electrical conduction of AF. Given the novelty of EGF mapping and relative unfamiliarity of most clinical electrophysiologists with the mathematical principles powering the EGF algorithm, this paper provides an in-depth explanation of the technical/mathematical foundations of EGF mapping and demonstrates clinical applications of EGF mapping data and analyses. Starting with a 64-electrode basket catheter, unipolar EGMs are recorded and processed using an algorithm to visualize the electrographic flow and highlight the location of high prevalence AF "source" activity. The AF sources are agnostic to the specific mechanisms of source signal generation., (© 2022. The Author(s).)

Background: Pulsed field ablation uses electrical pulses to cause nonthermal irreversible electroporation and induce cardiac cell death. Pulsed field ablation may have effectiveness comparable to traditional catheter ablation while preventing thermally mediated complications., Methods: The PULSED AF pivotal study (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF) was a prospective, global, multicenter, nonrandomized, paired single-arm study in which patients with paroxysmal (n=150) or persistent (n=150) symptomatic atrial fibrillation (AF) refractory to class I or III antiarrhythmic drugs were treated with pulsed field ablation. All patients were monitored for 1 year using weekly and symptomatic transtelephonic monitoring; 3-, 6-, and 12-month ECGs; and 6- and 12-month 24-hour Holter monitoring. The primary effectiveness end point was freedom from a composite of acute procedural failure, arrhythmia recurrence, or antiarrhythmic escalation through 12 months, excluding a 3-month blanking period to allow recovery from the procedure. The primary safety end point was freedom from a composite of serious procedure- and device-related adverse events. Kaplan-Meier methods were used to evaluate the primary end points., Results: Pulsed field ablation was shown to be effective at 1 year in 66.2% (95% CI, 57.9 to 73.2) of patients with paroxysmal AF and 55.1% (95% CI, 46.7 to 62.7) of patients with persistent AF. The primary safety end point occurred in 1 patient (0.7%; 95% CI, 0.1 to 4.6) in both the paroxysmal and persistent AF cohorts., Conclusions: PULSED AF demonstrated a low rate of primary safety adverse events (0.7%) and provided effectiveness consistent with established ablation technologies using a novel irreversible electroporation energy to treat patients with AF., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT04198701., Competing Interests: Disclosures Drs Verma, Boersma, Calkins, Haines, Hindricks, Kuck, Marchlinski, Natale, Packer, De Lurgio, and Sanders receive consultation funds from Medtronic, Inc. Dr Onal and J. Cerkvenik are employees of Medtronic, Inc. Dr Verma receives grants or consultation funds from Biosense Webster, Bayer, Medlumics, Adagio Medical, and Boston Scientific. Dr De Lurgio receives consultation or honoraria funds from Atricure and Boston Scientific. Dr Marchlinski receives grants, consultation, or honoraria funds from Biosense Webster, Abbott Medical, and Biotronik. Dr Sood receives consultation or honoraria funds from Johnson & Johnson, Boston Scientific, Atricure, Bristol Myers, and Pfizer. Dr Boersma receives consultation funds from Boston Scientific, Abbott Medical, Adagio Medical, Acutus Medical, and Philips Medical. Dr Kuck receives consultation funds from Cardiovalve. Dr Natale receives consultation funds from Abbott Medical, Baylis, Biosense Webster, Biotronik, and Boston Scientific. Dr Sanders receives grants or honoraria funds from Boston Scientific, Abbott Medical, Becton Dickenson, Pacemate, and CathRx. Dr Tada receives funds from Abbott Medical Japan LLC, Nippon Boehringer Ingelheim Co Ltd, Daiichi Sankyo Company Ltd, Alvaus Inc, Biotronik Japan Inc, Bristol Myers Squibb, and Novartis Pharma KK. Dr Calkins receives consultation or honoraria funds from Boston Scientific, Abbott Medical, Atricure, and Biosense Webster.

Pulsed field ablation (PFA) has the potential to evolve into an efficient alternative to traditional RF ablation for atrial fibrillation treatment. However, achieving irreversible tissue electroporation is critical to suppressing arrhythmic pathways, raising the need for accurate lesion characterization. To understand the physics behind the tissue response PFA, we propose a quasi-dynamic model that quantifies tissue conductance at end-electroporation and identifies regions that have undergone fully irreversible electroporation (IRE). The model uses several parameters and numerically solves the electrical field diffusion into the tissue by iteratively updating the tissue conductance until equilibrium at end-electroporation. The model yields a steady-state tissue conductance map used to identify the irreversible lesion. We conducted numerical experiments mimicking a lasso catheter featuring nine 3-mm electrodes spaced circumferentially at 3.75 mm and fired sequentially using a 1500 V and 3000 V pulse amplitude. The IRE lesion region has a surface area and volume of 780 mm 2 and 1411 mm 3 , respectively, at 1500 V, and 1178 mm 2 and 2760 mm 3 , respectively, at 3000 V. Lesion discontinuity was observed at 5.0 mm depth with 1500 V, and 7.2 mm depth with 3000 V. This quasi-dynamic model yields tissue conductance maps, predicts irreversible lesion and lesion penumbra at end-electroporation, and confirms larger lesions with higher pulse amplitudes.

Background: Phrenic nerve palsy is a well-known complication of cardiac ablation, resulting from the application of direct thermal energy. Emerging pulsed field ablation (PFA) may reduce the risk of phrenic nerve injury but has not been well characterized., Methods: Accelerometers and continuous pacing were used during PFA deliveries in a porcine model. Acute dose response was established in a first experimental phase with ascending PFA intensity delivered to the phrenic nerve (n=12). In a second phase, nerves were targeted with a single ablation level to observe the effect of repetitive ablations on nerve function (n=4). A third chronic phase characterized assessed histopathology of nerves adjacent to ablated cardiac tissue (n=6)., Results: Acutely, we observed a dose-dependent response in phrenic nerve function including reversible stunning (R 2 =0.965, P <0.001). Furthermore, acute results demonstrated that phrenic nerve function responded to varying levels of PFA and catheter proximity placements, resulting in either: no effect, effect, or stunning. In the chronic study phase, successful isolation of superior vena cava at a dose not predicted to cause phrenic nerve dysfunction was associated with normal phrenic nerve function and normal phrenic nerve histopathology at 4 weeks., Conclusions: Proximity of the catheter to the phrenic nerve and the PFA dose level were critical for phrenic nerve response. Gross and histopathologic evaluation of phrenic nerves and diaphragms at a chronic time point yielded no injury. These results provide a basis for understanding the susceptibility and recovery of phrenic nerves in response to PFA and a need for appropriate caution in moving beyond animal models.

Background: An important complication of cardiac implantable electronic devices (CIED) implantation is the development of hematoma and device infection., Objective: We aimed to evaluate a novel mechanical compression device for hematoma prevention and cosmetic outcomes following CIED implantation., Methods: An open, prospective, randomized, single-center clinical trial was performed in patients undergoing CIED implantation. Patients were randomized to receive a novel mechanical compression device (PressRite, PR) or to receive the standard of care post device implantation. Skin pliability was measured with a calibrated durometer; the surgical site was evaluated using the Manchester Scar Scale (MSS) by a blinded plastic surgeon and the Patient and Observer Scar Scale (POSAS). Performance of PR was assessed through pressure measurements, standardized scar scales and tolerability., Results: From the total of 114 patients evaluated for enrollment, 105 patients were eligible for analysis. Fifty-one patients were randomized to management group (PR) and 54 to the control group. No patients required early removal or experienced adverse effects from PR application. There were 11 hematomas (14.8% vs. 5.9% in the control and PR group respectively, p = NS). The control group had higher post procedure durometer readings in the surgical site when compared with the PR group (7.50 ± 3.45 vs. 5.37 ± 2.78; p = < .01). There were lower MSS scores in the PR group after 2 weeks (p = .03)., Conclusion: We have demonstrated the safety of PR application and removal. In addition, PR appears to improve postoperative skin pliability, which could facilitate wound healing., (© 2022 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

The incidence of new-onset secondary atrial fibrillation (NOSAF) is as high as 44% in noncardiac critical illness. A systematic review and meta-analysis were performed to evaluate the impact of NOSAF, compared with history of prior atrial fibrillation (AF) and no history of AF in noncardiac critically ill patients. Patients undergoing cardiothoracic surgery were excluded. NOSAF incidence, intensive care unit (ICU)/hospital length of stay (LOS), and mortality outcomes were analyzed. Of 2,360 studies reviewed, 19 studies met inclusion criteria (n = 306,805 patients). NOSAF compared with no history of AF was associated with increased in-hospital mortality (risk ratio [RR] 2.06, 95% confidence interval [CI] 1.76 to 2.41, p <0.001), longer ICU LOS (standardized difference in means [SMD] 0.66, 95% CI 0.41 to 0.91, p <0.001), longer hospital LOS (SMD 0.31, 95% CI 0.07 to 0.56, p = 0.001) and increased risk of long-term (>1 year) mortality (RR 1.76, 95% CI 1.29 to 2.40, p <0.001). NOSAF compared with previous AF was also associated with higher in-hospital mortality (RR 1.29, 95% CI 1.12 to 1.49, p <0.001), longer ICU LOS (SMD 0.37, 95% CI 0.03 to 0.70, p = 0.03) but no difference in-hospital LOS (SMD -0.18, 95% CI -0.66 to 0.31, p = 0.47). In conclusion, NOSAF, in the setting of noncardiac critical illness is associated with increased in-hospital mortality compared with no history of AF and previous AF. NOSAF (vs no history of AF) is also associated with increased long-term mortality., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Pulsed field ablation (PFA) is a novel form of ablation using electrical fields to ablate cardiac tissue. There are only limited data assessing the feasibility and safety of this type of ablation in humans., Methods: PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; https://www.clinicaltrials.gov; unique identifier: NCT04198701) is a nonrandomized, prospective, multicenter, global, premarket clinical study. The first-in-human pilot phase evaluated the feasibility and efficacy of pulmonary vein isolation using a novel PFA system delivering bipolar, biphasic electrical fields through a circular multielectrode array catheter (PulseSelect; Medtronic, Inc). Thirty-eight patients with paroxysmal or persistent atrial fibrillation were treated in 6 centers in Australia, Canada, the United States, and the Netherlands. The primary outcomes were ability to achieve acute pulmonary vein isolation intraprocedurally and safety at 30 days., Results: Acute electrical isolation was achieved in 100% of pulmonary veins (n=152) in the 38 patients. Skin-to-skin procedure time was 160±91 minutes, left atrial dwell time was 82±35 minutes, and fluoroscopy time was 28±9 minutes. No serious adverse events related to the PFA system occurred in the 30-day follow-up including phrenic nerve injury, esophageal injury, stroke, or death., Conclusions: In this first-in-human clinical study, 100% pulmonary vein isolation was achieved using only PFA with no PFA system-related serious adverse events. Graphic Abstract: A graphic abstract is available for this article.

Background: Transfemoral venous access (TFV) is the cornerstone of minimally invasive cardiac procedures. Although the presence of inferior vena cava filters (IVCFs) was considered a relative contraindication to TFV procedures, small experiences have suggested safety. We conducted a systematic review of the available literature on cardiac procedural success of TFV with IVCF in-situ., Methods: Two independent reviewers searched PubMed, EMBASE, SCOPUS, and Google Scholar from inception to October 2020 for studies that reported outcomes in patients with IVCFs undergoing TFV for invasive cardiac procedures. We investigated a primary outcome of acute procedural success and reviewed the pooled data for patient demographics, procedural complications, types of IVCF, IVCF dwell time, and procedural specifics., Results: Out of the 120 studies initially screened, 8 studies were used in the final analysis with a total of 100 patients who underwent 110 procedures. The most common IVCF was the Greenfield Filter (36%), 60% of patients were males and the mean age was 67.8 years. The overall pooled incidence of acute procedural success was 95.45% (95% confidence interval = 89.54-98.1) with no heterogeneity (I 2  = 0%, p = 1) and there were no reported filter-related complications., Conclusion: This systematic review is the largest study of its kind to demonstrate the safety and feasibility of TFV access in a variety of cardiac procedures in the presence of IVCF., (© 2021 Wiley Periodicals LLC.)

Importance: It has been suggested that atrial fibrillation (AF) is the new cardiovascular disease epidemic of the 21st century. Clinical cardiology has largely focused on AF treatment and associated stroke prevention rather than preventing AF itself. To reduce the global consequences and associated costs of AF, it is critical to now embrace prevention as a priority. Proactively addressing the risk factors for AF and the underlying unhealthy lifestyle habits that contribute to them, using research-based counseling approaches, represents a complementary and adjunctive alternative in combatting this disease burden., Observations: Encouraging and sustaining patient involvement to reduce AF incidence and improve outcomes begins with screening to identify risk factors, unhealthy lifestyle habits, and characteristics associated with failed attempts at favorably modifying these causalities. Modulators of and common barriers to achieving risk reduction and lifestyle change include self-efficacy, social support, age, sex, marital and socioeconomic status, education, employment, and psychosocial factors such as depression, isolation, anxiety and chronic life stress. Focused behavioral counseling approaches, including assessing the patient's readiness to change, motivational interviewing and using the 5 A's (assess, advise, agree, assist, arrange), along with employing initial downscaled goals to overcome inertia, are proven methodologies to overcome these common barriers to favorably modifying risk factors and unhealthy lifestyle habits., Conclusions and Relevance: To complement and enhance the current armamentarium for the medical management of cardiac arrhythmias, there is an urgent need to proactively address the causative factors triggering new-onset, recurrent and persistent AF. Beyond the counseling skills of highly trained professionals (eg, psychiatrists, psychologists), this narrative review highlights the need for and potential impact on lifestyle modification that non-behavioral scientists, including internal medicine, cardiology, and allied health professionals, can have on the patients they serve., Competing Interests: Declaration of competing interest None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

There are an increasing number of cardiac electronic device implants and generator changes with a longer patient life expectancy along with concomitant increase in antiplatelet and anticoagulant regimens, which can increase the incidence of pocket hematomas. We have conducted an in-depth analysis on the relevant literature, which is rife with varying definition of hematomas, on ways to reduce pocket hematomas. We have analyzed studies on periprocedural medication management, intraprocedural use of prohemostatic agents, and postprocedure role of compression devices., (Copyright © 2020 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)