Search

Aims The aim of this study was to determine the relationship between improved ejection fraction (EF) and occurrence of arrhythmias in patients with cardiac resynchronization therapy devices with defibrillator function (CRT-D). The hypothesis was that patients who experienced a marked improvement in EF also had fewer appropriate defibrillator interventions. Methods and results We analysed data of 270 patients from2 prospective registries with follow-up of ≥12 months and echocardiography performed ≥8 months after CRT-D implantation. The discriminator was whether left ventricular ejection fraction (LVEF) improved to >35% [cut-off for primary prevention implantable cardioverter-defibrillator (ICD) implantation]. Mean age was 61 ± 11 years, LVEF 22 ± 5%, and follow-up 40 ± 22 months. Ischaemic cardiomyopathy was present in 48%, and secondary prevention indication was present in 25%. Implantable cardioverter-defibrillator interventions were delivered to 35% of patients. Echocardiography (20 ± 15 months after implantation) showed an improvement in LVEF from 22% (SD 5.4%) to 30% (SD 9.8%). Improvement to >35% was seen in 21% of patients. Those who improved to >35% had fewer ICD interventions than those who did not (23 vs.38%; P-value 0.03). Analysing only patients with a primary prevention indication and stratifying again in patients with and without improvement of LVEF to >35%, the latter had highly significant more ICD-therapies (6 vs. 31%; P-value 0.0008). Conclusion Patients with CRT-D for primary prevention, whose LVEF improved to >35% during mid-term follow-up, are at low risk of first ICD therapies beyond year 1. If similar findings are reported in other patient cohorts, this might impact on decision-making at the time of battery depletion. [ABSTRACT FROM AUTHOR]

Aim: Diagnosis of early stages of arrhythmogenic right ventricular cardiomyopathy (ARVC) with minimal structural abnormalities is challenging. The purpose of this study was to assess the value of repeated cardiac magnetic resonance imaging (CMR) in patients referred for right ventricular arrhythmias and clinical suspicion of ARVC. Methods and Results: Prospective follow-up study of 18 patients (8 females) studied with CMR for suspected ARVC. Patients with implanted defibrillators (ICD) were excluded. Mean follow-up was 37 ± 16 (12–59) months. Patients were assigned to 2 categories (ARVC likely or ARVC unlikely) according to a CMR-score based on right ventricular abnormalities. Clinical follow-up revealed no disease progression in 17 patients (94%). In 1 patient, an ICD was implanted because of disease progression. Of 9 patients with initial findings suggestive of ARVC, follow-up CMR remained positive in 3 and was diagnosed as normal in 6, mainly due to the inability to confirm the presence of fatty infiltrates at follow-up (5 of 6 patients). Initially, 9 patients had a normal CMR and 8 of those remained normal during follow-up. Conclusion: Repeated CMR after an average follow-up of 3 years was normal in 6 of 9 patients with clinical findings consistent with early stages of ARVC at the time of baseline CMR. Thus, CMR diagnosis of early stage ARVC is difficult and should be made with caution. [ABSTRACT FROM AUTHOR]

Three patients with advanced systemic sclerosis and recurrent or incessant monomorphic ventricular tachycardia underwent cardiac electrophysiologic studies. Biventricular transcatheter mapping showed findings most compatible with a reentrant mechanism, which was effectively treated with transcatheter ablation. [ABSTRACT FROM AUTHOR]

Presents case reports which described patients with recurrent exercise-related syncope in whom prolonged asystole after exercise was documented. Case histories of the patients; Results and discussion.

Randomized controlled trials of pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have proven the procedure's efficacy. Studies assessing its empirical cost-effectiveness outside randomized trial settings are lacking. We aimed to evaluate the effectiveness and cost-effectiveness of PVI versus medical therapy for AF. We followed a target trial approach using the Swiss-AF cohort, a prospective observational cohort study that enrolled patients with AF between 2014 and 2017. Resource utilization and cost information were collected through claims data. Quality of life was measured with EQ-5D-3L utilities. We estimated incremental cost-effectiveness ratios (ICERs) from the perspective of the Swiss statutory health insurance system. Patients undergoing PVI compared with medical therapy had a 5-year overall survival advantage with a hazard ratio of 0.75 (95% CI 0.46-1.21; P =.69) and a 19.8% SD improvement in quality of life (95% CI 15.5-22.9; P <.001), at an incremental cost of 29 604 Swiss francs (CHF) (95% CI 16 354-42 855; P <.001). The estimated ICER was CHF 158 612 per quality-adjusted life-year (QALY) gained within a 5-year time horizon. Assuming similar health effects and costs over 5 additional years changed the ICER to CHF 82 195 per QALY gained. Results were robust to the sensitivity analyses performed. Our results show that PVI might be a cost-effective intervention within the Swiss healthcare context in a 10-year time horizon, but unlikely to be so at 5 years, if a willingness-to-pay threshold of CHF 100 000 per QALY gained is assumed. Given data availability, we find target trial designs are a valuable tool for assessing the cost-effectiveness of healthcare interventions outside of randomized controlled trial settings. • What is the real-world cost-effectiveness of pulmonary vein isolation (PVI) compared with standard medical therapy for patients with atrial fibrillation? • In this economic evaluation designed with a target trial approach including 2379 patients with real-world clinical, quality of life, and costing data, we estimate the incremental cost-effectiveness ratio of PVI compared with standard medical therapy to be 158 612 Swiss francs per quality-adjusted life-year gained (1 US dollar ∼ 0.93 Swiss francs) at 5 years and 82 195 per quality-adjusted life-year at 10 years. • In our target trial emulation-based cost-effectiveness assessment, PVI for the management of atrial fibrillation might be cost-effective over a 10-year period. [ABSTRACT FROM AUTHOR]

Background: Prediction of the chamber of origin in patients with outflow tract ventricular arrhythmias (OTVA) remains challenging. A clinical risk score based on age, sex and presence of hypertension was associated with a left ventricular outflow tract (LVOT) origin. We aimed to validate this clinical score to predict an LVOT origin in patients with OTVA. Methods: In a two‐center observational cohort study, unselected patients undergoing catheter ablation (CA) for OTVA were enrolled. All procedures were performed using an electroanatomical mapping system. Successful ablation was defined as a ≥80% reduction of the initial overall PVC burden after 3 months of follow‐up. Patients with unsuccessful ablation were excluded from this analysis. Results: We included 187 consecutive patients with successful CA of idiopathic OTVA. Mean age was 52 ± 15 years, 102 patients (55%) were female, and 74 (40%) suffered from hypertension. A LVOT origin was found in 64 patients (34%). A score incorporating age, sex and presence of hypertension reached 73% sensitivity and 67% specificity for a low (0–1) and high (2–3) score, to predict an LVOT origin. The combination of one ECG algorithm (V2S/V3R‐index) with the clinical score resulted in a sensitivity and specificity of 81% and 70% for PVCs with R/S transition at V3. Conclusion: The published clinical score yielded a lower sensitivity and specificity in our cohort. However, for PVCs with R/S transition at V3, the combination with an existing ECG algorithm can improve the predictability of LVOT origin. [ABSTRACT FROM AUTHOR]

Abstract: A case of a professional ice-hockey with a blunt chest trauma is presented. A year after the first cardiac evaluation, he experienced sustained ventricular tachycardia after another slight chest trauma. An implantable cardioverter-defibrillator was implanted. The pathophysiological background of tachycardias after a blunt chest trauma and its management are discussed. [Copyright &y& Elsevier]

Introduction: Electrophysiological testing has been proposed in the latest European Society of Cardiology (ESC) guidelines for cardiac pacing to identify left bundle branch block (LBBB) patients with infrahisian conduction delay (IHCD) after transcatheter aortic valve replacement (TAVR). While in general IHCD is defined by a His‐ventricular (HV) interval of >55 ms, a cut‐off of ≥70 ms to trigger pacemaker (PM) implantation has been proposed in the latest ESC guidelines. The ventricular pacing (VP) burden during follow‐up in such patients is largely unknown. As such, we aimed to assess the VP burden during follow‐up of patients receiving PM therapy for LBBB after TAVR based on an HV interval > 55 ms and ≥70 ms. Methods: All patients with new‐onset or pre‐existing LBBB after undergoing TAVR at a tertiary referral center underwent EP testing the day after TAVR. In patients with a prolonged HV interval (>55 ms), PM implantation was performed by a trained electrophysiologist in a standardized fashion. All devices were programmed to avoid unnecessary VP by specific algorithms (e.g., AAI‐DDD). Results: 701 patients underwent TAVR at the University Hospital of Basel. One hundred seventy‐seven patients presented with new‐onset or pre‐existing LBBB the day following TAVR and underwent EP testing. An HV interval > 55 ms was found in 58 patients (33%) and an HV interval ≥ 70 ms in 21 patients (12%). 51 patients (mean age 84 ± 6.2 years, 45% women) agreed to receive a PM, out of which 20 (39%) patients had an HV Interval over 70 ms. Atrial fibrillation was present in 53% of the patients. A dual chamber PM was implanted in 39 (77%), and a single chamber PC in 12 (23%) patients, respectively. Median follow‐up was 21 months. The median VP burden overall was 3%. The median VP burden was not significantly different between patients with an HV ≥ 70 ms (6.5 [0.8−52]) and those with an HV between 55 and 69 ms (2 [0−17], p =.23). 31% of patients demonstrated a VP burden < 1%, 27% 1%−5% and 41% > 5%. The median HV intervals in patients with VP burdens < 1%, 1%−5% and >5% were 66 (IQR 62−70) ms, 66 (IQR 63−74) ms and 68 (IQR 60−72) ms, respectively, p =.52. When only assessing patients with an HV interval 55−69 ms, 36% demonstrated a VP burden of <1%, 29% of 1%−5% and 35% of >5%. In patients with an HV Interval ≥ 70 ms, 25% demonstrated a VP burden < 1%, 25% of 1%−5% and 50% of >5% %, p =.64 (Figure). Conclusion: In patients with LBBB after TAVR and IHCD defined by an HV interval > 55 ms, VP burden is relevant in a non‐negligible amount of patients during follow‐up. Further studies are warranted to define the optimal cut‐off value for the HV interval or to develop risk models incorporating HV measurements and other risk factors to trigger PM implantation in patients with LBBB after TAVR. [ABSTRACT FROM AUTHOR]

Background: A pace and ablate strategy may be performed in refractory atrial fibrillation with rapid ventricular response. Objective: We aimed to assess sex-related differences in patient selection and clinical outcomes after pace and ablate. Methods: In a retrospective multicentre study, patients undergoing AV junction ablation were studied. Sex-related differences in baseline characteristics, all-cause mortality, heart failure (HF) hospitalizations, and device-related complications were assessed. Results: Overall, 513 patients underwent AV junction ablation (median age 75 years, 50% men). At baseline, men were younger (72 vs. 78 years, p < 0.001), more frequently had non-paroxysmal AF (82% vs. 72%, p = 0.006), had a lower LVEF (35% vs. 55%, p < 0.001) and more frequently had cardiac resynchronization therapy (75% vs. 25%, p < 0.001). Interventional complications were rare in both groups (1.2% vs. 1.6%, p = 0.72). Patients were followed for a median of 42 months in survivors (IQR 22–62). After 4 years of follow-up, the combined endpoint of all-cause death or HF hospitalization occurred more often in men (38% vs. 27%, p = 0.008). The same was observed for HF hospitalizations (22% vs. 11%, p = 0.021) and all-cause death (28% vs. 21%, p = 0.017). Sex category remained an independent predictor of death or HF hospitalization after adjustment for age, LVEF and type of stimulation. Lead-related complications, infections, and upgrade to ICD or CRT occurred in 2.1%, 0.2% and 3.5% of patients, respectively. Conclusions: Pace and ablate is safe with a need for subsequent device-related re-interventions in 5.8% over 4 years. We found significant sex-related differences in patient selection, and women had a more favourable clinical course after AV junction ablation. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) has been linked to left atrial (LA) enlargement. Whereas most studies focused on 2D-based estimation of static LA volume (LAV), we used a fully-automatic convolutional neural network (CNN) for time-resolved (CINE) volumetry of the whole LA on cardiac MRI (cMRI). Aim was to investigate associations between functional parameters from fully-automated, 3D-based analysis of the LA and current classification schemes in AF. Methods: We retrospectively analyzed consecutive AF patients who underwent cMRI on 1.5T systems including a stack of oblique-axial CINE series covering the whole LA. The LA was automatically segmented by a validated CNN. In the resulting volume-time curves, maximum, minimum and LAV before atrial contraction were automatically identified. Active, passive and total LA emptying fractions (LAEF) were calculated and compared to clinical classifications (AF Burden score (AFBS), increased stroke risk (CHA2DS2VASc≥2), AF type (paroxysmal/persistent), EHRA score, and AF risk factors). Moreover, multivariable linear regression models (mLRM) were used to identify associations with AF risk factors. Results: Overall, 102 patients (age 61±9 years, 17% female) were analyzed. Active LAEF (LAEF_active) decreased significantly with an increase of AFBS (minimal: 44.0%, mild: 36.2%, moderate: 31.7%, severe: 20.8%, p<0.003) which was primarily caused by an increase of minimum LAV. Likewise, LAEF_active was lower in patients with increased stroke risk (30.7% vs. 38.9%, p = 0.002). AF type and EHRA score did not show significant differences between groups. In mLRM, a decrease of LAEF_active was associated with higher age (per year: -0.3%, p = 0.02), higher AFBS (per category: -4.2%, p<0.03) and heart failure (-12.1%, p<0.04). Conclusions: Fully-automatic morphometry of the whole LA derived from cMRI showed significant relationships between LAEF_active with increased stroke risk and severity of AFBS. Furthermore, higher age, higher AFBS and presence of heart failure were independent predictors of reduced LAEF_active, indicating its potential usefulness as an imaging biomarker. [ABSTRACT FROM AUTHOR]

The article reports about a medical research conducted on a 72-year-old woman with breast cancer, that had metastasized to the glossopharyngeal region, who had recurrent episodes of sudden lightheadedness, diaphoresis, and syncope. A dual-chamber pacemaker was implanted, but syncope recurred, always preceded by severe neck pain. During the tilt-table test with the pacemaker inactivated, the patient's usual symptoms developed. She lost consciousness and had a seizure, but regained consciousness after she was returned to the supine position. Treatment with disopyramide eliminated the syncopal episodes over five months of follow-up.

The effect of the ventricular repolarization heterogeneity has not been systematically assessed in patients with atrial fibrillation (AF). Aim of this study is to assess ventricular repolarization heterogeneity as predictor of cardiovascular (CV) death and/or other CV events in patients with AF. From the multicenter prospective Swiss-AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1711 patients who were in sinus rhythm (995) or AF (716). Resting ECG recordings of 5-min duration were obtained at baseline. Parameters assessing ventricular repolarization were computed (QTc, Tpeak-Tend, J-Tpeak and V-index). During AF, the V-index was found repeatable (no differences when computed over the whole recording, on the first 2.5-min and on the last 2.5-min segments). During a mean follow-up time of 2.6 ± 1.0 years, 90 patients died for CV reasons. In bivariate Cox regression analysis (adjusted for age only), the V-index was associated with an increased risk of CV death, both in the subgroup of patients in sinus rhythm (SR) as well as those in AF. In multivariate analysis adjusted for clinical risk factors and medications, both prolonged QTc and V-index were independently associated with an increased risk of CV death (QTc: hazard ratio [HR] 2.78, 95% CI 1.79–4.32, p < 0.001; V-index: HR 1.73, 95% CI 1.12–2.69, p = 0.014). QTc and V-index, measured in a single 5-min ECG recording, were independent predictors of CV death in a cohort of patients with AF and might be a valuable tool for further risk stratification to guide patient management. Clinical Trial Identifier Swiss-AF study: NCT02105844 • The V-index can be assessed in routine ambulatory 5-min ECG in patients with AF. • V-index and QTc independent predictors of cardiovascular mortality in AF patients. • The largest study for prognostic implications of ventricular repolarization in AF. • Large ventricular repolarization heterogeneity identifies high-risk AF patients. [ABSTRACT FROM AUTHOR]

Background: Inflammatory biomarkers are associated with severity of coronavirus disease 2019 (COVID-19). However, direct comparisons of their utility in COVID-19 versus other respiratory infections are largely missing. Objective: We aimed to investigate the prognostic utility of various inflammatory biomarkers in COVID-19 compared to patients with other respiratory infections. Materials and methods: Patients presenting to the emergency department with symptoms suggestive of COVID-19 were prospectively enrolled. Levels of Interleukin-6 (IL-6), c-reactive protein (CRP), procalcitonin, ferritin, and leukocytes were compared between COVID-19, other viral respiratory infections, and bacterial pneumonia. Primary outcome was the need for hospitalisation, secondary outcome was the composite of intensive care unit (ICU) admission or death at 30 days. Results: Among 514 patients with confirmed respiratory infections, 191 (37%) were diagnosed with COVID-19, 227 (44%) with another viral respiratory infection (viral controls), and 96 (19%) with bacterial pneumonia (bacterial controls). All inflammatory biomarkers differed significantly between diagnoses and were numerically higher in hospitalized patients, regardless of diagnoses. Discriminative accuracy for hospitalisation was highest for IL-6 and CRP in all three diagnoses (in COVID-19, area under the curve (AUC) for IL-6 0.899 [95%CI 0.850–0.948]; AUC for CRP 0.922 [95%CI 0.879–0.964]). Similarly, IL-6 and CRP ranged among the strongest predictors for ICU admission or death at 30 days in COVID-19 (AUC for IL-6 0.794 [95%CI 0.694–0.894]; AUC for CRP 0.807 [95%CI 0.721–0.893]) and both controls. Predictive values of inflammatory biomarkers were generally higher in COVID-19 than in controls. Conclusion: In patients with COVID-19 and other respiratory infections, inflammatory biomarkers harbour strong prognostic information, particularly IL-6 and CRP. Their routine use may support early management decisions. [ABSTRACT FROM AUTHOR]

Perioperative myocardial infarction/injury (PMI) is a frequent, often missed and incompletely understood complication of noncardiac surgery. The aim of this study was to evaluate whether patient- or procedure-related factors are more strongly associated to the development of PMI in patients undergoing repeated noncardiac surgery. In this prospective observational study, patient- and procedure-related factors were evaluated for contribution to PMI using: 1) logistic regression modelling with PMI as primary endpoint, 2) evaluation of concordance of PMI occurrence in the first and the second noncardiac surgery (surgery 1 and 2). and 3) the correlation of the extent of cardiomyocyte injury quantified by high-sensitivity cardiac troponin T between surgery 1 and 2. The secondary endpoint was all-cause mortality associated with PMI reoccurrence in surgery 2. Among 784 patients undergoing repeated noncardiac surgery (in total 1′923 surgical procedures), 116 patients (14.8%) experienced PMI during surgery 1. Among these, PMI occurred again in surgery 2 in 35/116 (30.2%) patients. However, the vast majority of patients developing PMI during surgery 2 (96/131, 73.3%) had not developed PMI during surgery 1 (phi-coefficient 0.150, p < 0.001). The correlation between the extent of cardiomyocyte injury occurring during surgery 1 and 2 was 0.153. All-cause mortality following a second PMI in surgery 2 was dependent on time since surgery (adjusted hazard ratio 5.6 within 30 days and 2.4 within 360 days). In high-risk patients, procedural factors are more strongly associated with occurrence of PMI than patient factors, but patient factors are also contributors to the occurrence of PMI. • Perioperative myocardial infarction/injury (PMI) detected by cardiac troponin is a frequent complication of noncardiac surgery. • Procedural factors are more strongly associated with occurrence of PMI than patient factors in contrast to spontaneous AMI. • Repeated PMI increased 1-year mortality considerably. Mortality was particularly high in the first weeks after surgery. [ABSTRACT FROM AUTHOR]

Biomarkers may help to improve our knowledge about the complex pathophysiology of atrial fibrillation (AF). In this study we sought to identify significant changes in biomarkers and clinical measures in patients with and without AF recurrence after electrical cardioversion. We measured 21 conventional and new biomarkers before and 30 days after electrical cardioversion and assessed the associations of changes in biomarker levels with rhythm status at follow-up. Significant between-group changes were observed for bone morphogenetic protein 10 (BMP10), N-terminal pro-B-type natriuretic peptide (NT-proBNP) and total bilirubin. Their respective changes were − 10.4%, − 62.0% and − 25.6% in patients with sinus rhythm, and 3.1%, 1.1% and − 9.4% in patients with recurrent AF, for a between-group difference of − 13.5% (95% confidence interval [CI] − 19.3% to − 7.6%; P < 0.001), − 63.1% (95% CI − 76.6% to − 49.6%; P < 0.001) and − 16.3% (95% CI − 27.9% to − 4.7%; P = 0.007). In multivariable models, the reductions of BMP10 and NT-proBNP were significantly associated with follow-up rhythm status (β coefficient per 1 − SD decrease, − 3.85; 95% CI − 6.34 to − 1.35; P = 0.003 for BMP10 and − 5.84; 95% CI − 10.22 to − 1.47; P = 0.009 for NT-proBNP. In conclusion, changes in BMP10 und NT-proBNP levels were independently associated with rhythm status after cardioversion, suggesting that these markers may be dependent on the actual heart rhythm. [ABSTRACT FROM AUTHOR]

Remote monitoring is useful for management of implantable cardioverter defibrillator (ICD) patients regarding detection of arrhythmias and probable device or lead failure. We report the case of a patient who died suddenly while being on remote monitoring. The ICD was not retrieved postmortem. Even though clinical circumstances were suspicious of an arrhythmic death, this was excluded due to a distinctive manufacturer feature of the system. (PACE 2012; 35:e280-e283) [ABSTRACT FROM AUTHOR]

Objective: To evaluate if subclinical thyroid dysfunction is associated w ith cardiovascular (CV) risk in patients with atrial fibrillation (AF). Methods: Swiss-AF is a prospective cohort of community-dwelling partici pants aged = 65 years with AF. Primary outcome was a composite endpoint of CV events (myocardial infar ctions, stroke/transitory ischemic events, systemic embolism, heart failure (HF) hospitalizations, CV deaths). Seco ndary outcomes were component endpoints, total mortality, and AF-progression. Exposures were thyroid dysfunction categories, TSH and fT4. Sensitivity analyses were performed for amiodarone use, thyroid hormones use, and competi ng events. Results: 2415 patients were included (mean age: 73.2 years; 27% women). 196 (8.4%) had subclinical hypothyroidism and 53 (2.3%) subclinical hyperthyroidism. Subclinical thyroid dysfunction was not associated with CV events, during a median follow-up of 2.1 years (max 5 years): age- and sex-adj usted hazard ratio (adjHR) of 0.99 (95% CI: 0.69-1.41) for subclinical hypothyroidism and 0.55 (95% CI: 0.23-1.32) for subclinical hyperthyroidism. Results remained robust following multivariable adjustment and sensitivity analyses. In euthyroid patients, fT4 levels were associated with an increased risk for the composite endpoint and HF (adjHR: 1.46, 95% CI: 1.04-2.05; adjHR: 1.70, 95% CI: 1.08-2.66, respectively, for the highest quintile vs the middle quintile). Results remained similar following multivariable adjustment and remained significant for HF in sensitivity analys es. No association between subclinical thyroid dysfunction and total mortality or AF-progression was found. Conclusions: Subclinical hypothyroidism was not associated with increased CV risk in AF patients. Higher levels of fT4 with normal TSH were associated with a higher risk for HF. [ABSTRACT FROM AUTHOR]

Context: The risk-benefit ratio of invasive vs medical management of elderly patients with symptomatic chronic coronary artery disease (CAD) is unclear. The Trial of Invasive versus Medical therapy in Elderly patients (TIME) recently showed early benefits in quality of life from invasive therapy in patients aged 75 years or older, although with a certain excess in mortality. Objective: To assess the long-term value of invasive vs medical management of chronic CAD in elderly adults in terms of quality of life and prevention of major adverse cardiac events. Design: One-year follow-up analysis of TIME, a prospective randomized trial with enrollment between February 1996 and November 2000. Setting and Participants: A total of 282 patients with Canadian Cardiac Society class 2 or higher angina despite treatment with 2 or more anti-anginal drugs who survived for the first 6 months after enrollment in TIME (mean age, 80 years [range, 75-91 years]; 42% women), enrolled at 14 centers in Switzerland. Interventions: Participants were randomly assigned to undergo coronary angiography followed by revascularization (if feasible) (n = 140 surviving 6 months) or to receive optimized medical therapy (n = 142 surviving 6 months). Main Outcome Measures: Quality of life, assessed by standardized questionnaire; major adverse cardiac events (death, nonfatal myocardial infarction, or hospitalization for acute coronary syndrome) after 1 year. Results: After 1 year, improvements in angina and quality of life persisted for both therapies compared with baseline, but the early difference favoring invasive therapy disappeared. Among invasive therapy patients, later hospitalization with revascularization was much less likely (10% vs 46%; hazard ratio [HR], 0.19; 95% confidence interval [CI], 0.11-0.32; P<.001). However, 1-year mortality (11.1% for invasive; 8.1% for medical; HR, 1.51; 95% CI, 0.72-3.16; P = .28) and death or nonfatal myocardial infarction rates (17.0% for invasive; 19.6%... [ABSTRACT FROM AUTHOR]

Background: Radiofrequency catheter ablation of idiopathic premature ventricular complexes (PVCs) is an effective method for eliminating symptoms and preventing/reversing arrhythmia‐induced cardiomyopathy. One reason for procedural failure is low PVC frequency during the procedure. We aimed to investigate the relation between pre‐procedural PVC burden and outcome of idiopathic PVC catheter ablation. Methods: Patients who underwent idiopathic PVC ablation between 2013 and 2019 at two tertiary referral centers were retrospectively included. All procedures were performed using irrigated‐tip ablation catheters and a 3D electro‐anatomical mapping system. Sustained ablation success was defined as a ≥80% reduction of pre‐procedural PVC burden determined by 24h‐Holter at follow‐up. Results: Overall, 254 patients (median age 54 years [IQR 42–64]; 47% male) were enrolled. The median pre‐ablation PVC‐burden was 22% (IQR 11–31%), which was reduced to a post‐ablation PVC burden of 0.3% (IQR 0–4%) after a median of 90 days. Sustained ablation success was achieved in 182 patients (72%). Pre‐procedural PVC burden did not differ between patients with sustained ablation success and recurrence during follow‐up (median 21% vs. 22%, p =.76). When assessed in pre‐ablation PVC‐burden groups of ≤5%, 6–15%, 16–30%, and ≥31%, sustained ablation success was achieved in 67%, 75%, 71%, and 72%, respectively, with no significant difference (p =.89). Sustained ablation outcome for PVC‐burden ≤5% versus >5% showed no difference either (67% vs. 72%, p =.52). Conclusions: Pre‐procedural Holter‐determined PVC burden does not predict the outcome of idiopathic PVC ablation. Thus, catheter ablation may be a reasonable first choice also for patients with symptomatic yet rare PVCs. [ABSTRACT FROM AUTHOR]

Background: In Switzerland, long-term circulatory support programs have been limited to heart transplant centers. In 2014, to improve the management of patients with end-stage heart failure not eligible for transplantation, we implemented a left ventricular assist device (LVAD) program for destination therapy at the University Hospital of Basel.Methods: We described the program set-up with practical aspects. Patients aged 65 and above with therapy refractory end-stage heart failure without major contraindication for LVAD implantation were included. Younger patients with bridge-to-candidacy profile were also considered. Using the Kaplan-Meier estimate, we retrospectively analyzed the overall survival and freedom from major adverse events after LVAD implantation. We compared our results to internationally reported data.Results: Between October 2014 and September 2019, 16 patients received an LVAD in our center. The mean age at implantation was 67.1 years. The mean EuroSCORE II was 24.4% and the median INTERMACS level was 4. Thirteen patients received an LVAD as destination therapy and three patients as bridge-to-candidacy. The overall survival was 87.5 and 70% at 1 and 2 years, respectively. Freedom from stroke was 81.3% at 1 and 2 years. Freedom from device infection was 67.7 and 58.7% at 1 and 2 years, respectively. Freedom from gastrointestinal bleeding was 75 and 56.3% at 1 and 2 years, respectively. Freedom from readmission was 50 and 31.3% and at 6 months and 1 year, respectively.Conclusions: The Basel experience demonstrated the possible implementation of an LVAD program for destination therapy or bridge-to-candidacy in a non-transplant comprehensive heart-failure center with midterm survival results and freedom from major adverse events comparable to international registries. Patient selection remains crucial.Trial Registration: This study was registered on the ClinicalTrials.gov database ( NCT04263012 ). [ABSTRACT FROM AUTHOR]

Objective: The pandemic of coronavirus disease (COVID-19) has rapidly spread globally and infected millions of people. The prevalence and prognostic impact of dysnatremia in COVID-19 is inconclusive. Therefore, we investigated the prevalence and outcome of dysnatremia in COVID-19. Design: The prospective, observational, cohort study included consecutive patients with clinical suspicion of COVID-19 triaged to a Swiss Emergency Department between March and July 2020. Methods: Collected data included clinical, laboratory and disease severity scoring parameters on admission. COVID-19 cases were identified based on a positive nasopharyngeal swab test for SARS-CoV-2, patients with a negative swab test served as controls. The primary analysis was to assess the prognostic impact of dysnatremia on 30-day mortality using a cox proportional hazard model. Results: 172 (17%) cases with COVID-19 and 849 (83%) controls were included. Patients with COVID-19 showed a higher prevalence of hyponatremia compared to controls (28.1% vs 17.5%, P < 0.001); while comparable for hypernatremia (2.9% vs 2.1%, P = 0.34). In COVID-19 but not in controls, hyponatremia was associated with a higher 30-day mortality (HR: 1.4, 95% CI: 1.10-16.62, P = 0.05). In both groups, hypernatremia on admission was associated with higher 30-day mortality (COVID-19 - HR: 11.5, 95% CI: 5.00-26.43, P < 0.001; controls - HR: 5.3, 95% CI: 1.60-17.64, P = 0.006). In both groups, hyponatremia and hypernatremia were significantly associated with adverse outcome, for example, intensive care unit admission, longer hospitalization and mechanical ventilation. Conclusion: Our results underline the importance of dysnatremia as predictive marker in COVID-19. Treating physicians should be aware of appropriate treatment measures to be taken for patients with COVID-19 and dysnatremia. [ABSTRACT FROM AUTHOR]

Background: Little is known about the association between alcohol consumption and risk of cardiovascular events in patients with established atrial fibrillation (AF). The main aim of the current study was to investigate the associations of regular alcohol intake with incident stroke or systemic embolism in patients with established AF.Methods: To assess the association between alcohol consumption and cardiovascular events in patients with established AF, we combined data from 2 comparable prospective cohort studies that followed 3852 patients with AF for a median of 3.0 years. Patients were grouped into 4 categories of daily alcohol intake (none, > 0 to < 1, 1 to < 2 and ≥ 2 drinks/d). The primary outcome was a composite of stroke and systemic embolism. Secondary outcomes were all-cause mortality, myocardial infarction, hospital admission for acute heart failure, and a composite of major and clinically relevant nonmajor bleeding. Associations were assessed using time-updated, multivariable-adjusted Cox proportional hazards models.Results: Mean age (± standard deviation) was 71 ± 10 years (28% were women and 84% were on oral anticoagulants). We observed 136 confirmed strokes or systemic emboli. Compared with nondrinkers, adjusted hazard ratios for the primary outcome event were 0.87, 95% confidence interval (CI) 0.55-1.37 for > 0 to < 1 drinks/d; 0.70, 95% CI 0.39-1.25 for 1 to < 2 drinks/d; and 0.96, 95% CI 0.56-1.67 for ≥ 2 drinks/d (p for linear [quadratic] trend 0.71 [0.22]). There was no significant association between alcohol consumption and bleeding, but there was a nonlinear association with heart failure (p for quadratic trend 0.01) and myocardial infarction (p for quadratic trend 0.007).Interpretation: In patients with AF, we did not find a significant association between low to moderate alcohol intake and risk of stroke or other cardiovascular events. Our findings do not support special recommendations for patients with established AF with regard to alcohol consumption.Trial Registration: ClinicalTrials.gov, no. NCT02105844. [ABSTRACT FROM AUTHOR]

Background: In the treatment of de-novo coronary small vessel disease, drug-coated balloons (DCBs) are non-inferior to drug-eluting stents (DESs) regarding clinical outcome up to 12 months, but data beyond 1 year is sparse. We aimed to test the long-term efficacy and safety of DCBs regarding clinical endpoints in an all-comer population undergoing percutaneous coronary intervention.Methods: In this prespecified long-term follow-up of a multicentre, randomised, open-label, non-inferiority trial, patients from 14 clinical sites in Germany, Switzerland, and Austria with de-novo lesions in coronary vessels <3 mm and an indication for percutaneous coronary intervention were randomly assigned 1:1 to DCB or second-generation DES and followed over 3 years for major adverse cardiac events (ie, cardiac death, non-fatal myocardial infarction, and target-vessel revascularisation [TVR]), all-cause death, probable or definite stent thrombosis, and major bleeding (Bleeding Academic Research Consortium bleeding type 3-5). Analyses were performed on the full analysis set according to the modified intention-to-treat principle. Dual antiplatelet therapy was recommended for 1 month after DCB and 6 months after DES with stable symptoms, but 12 months with acute coronary syndromes. The study is registered with ClinicalTrials.gov, NCT01574534 and is ongoing.Findings: Between April 10, 2012, and Feb 1, 2017, of 883 patients assessed, 758 (86%) patients were randomly assigned to the DCB group (n=382) or the DES group (n=376). The Kaplan-Meier estimate of the rate of major adverse cardiac events was 15% in both the DCB and DES groups (hazard ratio [HR] 0·99, 95% CI 0·68-1·45; p=0·95). The two groups were also very similar concerning the single components of adverse cardiac events: cardiac death (Kaplan-Meier estimate 5% vs 4%, HR 1·29, 95% CI 0·63-2·66; p=0·49), non-fatal myocardial infarction (both Kaplan-Meier estimate 6%, HR 0·82, 95% CI 0·45-1·51; p=0·52), and TVR (both Kaplan-Meier estimate 9%, HR 0·95, 95% CI 0·58-1·56; p=0·83). Rates of all-cause death were very similar in DCB versus DES patients (both Kaplan-Meier estimate 8%, HR 1·05, 95% CI 0·62-1·77; p=0·87). Rates of probable or definite stent thrombosis (Kaplan-Meier estimate 1% vs 2%; HR 0·33, 95% CI 0·07-1·64; p=0·18) and major bleeding (Kaplan-Meier estimate 2% vs 4%, HR 0·43, 95% CI 0·17-1·13; p=0·088) were numerically lower in DCB versus DES, however without reaching significance.Interpretation: There is maintained efficacy and safety of DCB versus DES in the treatment of de-novo coronary small vessel disease up to 3 years.Funding: Swiss National Science Foundation, Basel Cardiovascular Research Foundation, and B Braun Medical. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF), the most common sustained cardiac arrhythmia, is considered as risk factor for the development of mild cognitive impairment (MCI) and dementia. However, dynamics of cognitive functions are subtle, and neurocognitive assessments largely differ in detecting these changes. We aimed to develop and evaluate a score which represents the common aspects of the cognitive functions measured by validated tests (i.e., "general cognitive construct"), while reducing overlap between tests and be more sensitive to identify changes in overall cognitive functioning. Methods: We developed the CoCo (cognitive construct) score to reflect the cognitive performance obtained by all items of four neurocognitive assessments (Montreal Cognitive Assessment (MoCA); Trail Making Test; Semantic Fluency, animals; Digital Symbol Substitution Test). The sample comprised 2,415 AF patients from the Swiss Atrial Fibrillation Cohort Study (Swiss-AF), 87% aged at least 65 years. Psychometric statistics were calculated for two cognitive measures based on (i) the full set of items from the neurocognitive test battery administered in the Swiss-AF study (i.e., CoCo item set) and (ii) the items from the widely used MoCA test. For the CoCo item set, a factor score was derived based on a principal component analysis, and its measurement properties were analyzed. Results: Both the MoCA item set and the full neurocognitive test battery revealed good psychometric properties, especially the full battery. A one-factor model with good model fit and performance across time and groups was identified and used to generate the CoCo score, reflecting for each patient the common cognitive skill performance measured across the full neurocognitive test battery. The CoCo score showed larger effect sizes compared to the MoCA score in relation to relevant clinical variables. Conclusion: The derived factor score allows summarizing AF patients' cognitive performance as a single score. Using this score in the Swiss-AF project increases measurement sensitivity and decreases the number of statistical tests needed, which will be helpful in future studies addressing how AF affects the risk of developing cognitive impairment. [ABSTRACT FROM AUTHOR]

Ectopic beats originating from the superior vena cava (SVC) may initiate atrial fibrillation. This report describes a patient undergoing radiofrequency catheter ablation for electrical isolation of the SVC resulting in SVC stenosis. Noncircumferential lesion sets for SVC isolation to reduce ablation times may be preferred. (PACE 2010; e36–e38) [ABSTRACT FROM AUTHOR]

Sex-related electrocardiographic differences are a well-known phenomenon, but not their expression in patients with atrial fibrillation (AF). In this study we aim to assess the presence of significant sex-related differences in ECG features, with particular attention to P-wave parameters, of a large cohort of patients affected by different types of AF. A 5-min resting 16-lead ECG was evaluated for 1119 AF patients in sinus rhythm. The durations of the main ECG waves and intervals were measured for both atrial and ventricular activity. Moreover, the beat-to-beat P-wave variability was computed for lead II and for the first principal component (PC1) computed across the 16 leads. The percentage of variance explained by PC1 was computed. Males compared to females showed significantly longer RR interval (1.02 ± 0.16 s vs 0.97 ± 0.15 s, p <.001), PQ interval (191 ± 34 ms vs 183 ± 35 ms, p =.008), QRS duration (105 ± 17 ms vs 98 ± 13 ms, p =.021), significantly lower percentage of variance explained by PC1 and P-wave variability. Males with paroxysmal AF compared to females with paroxysmal AF had significantly longer RR interval (1.01 ± 0.17 s vs 0.96 ± 0.14 s, p <.001), shorter QTc (388 ± 27 ms vs 402 ± 27 ms, p <.001), lower P-wave variability in PC1. Males with persistent AF compared to females with persistent AF had significantly shorter QTc interval (396 ± 30 ms vs 407 ± 26 ms, p =.019), longer PQ interval (194 ± 35 ms vs 182 ± 30 ms, p =.037), higher V1 terminal force (2.1 ± 1.2 mV*ms vs 1.8 ± 1 mV*ms, p =.007), lower percentage of variance explained by PC1. AF patients present with several sex-related ECG differences. Consequently, sex should be taken into account when developing ECG algorithms identifying patients at risk for AF progression. • ECG parameters show significant differences between males and females with AF in SR. • Male AF patients had longer RR, PQ and QRS intervals than females during SR. • Male AF patients had significantly lower P-wave variability than females during SR. • Male/females differences were found also in paroxysmal and persistent AF groups. [ABSTRACT FROM AUTHOR]

Introduction. The natural course of atrial fibrillation (AF) is not well defined. We aimed to investigate the change in AF burden over time and its associated risk factors among AF patients. Methods. Fifty-four participants with recently documented paroxysmal or persistent AF were enrolled. Main exclusion criteria were permanent AF or previous catheter ablation for AF. AF burden was calculated as time in AF divided by total recording time using yearly continuous 7-day Holter-ECG recordings. A relative change ≥10% or an absolute change >0.5% in AF burden between two yearly Holter-ECG recordings was considered significant. Results. Mean age was 67 years, 72% were men. The proportion of patients with no recorded AF increased from 53.7% at baseline to 78.6% (p = 0.1) after 4 years of follow-up. In 7-day Holter-ECG recordings performed after baseline, 23.7% of participants had a decrease and 23.7% an increase in AF burden. In separate mixed effect models, AF burden over time was associated with prior stroke (β 42.59, 95% CI (23.40; 61.77); p < 0.0001), BNP (β 0.05, CI (0.02; 0.09); p = 0.005) end-diastolic (β 0.49, CI (0.23; 0.74); p = 0.0003) as well as end-systolic (β 0.25, CI (0.05; 0.46); p = 0.02) left atrial volume, left atrial ejection fraction (β −0.43, CI (−0.76;−0.10); p = 0.01), E-wave (β 36.67, CI (12.96; 60.38); p = 0.003), and deceleration time (β −0.1, CI (−0.16; −0.05); p = 0.002). In a multivariable model, a history of prior stroke (β 29.87, CI (2.61; 57.13); p = 0.03) and BNP levels (β 0.05, CI (0.01; 0.08); p = 0.007) remained significantly associated with AF burden. Conclusions. Few patients with paroxysmal or persistent AF have AF episodes on yearly 7-day Holter-ECG recordings, and AF progression is rare. AF burden was independently associated with a history of prior stroke and BNP levels. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) is performed to eliminate symptoms and to prevent or reverse arrhythmia‐induced cardiomyopathy. Preprocedural prediction of the chamber of VA origin is critical for patient counseling, procedure planning, and guidance of invasive mapping. Objective: We aimed to assess the performance of manual expert versus automated 12‐lead electrocardiogram (ECG) analysis in the prediction of VA origin. Methods: Patients with ablation of idiopathic VA and sustained success were included. The VA origin was defined as the site where ablation caused arrhythmia suppression. Standard baseline 12‐lead ECGs with documentation of the VA were analyzed manually in a blinded fashion by three electrophysiologists and three electrophysiology (EP) fellows. In addition, the same standard 12‐lead ECG was analyzed by an automated computer algorithm using a vectorcardiographic approach. Results: Thirty‐eight patients (median age, 47 [interquartile range, 37–58]; 68% female) were enrolled. The VA originated from the right ventricle in 24 (63%) and the left ventricle in 14 (37%) patients. The electrophysiologists and EP fellows identified the VA chamber of origin with a similar accuracy of 73% and 72% (P =.72). The automated algorithm showed a higher accuracy of 89% (P =.03 compared with electrophysiologists and EP fellows). This resulted in a sensitivity of 95% and specificity of 86%. Conclusion: While the manual ECG analysis of the standard 12‐lead ECG by both electrophysiologists and EP fellows correctly identified the chamber of VA origin in around 75% of cases, an automated vectorcardiographic computer algorithm achieved an accuracy of 89% with clinically acceptable diagnostic parameters. [ABSTRACT FROM AUTHOR]

Background: Due to high failure rates, Medtronic withdrew the Sprint Fidelis lead (SFL) from the market. Passive fixation lead models exhibited better survival than active models, but most studies have limited follow‐up. Aim of this study was to give insights into passive lead survival with a follow‐up of 10 years. Methods: In two large Swiss centers, patients with passive SFLs were identified and data from routine implantable cardioverter defibrillator (ICD) follow‐ups were collected. Patients were censored at time of death, last device interrogation (if lost to follow‐up), time of lead revision (in non‐SFL‐related problems), or at database closure (31th December 2017). We defined lead failure as any of the following: lead fracture with inappropriate discharge; sudden increase in low‐voltage impedance to >1500 or high‐voltage impedance to >100 Ω; >300 nonphysiological short VV‐intervals. Results: We identified 145 patients. Age at implant was 60 ± 12 years with a median follow‐up of 10.2 (interquartile range [IQR]: 5.0‐11.2) years. Thirty‐five percent of patients died after 5.4 ± 2.7 years. A total of 19 leads (13%) failed after 6.7 ± 3.2 years (range: 1.2‐12.0). Overt malfunction with shocks existed in four patients (3%). Cumulative lead survival was 93.1% at 6, 88.2% at 8, 83.8% at 10, and 77.6% at 11 years, respectively, with 35% of implanted leads under monitoring at 10 years. Lead survival fits best a Weibull distribution with accelerating failure rates (k = 1.95, 95% CI 1.32‐2.87, P < 0.001). Conclusions: During very long‐term follow‐up, failure rate of the passive SFL shows an increase resulting in an impaired lead survival of 84% at 10 years. [ABSTRACT FROM AUTHOR]

Introduction: Difference between high-sensitivity cardiac troponin T concentrations (hs-cTnT) before and after ablation procedure (delta concentration) reflects the amount of myocardial injury. The aim of the study was to investigate hs-cTnT prognostic power for predicting atrial fibrillation (AF) recurrence after repeat pulmonary vein isolation (PVI) procedure. Materials and methods: Consecutive patients with paroxysmal AF undergoing repeat PVI using a focal radiofrequency catheter were included in the study. Hs-cTnT was measured before and 18-24 hours after the procedure. Standardized 3, 6 and 12-month follow-up was performed. Cox-regression analysis was used to identify predictors of AF recurrence. Results: A total of 105 patients undergoing repeat PVI were analysed (24% female, median age 61 years). Median (interquartile range) hs-cTnT delta after repeat PVI was 283 (127 - 489) ng/L. After a median follow-up of 12 months, AF recurred in 24 (23%) patients. A weak linear relationship between the total radiofrequency energy delivery time and delta hs-cTnT was observed (Pearson R2 = 0.31, P = 0.030). Delta Hs-cTnT was not identified as a significant long-term predictor of AF recurrence after repeated PVI (P = 0.920). Conclusion: This was the first study evaluating the prognostic power of delta hs-cTnT in predicting AF recurrence after repeat PVI. Delta hs-cTnT does not predict AF recurrence after repeat PVI procedures. Systematic measurement of hs-cTnT after repeat PVI does not add information relevant to outcome. [ABSTRACT FROM AUTHOR]

Background: Dual antiplatelet therapy (DAPT) prevents thrombotic events after coronary stent implantation but may induce bleedings, specifically in elderly patients. However, a competitive risk analysis is lacking. Objectives: To assess the determinants of major bleeding and the balance between the competing risks of major bleeding and thrombotic events during prasugrel-based DAPT after stent implantation. Methods: Overall, 2,291 patients randomized to drug-eluting or bare metal stents and treated with prasugrel 10mg/day for 1 year were followed over 2 years for major bleeding (BARC 3/5) and thrombotic events (cardiac death, myocardial infarction, definitive/probable stent thrombosis). Prasugrel dose was reduced to 5mg in patients >75 years and/or <60kg. Predictors of major bleeding and competing risks of major bleeding and thrombotic events were assessed. Results: Two-year rates of major bleeding and thrombotic events were 2.9% and 9.0%, respectively. The only independent predictor of major bleeding was age (hazard ratio per year increase 1.05 [1.02,1.07], p<0.001). The relationship between major bleeding and age was non-linear, with lowest hazard ratios at 57 years and an exponential increase only above 65 years. In contrast, the relationship between thrombotic events and age was linear and continuously increasing with older age. While the competing risk of thrombotic events was higher than that of major bleeding in younger patients, the two risks were similar in older patients. After discontinuation of prasugrel, bleeding events leveled off in all patients, while thrombotic events continued to increase. Conclusions: In prasugrel-based DAPT, age is the strongest risk factor for major bleeding, increasing exponentially >65 years. In younger patients, thrombotic events represent a higher risk than bleeding, while thrombotic and bleeding risks were similar in older patients. Important clinical implications relate to prasugrel dose in the elderly, duration of DAPT and the competing risk balance necessitating individualized treatment decisions. [ABSTRACT FROM AUTHOR]

Background: Drug-coated balloons (DCB) are a novel therapeutic strategy for small native coronary artery disease. However, their safety and efficacy is poorly defined in comparison with drug-eluting stents (DES).Methods: BASKET-SMALL 2 was a multicentre, open-label, randomised non-inferiority trial. 758 patients with de-novo lesions (<3 mm in diameter) in coronary vessels and an indication for percutaneous coronary intervention were randomly allocated (1:1) to receive angioplasty with DCB versus implantation of a second-generation DES after successful predilatation via an interactive internet-based response system. Dual antiplatelet therapy was given according to current guidelines. The primary objective was to show non-inferiority of DCB versus DES regarding major adverse cardiac events (MACE; ie, cardiac death, non-fatal myocardial infarction, and target-vessel revascularisation) after 12 months. The non-inferiority margin was an absolute difference of 4% in MACE. This trial is registered with ClinicalTrials.gov, number NCT01574534.Findings: Between April 10, 2012, and February 1, 2017, 382 patients were randomly assigned to the DCB group and 376 to DES group. Non-inferiority of DCB versus DES was shown because the 95% CI of the absolute difference in MACE in the per-protocol population was below the predefined margin (-3·83 to 3·93%, p=0·0217). After 12 months, the proportions of MACE were similar in both groups of the full-analysis population (MACE was 7·5% for the DCB group vs 7·3% for the DES group; hazard ratio [HR] 0·97 [95% CI 0·58-1·64], p=0·9180). There were five (1·3%) cardiac-related deaths in the DES group and 12 (3·1%) in the DCB group (full analysis population). Probable or definite stent thrombosis (three [0·8%] in the DCB group vs four [1·1%] in the DES group; HR 0·73 [0·16-3·26]) and major bleeding (four [1·1%] in the DCB group vs nine [2·4%] in the DES group; HR 0·45 [0·14-1·46]) were the most common adverse events.Interpretation: In small native coronary artery disease, DCB was non-inferior to DES regarding MACE up to 12 months, with similar event rates for both treatment groups.Funding: Schweizerischer Nationalfonds zur Förderung der Wissenschaftlichen Forschung, Basel Cardiovascular Research Foundation, and B Braun Medical AG. [ABSTRACT FROM AUTHOR]

Background: Patients with atrial fibrillation (AF) have an increased risk for the development of heart failure (HF). In this study, we aimed to detect predictors of HF hospitalizations in an unselected AF population. Methods: The Basel Atrial Fibrillation Cohort Study is an ongoing observational multicenter cohort study in Switzerland. For this analysis, 1193 patients with documented AF underwent clinical examination, venous blood sampling and resting 12-lead ECG at baseline. Questionnaires about lifestyle and medical history were obtained in person at baseline and during yearly follow-up phone calls. HF hospitalizations were validated by two independent physicians. Cox regression analyses were performed using a forward selection strategy. Results: Overall, 29.8% of all patients were female and mean age was 69 ±12 years. Mean follow-up time was 3.7 ±1.5 years. Hospitalization for HF occurred in 110 patients, corresponding to an incidence of 2.5 events per 100 person years of follow-up. Independent predictors for HF were body mass index (HR 1.40 [95%CI 1.17; 1.66], p = 0.0002), chronic kidney disease (2.27 [1.49; 3.45], p = 0.0001), diabetes mellitus (2.13 [1.41; 3.24], p = 0.0004), QTc interval (1.25 [1.04; 1.49], p = 0.02), brain natriuretic peptide (2.19 [1.73; 2.77], p<0.0001), diastolic blood pressure (0.79 [0.65; 0.96], p = 0.02), history of pulmonary vein isolation or electrical cardioversion (0.54 [0.36; 0.80], p = 0.003) and serum chloride (0.82 [0.70; 0.96], p = 0.02). Conclusions: In this unselected AF population, several traditional cardiovascular risk factors and arrhythmia interventions predicted HF hospitalizations, providing potential opportunities for the implementation of strategies to reduce HF among AF patients. [ABSTRACT FROM AUTHOR]

Background A longer QTc interval has been associated with more adverse cardiovascular events and death in the general population. Little evidence is available on these relationships among patients with atrial fibrillation (AF). Methods We performed a prospective observational multicenter cohort study of 1413 patients with AF. A resting 12‑lead electrocardiogram (ECG) was performed at baseline. QT interval was corrected for heart rate using the Bazett formula (QTc). Endpoints for this study included hospitalizations for congestive heart failure (CHF), a combination of cardiovascular death, myocardial infarction, stroke, systemic arterial embolism (MACE) and all-cause mortality. Results Mean age of our population was 68 ± 12 years and 420 (30%) participants were female. Median QTc was 432 ms (interquartile range 409; 457). The mean follow-up time was 3.6 ± 1.5 years. After multivariable adjustment, there was a linear increase in risk with increasing QTc interval for incident CHF (hazard ratio (HR) per 1-SD increase in QTc 1.3 [95% CI 1.1; 1.6], p = 0.008), MACE (HR 1.2 [1.0; 1.4], p = 0.02) and all-cause mortality (HR 1.3 [1.0; 1.6], p = 0.002). Results were consistent whether or not patients were in sinus rhythm on the baseline ECG (HR for CHF 1.7 versus 1.3, p interaction 0.08; HR for MACE 1.3 versus 1.2, p interaction 0.9; HR for all-cause mortality 1.4 versus 1.4, p interaction 0.9). Conclusions In this large well-characterized cohort of AF patients, QTc interval was independently associated with adverse outcomes. These results were independent of the rhythm on the baseline ECG. [ABSTRACT FROM AUTHOR]

Background Anatomically guided pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. However, the position where to confirm electrical isolation is ill-defined. The aim of the current study was to quantify the relationship between the anatomical and electrical definition of the pulmonary vein ostium. Methods We analyzed 20 patients with paroxysmal AF undergoing PVI using radiofrequency energy and an electroanatomical mapping system. The anatomical ostium was defined based on the geometry obtained from preprocedural magnetic resonance imaging and computed tomography. The electrical ostium was defined at the position with a far-field atrial signal preceding a sharp pulmonary vein (PV) signal without any isoelectric interval in between. Results The electrically defined ostia were 8.4 ± 4.7 mm more distal in the PV compared to the anatomically defined ostia. The distances varied considerably between the four PVs and were 10.5 ± 6.5 mm, 7.4 ± 4.3 mm, 5.3 ± 4.0 mm, and 8.3 ± 3.4 mm for the left superior, left inferior, right superior, and right inferior PVs, respectively (P = 0.009). Conclusions The position of the electrical and anatomical ostium differs markedly. The site of the electrical ostium is variable within the PV but always more distal in the PV compared to the site of the anatomical ostium. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 18-year-old male with a history of symptomatic tachycardia who was referred for ablation. Echocardiography was performed which showed Ebstein's anomaly with apical displacement of the septal tricuspid valve leaflet and tricuspid valve regurgitation. The study demonstrates that the abnormal activation of the right ventricle leading to the wide right bundle branch block pattern may be unmasked during orthodromic atrioventricular-reentry tachycardia.

Echocardiography to Predict AF Recurrence Background Arrhythmia recurrence after atrial fibrillation (AF) ablation remains high and requires repeat interventions in a substantial number of patients. We assessed the value of conventional and 3-D echocardiography to predict AF recurrence. Methods and Results Consecutive patients undergoing AF ablation by means of pulmonary vein isolation were included in a prospective registry. Echocardiograms were obtained prior to the ablation procedure, and analyzed offline in a standardized manner, including 3-D left atrial (LA) volumetry and determination of LA function and sphericity. The primary endpoint, AF recurrence (>30 seconds) between 3 to 12 months after AF ablation, was independently adjudicated. We included 276 patients (73% male, mean age 59.9 ± 9.9 years). Paroxysmal and persistent AF were present in 178 (64%) and 98 (36%) patients, respectively. Mean left ventricular ejection fraction and indexed LA volume in 3-D (LAVI) were 52 ± 12% and 42 ± 13 mL/m2, respectively. AF recurrence was observed in 110 (40%) patients after a single procedure. Median (interquartile range) time to AF recurrence was 123 (92; 236) days. In multivariable Cox regression models, the only predictors for AF recurrence were the minimal, maximal, and indexed 3-D LA volumes, P = 0.024, P = 0.016, and P = 0.014, respectively. Quartile specific analysis of 3-D LAVI showed an HR of 1.885 (95%CI 1.066-3.334; P for trend = 0.015) for the highest compared to the lowest quartile. Conclusion Our results show the important role of LA volume for the long-term freedom from arrhythmia after AF ablation. These data also highlight the potential of 3-D echocardiography in this context and may facilitate patient selection for AF ablation. [ABSTRACT FROM AUTHOR]

Aims: Treatment goals in acute heart failure (AHF) are poorly defined. We aimed to characterize further the impact of in-hospital haemoconcentration and worsening renal function (WRF) on short- and long-term mortality.Methods and Results: Haematocrit, haemoglobin, total protein, serum creatinine, and albumin levels were measured serially in 1019 prospectively enrolled AHF patients. Haemoconcentration was defined as an increase in at least three of four of the haemoconcentration-defining parameters above admission values at any time during the hospitalization. Patients were divided into early (Day 1-4) and late haemoconcentration (>Day 4). Ninety-day mortality was the primary endpoint. Haemoconcentration occurred in 392 (38.5%) patients, with a similar incidence of the early (44.6%) and late (55.4%) phenotype. Signs of decongestion (reduction in BNP blood concentrations, P = 0.003; weight loss, P = 0.002) were significantly more pronounced in haemoconcentration patients. WRF was more common in haemoconcentration patients (P = 0.04). After adjustment for established risk factors for AHF mortality, including WRF and HF therapy at discharge, haemoconcentration was significantly associated with a reduction in 90-day mortality [hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.37-0.95, P = 0.01]. The beneficial effect of haemoconcentration seemed to be exclusive for late haemoconcentration (late vs. early: adjusted HR 0.41, 95% CI 0.19-0.90, P = 0.03) and persisted in patients with or without WRF.Conclusions: Haemoconcentration represents an inexpensive and easily assessable pathophysiological signal of adequate decongestion in AHF and is associated with lower mortality. WRF in the setting of haemoconcentration does not appear to offset the benefits of haemoconcentration. [ABSTRACT FROM AUTHOR]

Aims: Treatment goals in acute heart failure (AHF) are poorly defined. We aimed to characterize further the impact of in-hospital haemoconcentration and worsening renal function (WRF) on short- and long-term mortality. Methods and results: Haematocrit, haemoglobin, total protein, serum creatinine, and albumin levels were measured serially in 1019 prospectively enrolled AHF patients. Haemoconcentration was defined as an increase in at least three of four of the haemoconcentration-defining parameters above admission values at any time during the hospitalization. Patients were divided into early (Day 1-4) and late haemoconcentration (>Day 4). Ninety-day mortality was the primary endpoint. Haemoconcentration occurred in 392 (38.5%) patients, with a similar incidence of the early (44.6%) and late (55.4%) phenotype. Signs of decongestion (reduction in BNP blood concentrations, P = 0.003; weight loss, P = 0.002) were significantly more pronounced in haemoconcentration patients. WRF was more common in haemoconcentration patients (P = 0.04). After adjustment for established risk factors for AHF mortality, including WRF and HF therapy at discharge, haemoconcentration was significantly associated with a reduction in 90-day mortality [hazard ratio (HR) 0.59, 95% confidence interval (CI) 0.37-0.95, P = 0.01]. The beneficial effect of haemoconcentration seemed to be exclusive for late haemoconcentration (late vs. early: adjusted HR 0.41, 95% CI 0.19-0.90, P = 0.03) and persisted in patients with or without WRF. Conclusions: Haemoconcentration represents an inexpensive and easily assessable pathophysiological signal of adequate decongestion in AHF and is associated with lower mortality. WRF in the setting of haemoconcentration does not appear to offset the benefits of haemoconcentration. [ABSTRACT FROM AUTHOR]

Background Prediction of events in chronic heart failure (CHF) patients is still difficult and available scores are often complex to calculate. Therefore, we developed and validated a simple-to-use, multidimensional prognostic index for such patients. Methods A theoretical model was developed based on known prognostic factors of CHF that are easily obtainable: Body mass index (B), Age (A), Resting systolic blood pressure (R), Dyspnea (D), N-termInal pro brain natriuretic peptide (NT-proBNP) (I), Cockroft-Gault equation to estimate glomerular filtration rate (C), resting Heart rate (H), and Exercise performance using the 6-min walk test (E) (the BARDICHE-index). Scores were given for all components and added, the sum ranging from 1 (lowest value) to 25 points (maximal value), with estimated risk being highest in patients with highest scores. Scores were categorized into three groups: a low (≤ 8 points); medium (9–16 points), or high (> 16 points) BARDICHE-score. The model was validated in a data set of 1811 patients from two prospective CHF-cohorts (median follow-up 887 days). The primary outcome was 5-year all-cause survival. Secondary outcomes were 5-year survival without all-cause hospitalization and 5-year survival without CHF-related hospitalization. Results There were significant differences between BARDICHE-risk groups for mortality (hazard ratio = 3.63 per BARDICHE-group, 95%-CI 3.10–4.25), mortality or all-cause hospitalization (HR = 2.00 per BARDICHE-group, 95%-CI 1.83–2.19), and mortality or CHF-related hospitalization (HR = 3.43 per BARDICHE-group, 95%-CI 3.01–3.92; all P < 10–50). Outcome was predicted independently of left ventricular ejection fraction (LVEF) and gender. Conclusions The BARDICHE-index is a simple multidimensional prognostic tool for patients with CHF, independently of LVEF. [ABSTRACT FROM AUTHOR]

Introduction: Left atrial (LA) enlargement is an important risk factor for incident stroke and a key determinant for the success of rhythm control strategies in patients with atrial fibrillation (AF). However, factors associated with LA volume in AF patients remain poorly understood. Methods: Patients with paroxysmal or persistent AF were enrolled in this study. Real time 3-D echocardiography was performed in all participants and analyzed offline in a standardized manner. We performed stepwise backward linear regression analyses using a broad set of clinical parameters to determine independent correlates for 3-D LA volume. Results: We included 210 patients (70.9% male, mean age 61±11years). Paroxysmal and persistent AF were present in 95 (45%) and 115 (55%) patients, respectively. Overall, 115 (55%) had hypertension, 11 (5%) had diabetes, and 18 (9%) had ischemic heart disease. Mean indexed LA volume was 36±12ml/m2. In multivariable models, significant associations were found for female sex (β coefficient -10.51 (95% confidence interval (CI) -17.85;-3.16), p = 0.0053), undergoing cardioversion (β 11.95 (CI 5.15; 18.74), p = 0.0006), diabetes (β 14.23 (CI 2.36; 26.10), p = 0.019), body surface area (BSA) (β 34.21 (CI 19.30; 49.12), p<0.0001), glomerular filtration rate (β -0.21 (CI -0.36; -0.06), p = 0.0064) and plasma levels of NT-pro brain natriuretic peptide (NT-proBNP) (β 6.79 (CI 4.05; 9.52), p<0.0001), but not age (p = 0.59) or hypertension (p = 0.42). Our final model explained 52% of the LA volume variability. Conclusions: In patients with AF, the most important correlates with LA volume are sex, BSA, diabetes, renal function and NT-proBNP, but not age or hypertension. These results may help to refine rhythm control strategies in AF patients. [ABSTRACT FROM AUTHOR]

Direct oral anticoagulants (DOACs) have a favourable risk-benefit profile compared to vitamin K-antagonists (VKAs) in atrial fibrillation (AF). Dosing is based on age, weight and renal function, without need of routine monitoring. In two prospective, multicentre AF cohorts (Swiss-AF, BEAT-AF) patients were stratified as receiving VKAs or adequately-, under- or overdosed DOACs, according to label. Primary outcome was a composite of major adverse clinical events (MACE), defined as cardiovascular death, myocardial infarction (MI), ischaemic stroke and systemic embolism. Secondary outcomes included major bleeding. Adjustment for confounding was performed. Median follow-up was 4 years. Of 3236 patients, 1875 (58%) were on VKAs and 1361 (42%) were on DOACs, of which 1137 (83%) were adequately-, 134 (10%) over- and 90 (7%) under-dosed. Compared to adequately dosed individuals, overdosed patients were more likely to be older and female. Underdosing correlated with concomitant aspirin therapy and coronary artery disease. Both groups had higher CHA 2 DS 2 -VASc scores. Patients on overdosed DOACs had higher incidence of MACE (HR 1.75; CI 1.10–2.79; adjusted-HR: 1.22) and major bleeding (HR 1.99; CI 1.14–3.48; adjusted-HR: 1.51). Underdosing was not associated with a higher incidence of MACE (HR 0.94; CI 0.46–1.92; adjusted-HR 0.61) or major bleeding (HR 1.07; CI 0.46–2.46; adjusted-HR 0.82). After adjustment, all CIs crossed 1.0. Inappropriate DOAC-dosing was more prevalent in multimorbid patients, but did not correlate with higher risks of adverse events after adjusting for confounders. DOAC prescription should follow label. [ABSTRACT FROM AUTHOR]

Objective The novel high-sensitivity cardiac troponin (hs-cTn) 0 h/1 h-algorithm substantially improves the early triage of patient's assigned “rule-out” or “rule-in” of acute myocardial infarction (AMI), while diagnostic uncertainty remains in that 25–30% of patients assigned to “observe”. We aimed to better characterize these patients. Methods In a prospective multicenter diagnostic study, we applied the hs-cTnT 0 h/1 h-algorithm in 2213 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists using all available information. Survival at 720-days was the prognostic endpoint. Findings were validated using a hs-cTnI 0 h/1 h-algorithm. Results Twenty-four percent (n = 523) of patients were assigned to “observe” by the hs-cTnT 0 h/1 h-algorithm. These patients differed significantly in multiple characteristics from “rule-out” and “rule-in” patients: they were older, in 75% male, and very often (57%) had pre-existing coronary artery disease (CAD). Diagnostic uncertainty for the presence of an AMI/UA was high. Only 39% of patients were suitable for coronary computed tomography angiography (CCTA). The most common final adjudicated diagnoses were non-cardiac disease (38%), non-coronary cardiac disease (24%), unstable angina (UA, 21%), and AMI (15%). Absolute hs-cTnT-changes within 3 h had the highest diagnostic accuracy for AMI (AUC 0.86). Cumulative 720-day survival rate was 86%, which was significantly lower as compared to “rule-out” (p < 0.001) and comparable to “rule-in” (p = ns). Findings were similar for the hs-cTnI “observe” zone. Conclusion “Observe” patients are typically elderly men with pre-existing CAD and high long-term mortality. Absolute hs-cTn-changes within 3 h, functional stress imaging and coronary angiography are the key diagnostic modalities. [ABSTRACT FROM AUTHOR]

Introduction: The advent of electroanatomical mapping (EAM) systems for pulmonary vein isolation (PVI) has dramatically decreased radiation exposure. However, the need for some fluoroscopy remains for obtaining left atrial (LA) access. The aim was to test the feasibility of fluoroscopy-free PVI in patients with atrial fibrillation (AF) and a patent foramen ovale (PFO) guided solely by an EAM system. Methods: Consecutive patients with AF undergoing PVI and documented PFO were studied. An EAM-guided approach without fluoroscopy and ultrasound was used. After completing the map of the right atrium, the superior vena cava and the coronary sinus, a catheter pull-down to the PFO was performed allowing LA access. The map of the LA and subsequent PVI was also performed without fluoroscopy. Results: 30 patients [age 61±12 years, 73% male, ejection fraction 0.64 (0.53–0.65), LA size in parasternal long axis 38±7 mm] undergoing PVI were included. The time required for right atrial mapping including transseptal crossing was 9±4 minutes. Total procedure time was 127±37 minutes. Fluoroscopy-free PVI was feasible in 26/30 (87%) patients. In four patients, fluoroscopy was needed to access (n = 3) or to re-access (n = 1) the LA. In these four patients, total fluoroscopy time was 5±3 min and the DAP was 14.9±13.4 Gy*cm2. Single-procedure success rate was 80% (24/30) after a median follow-up of 12 months. Conclusion: In patients with a documented PFO, completely fluoroscopy-free PVI is feasible in the vast majority of cases. [ABSTRACT FROM AUTHOR]

Objective We explored whether hemodynamic cardiac stress leads to a differential release of cardiomyocyte injury biomarkers, used in the diagnosis of acute myocardial infarction (AMI). Methods In an observational international multicenter study, we enrolled 831 unselected patients presenting with symptoms suggestive of AMI to the emergency department. The final diagnosis was adjudicated by two independent cardiologists. Hemodynamic cardiac stress was quantified by levels of B-type natriuretic peptide (BNP). Spearman's rho correlation was used to analyze the correlations between BNP and high-sensitivity cardiac troponin T (hs-cTnT), Siemens cTnI-Ultra (cTnI-ultra), CK-MB and Myoglobin. Patients were categorized according to the extent of hemodynamic cardiac stress as quantified by BNP tertiles. Results Among all patients, the positive pair-wise correlation with BNP was strongest with hs-cTnT and cTnI-ultra (r = 0.58 and 0.50, respectively), moderate for Myoglobin (r = 0.43), and weakest with CK-MB (r = 0.25; p < 0.001 for each). Similar pattern of correlations was also observed among AMI patients. Among patients diagnosed with non-cardiac cause of chest pain (n = 385, 46%) and cardiac but non-coronary (n = 109, 13%), BNP had significant positive correlations with hs-cTnT, cTnI-ultra and Myoglobin (p < 0.05), but not with CK-MB (p = NS). A similar pattern of stronger correlation between BNP and hs-cTnT, cTnI-ultra and Myoglobin as compared to that with CK-MB was also observed within the higher BNP tertile range. There was no correlation between BNP and other biomarkers within the 1st BNP tertile group. Conclusion Hemodynamic cardiac stress, as quantified by BNP, as a likely cause of cardiomyocyte injury, is more closely reflected by concentrations of hs-cTnT, cTnI-ultra and Myoglobin than CK-MB. [ABSTRACT FROM AUTHOR]

Background A recent pilot study suggested that exercise-induced myocardial ischaemia may lead to a delayed release of cardiac biomarkers, so that later sampling, for example, at 4 h after exercise could be used for diagnostic purpose. Materials and methods In an observational study, we enrolled 129 consecutive patients referred for evaluation of a suspected coronary artery disease by rest/stress myocardial perfusion single-photon emission computed tomography. The treating cardiologist used all available clinical information to quantify clinical judgment regarding the presence of myocardial ischaemia using a visual analogue scale twice: prior and after stress testing. BNP levels were determined in a blinded fashion at rest, at peak stress and 4 h after peak stress. The presence of myocardial ischaemia was adjudicated based on perfusion single-photon emission computed tomography and coronary angiography findings by an independent cardiologist. Results Myocardial ischaemia was detected in 58 patients (45%). Patients with myocardial ischaemia had significantly higher BNP levels at all times, compared to patients without ischaemia: BNP rest (99 vs. 61 pg/mL P = 0·007), BNP stress (125 vs. 77 pg/mL P = 0·02) and BNP 4 h (114 vs. 71 pg/mL P = 0·018). Diagnostic accuracy as quantified by the area under the receiver operating characteristics curve ( AUC) was moderate for all time points ( AUC 0·64-0·66). The change in BNP between rest and 4 h did not provide added value, neither to the baseline BNP level nor to clinical judgment. Conclusion In contrast to our hypothesis, myocardial ischaemia did not lead to a differential delayed release of BNP. Late sampling did not seem clinically useful. [ABSTRACT FROM AUTHOR]

Background Many patients receiving an implantable cardioverter-defibrillator (ICD) also have atrial fibrillation (AF). Shock testing during ICD implantation carries a potential risk of cardioversion to sinus rhythm (SR) and thrombembolic events. We aimed to analyze the recurrence of AF after cardioversion to SR during ICD shock testing. Methods A total of 555 consecutive patients referred to a tertiary hospital in Switzerland for ICD implantation or generator exchange between 02/2002 and 03/2010 were screened for AF. Fifty-seven patients who were in AF at the time of ICD shock testing were included. Results Forty-four patients (77%) were successfully cardioverted from AF to SR. Type of AF (persistent, not permanent 64 vs 31% of cardioverted patients) was the only predictor. Thirty-nine patients (89%) experienced a recurrence of AF/atrial flutter after a median of 54 days (interquartile range 35-251 days). The only predictor for recurrence of AF was previous AF declared as permanent. No ischemic stroke occurred during hospitalization for the procedure. Conclusions For patients in AF undergoing shock testing at the time of ICD implant, there is a high chance of cardioversion from AF to SR, but there is also a high risk of early recurrence. Decisions regarding long-term anticoagulation should not be based on the heart rhythm immediately following shock testing. [ABSTRACT FROM AUTHOR]