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BACKGROUND: Atrial fibrillation (AF) ablation strategy is associated with a non-negligible risk of complications and often requires repeat procedures (AF ablation track), implying repetitive exposure to procedural risk. OBJECTIVE: The purpose of this study was to develop and validate a model to estimate individualized cumulative risk of complications in patients undergoing the AF ablation track (Atrial Fibrillation TRAck Complication risK [AF-TRACK] calculator). METHODS: The model was derived from a multicenter cohort including 3762 AF ablation procedures in 2943 patients. A first regression model was fitted to predict the propensity for repeat ablation. The AF-TRACK calculator computed the risk of AF ablation track complications, considering the propensity for repeat ablation. Internal (cross-validation) and external (independent cohort) validation were assessed for discrimination capacity (area under the curve [AUC]) and goodness of fit (Hosmer-Lemeshow [HL] test). RESULTS: Complications (N = 111) occurred in 3.7% of patients (2.9% of procedures). Predictors included female sex, heart failure, sleep apnea syndrome, and repeat procedures. The model showed fair discrimination capacity to predict complications (AUC 0.61 [0.55-0.67]) and likelihood of repeat procedure (AUC 0.62 [0.60-0.64]), with good calibration (HL χ2 12.5; P = .13). The model maintained adequate discrimination capacity (AUC 0.67 [0.57-0.77]) and calibration (HL χ2 5.6; P = .23) in the external validation cohort. The validated model was used to create the Web-based AF-TRACK calculator. CONCLUSION: The proposed risk model provides individualized estimates of the cumulative risk of complications of undergoing the AF ablation track. The AF-TRACK calculator is a validated, easy-to-use, Web-based clinical tool to calibrate the risk-to-benefit ratio of this treatment strategy.

Background Adequate synchronization between the passive ("E") and active ("a") left ventricular (LV) diastolic filling contributes to the efficiency of the heartbeat. E/a superposition in dual-chamber pacemaker (PM) recipients is an under-recognized phenomenon that may be corrected by shortening the atrio-ventricular interval (AVI). We aimed at establishing the prevalence of E/a superposition in PM patients and to analyze the clinical, echocardiographic, and biological impact of AVI shortening. Methods Seventy patients with dual-chamber PMs (74 +/- 8 years old, 12 women) were consecutively enrolled in this study. Patients with baseline E/a superposition were crossed over from default to manually shortened AVI or vice versa in a case-control fashion (intervention group). Patients without baseline E/a superposition (controls) served as a reference for a descriptive comparison with the intervention group. Results Thirty-three patients had E/a superposition after PM implantation (47%). Controls (n = 37) had higher LV ejection fraction (59 +/- 8% vs. 53 +/- 10%, p = 0.048) and lower levels of high sensitive troponin T and ST2 (p < 0.05) than intervention group patients. The AVI was shortened at 48 +/- 9 ms in order to ensure adequate E/a separation. The walked distance increased from 75 +/- 17 to 78 +/- 10% (p = 0.049) and the Euro-QoL score from 0.50 +/- 0.27 to 0.63 +/- 0.19 (p = 0.011) with short AVI. Conclusions E/a superposition occurs in approximately half of dual-chamber PM recipients and is associated with reduced LV function and increased myocardial injury biomarkers. AVI shortening produces a modest but significant effect in functional capacity and quality of life.

Up to one-third of patients who undergo cardiac resynchronization therapy do not obtain clinical benefit. A systematic approach can identify treatable causes in many nonresponding patients. We present a case of nonresponse to cardiac resynchronization therapy that resolved by ablation of the atrioventricular node in a patient with complete atrioventricular block. (Level of Difficulty: Advanced.), Graphical abstract

Objectives This study sought to analyze safety and outcomes of ventricular tachycardia (VT) substrate ablation during sinus rhythm (SR), without baseline VT induction. Background Safety and outcomes after scar-related VT ablation during SR are not well known. Hemodynamic instability and need for electrical cardioversion can compromise safety of VT ablation procedures. Methods Four hundred twelve consecutive patients with structural heart disease undergoing VT ablation were included in a prospective multicenter registry. Substrate ablation during SR, without baseline VT induction, was the first step of the ablation procedure and the standard protocol. Scar dechanneling was the substrate ablation technique used. VT inducibility was tested after substrate ablation. Results VT induction protocol was negative after substrate ablation in 289 patients (70.1%), completing the procedure in SR. Procedure-related complication rate was 6.5%, including 1 death (0.2%). Thirty-day mortality after first VT ablation procedure was 1.7%. Overall survival was 95.8% and 88.6% at 1 and 3 years of follow-up, respectively. In a multivariable proportional hazards regression model, age ≥70 years (hazard ratio [HR]: 4.95 [2.59 to 9.47]; p Conclusions Substrate ablation during SR avoiding multiple VT induction has low procedure-related complications and low early mortality. Age, chronic obstructive pulmonary disease, and reduced left ventricular ejection fraction, but also incomplete substrate elimination, are predictors of mortality.

Resumen La insuficiencia cardiaca (IC) y la fibrilacion auricular (FA) son patologias altamente prevalentes, relacionadas con un aumento de la morbimortalidad y de reingresos hospitalarios. Ambas entidades se encuentran estrechamente interrelacionadas, de forma que la IC constituye un factor de riesgo para desarrollar FA, y viceversa, y coexisten hasta en el 30% de los pacientes. Las opciones terapeuticas de la FA en pacientes con IC son diversas. El tratamiento farmacologico es el tratamiento mas aceptado; sin embargo, en muchas ocasiones no logra un control optimo y su impacto pronostico es limitado. En recientes estudios aleatorizados la ablacion de la FA ha mostrado ser superior al tratamiento farmacologico en terminos de carga arritmica y de mortalidad. La evidencia que apoya la ablacion como estrategia para el tratamiento de la FA en pacientes con IC es objeto de esta revision.

Background Catheter ablation of accessory pathways (AP) with bidirectional conduction may be challenging due to issues related to anatomical course or location. Objective We describe an alternative electro-anatomical mapping technique which aims at depicting the entire anatomic course of the AP from the atrial toward the ventricular insertion in order to guide catheter ablation. Methods Twenty consecutive patients with confirmed bidirectional AP conduction and at least one previous ablation procedure or para-Hisian location were included. 3-D electro-anatomical mapping was used to depict the merged 10-ms isochrone area of maximum early activation of both the ventricular and atrial signals during sinus rhythm and ventricular pacing/orthodromic tachycardia, respectively. Catheter ablation was performed within the depicted earliest isochrone area. Results Acute bidirectional AP conduction block was achieved in all patients 4.2 +/- 1.7 s after the first radiofrequency energy pulse was delivered, without reconnection during a 30 +/- 10 min post-ablation observation time. No procedural complications were seen. After a mean follow-up period of 9 +/- 7 months (range 3 to 16), no recurrences were documented. Conclusion This merged two-way mapping technique is a safe, efficient, and effective technique for ablation of APs with bidirectional conduction.

Background: Freezing rate of second-generation cryoballoon (CB) is a biophysical parameter that could assist pulmonary vein isolation. The aim of this study is to assess freezing rate (time to reach –30°C ([TT-30C]) as an early predictor of acute pulmonary vein isolation using the CB. Methods: Biophysical data from CB freeze applications within a multicenter, nation-wide CB ablation registry were gathered. Successful application (SA), was defined as achieving durable intraprocedural vein isolation with time to isolation in under 60 s (SA-TTI

Resumen La fibrilacion auricular es muy frecuente en el paciente anciano. Aunque existe una amplia experiencia con los antagonistas de la vitamina K, el empleo de estos farmacos en el paciente anciano presenta numerosas limitaciones, con una mayor susceptibilidad a las hemorragias y un peor control de la anticoagulacion que en la poblacion general. Los anticoagulantes orales de accion directa han demostrado ser una mejor alternativa terapeutica para los pacientes ancianos, no solo por su mayor simplicidad de uso, sino por sus mayores eficacia y seguridad en comparacion con los antagonistas de la vitamina K, con datos que en general concuerdan con los ensayos clinicos fundamentales. Sin embargo, en el paciente anciano hay una tendencia al uso de dosis inadecuadas, generalmente por infradosificacion, sobre todo con algunos de ellos, lo que conlleva una menor proteccion contra los ictus, sin una clara ventaja antihemorragica. El rivaroxaban se ha estudiado ampliamente en la poblacion anciana y no solo en ensayos clinicos, sino tambien en multitud de estudios en la practica clinica real, con datos muy consistentes. En estos estudios, en comparacion con los antagonistas de la vitamina K, se ha demostrado que el rivaroxaban reduce el riesgo de ictus sin un incremento de las hemorragias mortales, con lo que tiene un beneficio clinico neto favorable en la poblacion con fibrilacion auricular no valvular con mayor riesgo tromboembolico.

Resumen Introduccion y objetivos En Espana no se dispone de datos sobre la implantacion de electrodos de desfibrilacion. Registros internacionales han descrito en los ultimos anos un cambio en favor de los electrodos monobobina. El objetivo primario de nuestro estudio fue tratar de inferir como ha sido la implantacion de electrodos de desfibrilacion durante los ultimos anos en nuestro pais. El objetivo secundario busca identificar diferencias entre ambos tipos de electrodos. Metodos Se analizaron datos de 4.131 pacientes espanoles portadores de un desfibrilador automatico implantable, incluidos consecutivamente en el registro UMBRELLA y seguidos remotamente mediante sistema CareLink, entre 2005 y 2016. Resultados Inicialmente la proporcion de electrodos de desfibrilacion monobobina era Conclusiones La practica clinica con desfibriladores ha ido cambiando tanto en la forma de implantar como en la forma de programar los dispositivos. En lo que a electrodos de desfibrilacion se refiere, en nuestro registro se observo un cambio en la eleccion del tipo de electrodo de desfibrilacion, ya que fueron los electrodos monobobina los implantados con mas frecuencia en los ultimos anos.

Resumen Introduccion y objetivos Se describen los resultados en Espana de la segunda encuesta de la Sociedad Europea de Cardiologia sobre terapia de resincronizacion cardiaca (CRT-Survey II) y se comparan con los de los demas paises participantes. Metodos Pacientes a los que se implanto un dispositivo de terapia de resincronizacion cardiaca entre octubre de 2015 y diciembre de 2016 en 36 centros participantes. Se recogieron datos sobre las caracteristicas basales de los pacientes y del implante, y un seguimiento a corto plazo hasta el alta hospitalaria. Resultados La tasa de exito del implante fue del 95,9%. La mediana [intervalo intercuartilico] de implantes anuales/centro en Espana fue significativamente menor que en los demas paises participantes: 30 [21-50] frente a 55 [33-100] implantes/ano (p = 0,00003). En los centros espanoles hubo una menor proporcion de pacientes de edad ≥ 75 anos (el 27,9 frente al 32,4%; p = 0,0071), una mayor proporcion de pacientes en clase funcional II de la New York Heart Association (el 46,9 frente al 36,9%; p Conclusiones La encuesta CRT-Survey II muestra que en Espana hay una menor proporcion de pacientes de 75 o mas anos que reciben un dispositivo de terapia de resincronizacion cardiaca, una mayor proporcion de pacientes en clase funcional II de la New York Heart Association, con bloqueo completo de la rama izquierda del haz de His y con seguimiento a distancia, con estancias hospitalarias significativamente menores.

Funding Acknowledgements Type of funding sources: None. Background Persistent symptoms after the acute phase of SARS-CoV-2 infection are referred to as "post-COVID-19 syndrome" (PCS), with a reported incidence ranging between 35% and 87%. Fatigue, palpitations and exercise intolerance are common complains among PCS patients in whom unexplained sinus tachycardia, occasionally exacerbated by postural changes, is a frequent observation that remains poorly characterized. Purpose We sought to characterize the prevalence of inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia (POTS) in a consecutive and prospective population of patients with PCS. Methods Consecutive patients with persistent symptoms 3 months after an acute SARS-CoV-2 infection were prospectively evaluated at a multi-disciplinary PCS unit. All patients were screened for IST or POTS and those with confirmed criteria underwent comprehensive cardiovascular examination including echocardiography, 24-hour Holter, Minnesota Living with Heart Failure Questionnaire (MLHFQ), six-minute walking test (6MWT) and inflammation and myocardial biomarkers. Two control patients, matched by age and gender, were assigned to each case: one with previous SARS-CoV-2 infection without PCS (group 2) and one without prior SARS-CoV-2 infection (group 3). Results IST or POTS criteria were met in 34 out of the 200 PCS patients (17%). The mean age was 39 ± 10 years, with 29 women (91%). The interval from the index COVID-19 disease to the PCS diagnosis was 71 ± 17 days, with a majority of patients (n = 29,85%) not requiring hospital admission during the acute phase. At physical examination, the mean heart rate was 96 ± 3bpm at supine and 112 ± 17bpm at the upright position, with 8 patients fulfilling diagnostic criteria of POTS. No underlying structural heart disease, pro-inflammatory state, myocyte injury or hypoxia were identified among our patient population. The 6MWT showed a significantly diminished exercise capacity with a 59% of the estimated distance after adjustment by age, sex and body mass index; an impaired quality of life was also identified, as suggested by a median MLFHQ total score of 67 out of 105 points. The 24-hour Holter showed an increase in HR predominantly during daytime in group 1 (mean daytime HR of 94 ± 3bpm), an altered heart rate variability with a decrease in time domain parameters [PNN50 4 ± 4 in group 1 (vs. 11 ± 9 in group 2 and 18 ± 9 in group 3; p Conclusions IST and its POTS variant are a prevalent condition among PCS patients and may at least partially explain the common symptoms of fatigue, impaired exercise and palpitations that characterize the PCS. Cardiac autonomic nervous system imbalance may account as a plausible pathophysiological mechanism of IST in PCS patients.

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Instituto de Salud Carlos III BACKGROUND Cardiac regenerative therapy is a promising treatment for patients with myocardial infarction (MI) and heart failure. Nevertheless, previous ex-vivo studies have raised concern on the potential increased risk of arrhythmic events following certain cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. PURPOSE To assess the effect of the AGTP on the post-MI scar composition and image-based ventricular tachycardia (VT) corridors detection by means of late gadolinium enhanced cardiac magnetic resonance (LGE-CMR). METHODS A left circumflex artery (first marginal branch) MI was induced in 9 Landrace X Large White Pigs by delivering 1-3 coils. Two weeks post-MI, all subjects underwent a 3 Tesla LGE-CMR and randomized to the AGTP or sham group. LGE-CMR was repeated 30 days post-treatment (6 weeks post-MI). The arrhythmogenic substrate was characterized with an advanced image post-processing tool (ADAS 3D) and included quantification of dense scar and border zone (BZ) mass and detection of ventricular tachycardia (VT) corridors (including corridor scar mass). RESULTS The overall scar mass did not differ between scans in the overall population (7.6 ± 3.5 g vs 7.5 ± 2.2 g in the baseline and post-treatment scans, respectively; p = 0.9). Compared to the sham subjects, those receiving AGTP showed an absolute reduction of the total (-3.2 ± 1.4 g vs. +2.4 ± 1.7 g, p = 0.04) and dense scar (-0.9 ± 0.4 g vs. +0.7 ± 0.5 g, p = 0.03). BZ mass tended to decrease in the AGTP group (-2.2 vs 1.63 g; p = 0.06). The AGTP group showed a trend to reduce the number of VT corridors (-1 ± 0.7 vs. +0.4 ± 0.2, p = 0.078) and corridor scar mass (-0.3 ± 0.26 g vs. +0.1 ± 0.1 g, p = 0.11) (figure). CONCLUSIONS Cardiac reparative therapy of MI with AGTP reduced dense scar mass, compared to the increase observed in the sham group. The trend to reduce the BZ mass and the number/mass of VT corridors suggests a beneficial effect on the arrhythmic remodeling of the post-MI scar. Abstract Figure. Reduction in corridor"s number

Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Insituto de Salud Carlos III BACKGROUND Cardiac regenerative therapy is a promising treatment for patients with ischemic heart disease, but there are some concerns on the potential increased risk of arrhythmic events following specific cell therapies. Adipose graft transposition procedure (AGTP) is a cardiac reparative therapy consisting in transposing a vascularized adipose flap from the autologous pericardium and placing it over the epicardial scar area and has demonstrated to reduce infarct size and improve the left ventricular ejection fraction in preclinical and human studies. Specific electrophysiological properties of the scar, (i.e. slow conduction velocity (CV)) have been identified as key features of ventricular tachycardia (VT) isthmuses. PURPOSE To assess the effect of the AGTP on VT inducibility and the electrophysiological properties of the post-MI scar with ultra-high density (UHD) mapping. METHODS A left circumflex artery (first marginal branch) MI was induced in 10 Landrace X Large White pigs by delivering 1-3 coils. Two weeks post-MI, all subjects underwent baseline left ventricular endocardial UHD mapping during right ventricular pacing with 64-electrode basket mapping catheter, as well as electrophysiological study (EPS) to test for VT inducibility. Following the mapping, subjects were allocated 1:1 to AGTP or sham group. UHD mapping and EPS were repeated 30 days post-treatment (6 weeks after MI). Voltage and activation maps were analyzed off-line with self-customized Paraview-based software. Voltage cut-offs of 1.5 and 0.5mV (bipolar) defined normal tissue, border zone (BZ) and dense scar, respectively, and 6.7mV for unipolar. Conduction velocity (CV) was determined for every pair of contiguous points and areas of similar CV were quantified for every 0.2m/s steps (for up to 4 m/s). RESULTS There were no differences between groups with regard of dense scar, BZ an low unipolar voltage areas. The AGTP group had a significant reduction of the size of slow CV ( CONCLUSIONS Cardiac reparative therapy with AGTP of post-MI scar reduced the size of slow conduction areas and could provide a protective effect against arrhythmic events in ischemic heart disease. Abstract Figure.

Funding Acknowledgements Type of funding sources: None. BACKGROUND Left atrial fibrosis is a marker of atrial disease and it has an important role in the pathophysiology of atrial fibrillation (AF). Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) is an emerging tool to detect left atrial fibrosis. However, data on the correlation between LGE-CMR detected fibrosis and low voltage areas to define fibrotic tissue is scarce. PURPOSE To assess the correlation and degree of concordance between LGE-CMR and high-density bipolar voltage mapping for the identification of left atrial abnormal tissue. METHODS Seven patients scheduled for AF ablation (including first and redo procedures) underwent a preprocedural 1.5 Tesla LGE-CMR including left atrial 3D inversion-recovery steady-state free precession sequence (ECG and respiratory triggering) 20 minutes after the injection of 0.2 mmol/kg of gadobutrol. A high-density electroanatomical voltage mapping was acquired with a 16-electrode grid configuration mapping catheter during sinus rhythm. LGE-CMR studies were analyzed off-line with an advanced image post-processing tool (ADAS 3D). Atrial wall intensity was normalized to blood pool, obtaining an image intensity ratio (IIR) value for each CMR point of the 3D model. High-density bipolar voltage maps and LGE-CMR 3D left atrial reconstruction were merged (figure, panel A). Voltage points were projected to the LGE-CMR left atrial 3D model, allowing point-by-point correlation analysis between voltage (log transformed due to non-normal distribution) with IIR. Left atrial fibrosis area and percentage were quantified using the standard cut-off values (bipolar voltage 1.2). We assessed the degree of concordance for normal and abnormal (fibrosis) tissue classification between the two techniques using different cut-off values (< 0.5mV and 0.9, >1, >1.1 and >1.2 for IIR). RESULTS The average fibrosis area detected with LGE-CMR was lower than that detected with high-density bipolar voltage, using standard cut-off values (18.6 ± 5.7 cm2 vs. 40.6 ± 12.5 cm2, p = 0.13 respectively). There was a poor global point-by-point correlation between log-transformed voltage and IIR was r=-0.093, p 1, with an agreement percentage of 54.6%. CONCLUSIONS Left atrial tissue characterization between LGE-CMR and high-density bipolar voltage mapping showed significant but poor point-by-point correlation. Although the highest concordance was obtained using standard cutoff values, the Kappa index was best when applying non-standard cutoffs (1mV for bipolar voltage and >1 for IIR). Abstract Figure.

Objectives Recent data suggest that some adult patients with autoimmune rheumatic diseases may develop cardiac conduction and repolarization abnormalities mediated by anti-Ro/SSA antibodies. We aim to investigate the utility of a cardiac screening in patients with systemic lupus erythematous (SLE) and anti-Ro/SSA positivity. Methods SLE patients who consecutively attended a Rheumatology clinic during 1 year where evaluated for the presence and levels of anti-Ro/SSA antibodies, and clinical and biological markers of organ damage and disease activity. All participants underwent a cardiovascular anamnesis and physical examination, ECG, echocardiography, and 24-hour Holter. Results Of the 145 recruited patients, 49 (32%) had anti-Ro/SSA positivity. None had any degree of atrioventricular block in the ECG or Holter monitoring. No significant differences were observed between anti-Ro/SSA–positive vs. negative patients in terms of PR, QRS or QTc intervals. No clinically significant arrhythmias were recorded during Holter monitoring and no differences in average heart rate, heart rate variability, or atrial or ventricular ectopy burden were observed. Finally, no differences were found in echocardiographic measurements. Conclusions In this study of SLE patients, anti-Ro/SSA positivity was not associated with significant alterations in ECG, echocardiography, or 24-hour Holter. These findings do not support ordinary cardiac evaluation in these patients. ( Clinicaltrials.gov registration number: NCT02162992).

Background Large‐scale studies describing modern populations using an implantable cardioverter‐defibrillator (ICD) are lacking. We aimed to analyze the incidence of arrhythmia, device interventions, and mortality in a broad spectrum of real‐world ICD patients with different heart disorders. Methods and Results The UMBRELLA study is a prospective, multicenter, nationwide study of contemporary patients using an ICD followed up by remote monitoring, with a blinded review of arrhythmic episodes. From November 2005 to November 2017, 4296 patients were followed up. After 46.6±27.3 months, 16 067 episodes of sustained ventricular arrhythmia occurred in 1344 patients (31.3%). Appropriate ICD therapy occurred in 27.3% of study population. Patients with ischemic cardiomyopathy (hazard ratio [HR], 1.51; 95% CI, 1.29–1.78), dilated cardiomyopathy (HR, 1.28; 95% CI, 1.07–1.53), and valvular heart disease (HR, 1.94; 95% CI, 1.43–2.62) exhibited a higher risk of appropriate ICD therapies, whereas patients with hypertrophic cardiomyopathy (HR, 0.72; 95% CI, 0.54–0.96) and Brugada syndrome (HR, 0.25; 95% CI, 0.14–0.45) showed a lower risk. All‐cause death was 13.4% at follow‐up. Ischemic cardiomyopathy (HR, 3.09; 95% CI, 2.58–5.90), dilated cardiomyopathy (HR, 3.33; 95% CI, 2.18–5.10), and valvular heart disease (HR, 3.97; 95% CI, 2.25–6.99) had the worst prognoses. Delayed high‐rate detection was enabled in 39.7% of patients, and single‐zone programming occurred in 52.6% of primary prevention patients. Both parameters correlated with lower risk of first appropriate ICD therapy, with no excess risk of mortality. The rate of inappropriate shocks at follow‐up was low (6%) and did not differ among type of ICD but was lower in SmartShock‐capable devices. Conclusions Irrespective of the cause, contemporary ICD patients with heart failure–related disorders had a similar risk of ICD life‐saving interventions and death. Current ICD programming recommendations still need to be implemented. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NTC01561144.

Background: Myocardial fibrosis is key for atrial fibrillation maintenance. We aimed to test the efficacy of ablating cardiac magnetic resonance (CMR)-detected atrial fibrosis plus pulmonary vein isolation (PVI). Methods: This was an open-label, parallel-group, randomized, controlled trial. Patients with symptomatic drug-refractory atrial fibrillation (paroxysmal and persistent) undergoing first or repeat ablation were randomized in a 1:1 basis to receive PVI plus CMR-guided fibrosis ablation (CMR group) or PVI alone (PVI-alone group). The primary end point was the rate of recurrence (>30 seconds) at 12 months of follow-up using a 12-lead ECG and Holter monitoring at 3, 6, and 12 months. The analysis was conducted by intention-to-treat. Results: In total, 155 patients (71% male, age 59±10, CHA 2 DS 2 -VASc 1.3±1.1, 54% paroxysmal atrial fibrillation) were allocated to the PVI-alone group (N=76) or CMR group (N=79). First ablation was performed in 80% and 71% of patients in the PVI-alone and CMR groups, respectively. The mean atrial fibrosis burden was 12% (only ≈50% of patients had fibrosis outside the pulmonary vein area). One hundred percent and 99% of patients received the assigned intervention in the PVI-alone and CMR group, respectively. The primary outcome was achieved in 21 patients (27.6%) in the PVI-alone group and 22 patients (27.8%) in the CMR group (odds ratio: 1.01 [95% CI, 0.50–2.04]; P =0.976). There were no differences in the rate of adverse events (3 in the CMR group and 2 in the PVI-alone group; P =0.68). Conclusions: A pragmatic ablation approach targeting CMR-detected atrial fibrosis plus PVI was not more effective than PVI alone in an unselected population undergoing atrial fibrillation ablation with low fibrosis burden. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02698631.

Obstructive sleep apnea-hypopnea syndrome (OSA) compromises the efficacy of atrial fibrillation (AF) control strategies. Continuous positive airway pressure (CPAP) may ameliorate arrhythmia control especially in early AF stages (new-onset AF). We investigated a practical screening strategy to determine the likelihood of CPAP indication in new-onset AF patients. Seventy-seven consecutive patients with new-onset (= 4 being newly established (sensitivity/specificity 76/65%). In conclusion, in patients referred with new-onset AF we documented a high risk of OSA and of need for CPAP. A STOP-BANG scoring of >= 4 in our population was a practical screening alternative to direct polysomnography in this setting. (C) 2020 Elsevier Inc. All rights reserved.

This study sought to analyze safety and outcomes of ventricular tachycardia (VT) substrate ablation during sinus rhythm (SR), without baseline VT induction.Safety and outcomes after scar-related VT ablation during SR are not well known. Hemodynamic instability and need for electrical cardioversion can compromise safety of VT ablation procedures.Four hundred twelve consecutive patients with structural heart disease undergoing VT ablation were included in a prospective multicenter registry. Substrate ablation during SR, without baseline VT induction, was the first step of the ablation procedure and the standard protocol. Scar dechanneling was the substrate ablation technique used. VT inducibility was tested after substrate ablation.VT induction protocol was negative after substrate ablation in 289 patients (70.1%), completing the procedure in SR. Procedure-related complication rate was 6.5%, including 1 death (0.2%). Thirty-day mortality after first VT ablation procedure was 1.7%. Overall survival was 95.8% and 88.6% at 1 and 3 years of follow-up, respectively. In a multivariable proportional hazards regression model, age ≥70 years (hazard ratio [HR]: 4.95 [2.59 to 9.47]; p 0.001), chronic obstructive pulmonary disease (HR: 2.37 [1.24 to 4.52]; p = 0.008), left ventricular ejection fraction 30% (HR: 2.43 [1.37 to 4.33]; p = 0.002), and incomplete substrate ablation (HR: 2.37 [1.24 to 4.52]; p = 0.026) were independent predictors of overall mortality. At 12 months' follow-up, VT-free survival was 82.5% after 1 procedure and 87.8% after n procedures CONCLUSIONS: Substrate ablation during SR avoiding multiple VT induction has low procedure-related complications and low early mortality. Age, chronic obstructive pulmonary disease, and reduced left ventricular ejection fraction, but also incomplete substrate elimination, are predictors of mortality.

INTRODUCTION Cardiac implantable electronic device (CIED) infection is a severe disease with an increasing incidence due to the rise in the number of CIEDs implanted world-wide. Complete hardware removal is the treatment of choice, but there is little clinical data about the best antimicrobial strategy, such as the best choice of antibiotics, treatment duration and when to switch to oral administration in cases of local CIED infections. PURPOSE In 2013, we designed a new protocol for CIED infection management, by which local infections were treated with complete hardware removal followed by empiric parenteral antibiotic during the first 72h, which was replaced to an oral agent (in case of negative blood cultures) and continued for 10 days. The oral antibiotic was selected according to the local cultures when positive, or to Clindamicin, Levofloxacin or Cotrimoxazole when no germ was identified. Our purpose is to describe our experience and results after the implementation of this strategy. METHODS We retrospectively reviewed all consecutive local CIED infection cases from the implementation of the protocol until September 2019, and evaluated the population characteristics, type of infection, rate of positive cultures and outcomes. RESULTS We identified 74 cases of CIED infection, of which 46 (62%) were local. The average age of this population was 75.3 ± 13.2 yo and 65% (30) were male. The predominant comorbidities were diabetes (41%), congestive heart failure (30%), and malignancies (22%). Eighteen patients (39%) had previous local infection treated medically without hardware removal. Mean number of previous procedures was 2.65 ± 1.8, and 34 (74%) of the devices were pacemakers (single and dual chamber), 5 (11%) ICDs, 6 (13%)CRT-P and 1 (2%) CRT-D. Blood cultures were negative in all cases, whereas local cultures (exudate or intraoperative tissue) were positive in 32 (70%). The most frequent microorganisms were Staphylococcus epidermidis in 18 (56%) and Staphylococcus aureus in 8 (25%), including 1 case of meticillin-resistance. Intravenous Vancomycin was administered in all cases during 72 h, followed by oral antibiotics for a mean duration of 8.8 ± 3.3 days. Hardware removal was intended in all cases, with complete or clinical success in 42 and 3 cases respectively (global success rate 97.8%), and in one case (2.2%) an epicardial lead was not removed. During a mean follow-up of 30 months, 1 infection-related death occurred (2%) due to a side effect of intravenous antibiotic therapy, and there was 1 infection relapse (2%) in the only patient without complete hardware removal, related to the remnant epicardial lead. CONCLUSIONS Oral antimicrobial treatment with good bioavailability agents, associated with complete hardware removal is an effective strategy for the management of local CIED infections, with a low recurrence rate, and avoiding long hospitalizations and potential side effects of intravenous antibiotic therapy.

ObjectivesThe association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.MethodsBaseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.ResultsAmong 3333 patients, 728 (21.8%) were classified as normal (BMI 2), 1537 (46.1%) as overweight (BMI 25.5–29.0 kg/m2) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m2). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p2led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).ConclusionsPatients with a baseline BMI ≥30 kg/m2have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.

Objectives The aim of this study was to analyze whether scar characterization could improve the risk stratification for life-threatening ventricular arrhythmias and sudden cardiac death (SCD). Background Among patients with a cardiac resynchronization therapy (CRT) indication, appropriate defibrillator (CRT-D) therapy rates are low. Methods Primary prevention patients with a class I indication for CRT were prospectively enrolled and assigned to CRT-D or CRT pacemaker according to physician’s criteria. Pre-procedure contrast-enhanced cardiac magnetic resonance was obtained and analyzed to identify scar presence or absence, quantify the amount of core and border zone (BZ), and depict BZ distribution. The presence, mass, and characteristics of BZ channels in the scar were recorded. The primary endpoint was appropriate defibrillator therapy or SCD. Results 217 patients (39.6% ischemic) were included. During a median follow-up of 35.5 months (12 to 62 months), the primary endpoint occurred in 25 patients (11.5%) and did not occur in patients without myocardial scar. Among patients with scar (n = 125, 57.6%), those with implantable cardioverter-defibrillator (ICD) therapies or SCD exhibited greater scar mass (38.7 ± 34.2 g vs. 17.9 ± 17.2 g; p Conclusions The presence, extension, heterogeneity, and qualitative distribution of BZ tissue of myocardial scar independently predict appropriate ICD therapies and SCD in CRT patients.

Introduction and objectives Recently, a new electrocardiography algorithm has shown promising results for the the diagnosis of acute myocardial infarction in the presence of left bundle branch block (LBBB). We aimed to assess these new electrocardiography rules in a cohort of patients referred for primary percutaneous coronary intervention (pPCI). Methods Retrospective observational cohort study that included all patients with suspected myocardial infarction and LBBB on the presenting electrocardiogram, referred for pPCI to 4 tertiary hospitals in Barcelona, Spain. Results A total of 145 patients were included. Fifty four (37%) had an ST-segment elevation myocardial infarction (STEMI) equivalent. Among patients with STEMI, 25 (46%) presented in Killip class III or IV, and in-hospital mortality was 15%. Smith I and II rules performed better than Sgarbossa algorithms and showed good specificity (90% and 97%, respectively) but their sensitivity was 67% and 54%, respectively. In a strategy guided by Smith I or Smith II rules, 18 (33%) or 25 (46%) patients with STEMI would have not received a pPCI, respectively. Moreover, the severity and prognosis of STEMI patients was similar regardless of the positivity of Smith rules. Cardiac biomarkers were positive in 54% of non-STEMI patients, limiting their usefulness for initial diagnostic screening. Conclusions Diagnosis of STEMI in the presence of LBBB remains a challenge. Smith rules can be useful but are limited by suboptimal sensitivity. The search for new electrocardiography algorithms should be encouraged to avoid unnecessary aggressive treatments in the majority of patients, while providing timely reperfusion to a high-risk subgroup of patients.

Resumen Introduccion y objetivos Recientemente, un nuevo algoritmo electrocardiografico ha mostrado resultados esperanzadores para el diagnostico del infarto agudo de miocardio (IAM) en presencia de bloqueo completo de rama izquierda del haz de His (BRIHH). Se decidio evaluar estos nuevos algoritmos en una cohorte de pacientes remitidos para intervencion coronaria percutanea primaria (ICPp). Metodos Estudio observacional de cohorte retrospectiva que incluyo a todos los pacientes con sospecha de IAM y BRIHH en el ecocardiograma inicial remitidos para ICPp a 4 hospitales terciarios de Barcelona, Espana. Resultados Se incluyo a 145 pacientes; 54 (37%) tenian un cuadro clinico equivalente a un IAM con elevacion del segmento ST (IAMCEST). Entre los pacientes con IAMCEST, 25 (46%) estaban en Killip III o IV y la mortalidad hospitalaria fue del 15%. Los algoritmos I y II de Smith presentaron mejores resultados que los algoritmos de Sgarbossa y tuvieron buena especificidad (el 90 y el 97% respectivamente); sin embargo, su sensibilidad fue del 67 y el 54% respectivamente. En una estrategia terapeutica guiada por los algoritmos de Smith, 18 (33%) o 25 (46%) pacientes con IAMCEST no habrian recibido ICPp. Por otra parte, la gravedad y el pronostico de los pacientes con IAMCEST era similar independientemente de la positividad de los algoritmos de Smith. Los marcadores de dano miocardico fueron positivos en un 54% de los pacientes sin IAMCEST, lo que limita su utilidad para el diagnostico inicial. Conclusiones El diagnostico de IAMCEST en presencia de BRIHH sigue siendo un desafio. Los algoritmos de Smith pueden ser utiles, pero estan limitados por una sensibilidad suboptima. Se tiene que promover la busqueda de nuevos criterios electrocardiograficos para evitar tratamientos agresivos no necesarios a la mayoria de los pacientes y, al mismo tiempo, proporcionar reperfusion emergente a un subgrupo con alto riesgo.

Aims Sudden cardiac death (SCD) risk estimation in patients referred for cardiac resynchronization therapy (CRT) remains a challenge. By CRT-mediated improvement of left ventricular ejection fraction (LVEF), many patients loose indication for primary prevention implantable cardioverter-defibrillator (ICD). Increasing evidence shows the importance of myocardial scar for risk prediction. The aim of this study was to investigate the prognostic impact of myocardial scar depending on the echocardiographic response in patients undergoing CRT. Methods and results Patients with indication for CRT were prospectively enrolled. Decision about ICD or pacemaker implantation was based on clinical criteria. All patients underwent delayed-enhancement cardiac magnetic resonance imaging. Median follow-up duration was 45 (24–75) months. Primary outcome was a composite of sustained ventricular arrhythmia, appropriate ICD therapy, or SCD. A total of 218 patients with LVEF 25.5 ± 6.6% were analysed [158 (73%) male, 64.9 ± 10.7 years]. Myocardial scar was observed in 73 patients with ischaemic cardiomyopathy (ICM) (95% of ICM patients); in 62 with non-ischaemic cardiomyopathy (45% of these patients); and in all but 1 of 36 (17%) patients who reached the primary outcome. Myocardial scar was the only significant predictor of primary outcome [odds ratio 27.7 (3.8–202.7)], independent of echocardiographic CRT response. A total of 55 (25%) patients died from any cause or received heart transplant. For overall survival, only a combination of the absence of myocardial scar with CRT response was associated with favourable outcome. Conclusion Malignant arrhythmic events and SCD depend on the presence of myocardial scar but not on CRT response. All-cause mortality improved only with the combined absence of myocardial scar and CRT response.

A 52-year-old man was admitted due to out-hospital cardiac arrest. Recurrent ventricular fibrillation (VF) occurred under therapeutic hypothermia thereafter. Previously inadverted full pre-excitation was documented exclusively and immediately prior to 4 out of the 5 VF relapses. Coronary vasospasm and early repolarization were also documented. An electrophysiological study demonstrated poor anterograde conduction over a left-sided accessory pathway. We theorize that maximum pre-excitation favored in-hospital VF by augmenting the repolarization vulnerability induced by therapeutic hypothermia, with coronary vasospasm accounting as the probable cause of out-hospital VF. A plausible VF mechanism in WPW syndrome unrelated to pre-excited atrial fibrillation is discussed.

Background: Persistent symptoms after the acute SARS-CoV-2 infection are referred to as post-COVID-19 syndrome(PCS). Fatigue, palpitations and exercise intolerance are common complains among PCS patients in whom unexplained sinus tachycardia is a frequent observation. Objective: To evaluate the prevalence and the pathophysiological mechanisms of IST in a consecutive and prospective population of patients with PCS. Methods: Consecutive patients with persistent symptoms 3 months after an acute COVID-19 were prospectively evaluated at a multi-disciplinary PCS unit. All patients were screened for IST and those with confirmed criteria underwent comprehensive CV examination: ECO, 24h Holter (assessment of the cardiac autonomic function), QoL Questionnaire (MLHFQ), six-min walking test (6MWT) and blood sample with inflammation and myocardial biomarkers. Two control patients, matched by age and gender, were assigned to each case: one with previous SARS-CoV-2 infection without PCS (group 2,recovered asymptomatic) and one without prior COVID (group 3,uninfected). Results: IST were met in 43/200 PCS patients (21%) being more common in young (mean age 39y) woman (91%) without clinical history and with mild COVID (not requiring hospital admission during the acute phase). Mean HR 96±3 (supine) and 112±17 (upright position), with 8 patients fulfilling diagnostic of POTS. No underlying structural heart disease, proinflammatory state, myocyte injury or hypoxia were identified 6MWT showed a significantly diminished exercise capacity(59% of the estimated distance). An impaired QoL was also identified. Regarding the 24h Holter, all HRV parameters were significantly deteriorated in IST patients compared with control groups (significantly decrease in time and frequency domain parameters). The most reduced components were those related with the cardiovagal tone: PNN50 4±4 in group 1 (vs 11±9 in group 2 and 18±9 in group 3;p

BACKGROUND Left atrial (LA) sphericity (LASP) is a new remodeling parameter based on LA shape analysis, with independent predictive value for recurrence after atrial fibrillation (AF) ablation. OBJECTIVES To evaluate the association between LASP and thromboembolic events (TE) in patients with AF. METHODS Twenty-nine AF patients and prior TE and 29 age- and gender-matched controls were included. LASP was calculated using a 3D-LA reconstruction. The LA appendage (LAA) volume and morphology were assessed. ROC curve analysis was performed for LASP, LA volume, LAA volume, and CHAD/CHA2 D-VASc scores (Stroke2 -the grouping variable-was excluded). RESULTS Mean age of the study population was 61 ± 11 years (79.3% males, 53.4% hypertension, 8.6% diabetes). Patients with prior TE had higher LASP than those without (82.5 ± 3.3% vs. 80.2 ± 3.1%, P = 0.008); there were no differences in CHAD or CHA2 D-VASc scores, LA volume, LAA volume, or LAA morphology. The C-statistic was higher for LASP (0.71) than for other tested variables (CHAD score = 0.58, CHA2 D-VASc score = 0.59, LA volume = 0.50, LAA volume = 0.46; P < 0.01 for all vs. LASP). The best cutoff value for LASP was 83.6% (sensitivity 0.52, specificity 0.90). Logistic regression analysis showed predictive value for LASP (OR 1.26 per each 1% increase [1.85-52.20], P = 0.013), but not for clinical risk scores. The addition of LASP to the CHAD and CHA2 D-VASc scores increased the predictive value over the risk scores alone (P = 0.004), and reclassified 45.5% of patients with CHAD = 0 (no anticoagulation indicated) to moderate-risk (anticoagulation indicated). CONCLUSION LA sphericity is associated with prior TE in AF patients and improves the performance of the CHAD and CHA2 D-VASc scores alone.

Resumen Introduccion y objetivos Los resultados del tratamiento de resincronizacion cardiaca (TRC) han sido extensamente publicados. Sin embargo, hay datos limitados en poblaciones no seleccionadas. El objetivo del estudio fue analizar la eficacia y la seguridad del TRC en Cataluna. Metodos Se analizo prospectivamente una serie de pacientes consecutivos a los que se les implanto durante un ano un dispositivo de TRC en 7 hospitales universitarios de Cataluna, los cuales representan el 90% del total de dispositivos implantados. Se definio como remodelado ecocardiografico inverso el aumento de 5 puntos de la fraccion de eyeccion del ventriculo izquierdo, y respondedores clinicos los pacientes que a los 12 meses habian aumentado > 10% la distancia recorrida en la prueba de caminar 6 minutos o un punto la clase de la New York Heart Association. El seguimiento de los pacientes fue por un ano y se analizaron los ingresos hospitalarios y la mortalidad. Resultados De los 200 pacientes incluidos en el estudio, el 99% cumplia las indicaciones de las guias clinicas actuales de TRC y el 68% recibio TRC con desfibrilador automatico implantable. La tasa de complicaciones fue del 12,5%. Durante el seguimiento 16 pacientes (8%) murieron. El 52% (104) de la poblacion fue respondedor clinico y un 62% (124) presento remodelado ecocardiografico. En comparacion con el ano previo al implante los ingresos hospitalarios se redujeron un 82%, lo que resulto en una diferencia estadisticamente significativa (p Conclusiones En una poblacion no seleccionada de Cataluna observamos que el TRC fue eficaz y redujo el numero de hospitalizaciones.

Introduction Recurrences after atrial fibrillation (AF) ablation are still common. Among the reported clinical and imaging predictors of recurrences, diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcome in single-center studies. We aimed to validate DAT in a multicenter real-life cohort. Methods This was a multicenter study including consecutive patients undergoing first paroxysmal and persistent AF ablation with radiofrequency or cryoballoon catheters during 2013. Cox proportional hazard regression models were performed to identify predictors of recurrence. Results In total, 309 patients were included across nine centers (71% men, 57 ± 10 years old, 46% with hypertension, and 66% with CHA2 DS2 -VASc ≤ 1). Most patients had paroxysmal AF (67%) and underwent radiofrequency ablation (68%) with a median DAT of 51 (43) months. Patients with DAT ≤ 1 year (16.6%) were less likely to have repeat procedures (4% vs 18%; P = .017). The adjusted proportional hazards Cox model identified hypertension (P = .005), heart failure (P = .011), nonparoxysmal AF (P = .038), DAT > 1 year (P = .007), and LA diameter (P = .026) as independent predictors for AF recurrence. DAT > 1 year was the only modifiable factor independently associated with recurrence (HR 4.2 [95% CI, 1.5-11.9]) CONCLUSION: Diagnosis-to-ablation time is a modifiable factor independently associated with recurrent arrhythmia and repeat ablation after first AF ablation. An early intervention strategy during the first year from AF diagnosis might improve outcomes.