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Ventricular scar is traditionally highlighted on a bipolar voltage (BiVolt) map in areas of myocardium0.50mV. We describe an alternative approach using Ripple Mapping (RM) superimposed onto a BiVolt map to differentiate post-infarct scar from conducting borderzone (BZ) during VT ablation.15 consecutive patients (LVEF 30±7%) underwent endocardial LV Pentaray mapping (median 5148 points) and ablation targeting areas of late Ripple activation. BiVolt maps were studied offline at initial voltage of 0.50-0.50mV to binarize the color display (red and purple). RMs were superimposed, and the BiVolt limits were sequentially reduced until only areas devoid of Ripple bars appeared red, defined as RM-scar. The surrounding area supporting conducting Ripple wavefronts in tissue0.50mV defined the RM-Borderzone (RM-BZ).RM-scar was significantly smaller than the traditional 0.50mV cutoff (median 4% vs 12% shell area, p0.001). 65±16% of tissue0.50mV supported Ripple activation within the RM-BZ. The mean BiVolt threshold that differentiated RM-scar from borderzone tissue was 0.22±0.07mV, though this ranged widely (from 0.12mV-0.35mV). In this study, septal infarcts (7/15) were associated with more rapid VTs (282 vs 347ms, p=0.001), and had a greater proportion of RM-BZ to RM-scar (median ratio 3.2 vs 1.2, p=0.013) with faster RM-BZ conduction speed (0.72 vs 0.34 m/sec, p=0.001). Conversely, scars that supported hemodynamically stable sustained VT (6/15) were slower (367±38ms), had a smaller proportion of RM-BZ to RM-scar (median ratio 1.2 vs 3.2, p=0.059), and slower RM-BZ conduction speed (0.36 vs 0.63 m/sec, p=0.036). RM guided ablation collocated within 66±20% of RM-BZ, most concentrated around the RM-scar perimeter, with significant VT reduction (median 4.0 episodes pre-ablation vs 0 post, p0.001) at 11±6 months follow-up.Post-infarct scars appear significantly smaller than traditional 0.50mV cut-offs suggest, with voltage thresholds unique to each patient. This article is protected by copyright. All rights reserved.

Very high power short duration (vHPSD) radiofrequency ablation (RFA) may reduce ablation times and improve patient tolerability, permitting pulmonary vein isolation (PVI) under mild conscious sedation (mCS) and promoting same day discharge (SDD).First, a retrospective feasibility study was performed at 2 tertiary cardiac centres in the UK. Consecutive cases of first-time PVI using vHPSD ablation with 90 W lesions for up to 4 s were compared against cases performed using standard RF (sRF) and cryoballoon (Cryo) therapy. Subsequently, a prospective study of patients who had vHPSD or Cryo exclusively under mCS was undertaken. Questionnaires based on Likert and visual analogue scales (VAS) were used to measure anxiety, discomfort and pain.In total, 182 patients (59 vHPSD, 62 sRF and 61 Cryo) were included in the retrospective study, with 53 (90%) of vHPSD cases successfully performed under mCS. PVI ablation time in the vHPSD group (5.8 ± 1.7 min) was shorter than for sRF (16.5 ± 6.3 min, p 0.001) and Cryo (17.5 ± 5.9 min, p 0.001). Fifty-one vHPSD and 52 Cryo patients were included in the prospective study. PVI ablation time in the vHPSD group was shorter than for the Cryo group (6.4 ± 2.9 min vs 17.9 ± 5.7 min, p 0.001), but overall procedure duration was longer (121 ± 39 min vs 95 ± 20 min, p 0.001). There were no differences in the patient experience of anxiety, discomfort or pain. SDD rates were the same in both groups (61% vs 67%, p = 0.49).vHPSD RFA for PVI can be performed under mCS to achieve SDD rates comparable to cryoablation, without compromising patient experience.

AimsTo examine (i) the sex-specific associations between three social determinants of health (SDOH) and use of ablation after incident atrial fibrillation (AF), and (ii) the temporal trends in these associations.Methods and resultsWe conducted a nationwide cohort study of patients with an incident hospital diagnosis of AF between 2005 and 2018. SDOH at the time of AF diagnosis included three levels of educational attainment, tertile groups of family income, and whether the patient was living alone. Outcome was catheter ablation for AF. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% CI and adjusted for age. To examine temporal trends, we included an interaction term between the exposure and calendar years. Among 122 276 men, those with lower education [HR 0.49 (95%CI 0.45–0.53)] and 0.72 (0.68–0.77) for lower and medium vs. higher], lower income [HR 0.31 (0.27–0.34) and 0.56 (0.52–0.60) for lower and medium vs. higher], and who lived alone [HR 0.60 (0.55–0.64)] were less likely to receive AF ablation. Among 98 476 women, those with lower education [HR 0.45 (0.40–0.50) and 0.83 (0.75–0.91) for lower and medium vs. higher], lower income [HR 0.34 (0.28–0.40) and 0.51 (0.46–0.58) for lower and medium vs. higher], and who lived alone [HR 0.67 (0.61–0.74)] were less likely to receive AF ablation. We found no evidence of temporal trends in the associations.ConclusionIn the Danish universal healthcare system, patients with AF who had lower educational attainment, lower family income, or were living alone were less likely to undergo AF ablation.

Background Atrial fibrillation (AF) is a well-established risk factor for intracardiac thrombosis. Left atrial appendage occlusion (LAAO) is emerging as a viable alternative to oral anticoagulation (OAC) for high-risk AF patients who are contraindicated to long-term OAC. Case summary A 74-year-old man with a history of permanent AF and subdural haemorrhage on warfarin therapy was referred to our facility for further management. Cardiac CT imaging revealed large bi-atrial thrombi for which apixaban therapy was initiated. Serial imaging over nine months showed gradual shrinkage and then resolution of the thrombi. In line with the patient’s preference to avoid life-long OAC, he received LAAO using an Amplatzer™ Amulet™ device. Follow-up transoesophageal echocardiography showed a well-seated device with no leak and no thrombus. Discussion We discussed the key issues surrounding management of bi-atrial thrombi and the decision to perform LAAO in these circumstances, relying on shared decision making and multi-disciplinary team input.

Introduction: South Asian individuals comprise almost a quarter of the world's population and have an excess risk of atherosclerotic cardiovascular disease (ASCVD) compared to other ethnicities. In part, this can be explained by higher prevalence, earlier onset, and suboptimal control of traditional cardiovascular risk factors, such as insulin resistance, metabolic syndrome, and dyslipidaemia. However, there remains a significant residual excess risk associated with South Asian ethnicity after controlling for traditional risk factors.Areas covered: In this review, we describe the epidemiology of ASCVD in both native and diaspora South Asian populations. We explore how traditional cardiovascular risk factors, novel cardiovascular risk factors, and social determinants of health may contribute to the excess ASCVD risk seen in South Asian populations.Expert opinion: There should be increased awareness of the relative importance of South Asian ethnicity and related social determinants of health, as risk factors for ASCVD. Systematic screening processes should be tailored to this population, and modifiable risk factors should be treated aggressively. Further research is required to quantify determinants of the excess ASCVD risk seen in South Asian populations and to develop targeted interventions to address these factors. Introduction: South Asian individuals comprise almost a quarter of the world's population and have an excess risk of atherosclerotic cardiovascular disease (ASCVD) compared to other ethnicities. In part, this can be explained by higher prevalence, earlier onset, and suboptimal control of traditional cardiovascular risk factors, such as insulin resistance, metabolic syndrome, and dyslipidaemia. However, there remains a significant residual excess risk associated with South Asian ethnicity after controlling for traditional risk factors.Areas covered: In this review, we describe the epidemiology of ASCVD in both native and diaspora South Asian populations. We explore how traditional cardiovascular risk factors, novel cardiovascular risk factors, and social determinants of health may contribute to the excess ASCVD risk seen in South Asian populations.Expert opinion: There should be increased awareness of the relative importance of South Asian ethnicity and related social determinants of health, as risk factors for ASCVD. Systematic screening processes should be tailored to this population, and modifiable risk factors should be treated aggressively. Further research is required to quantify determinants of the excess ASCVD risk seen in South Asian populations and to develop targeted interventions to address these factors.

Atrial fibrillation (AF) has a recognized association with not only stroke, but also neurocognitive impairment and both vascular and Alzheimer's dementia. Effective management of AF can reduce the risk of such complications. In this narrative review article, we discuss the pathophysiological links between AF and dementia, as well as the benefits of adherence to the guideline-recommended ‘ABC’ pathway.

Aims To examine the associations between three social determinants of health (SDOH) and recurrence of AF after ablation. Methods and results We selected patients who underwent a first ablation after an incident hospital diagnosis of AF between 2005 and 2018 from the entire Danish population. Educational attainment, family income, and whether the patient was living alone were assessed at the time of ablation. We used cause-specific proportional hazard models to estimate hazard ratios (HR) with 95% confidence interval (CI) adjusted for age and sex. In secondary analyses, we adjusted for comorbidities, antiarrhythmic medication, and prior electrical cardioversion. We selected 9728 patients (mean age 61 years, 70% men), and 5881 patients had AF recurrence over an average of 1.37 years after ablation (recurrence rate 325.7 (95% CI 317.6–334.2) per 1000 person-years). Lower education (HR 1.09 [1.02–1.17] and 1.07 [1.01–1.14] for lower and medium vs. higher), lower income [HR 1.14 (1.06–1.22) and 1.09 (1.03–1.17) for lower and medium vs. higher], and living alone [HR 1.07 (1.00–1.13)] were associated with increased rates of recurrence of AF. We found no evidence of interaction between sex or prior HF with SDOH. The association between family income and AF recurrence was stronger among patients Conclusion AF was more likely to recur among patients with lower educational attainment, lower family income, or those living alone. Multidisciplinary efforts are needed to reduce socioeconomic inequity in the effect of ablation.

The unprecedented scale of testing required to effectively control the coronavirus disease (COVID-19) pandemic has necessitated urgent implementation of rapid testing in clinical microbiology laboratories. To date, there are limited data available on the analytical performance of emerging commercially available assays for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and integration of these assays into laboratory workflows. Here, we performed a prospective validation study of a commercially available assay, the AusDiagnostics Coronavirus Typing (8-well) assay. Respiratory tract samples for SARS-CoV-2 testing were collected between 1 March and 25 March 2020. All positive samples and a random subset of negative samples were sent to a reference laboratory for confirmation. In total, 2673 samples were analysed using the Coronavirus Typing assay. The predominant sample type was a combined nasopharyngeal/throat swab (2640/2673; 98.8%). Fifty-four patients were positive for SARS-CoV-2 (2.0%) using the Coronavirus Typing assay; 53/54 (98.1%) positive results and 621/621 (100%) negative results were concordant with the reference laboratory. Compared to the reference laboratory gold standard, sensitivity of the Coronavirus Typing assay for SARS-CoV-2 was 100% (95% CI 93.2-100%), specificity 99.8% (95% CI 99.1-100%), positive predictive value 98.1% (95% CI 90.2-99.7%) and negative predictive value 100% (95% CI 99.4-100%). In many countries, standard regulatory requirements for the introduction of new assays have been replaced by emergency authorisations and it is critical that laboratories share their post-market validation experiences, as the consequences of widespread introduction of a suboptimal assay for SARS-CoV-2 are profound. Here, we share our in-field experience, and encourage other laboratories to follow suit.

Ablation of atrial fibrillation is a key area of current research. A multitude of techniques have been tested, some of which are poorly evidenced and not recommended in routine clinical practice whilst others are more promising. Additionally, a plethora of issues exist when researching ablation techniques, from control arm ablation strategy to the relevance of outcome measures. In this review article, we discuss these issues in the context of the current evidence base.

INTRODUCTION: Atrial fibrillation and heart failure frequently co-exist and the combination is associated with a worse prognosis than either condition alone. A number of pharmacological agents and invasive procedures have been shown to benefit this complex patient group.OBJECTIVE: In this review, we compare different therapeutic approaches to atrial fibrillation and heart failure, including pharmacotherapy, left atrial catheter ablation and pace-and-ablate.EXPERT OPINION: Left atrial catheter ablation is an efficacious option for restoring sinus rhythm and is most likely to provide benefit to those in whom durable sinus rhythm can be expected, and whose life expectancy is not significantly reduced by other pathologies or advanced age. A pace-and-ablate approach, particularly with physiological pacing, may provide more benefit to those with low chance of maintaining sinus rhythm. Both invasive options generally outperform pharmacotherapy, although it is important to individualize the approach for each patient through shared decision-making.

vHPvSD ablation represents a quantum leap from the RF settings that have traditionally been used in electrophysiology. If used to its full potential, it may improve procedural efficiency by reducing ablation and procedure times. However, with great power comes great responsibility; we need to ensure that we use it judiciously and safely.

BACKGROUND: There is a plethora of real-world data on the safety and effectiveness of direct-acting oral anticoagulants (DOACs); however, study heterogeneity has contributed to inconsistent findings. We compared the effectiveness and safety of apixaban with those of other direct-acting oral anticoagulants (DOACs) and vitamin K antagonists (VKA e.g., warfarin).METHODS: A systematic review and meta-analysis was conducted retrieving data from PubMed, SCOPUS and Web of Science from January 2009 to December 2021. Studies that evaluated apixaban (intervention) prescribed for adults (aged 18 years or older) with AF for stroke prevention compared to other DOACs or VKAs were identified. Primary outcomes included stroke/systemic embolism (SE), all-cause mortality, and major bleeding. Secondary outcomes were intracranial haemorrhage (ICH) and ischaemic stroke. Randomised controlled trials and non-randomised trials were considered for inclusion.RESULTS: In total, 67 studies were included, and 38 studies were meta-analysed. Participants taking apixaban had significantly lower stroke/SE compared to patients taking VKAs (relative risk (RR) 0.77, 95% confidence interval (CI) 0.64-0.93, I2 = 94%) and dabigatran (RR 0.84, 95% CI 0.74-0.95, I2 = 66%), but not to patients administered rivaroxaban. There was no statistical difference in mortality between apixaban and VKAs or apixaban and dabigatran. Compared to patients administered rivaroxaban, participants taking apixaban had lower mortality rates (RR 0.83, 95% CI 0.71-0.96, I2 = 96%). Apixaban was associated with a significantly lower risk of major bleeding compared to VKAs (RR 0.58, 95% CI 0.52-0.65, I2 = 90%), dabigatran (RR 0.79, 95% CI 0.70-0.88, I2 = 78%) and rivaroxaban (RR 0.61, 95% CI 0.53-0.70, I2 = 87%).CONCLUSIONS: Apixaban was associated with a better overall safety and effectiveness profile compared to VKAs and other DOACs.

The unprecedented scale of testing required to effectively control the coronavirus disease (COVID-19) pandemic has necessitated urgent implementation of rapid testing in clinical microbiology laboratories. To date, there are limited data available on the analytical performance of emerging commercially available assays for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and integration of these assays into laboratory workflows. Here, we performed a prospective validation study of a commercially available assay, the AusDiagnostics Coronavirus Typing (8-well) assay. Respiratory tract samples for SARS-CoV-2 testing were collected between 1st March and 25th March 2020. All positive samples and a random subset of negative samples were sent to a reference laboratory for confirmation. In total, 2,673 samples were analyzed using the Coronavirus Typing assay. The predominant sample type was a combined nasopharyngeal/throat swab (2,640/2,673; 98.8%). Fifty-four patients were positive for SARS-CoV-2 (0.02%) using the Coronavirus Typing assay; 53/54 (98.1%) positive results and 621/621 (100%) negative results were concordant with the reference laboratory. Compared to the reference standard, sensitivity of the Coronavirus Typing assay for SARS-CoV-2 was 100% [95% CI 93.2%-100%], specificity 99.8% [95% CI 99.1%-100%], positive predictive value 98.1% (95% CI 90.2%-99.7%] and negative predictive value 100% [95% CI 99.4%-100%]. In many countries, standard regulatory requirements for the introduction of new assays have been replaced by emergency authorizations and it is critical that laboratories share their post-market validation experiences, as the consequences of widespread introduction of a sub-optimal assay for SARS-CoV-2 are profound. Here, we share our in-field experience, and encourage other laboratories to follow suit.

In Ancient Greek mythology, terror and dread were the names given to the twin horses that drew the chariot of Ares, the god of war. The development of the technique of guerrilla warfare as a path to revolution, however, was to create an important additional role for terror in the theory of revolution. The modern use of the concept of terror in revolutionary circumstances derives from the French Revolution of 1789. The most spectacular feature of terror was the execution of members of the aristocracy, not charged with a crime, not even with conspiracy against the state, but simply because they were aristocrats. Up to the Second World War terror remained a feature primarily of the consolidation phase of great social revolutions. The most chilling examples of the use of terror as a permanent governmental device dedicated to the eradication of the possibility of revolution are, however, to be found in Chile and Uruguay.