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Background: Esophageal hematoma recently has been reported as a form of esophageal injury after atrial fibrillation (AF) ablation, attributed to the use of transesophageal echocardiography (TEE). We sought to determine the incidence, clinical features, and sequelae of this form of esophageal injury. Methods and Results: This was a prospective series of 1110 AF ablation procedures performed under general anesthesia (GA) over 9 years. TEE was inserted after induction of GA to exclude left atrial appendage thrombus, define cardiac function, and guide transseptal puncture. The procedural incidence of esophageal hematoma was 0.27% (3/1110 procedures, mortality 0%). Odonyphagia, regurgitation, and hoarseness were the predominant symptoms, with an onset within 12 hours. There was absence of fever and neurological symptoms. Chest computed tomography excluded atrio-esophageal fistula and was diagnostic of esophageal hematoma localized to either the upper esophagus or extending the length of the mid and lower esophagus; endoscopy confirmed the diagnosis. Management was conservative in all cases comprising of ceasing oral intake and anticoagulation. Long term sequelae included esophageal stricture formation requiring dilatation, persistent esophageal dysmotility (mid esophageal hematoma), and vocal cord paralysis, resulting in hoarse voice (upper esophageal hematoma). Conclusions: Esophageal hematoma is a rare but important differential diagnosis for esophageal injury after TEE-guided AF ablation under GA, and can result in significant patient morbidity. Key clinical features differentiate presentation of esophageal hematoma from that of an atrio-esophageal fistula. [ABSTRACT FROM AUTHOR]

Background: The pulmonary veins (PVs) and the PV-LA (left atrium) junction are established sources of triggers initiating atrial fibrillation. In addition, they have been implicated in the maintenance of arrhythmia.Objective: To undertake high-density electrophysiological characterization of the right superior PV-LA junction in humans.Methods: Mapping was performed in 18 patients without a history of atrial fibrillation undergoing cardiac surgery. A high-density epicardial plaque was positioned at the anterior right superior pulmonary vein covering 3 regions: LA, PV-LA junction, and the PV. Isochronal maps were created during (1) sinus rhythm (SR); (2) LA pacing (LA-Pace); (3) PV pacing (PV-Pace); (4) LA programmed electrical stimulation (LA-PES); and (5) PV programmed electrical stimulation (PV-PES). Regional differences in conduction slowing/conduction block (CS/CB) and the prevalence of fractionated signals (FS) and double potentials (DPs) were assessed.Results: A region of isochronal crowding representing CS/CB developed at the PV-LA junction in 84% of the maps. Three distinct activation patterns were seen. Pattern 1: Uniform SR activation without CS/CB. LA-Pace and PES caused 1 to 2 lines of isochronal crowding (CS/CB) at the PV-LA junction. Pattern 2: CS/CB occurred at the PV-LA junction in SR. LA/PV-Pace and LA/PV-PES caused an increase in CS/CB at the PV-LA junction with widely split DPs and FS. Pattern 3: A single incomplete line of CS at the PV-LA junction in SR. With LA/PV pacing and LA/PV-PES, multiple lines (≥3) of CS/CB developed at the PV-LA junction with evidence of circuitous activation and a marked increase in DPs and FS.Conclusion: High-density epicardial mapping of the right superior pulmonary vein demonstrates marked functional conduction delay and circuitous activation patterns at the PV-LA junction, creating the substrate for reentry. [ABSTRACT FROM AUTHOR]

Monomorphic ventricular tachycardia (VT) can arise from multiple different ventricular locations in the context of several different underlying myocardial substrates. Despite this variability, the surface 12-lead electrocardiograph (ECG) has proven to be a robust and reproducible initial mapping tool that can provide useful information in localizing the origin of both focal and reentrant forms of VT. The second part of this review series will look at the use of the ECG in mapping the various forms of VT encountered in clinical practice. [ABSTRACT FROM AUTHOR]

Background and Aims: Posterior wall isolation (PWI) is commonly incorporated into catheter ablation (CA) strategies for persistent atrial fibrillation (AF) in an attempt to improve outcomes. In the CAPLA randomized study, adjunctive PWI did not improve freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation (PVI) alone. Whether additional PWI reduces arrhythmia recurrence over the longer term remains unknown., Methods: In this multicenter, international, randomized study patients with persistent AF undergoing index CA using radiofrequency (RF) were randomized to PVI+PWI versus PVI alone. Patients underwent regular follow-up including rhythm monitoring for a minimum of 3 years post CA. AF burden at 3 years post-ablation was evaluated with either 28-day continuous ambulatory ECG monitoring, twice daily single-lead ECG or from cardiac implanted device. Evaluated endpoints included freedom from any documented atrial arrhythmia recurrence after a single procedure, AF burden, need for redo catheter ablation, rhythm at last clinical follow-up, healthcare utilisation metrics and AF-related quality of life., Results: 333 of 338 (98.5%) patients (mean age 64.3±9.4 years, 23% female) completed 3-year follow-up, with 169 patients randomized to PVI+PWI and 164 patients to PVI alone. At a median of 3.62 years post-index ablation, freedom from recurrent atrial arrhythmia occurred in 59 patients (35.5%) randomized to PVI+PWI vs 68 patients (42.1%) randomized to PVI alone (HR 1.15, 95% CI 0.88-1.51, p=0.55). Median time to recurrent atrial arrhythmia was 0.53 years (IQR 0.34-1.01 years). Redo ablation was performed in 54 patients (32.0%) in the PVI+PWI group vs 49 patients (29.9%, p=0.68) in the PVI alone group. Pulmonary vein reconnection was present in 54.5% (mean number of reconnected PVs 2.2±0.9) and posterior wall reconnection in 75%. Median AF burden at 3 years was 0% in both groups (IQR 0-0.85% PVI+PWI vs 0-1.43% PVI alone, p=0.49). Sinus rhythm at final clinical follow-up was present in 85.1% with PVI+PWI vs 87.1% with PVI alone (p=0.60). Mean AF Effect On Quality-Of-Life (AFEQT) score at 3 years post-ablation was 88.0±14.8 with PVI+PWI vs 88.9±15.4 with PVI alone (p=0.63)., Conclusions: In patients with persistent AF, the addition of PWI to PVI alone at index RF catheter ablation did not significantly improve freedom from atrial arrhythmia recurrence at long-term follow-up. Median AF burden remains low and AF quality of life high at 3 years with either ablation strategy., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background and Aims: Patterns of atrial fibrillation (AF) recurrence post-catheter ablation for persistent AF (PsAF) are not well described. This study aimed to describe the pattern of AF recurrence seen following catheter ablation for PsAF and the implications for healthcare utilization and quality of life (QoL)., Methods: This was a post-hoc analysis of the CAPLA study, an international, multicentre study that randomized patients with symptomatic PsAF to pulmonary vein isolation plus posterior wall isolation or pulmonary vein isolation alone. Patients underwent twice daily single lead ECG, implantable device monitoring or three monthly Holter monitoring., Results: 154 of 333 (46.2%) patients (median age 67.3 years, 28% female) experienced AF recurrence at 12-month follow-up. Recurrence was paroxysmal in 97 (63%) patients and persistent in 57 (37%). Recurrence type did not differ between randomization groups (P = .508). Median AF burden was 27.4% in PsAF recurrence and .9% in paroxysmal AF (PAF) recurrence (P < .001). Patients with PsAF recurrence had lower baseline left ventricular ejection fraction (PsAF 50% vs. PAF 60%, P < .001) and larger left atrial volume (PsAF 54.2 ± 19.3 mL/m² vs. PAF 44.8 ± 11.6 mL/m², P = .008). Healthcare utilization was significantly higher in PsAF (45 patients [78.9%]) vs. PAF recurrence (45 patients [46.4%], P < .001) and lowest in those without recurrence (17 patients [9.5%], P < .001). Patients without AF recurrence had greater improvements in QoL as assessed by the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire (Δ33.3 ± 25.2 points) compared to those with PAF (Δ24.0 ± 25.0 points, P = .012) or PsAF (Δ13.4 ± 22.9 points, P < .001) recurrence., Conclusions: AF recurrence is more often paroxysmal after catheter ablation for PsAF irrespective of ablation strategy. Recurrent PsAF was associated with higher AF burden, increased healthcare utilization and antiarrhythmic drug use. The type of AF recurrence and AF burden may be considered important endpoints in clinical trials investigating ablation of PsAF., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Linear and complex electrogram ablation (LCEA) beyond pulmonary vein isolation (PVI) is associated with an increase in left atrial macro-re-entrant tachycardias (LAMTs). Posterior wall isolation (PWI) is increasingly performed to improve AF ablation outcomes. However, the impact of PWI on the incidence of LAMT is unknown., Objectives: The purpose of this study was to establish the incidence of LAMT following PVI alone vs PVI + PWI vs PVI + PWI + LCEA., Methods: Consecutive patients undergoing catheter ablation for AF or LAMT post-AF ablation between 2008 and 2022 from 4 electrophysiology centers were reviewed with a minimum follow-up of 12 months., Results: In total, 5,619 (4,419 index, 1,100 redo) AF ablation procedures were performed in 4,783 patients (mean age 60.9 ± 10.6 years, 70.7% men). Over a mean follow-up of 6.4 ± 3.8 years, 246 procedures for LAMT were performed in 214 patients at a mean of 2.6 ± 0.6 years post-AF ablation. Perimitral (52.8% of patients), roof-dependent (27.1%), PV gap-related (17.3%), and anterior circuits (8.9%) were most common, with 16.4% demonstrating multiple circuits. The incidence of LAMT was significantly higher following PVI + PWI (6.2%) vs PVI alone (3.0%; P < 0.0001) and following PVI + PWI + LCEA vs PVI + PWI (12.5%; P = 0.019). Conduction gaps in previous ablation lines were responsible for LAMT in 28.4% post-PVI alone, 35.3% post-PVI + PWI (P = 0.386), and 81.8% post-PVI + PWI + LCEA (P < 0.005)., Conclusions: The incidence of LAMT following PVI + PWI is higher than with PVI alone but significantly lower than with more extensive atrial substrate modification. Given a low frequency of LAMT following PWI, empiric mitral isthmus ablation is not justified and may be proarrhythmic., Competing Interests: Funding Support and Author Disclosures Dr Lim is supported by a NHMRC postgraduate scholarship. Dr Ling has received grants from Abbott Australia. Dr Sugumar has received grants from the RACP Foundation. Prof Prabhu has received grants from NHMRC, University of Melbourne, and Baker Heart and Diabetes Institute; has received postdoctoral fellowship support from the Heart Foundation; has received advisory fees from Biosense Webster; and has received speaker fees from Abbott Medical. Prof Kalman is supported by an NHMRC practitioner fellowship; and has received research support from Biosense Webster and Medtronic. Prof Kistler is a recipient of an Investigatorship from the NHMRC of Australia; has received grants from Baker Department of Metabolic Health and University of Melbourne; and has received speaker fees from Abbott Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Nonrandomized data suggest that longer diagnosis-to-ablation time (DAT) is associated with poorer outcomes; however, a recent randomized trial found no difference in recurrences when ablation was delayed by 12 months., Objectives: This study sought to assess the impact of DAT on atrial fibrillation (AF) recurrence in patients undergoing catheter ablation for persistent AF., Methods: CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA randomized clinical trial) was a multicenter trial that randomized patients with persistent AF to pulmonary vein isolation + posterior wall isolation or pulmonary vein isolation alone. Follow-up was 12 months. Outcomes were assessed after a 3-month blanking period., Results: Median DAT in the 334 patients was 28 months (Q1-Q3: 12-66 months). Patients were divided into quartile groups: Q1 was DAT 0 to 12 months (n = 84, median DAT 7 months), Q2 was DAT 13 to 28 months (n = 85, median DAT 20 months), Q3 was DAT 29 to 66 months (n = 84, median DAT 41 months), and Q4 was DAT ≥67 months (n = 81, median DAT 119 months). AF recurrence rate was 36.9% for Q1, 44.7% for Q2, 47.6% for Q3, and 56.8% for Q4 (P = 0.082). On multivariable analysis, DAT Q4 was the only factor significantly associated with risk of recurrence (HR: 1.607; 95% CI: 1.005-2.570; P = 0.048). Median AF burden was 0% (Q1-Q3: 0%-0.47%) in Q1 and 0.33% (Q1-Q3: 0%-4.6%) in Q4 (P = 0.002). Quality of life (assessed by the Atrial Fibrillation Effect on Quality-of-Life questionnaire) improved markedly in all quartiles (Q1: Δ28.8 ± 24, Q2: Δ24.4 ± 23.4, Q3: Δ21.7 ± 26.6, Q4: Δ24.6 ± 21.4; P = 0.331)., Conclusions: In a cohort of patients with persistent AF undergoing ablation in a prospective trial with standardized entry criteria and intensive electrocardiogram monitoring, those with shorter DAT had lower rates of AF recurrence. However, differences were modest, and all quartiles demonstrated very low AF burden and improvements in quality of life., Competing Interests: Funding Support and Author Disclosures Dr Chieng was supported by a National heart foundation (NHF) Post-Doctoral Fellowship. Dr William was supported by a NHF postgraduate PhD scholarship. Dr Crowley was supported by a Baker Institute PhD scholarship. Dr Segan was supported by a cofunded National Health and Medical Research Council (NHMRC)/NHF postgraduate PhD scholarship. Dr Kalman has received research and fellowship support from Medtronic, Abbott, Zoll, and Biosense Webster. Dr Kistler has received an Investigator grant from the NHMRC; received funding for consultancy and speaking engagements from Abbott Medical; and served on the advisory board with fellowship support from Biosense Webster. Dr Sanders has served on the advisory board for Medtronic, Abbott Medical, CathRx, Pacemate, and Boston Scientific; and received a practitioner fellowship from the NHMRC and NHF. Dr Lee has received consulting fees from Biosense Webster. Dr Prabhu has received a NHMRC Post-Doctoral Research Fellowship; and received consulting fees, fellowship support, and educational grants from Biosense Webster, Abbott Medical, and Boston Scientific. Dr Ling has received grants from Abbott Australia. Dr Sterns has received personal fees from Biosense Webster. Dr Ginks has served on the Speakers Bureau for Biosense Webster; and as a speaker for Abbott. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Attention-deficit/hyperactivity disorder (ADHD) is the most common neurodevelopmental condition and is characterized by inattention, hyperactivity, and impulsivity. Research suggests that some populations, such as females and individuals with high intelligence quotients may be a risk for late ADHD diagnosis and subsequent treatment. Our goal is to advance our understanding of ADHD diagnosis, by examining (1) how child sex and cognitive abilities together are related to the age of diagnosis and (2) whether symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis., Methods: Our analyses contained children who completed the required tests (N = 568) from a pre-existing dataset of 1380 children with ADHD from the Province of Ontario Neurodevelopmental Disorders (POND) Network (pond-network.ca). First, we conducted a moderation analysis with sex as the predictor, cognitive abilities as the moderator, and age of diagnosis as the outcome. Second, we conducted correlation analyses examining how symptom presentation, current internalizing and externalizing symptoms, and demographic factors are related to age of diagnosis., Results: Higher IQ was related to a later age of diagnosis. Higher hyperactive-impulsive symptoms and externalizing symptoms were related to an earlier age of diagnosis. Internalizing symptoms were trend associated with a later age of diagnosis in girls. Higher socioeconomic status and non-White maternal ethnicity were related to later age of diagnosis., Conclusions: IQ, sex, ADHD symptomology, internalizing symptoms, externalizing symptoms, and socio-demographic factors affect the age of diagnosis., (© 2024 The Author(s). British Journal of Clinical Psychology published by John Wiley & Sons Ltd on behalf of British Psychological Society.)

Background: Sex-specific outcomes after catheter ablation (CA) for atrial fibrillation (AF) have reported conflicting findings., Objective: We examined the impact of female sex on outcomes in patients with persistent AF (PsAF) from the Catheter Ablation for Persistent Atrial Fibrillation: A Multicentre Randomized Trial of Pulmonary Vein Isolation vs PVI with Posterior Left Atrial Wall Isolation (CAPLA) randomized trial., Methods: A total of 338 patients with PsAF were randomized to pulmonary vein isolation (PVI) or PVI with posterior wall isolation (PWI). The primary outcome was arrhythmia recurrence at 12 months. Clinical and electroanatomical characteristics, arrhythmia recurrence, and quality of life were compared between women and men., Results: Seventy-nine women (23.4%; PVI 37; PVI + PWI 42) and 259 men (76.6%; PVI 131; PVI + PWI 128) underwent AF ablation. Women were older {median age 70.4 (interquartile range [IQR] 64.8-74.6) years vs 64.0 (IQR 56.7-69.7) years; P < .001} and had more advanced left atrial electroanatomical remodeling. At 12 months, arrhythmia-free survival was lower in women (44.3% vs 56.8% in men; hazard ratio 1.44; 95% confidence interval 1.02-2.04; log-rank, P = .036). PWI did not improve arrhythmia-free survival at 12 months (hazard ratio 1.02; 95% confidence interval 0.74-1.40; log-rank, P = .711). The median AF burden was 0% in both groups (women: IQR 0.0%-2.2% vs men: IQR 0.0%-2.8%; P = .804). Health care utilization was comparable between women (36.7%) and men (30.1%) (P = .241); however, women were more likely to undergo a repeat procedure (17.7% vs 6.9%; P = .007). Women reported more severe baseline anxiety (average Hospital Anxiety and Depression Scale [HADS] anxiety score 7.5 ± 4.9 vs 6.3 ± 4.3 in men; P = .035) and AF-related symptoms (baseline Atrial Fibrillation Effect on Quality-of-Life Questionnaire [AFEQT] score 46.7 ± 20.7 vs 55.9 ± 23.0 in men; P = .002), with comparable improvements in psychological symptoms (change in HADS anxiety score -3.8 ± 4.6 vs -3.0 ± 4.5; P = .152 (change in HADS depression score -2.9 ± 5.0 vs -2.6 ± 4.0; P = .542) and greater improvement in AFEQT score compared with men at 12 months (change in AFEQT score +45.9 ± 23.1 vs +39.2 ± 24.8; P = .048)., Conclusion: Women undergoing CA for PsAF report more significant symptoms and poorer quality of life at baseline than men. Despite higher arrhythmia recurrence and repeat procedures in women, the AF burden was comparably low, resulting in significant improvements in quality of life and psychological well-being after CA in both sexes., Competing Interests: Disclosures The following industry funding sources regarding activities outside the submitted work have been declared in accordance with the ICMJE guidelines. Dr Segan has received a combined National Heart Foundation/National Health and Medical Research Council (NHMRC) PhD scholarship. Dr Kistler is a recipient of the investigator grant from the NHMRC and has received funding from Abbott Medical for consultancy and speaking engagements and has served on the advisory board with fellowship support from Biosense Webster. Dr Kalman has received fellowship support from Medtronic and Biosense Webster. Dr Sanders has served on the advisory board of Medtronic, Abbott Medical, Boston Scientific, CathRx, and PaceMate and has received funding for research and consultancy from Medtronic, Abbott Medical, Boston Scientific, and MicroPort. Dr Lee has received consulting fees from Biosense Webster. Dr Sterns has received consulting fees from Biosense Webster. Dr Ginks has received funding for speaking engagements from Abbott and Biosense Webster. Dr Prabhu has received fellowship and training support from the National Heart Foundation, Abbott Medical, and Boston Scientific. He has also received speaker fees and advisory fees from Abbott Medical and Biosense Webster. The remaining authors have nothing to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

This study explored the interactions among prenatal stress, child sex, and polygenic risk scores (PGS) for attention-deficit/hyperactivity disorder (ADHD) on structural developmental changes of brain regions implicated in ADHD. We used data from two population-based birth cohorts: Growing Up in Singapore Towards healthy Outcomes (GUSTO) from Singapore (n = 113) and Generation R from Rotterdam, the Netherlands (n = 433). Prenatal stress was assessed using questionnaires. We obtained latent constructs of prenatal adversity and prenatal mood problems using confirmatory factor analyses. The participants were genotyped using genome-wide single nucleotide polymorphism arrays, and ADHD PGSs were computed. Magnetic resonance imaging scans were acquired at 4.5 and 6 years (GUSTO), and at 10 and 14 years (Generation R). We estimated the age-related rate of change for brain outcomes related to ADHD and performed (1) prenatal stress by sex interaction models, (2) prenatal stress by ADHD PGS interaction models, and (3) 3-way interaction models, including prenatal stress, sex, and ADHD PGS. We observed an interaction between prenatal stress and ADHD PGS on mean cortical thickness annual rate of change in Generation R (i.e., in individuals with higher ADHD PGS, higher prenatal stress was associated with a lower rate of cortical thinning, whereas in individuals with lower ADHD PGS, higher prenatal stress was associated with a higher rate of cortical thinning). None of the other tested interactions were statistically significant. Higher prenatal stress may promote a slower brain developmental rate during adolescence in individuals with higher ADHD genetic vulnerability, whereas it may promote a faster brain developmental rate in individuals with lower ADHD genetic vulnerability., (© 2024 The Authors. Developmental Psychobiology published by Wiley Periodicals LLC.)

Importance: Catheter ablation for patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) is associated with improved left ventricular ejection fraction (LVEF) and survival compared with medical therapy. Nonrandomized studies have reported improved success with posterior wall isolation (PWI)., Objective: To determine the impact of pulmonary vein isolation (PVI) with PWI vs PVI alone on outcomes in patients with HFrEF., Design, Setting, and Participants: This was an ad hoc secondary analysis of the CAPLA trial, a multicenter, prospective, randomized control trial that involved 11 centers in 3 countries (Australia, Canada, and UK). CAPLA featured 338 patients with persistent AF randomized to either PVI plusPWI or PVI alone. This substudy included patients in the original CAPLA study who had symptomatic HFrEF (LVEF <50% and New York Heart Association class ≥II)., Interventions: Pulmonary vein isolation with PWI vs PVI alone., Main Outcomes and Measures: The primary end point was freedom from any documented atrial arrhythmia greater than 30 seconds, after a single ablation procedure, without the use of antiarrhythmic drug (AAD) therapy at 12 months., Results: A total of 98 patients with persistent AF and symptomatic HFrEF were identified (mean [SD] age, 62.1 [9.8] years; 79.5% men; and mean [SD] LVEF at baseline, 34.6% [7.9%]). After 12 months, 58.7% of patients with PVI plus PWI were free from recurrent atrial arrhythmia without the use of AAD therapy vs 61.5% with PVI alone (hazard ratio, 1.02; 95% CI, 0.54-1.91; P = .96). There were no significant differences in freedom from atrial arrhythmia with or without AAD therapy after multiple procedures (PVI plus PWI vs PVI alone, 60.9% vs 65.4%; P = .73) or AF burden (median, 0% in both groups; P = .78). Mean LVEF improved substantially in PVI plus PWI (∆ LVEF, 19.3% [13.0%; P < .01) and PVI alone (18.2% [14.1%; P < .01), with no difference between groups (P = .71). Normalization of LV function occurred in 65.2% of patients in the PVI plus PWI group and 50.0% of patients with PVI alone (P = .13)., Conclusions and Relevance: The results of this study indicate that addition of PWI to PVI did not improve freedom from arrhythmia recurrence or recovery of LVEF in patients with persistent AF and symptomatic HFrEF. Catheter ablation was associated with significant improvements in systolic function, irrespective of ablation strategy used. These results caution against the routine inclusion of PWI in patients with HFrEF undergoing first-time catheter ablation for persistent AF., Trial Registration: http://anzctr.org.au Identifier: ACTRN12616001436460.

Importance: Adverse life experiences have been proposed to contribute to diverse mental health problems through an association with corticolimbic functioning. Despite compelling evidence from animal models, findings from studies in humans have been mixed; activation likelihood estimation (ALE) meta-analyses have failed to identify a consistent association of adverse events with brain function., Objective: To investigate the association of adversity exposure with altered brain reactivity using multilevel kernel density analyses (MKDA), a meta-analytic approach considered more robust than ALE to small sample sizes and methodological differences between studies., Data Sources: Searches were conducted using PsycInfo, Medline, EMBASE, and Web of Science from inception through May 4, 2022. The following search term combinations were used for each database: trauma, posttraumatic stress disorder (PTSD), abuse, maltreatment, poverty, adversity, or stress; and functional magnetic resonance imaging (fMRI) or neuroimaging; and emotion, emotion regulation, memory, memory processing, inhibitory control, executive functioning, reward, or reward processing., Study Selection: Task-based fMRI studies within 4 domains (emotion processing, memory processing, inhibitory control, and reward processing) that included a measure of adverse life experiences and whole-brain coordinate results reported in Talairach or Montreal Neurological Institute space were included. Conference abstracts, books, reviews, meta-analyses, opinions, animal studies, articles not in English, and studies with fewer than 5 participants were excluded., Data Extraction and Synthesis: Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guideline, 2 independent reviewers assessed abstracts and full-text articles for entry criteria. A third reviewer resolved conflicts and errors in data extraction. Data were pooled using a random-effects model and data analysis occurred from August to November 2022., Main Outcomes and Measures: Peak activation x-axis (left-right), y-axis (posterior-anterior), and z-axis (inferior-superior) coordinates were extracted from all studies and submitted to MKDA meta-analyses., Results: A total of 83 fMRI studies were included in the meta-analysis, yielding a combined sample of 5242 participants and 801 coordinates. Adversity exposure was associated with higher amygdala reactivity (familywise error rate corrected at P < .001; x-axis = 22; y-axis = -4; z-axis = -17) and lower prefrontal cortical reactivity (familywise error rate corrected at P < .001; x-axis = 10; y-axis = 60; z-axis = 10) across a range of task domains. These altered responses were only observed in studies that used adult participants and were clearest among those who had been exposed to severe threat and trauma., Conclusions and Relevance: In this meta-analysis of fMRI studies of adversity exposure and brain function, prior adversity exposure was associated with altered adult brain reactivity to diverse challenges. These results might better identify how adversity diminishes the ability to cope with later stressors and produces enduring susceptibility to mental health problems.

Background: Pulmonary vein isolation (PVI) is less effective in patients with persistent atrial fibrillation (PsAF). Adjunctive ablation targeting low voltage areas (LVAs) may improve arrhythmia outcomes., Objectives: This study aims to compare the outcomes of adding posterior wall isolation (PWI) to PVI, vs PVI alone in PsAF patients with posterior wall LVAs., Methods: The CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) study was a multicenter, randomized trial involving PsAF patients randomized 1:1 to either PVI alone or PVI with PWI. Voltage mapping performed during pacing pre-ablation was reviewed offline, with LVA defined as bipolar voltage of <0.5 mV. The primary endpoint was freedom from any documented atrial arrhythmia of >30 seconds off antiarrhythmic medication at 12 months after a single ablation procedure in patients with posterior LVA., Results: A total of 210 patients (average 64.6 ± 9.2 years,73.3% males, median atrial fibrillation duration 4.5 months [IQR: 2 to 8 months]) underwent multipolar left atrial mapping during coronary sinus pacing with posterior LVA present in 69 (32.9%). Patients with posterior LVA were more likely to have LVA in other atrial regions (91.7% vs 57.1%; P < 0.01), larger left atrial diameter (4.8 cm vs 4.4 cm; P < 0.01), and significantly increased risk of atrial arrhythmia recurrence at 12 months (LVA: 56.5% vs no LVA: 41.4%; HR: 1.51; 95% CI: 1.01-2.27; P = 0.04) compared to no posterior LVA. However, the addition of PWI to PVI did not significantly improve freedom from atrial arrhythmia recurrence over PVI alone (PVI with PWI: 44.8% vs PVI: 41.9%; HR: 0.95; 95% CI: 0.51-1.79; P = 0.95)., Conclusions: In patients with PsAF undergoing catheter ablation, posterior LVA was associated with a significant increase in atrial arrhythmia recurrence. However, the addition of PWI in those with posterior LVA did not reduce atrial arrhythmia recurrence over PVI alone., Competing Interests: Funding and Author Disclosures This study received seed grant funding from the Baker department of Cardiometabolic Health, University of Melbourne. Dr Lee has received consulting fees from Biosense Webster. Dr Sanders has served on advisory boards for Medtronic, Abbott Medical, Boston Scientific, CathRx, and PaceMate; and has received funding for research and consultancy from Medtronic, Abbott Medical, Boston Scientific, and Microport. Dr Kalman has received fellowship support from Medtronic and Biosense Webster. Dr Kistler has received the investigator grant from the NHMRC; has received funding from Abbott Medical for consultancy and speaking engagements; and has served on the advisory board with fellowship support from Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

According to recent accounts, bilingualism in childhood confers an advantage in a specific domain of executive functioning termed attentional disengagement. The current study tested this hypothesis in 492 children (245 boys; M age  = 10.98 years) from Canada, China, and Lebanon by testing for an association between language status and measures of attentional disengagement. Across the entire sample, monolinguals responded more quickly and accurately than bilinguals on a measure of attentional disengagement but differed in age, socioeconomic status, and general cognitive ability. Differences between monolinguals and bilinguals disappeared when the influence of these confounding variables was controlled using a matched samples analysis (ns = 105). Bayesian analyses further confirmed that the evidence was more likely under the null hypothesis than under the alternative hypothesis. In sum, there was little evidence of an association between language status and attentional disengagement in children., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Catheter ablation is an effective strategy in atrial fibrillation (AF). However, its timing in the course of management remains unclear. The aim of this study was to determine if an early vs. delayed AF ablation strategy is associated with differences in arrhythmia outcomes during 12-month follow-up., Methods and Results: One hundred patients with symptomatic AF referred to a tertiary centre for management were randomized in a 1:1 ratio to either an early ablation strategy (within 1 month of recruitment) or a delayed ablation strategy (optimized medical therapy followed by catheter ablation at 12 months post recruitment). The primary endpoint was atrial arrhythmia free survival at 12 months post-ablation. Secondary outcomes included: (i) AF burden, (ii) AF burden by AF phenotype, and (iii) antiarrhythmic drug (AAD) use at 12 months. Overall, 89 patients completed the study protocol (Early vs. Delayed: 48 vs. 41). Mean age was 59 ± 12.9 years (29% women). Pulmonary vein isolation was achieved in 100% of patients. At 12 months, 56.3% of patients in the early ablation group were free from recurrent arrhythmia, compared with 58.6% in the delayed ablation group (HR 1.12, 95% CI 0.59-2.13, P = 0.7). All secondary outcomes showed no significant difference including median AF burden (Early vs. Delayed: 0% [IQR 3.2] vs. 0% [5], P = 0.66), median AF burden amongst paroxysmal AF patients (0% [IQR 1.1] vs. 0% [4.5], P = 0.78), or persistent AF patients (0% [IQR 22.8] vs. 0% [5.6], P = 0.45) or AAD use (33% vs. 37%, P = 0.8)., Conclusion: Compared with an early ablation strategy, delaying AF ablation by 12 months for AAD management did not result in reduced ablation efficacy., Competing Interests: Conflict of interest All authors declare no conflict of interest for this contribution., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Patients with heart failure with preserved ejection fraction (HFpEF) frequently develop atrial fibrillation (AF). There are no randomized trials examining the effects of AF ablation on HFpEF outcomes., Objectives: The aim of this study is to compare the effects of AF ablation vs usual medical therapy on markers of HFpEF severity, including exercise hemodynamics, natriuretic peptide levels, and patient symptoms., Methods: Patients with concomitant AF and HFpEF underwent exercise right heart catheterization and cardiopulmonary exercise testing. HFpEF was confirmed with pulmonary capillary wedge pressure (PCWP) of 15 mm Hg at rest or ≥25 mm Hg on exercise. Patients were randomized to AF ablation vs medical therapy, with investigations repeated at 6 months. The primary outcome was change in peak exercise PCWP on follow-up., Results: A total of 31 patients (mean age: 66.1 years; 51.6% females, 80.6% persistent AF) were randomized to AF ablation (n = 16) vs medical therapy (n = 15). Baseline characteristics were comparable across both groups. At 6 months, ablation reduced the primary outcome of peak PCWP from baseline (30.4 ± 4.2 to 25.4 ± 4.5 mm Hg; P < 0.01). Improvements were also seen in peak relative VO 2 (20.2 ± 5.9 to 23.1 ± 7.2 mL/kg/min; P < 0.01), N-terminal pro-B-type natriuretic peptide levels (794 ± 698 to 141 ± 60 ng/L; P = 0.04), and MLHF (Minnesota Living with Heart Failure) score (51 ± -21.9 to 16.6 ± 17.5; P < 0.01). No differences were detected in the medical arm. Following ablation, 50% no longer met exercise right heart catheterization-based criteria for HFpEF vs 7% in the medical arm (P = 0.02)., Conclusions: AF ablation improves invasive exercise hemodynamic parameters, exercise capacity, and quality of life in patients with concomitant AF and HFpEF., Competing Interests: Funding Support and Author Disclosures Dr Chieng is supported by co-funded NHMRC/NHF post-graduate scholarship. Dr Prabhu has received an NHMRC Post-Doctoral Research Fellowship. Dr Voskoboinik has received a National Heart Foundation Early Career Fellowship. Dr Lee has received consulting fees from Biosense Webster. Dr Kistler has received funding from Abbott Medical for consultancy and speaking engagements; and has served on the advisory board with fellowship support from Biosense Webster. Dr Kalman has received fellowship support from Medtronic and Biosense Webster. Dr Kaye has received an NHMRC Investigator Grant. Dr Ling has received funding from Abbott Medical for project funding, consultancy, and speaking engagements; and has received funding from Abbott Medical for project funding, consultancy, and speaking engagements. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Brain entropy is a measure of the complexity of brain activity that has been linked to various cognitive abilities. The measure is based on Shannon Entropy, a measure from Information Theory that quantifies the information capacity of a system from the probability distribution of its states. Most fMRI studies measure brain entropy at the voxel level as time-series entropy and assume that entropic time-series indicate complex large-scale spatiotemporal patterns of activity., New Method: We developed a novel measure of brain entropy called Activity-State Entropy. The method quantifies entropy based on underlying patterns of coactivation identified using Principal Components Analysis. These patterns, termed eigenactivity states, combine in time-varying proportions., Results: We showed that Activity-State Entropy is sensitive to the complexity of the spatiotemporal patterns of activity in simulated fMRI data. We then applied this measure to real resting-state fMRI data and found that the eigenactivity states that explained the most variance in the data were comprised of large clusters of coactivating voxels, including clusters within Default Mode Network regions. More entropic brains were increasingly influenced by eigenactivity states comprised of smaller and more sparsely distributed clusters., Comparison to Existing Methods: We compared Activity-State Entropy to Sample Entropy and Dispersion Entropy, two time-series entropy measures commonly used in neuroimaging research, and found all three measures were positively correlated., Conclusions: Activity-State Entropy provides a measure of the spatiotemporal complexity of brain activity that complements time-series based measures of brain entropy., Competing Interests: Declaration of Competing Interest The authors declare no competing interests., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Although it is well known that children of East Asian immigrants show higher academic achievement than native-born North American children, the social-cognitive determinants of this difference remain poorly understood. Given the importance of executive functions (EF) for academic achievement, and evidence that EF develops more quickly in East Asian compared to North American cultures, it is conceivable that differences in academic achievement might be rooted in EF differences between these groups. We examine this possibility by reviewing evidence of cross-cultural differences in EF development but find core concepts and findings limited in several key respects. To address these limitations, we propose a framework for relating EF, culture, and academic achievement that draws on new theoretical ideas about the nature of EF and its relation to social context. We conclude by discussing avenues for future research on the relations between culture, executive functions, and academic achievement., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Cho, Hosseini-Kamkar, Song and Morton.)

The well-defined concept of aberrant ventricular conduction was introduced over 100 years ago and, despite advances in cardiac physiology and electrophysiologic testing, it is still widely misunderstood. Aberrant ventricular conduction is due to physiologic refractoriness of the His-Purkinje system and in most cases does not reflect underlying conduction system disease. Electrophysiologically, aberrant ventricular conduction can manifest with premature atrial ectopics, the Ashman phenomenon with atrial tachyarrhythmias, concealed conduction, echo beats and with the sinus mechanism including rate dependent bundle branch block, bradycardia dependent bundle branch block and early sinus beats. It is important to recognise aberrant ventricular conduction in the context of a broad complex tachycardia, as the differentiation between supraventricular tachyarrhythmias with aberrant ventricular conduction and ventricular tachyarrhythmias carry different therapeutic and prognostic implications. This review will define the ECG footprints of aberrant ventricular conduction to allow accurate ECG interpretation., Competing Interests: Conflicts of Interest None., (Crown Copyright © 2023. Published by Elsevier B.V. All rights reserved.)

BrainTagger (demo version: researcher-demo.braintagger.com) is a suite of Target Acquisition Games for Measurement and Evaluation (TAG-ME). Here we introduce TAG-ME Again, a serious game modeled after the well-established N-Back task, to assess working memory ability across three difficulty levels corresponding to 1-, 2-, and 3-back conditions. We also report on two experiments aimed at assessing convergent validity with the N-Back task. Experiment 1 examined correlations with N-Back task performance in a sample of adults ( n  = 31, 18-54 years old) across three measures: reaction time; accuracy; a combined RT/accuracy metric. Significant correlations between game and task were found, with the strongest relationship being for the most difficult version of the task (3-Back). In Experiment 2 ( n  = 66 university students, 18-22 years old), we minimized differences between the task and the game by equating stimulus-response mappings and spatial processing demands. Significant correlations were found between game and task for both the 2-Back and 3-Back levels. We conclude that TAG-ME Again is a gamified task that has convergent validity with the N-Back Task.

Importance: Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison., Objective: To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation., Design, Setting, and Participants: Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022., Interventions: The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone., Main Outcomes and Measures: Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications., Results: Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone., Conclusions and Relevance: In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF., Trial Registration: anzctr.org.au Identifier: ACTRN12616001436460.

Aims: Epidemiological studies report the beneficial effects of habitual coffee consumption on incident arrhythmia, cardiovascular disease (CVD), and mortality. However, the impact of different coffee preparations on cardiovascular outcomes and survival is largely unknown. The aim of this study was to evaluate associations between coffee subtypes on incident outcomes, utilizing the UK Biobank., Methods and Results: Coffee subtypes were defined as decaffeinated, ground, and instant, then divided into 0, <1, 1, 2-3, 4-5, and >5 cups/day, and compared with non-drinkers. Cardiovascular disease included coronary heart disease, cardiac failure, and ischaemic stroke. Cox regression modelling with hazard ratios (HRs) assessed associations with incident arrhythmia, CVD, and mortality. Outcomes were determined through ICD codes and death records. A total of 449 563 participants (median 58 years, 55.3% females) were followed over 12.5 ± 0.7 years. Ground and instant coffee consumption was associated with a significant reduction in arrhythmia at 1-5 cups/day but not for decaffeinated coffee. The lowest risk was 4-5 cups/day for ground coffee [HR 0.83, confidence interval (CI) 0.76-0.91, P < 0.0001] and 2-3 cups/day for instant coffee (HR 0.88, CI 0.85-0.92, P < 0.0001). All coffee subtypes were associated with a reduction in incident CVD (the lowest risk was 2-3 cups/day for decaffeinated, P = 0.0093; ground, P < 0.0001; and instant coffee, P < 0.0001) vs. non-drinkers. All-cause mortality was significantly reduced for all coffee subtypes, with the greatest risk reduction seen with 2-3 cups/day for decaffeinated (HR 0.86, CI 0.81-0.91, P < 0.0001); ground (HR 0.73, CI 0.69-0.78, P < 0.0001); and instant coffee (HR 0.89, CI 0.86-0.93, P < 0.0001)., Conclusion: Decaffeinated, ground, and instant coffee, particularly at 2-3 cups/day, were associated with significant reductions in incident CVD and mortality. Ground and instant but not decaffeinated coffee was associated with reduced arrhythmia., Competing Interests: Conflict of interest: D.C. is supported by cofunded NHMRC/NHF post-graduate scholarship. The following industry funding sources regarding activities outside the submitted work have been declared in accordance with ICMJE guidelines. P.M.K. has received funding from Abbott Medical for consultancy and speaking engagements and fellowship support from Biosense Webster. J.M.K. holds a Practitioner Fellowship of the NHMRC and has research and fellowship support from Medtronic, Abbott, and Biosense Webster. D.M.K. is the recipient of an NHMRC Research Fellowship. S.P. has an NHMRC Post-Doctoral Research Fellowship. A.V. has a National Heart Foundation Early Career Fellowship. The remaining authors have nothing to disclose., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Adapting attention flexibly is a fundamental ability of the human control system. In the color-word Stroop task, for example, congruency effects are typically smaller for colors and words that appear mainly in incongruent stimuli (mostly-incongruent items) than for colors and words that appear mainly in congruent stimuli (mostly-congruent items). At least part of this item-specific proportion-congruent (ISPC) effect is due to a process of reactive conflict adaptation that affords higher selectivity (i.e., more efficient selection of task-relevant information) when a specific stimulus is presented that is frequently associated in the experiment with conflicting task-irrelevant information. What is unclear, however, is whether, normally, this stimulus-specific adaptation is triggered by the task-relevant component, the task-irrelevant component, or both components of the stimulus. In two experiments, using modified color-word (Experiment 1) and spatial (Experiment 2) Stroop tasks that allowed task-relevant and task-irrelevant triggering processes to be dissociated, we found that the two processes have approximately equivalent impacts. Because these results were obtained in experiments imposing no limitations on the processes potentially contributing to the ISPC effect, these results challenge claims that the ISPC effect involves conflict-adaptation processes only in special situations. The ISPC effect may involve conflict-adaptation processes in most situations, with both task-relevant and task-irrelevant information triggering such processes., (© 2022. The Author(s).)

Introduction: Infantile hydrocephalus (HCP) is a condition in which there is an abnormal buildup of cerebrospinal fluid in the ventricles within the first few months of life, which puts pressure on surrounding brain tissues. Compression of the developing brain increases the risk of secondary brain injury and cognitive disabilities. Methods: In this study, we used diffusion-weighted imaging and resting-state functional magnetic resonance imaging to investigate the effects of ventricle dilatation on structural and functional brain networks in children with shunted infantile HCP and examined how these brain changes may impact executive function. Results: We found that children with HCP have altered structural and functional connectivity between and within large-scale networks. Moreover, hyperconnectivity between the ventral attention and default mode network in children with HCP correlated with reduced executive function scores. Compared with typically developing age-matched control participants, our patient population also had lower fractional anisotropy in posterior white matter. Discussion: Overall, these findings suggest that infantile HCP has long-term effects on brain network connectivity, white matter development, and executive function in children at school age. Future work will examine the relationship between ventricular volumes before shunt placement in infancy and brain network development throughout childhood.

Background: Mitral valve prolapse (MVP) is relatively common condition and while generally benign a small subset of patient suffers from malignant ventricular arrhythmias (MVA) and sudden cardiac death (SCD)., Method and Material: We report three cases of mitral valve prolapse, mitral regurgitation and malignant ventricular arrhythmias refractory to medical therapy, who had surgical cryoablation at the time of surgery on the mitral valve., Results: During a follow-up period ranging from 3 to 11 years all three patients have remained free of ventricular arrhythmias and cryoablation lesions targeting the base of the papillary muscles have not caused any detrimental effect on the valve function., Conclusion: Surgical cryoablation of papillary muscles as described in this article should be considered in MVP who suffer from MVA, aborted SCD or frequent ventricular ectopics likely to cause LV dysfunction., (Copyright © 2022 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

Background: Observational studies report that obstructive sleep apnea (OSA) is associated with an increasingly remodeled atrial substrate in atrial fibrillation (AF). However, the impact of OSA management on the electrophysiologic substrate has not been evaluated., Objectives: In this study, the authors sought to determine the impact of OSA management on the atrial substrate in AF., Methods: We recruited 24 consecutive patients referred for AF management with at least moderate OSA (apnea-hypopnea index [AHI] ≥15). Participants were randomized in a 1:1 ratio to commence continuous positive airway pressure (CPAP) or no therapy (n = 12 CPAP; n = 12 no CPAP). All participants underwent invasive electrophysiologic study (high-density right atrial mapping) at baseline and after a minimum of 6 months. Outcome variables were atrial voltage (mV), conduction velocity (m/s), atrial surface area <0.5 mV (%), proportion of complex points (%), and atrial effective refractory periods (ms). Change between groups over time was compared., Results: Clinical characteristics and electrophysiologic parameters were similar between groups at baseline. Compliance with CPAP therapy was high (device usage: 79% ± 19%; mean usage/day: 268 ± 91 min) and resulted in significant AHI reduction (mean reduction: 31 ± 23 events/h). There were no differences in blood pressure or body mass index between groups over time. At follow-up, the CPAP group had faster conduction velocity (0.86 ± 0.16 m/s vs 0.69 ± 0.12 m/s; P (time × group) = 0.034), significantly higher voltages (2.30 ± 0.57 mV vs 1.94 ± 0.72 mV; P < 0.05), and lower proportion of complex points (8.87% ± 3.61% vs 11.93% ± 4.94%; P = 0.011) compared with the control group. CPAP therapy also resulted in a trend toward lower proportion of atrial surface area <0.5 mV (1.04% ± 1.41% vs 4.80% ± 5.12%; P = 0.065)., Conclusions: CPAP therapy results in reversal of atrial remodeling in AF and provides mechanistic evidence advocating for management of OSA in AF., Competing Interests: Funding Support and Author Disclosures For this work, Dr Nalliah received the Eric Prystowsky Fellows Clinical Research Award, Heart Rhythm Society, May 2020, and the Ralph Reader Young Investigator Prize of the Cardiac Society of Australia and New Zealand, December 2020; and he is supported also by the National Heart Foundation and a Viertel Charitable Foundation Clinical Investigator Award. Dr Voskoboinik is supported by an NHMRC EL1 Investigator Grant and an NHF Early Career Fellowship. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

According to some accounts, the bilingual advantage is most pronounced in the domain of executive attention rather than inhibition and should therefore be more easily detected in conflict adaptation paradigms than in simple interference paradigms. We tested this idea using two conflict adaptation paradigms, one that elicits a list-wide proportion-congruent effect and one that elicits an item-specific proportion-congruent effect. In both cases, the relevant finding is that congruency effects are reduced when the proportion of congruent to incongruent items is smaller. These effects are validated measures of proactive and reactive control, respectively, and are aspects of executive attention known to be associated with individual differences in working memory capacity. We reasoned that if bilingualism affects executive attention in a similar way as does working memory capacity, indices of proactive and reactive control should be comparably associated with continuous variation in language status and working memory capacity. In two experiments, we replicated previous findings that working memory capacity is associated with variation in congruency effects (suggesting greater reliance on proactive control). In contrast, language status had no consistent association with performance, save for a hint that bilingualism may be associated with greater reliance on reactive control. Thus, the bilingual advantage may exist, but not in proactive control or any other aspects of executive attention that have been proposed thus far. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Background: The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations., Objectives: To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF., Methods: This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure., Conclusions: This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background During the COVID-19 pandemic, millions of children abruptly moved to online schooling, which required high levels of parental involvement. Family routines were disrupted, potentially increasing parental stress, and may be reflected in greater media screen time use in children. Objectives To determine whether (1) parenting styles and (2) parenting stress were associated with children's screen time use during the pandemic compared to the pre-pandemic period. Methods Parents (> 18 years of age) were recruited to complete an online survey regarding changes in their children's (6-12 years) screen time use and daily activities before and during the pandemic. Stress and parental involvement were assessed using the Perceived Stress Scale (PSS) and Alabama Parenting Questionnaires respectively. General linear models assessed whether parenting style and parent stress were associated with children's screen time during the pandemic, adjusting for demographic variables and daily activities. Results 104 parents were enrolled, and 73 (70.2%) parents completed the surveys. Children's screen time ( e.g ., watching television and playing video games) increased significantly, from 2.6 to 5.9h a day ( p   =   .001 ) during pandemic-related school closures. Fewer changes in children's screen time use were significantly associated with greater parental involvement ( p   =   .017 ). Parent stress ( p   =   .018 ) significantly predicted children's screen time use. Lower household income was associated with increased hours of screen time in both models (both, p   <   .05 ). Conclusions: Children's screen time increased significantly during the initial months of the pandemic. Parent stress and parenting styles may be modifiable risk factors to promote children's well-being during the ongoing pandemic., Competing Interests: The authors have no conflicts of interest to declare., (© 2021 The Author(s).)

Bilingual preschoolers from East Asia outperform monolingual preschoolers from North America or Europe in executive functioning tasks, which has been interpreted as evidence of a bilingual advantage in executive functioning. This study tested whether these differences actually reflect country-of-origin effects given that East Asian preschoolers frequently outperform North American or European children in executive functioning tasks. Consistent with previous findings, Korean-English bilingual preschoolers made fewer errors in an age-appropriate executive functioning task than did English monolingual children in Canada. However, Korean-English bilingual preschoolers performed comparably to Korean monolingual preschoolers in Korea. Differences between Korean and Canadian children's executive functioning were not attributable to differences in parental cultural values or attitudes. The current findings suggest that differences between East Asian bilingual and North American monolingual preschoolers' executive functioning is related to differences in country of origin rather than language status., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Although there is an abundance of evidence linking the function of the hypothalamic-pituitary-adrenal (HPA) axis to adverse early-life experiences, the precise nature of the association remains unclear. Some evidence suggests early-life adversity leads to cortisol hyper-reactivity, while other evidence suggests adversity leads to cortisol hypo-reactivity. Here, we distinguish between trauma and adversity, and use p-curves to interrogate the conflicting literature. In Study 1, trauma was operationalized according to DSM-5 criteria; the p-curve analysis included 68 articles and revealed that the literature reporting associations between trauma and blunted cortisol reactivity contains evidential value. Study 2 examined the relationship between adversity and cortisol reactivity. Thirty articles were included in the analysis, and p-curve demonstrated that adversity is related to heightened cortisol reactivity. These results support an inverted U-shaped function relating severity of adversity and cortisol reactivity, and underscore the importance of distinguishing between "trauma" and "adversity"., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Background: Catheter ablation is highly effective for atrioventricular nodal re-entrant tachycardia (AVNRT). Generally junctional rhythm (JR) is an accepted requirement for successful ablation however there is a lack of detailed prospective studies to determine the characteristics of JR and the impact on slow pathway conduction., Methods: Multicentre prospective observational study evaluating the impact of individual radiofrequency (RF) applications in typical AVNRT (slow/fast). Characteristics of JR during ablation were documented and detailed testing was performed after every RF application to determine outcome. Procedural success was defined as ≤1 AV nodal echo., Results: Sixty-seven patients were included (mean age 53 ± 18years, 57% female and a history of SVT 2.9 ± 4.7 years). RF (50w, 60°) ablation for AVNRT was applied in 301 locations with JR in 178 (59%). Successful slow pathway modification was achieved in 66 (99%) patients with slow pathway block in 30 (46%). Success was associated with JR in all patients. Success was achieved in six patients with RF < 10 s. There was no significant difference in the CL of JR during RF between effective (587 ± 150 ms) versus ineffective (611 ± 193 ms, p = .4) applications. Inadvertent junctional beat-atrial (JA) block with immediate termination of RF was observed in 19 (28%) patients with AVNRT no longer inducible in 14 (74%). Freedom from SVT was achieved in 66 (99%) patients at a mean follow up of 15 ± 6 months., Conclusion: In this prospective study, JR was required during RF for acute success in AVNRT. Cycle length of JR during RF was not predictive of success. Although unintended JA block during faster JR was associated with slow pathway block, this is a precursor to fast pathway block and should not be intentionally targeted., (© 2021 Wiley Periodicals LLC.)

There is considerable debate about whether bilingual children have an advantage in executive functioning relative to monolingual children. In the current meta-analysis, we addressed this debate by comprehensively reviewing the available evidence. We synthesized data from published studies and unpublished data sets, which equated to 1,194 effect sizes from 10,937 bilingual and 12,477 monolingual participants between the ages of 3 and 17 years. Bilingual language status had a small overall effect on children's executive functioning ( g = .08, 95% confidence interval = [.01, .14]). However, the effect of language status on children's executive functioning was indistinguishable from zero ( g = -.04) after we adjusted for publication bias. Further, no significant effects were apparent within the executive-attention domain, in which the effects of language status have been hypothesized to be most pronounced ( g = .06, 95% confidence interval = [-.02, .14]). Taken together, available evidence suggests that the bilingual advantage in children's executive functioning is small, variable, and potentially not attributable to the effect of language status.

Aims: Obstructive sleep apnoea (OSA) associates with atrial fibrillation (AF), but the relationship of OSA severity and AF phenotype with the atrial substrate remains poorly defined. We sought to define the atrial substrate across the spectrum of OSA severity utilizing high-density mapping., Methods and Results: Sixty-six consecutive patients (male 71%, age 61 ± 9) having AF ablation (paroxysmal AF 36, persistent AF 30) were recruited. All patents underwent formal overnight polysomnography and high-density left atrial (LA) mapping (mean 2351 ± 1244 points) in paced rhythm. Apnoea-hypopnoea index (AHI) (mean 21 ± 18) associated with lower voltage (-0.34, P = 0.005), increased complex points (r = 0.43, P < 0.001), more low-voltage areas (r = 0.42, P < 0.001), and greater voltage heterogeneity (r = 0.39, P = 0.001), and persisted after multivariable adjustment. Atrial conduction heterogeneity (r = 0.24, P = 0.025) but not conduction velocity (r = -0.09, P = 0.50) associated with AHI. Patchy regions of low voltage that co-localized with slowed conduction defined the atrial substrate in paroxysmal AF, while a diffuse atrial substrate predominated in persistent AF. The association of AHI with remodelling was most apparent among paroxysmal AF [LA voltage: paroxysmal AF -0.015 (-0.025, -0.005), P = 0.004 vs. persistent AF -0.006 (-0.017, 0.005), P = 0.30]. Furthermore, in paroxysmal AF an AHI ≥ 30 defined a threshold at which atrial remodelling became most evident (nil-mild vs. moderate vs. severe: 1.92 ± 0.42 mV vs. 1.84 ± 0.28 mV vs. 1.34 ± 0.41 mV, P = 0.006). In contrast, significant remodelling was observed across all OSA categories in persistent AF (1.67 ± 0.55 mV vs. 1.50 ± 0.66 mV vs. 1.55 ± 0.67 mV, P = 0.82)., Conclusion: High-density mapping observed that OSA associates with marked atrial remodelling, predominantly among paroxysmal AF cohorts with severe OSA. This may facilitate the identification of AF patients that stand to derive the greatest benefit from OSA management., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2021. For permissions, please email: journals.permissions@oup.com.)

Aims: Prior studies have described a variety of mechanisms for atrial fibrillation (AF) originating in the right atrium (RA). In this study, we report a series of patients in whom an extensive right atrial free wall low-voltage zone (LVZ) served as the AF substrate., Methods and Results: Five patients with a clinical syndrome of paroxysmal AF and atrial tachycardia (AT) underwent electrophysiologic evaluation. Five patients (3 M; age 52 ± 7 years) had symptomatic paroxysmal AF for (28 ± 17 months) not responsive to medical therapy. At the initial EP study, AT was inducible in four patients and was spontaneous in one patient. In all patients, tachycardia instability precluded detailed AT mapping. Sinus or pace maps indicated an extensive LVZ in the lateral RA trabeculated free wall which consisted of regions of low amplitude complex signals interspersed between electrically silent areas. Radiofrequency ablation aimed at rendering the LVZ electrical inert was successful in eliminating AF in four of five patients. At a follow-up of 28 ± 15 months, one patient had an isolated recurrence of AF. However, two patients required repeat ablation for recurrent AT., Conclusion: An extensive LVZ in the trabeculated RA free wall constitutes an unusual substrate for AF. These patients also demonstrate unstable ATs originating from the same zone. Radiofrequency ablation to render the low-voltage zone electrically inert is an effective strategy to manage AF and AT., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Objectives: This study evaluated if modifying electrocardiographic (ECG) precordial leads to a higher intercostal position improved the accuracy of outflow tract ventricular arrhythmia (OTVA) localization., Background: Precordial ECG prediction algorithms that use a standard lead configuration localize OTVA with variable accuracy., Methods: Patients who underwent OTVA ablation were prospectively enrolled to have a standard and modified (high) precordial ECG. R- and S-wave amplitudes and intervals were measured to develop an algorithm that differentiated the right ventricular outflow tract (RVOT) and the left ventricular outflow tract (LVOT) with high accuracy-the modified lead R-wave deflection interval (RWDI). This interval was defined from the earliest QRS onset (using all modified leads) to the lead with longest R-wave deflection. The RWDI was compared with all other ECG algorithms., Results: A total of 50 patients (38 women; mean age 51 ± 17 years) had successful catheter ablation for OTVA (RVOT 60%, LVOT 40%). The modified lead RWDI was significantly shorter in the RVOT group (18.5 ms, interquartile range 25th to 75th percentile [IQR 25-75 ]: 0 to 29.5 ms) compared with the LVOT group (67.5 ms, IQR 25-75 : 56.5 to 77 ms; p < 0.05). Using a RWDI ≤40 ms to predict an RVOT focus, the sensitivity and specificity of the modified lead RWDI were 100% and 95%, respectively; the area under the receiver-operating characteristic curve was 0.96. This was superior to all previously developed algorithms. In a computed tomography analysis (n = 50), the modified leads were significantly closer to the outflow tracts compared with the standard precordial leads., Conclusions: The modified lead RWDI is a simple, easily interpretable algorithm that can potentially differentiate a right- or left-sided origin of OTVA with high accuracy., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Baloxavir marboxil (formerly S-033188) is a prodrug of baloxavir acid (S-033447) and inhibits cap-dependent endonuclease, an essential protein involved in the initiation of viral transcription by cleaving capped mRNA bound to PB2. Its adverse event profile is comparable to oseltamivir but is still vulnerable to resistance. The single-dose baloxavir marboxil is an appealing antiviral regimen for the treatment of influenza among outpatients when compared with longer, twice-daily regimens of oral and inhaled neuraminidase inhibitors. This review focuses on the mode of action, antiviral activity, pharmacokinetics, clinical indications, and safety profiles of this drug. Considerations for formulary addition and its place in therapy are also discussed., (© The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Background: Multipolar catheters provide high-density mapping which may reduce the procedural duration and improve the success of catheter ablation (CA) for focal arrhythmias. The high-density grid (HDG) catheter is a 16 electrode mapping catheter with bipole recordings at orthogonal splines. The aim of this study is to compare the clinical and procedural features from a cohort who underwent CA for focal arrhythmias using multipolar mapping (MPM) with age and case-matched cohort using point-by-point (PbyP) mapping., Methods: Consecutive patients undergoing CA for focal arrhythmias between October 2018 and January 2020 guided by MPM were compared with PbyP mapping with the ablation catheter over a similar period. Demographics, procedural features, and outcomes were compared., Results: A total of 54 patients (27 in MPM vs. 27 in PbyP mapping) underwent CA for 68 focal arrhythmias (26 atrial and 42 ventricular). In the MPM group, the electrogram at the successful site was significantly earlier (39 ± 11 ms) than in the PbyP group (33 ± 7 ms; p = .02). In the MPM group, the mapping time (35 ± 24 vs. 53 ± 31 min in PbyP; p = .03) and procedural duration (126 ± 42 vs. 153 ± 39 min in PbyP; p = .02) were significantly shorter. There was no significant difference in radiofrequency and fluoroscopy times, acute procedural success, and arrhythmia recurrence., Conclusion: MPM with the HDG catheter for focal tachycardias identified earlier activation times and was associated with shorter mapping and procedure duration with equivalent success to PbyP mapping., (© 2020 Wiley Periodicals LLC.)

Background: Female gender is associated with an increased recurrence of atrial fibrillation (AF) after catheter ablation (CA). Although AF is more common in men, women constitute a significant proportion with persistent atrial fibrillation (PsAF)., Objective: The purpose of this study was to determine whether multiple ablation procedures improves arrhythmia outcomes in females with PsAF compared to men., Methods: We performed a multicenter observational study to determine long-term arrhythmia outcomes in patients undergoing >1 CA for PsAF. CA involved pulmonary vein (PV) isolation with additional ablation including linear, posterior wall isolation, electrogram-guided, or a combination of these., Results: A total of 281 patients had >1 ablation procedure for PsAF and were included in this analysis (mean age 58.7 ± 9.3 years; 86 [30.6%] female; left atrial [LA] area 27.0 ± 5.3 cm 2 ; PsAF duration 1.7 ± 1.7 years). At mean follow-up of 45.5 ± 31.8 months, freedom from recurrent AF was present in 148 patients(52.7%) after 2.2 ± 0.5 procedures. After multivariate analysis, female gender (hazard ratio [HR] 2.10; P <.001) and enduring PV isolation (HR 1.64; P = .01) were independently associated with AF recurrence. Enduring PV isolation was significantly higher in women than in men (33.7% vs 19.5%; P = .01)., Conclusion: Female gender was independently and strongly associated with arrhythmia recurrence in patients undergoing multiple procedures for PsAF. PV reconnection was less likely, and fewer reconnected PVs occurred in women. Further studies are required to better understand the mechanisms responsible for AF in females to assist in closing the gender gap in the success of CA., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Adolescence represents a key period of brain development underpinned by the ongoing maturation of the prefrontal cortex-a brain region involved in the regulation of behaviour and cognition. Given the high prevalence of obesity in adolescents worldwide, this Review examines neurobiological and neurocognitive evidence describing the adolescent propensity to consume calorie-dense foods, and the neurodevelopmental mechanisms that heighten the adverse impact of these foods on brain function. The excessive consumption of calorie-dense food can undermine self-regulatory processes through effects on brain function and behavioural control. These changes could introduce enduring maladaptive eating behaviours that underlie adult obesity and related metabolic syndromes. Better understanding of links between adolescence, dietary decision making, and brain function is essential for clinicians to develop effective intervention strategies and for reducing long-term health-care costs associated with obesity., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The transition from wakefulness to sleep is accompanied by widespread changes in brain functioning. Here we investigate the implications of this transition for interregional functional connectivity and their dynamic changes over time. Simultaneous EEG-fMRI was used to measure brain functional activity of 21 healthy participants as they transitioned from wakefulness into sleep. fMRI volumes were independent component analysis (ICA)-decomposed, yielding 42 neurophysiological sources. Static functional connectivity (FC) was estimated from independent component time courses. A sliding window method and k-means clustering (k = 7, L2-norm) were used to estimate dynamic FC. Static FC in Wake and Stage-2 Sleep (NREM2) were largely similar. By contrast, FC dynamics across wake and sleep differed, with transitions between FC states occurring more frequently during wakefulness than during NREM2. Evidence of slower FC dynamics during sleep is discussed in relation to sleep-related reductions in effective connectivity and synaptic strength., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study sought to determine the impact of rate and direction on left atrial (LA) substrate., Background: The extent to which substrate mapped in sinus rhythm varies according to cycle length and direction of wave front propagation is unknown., Methods: A total of 73 consecutive patients with atrial fibrillation (AF) underwent electroanatomic LA mapping before pulmonary vein isolation using multipolar catheter during distal coronary sinus (CS) pacing at 600 ms and 300 ms. Additional maps were created during left superior pulmonary vein pacing at 300 ms. Bipolar voltage, conduction velocity (CV), and complex signals were determined., Results: Mean age was 61 ± 9 years, 67% were men, and 53% had persistent AF. Global mean voltage was lower with CS pacing at 300 ms compared with 600 ms (1.56 ± 0.47 mV vs. 1.74 ± 0.48 mV; p < 0.001). This was seen in all LA segments. Global CV was reduced (30.4 ± 13.0 cm/s vs. 38.6 ± 14.0 cm/s; p < 0.001) with greater complex signals at 300 ms (8.9% vs. 5.3%; p < 0.005). Compared with CS pacing, left superior pulmonary vein pacing demonstrated highly regional changes with decreased voltage (1.04 ± 0.43 mV vs. 1.47 ± 0.53 mV; p = 0.01) and CV (24.4 ± 13.0 cm/s vs. 39.9 ± 16.6 cm/s; p = 0.008), and greater complex signals posteriorly. Longer AF duration in paroxysmal AF (p = 0.02) and shorter duration in persistent AF (p = 0.015) and left ventricular ejection fraction (p = 0.016) were independent predictors of voltage change., Conclusions: In patients with AF, variation in cycle length and direction of wave front activation produce both generalized and regional changes in voltage, CV, and complex fractionation, resulting in significant changes in substrate maps. This study highlights the potential limitations of static low-voltage maps to identify the AF ablation target zone., (Copyright © 2019. Published by Elsevier Inc.)

Idiopathic ventricular arrhythmias commonly originate from the right ventricular and left ventricular outflow tracts (OTs). Advances in real-time imaging have refined our understanding of the intimate anatomic structures implicated in the genesis of OT arrhythmias, making catheter ablation for arrhythmias beyond the right ventricular OT a feasible option for cure-indeed ablation is now a class I indication in recent guidelines. The surface 12-lead ECG is routinely used to localize the anatomic site of origin before catheter ablation. However, the intimate and complex anatomy of the OT limits predictive value ECG criteria alone for localization for these arrhythmias. Multiple ECG algorithms have been developed to assist preprocedural localization, and hence predict safety and efficacy for catheter ablation of OT ventricular arrhythmias. This review will summarize all of the published 12-lead ECG algorithms used to guide localization of OT ventricular arrhythmias.