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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]

Background The Medtronic Sprint Fidelis lead (SFL; Medtronic Inc., Minneapolis, MN, USA) has a significantly impaired long-term survival, and active fixation leads fare worse than passive leads. The goal of this study was to present data of a series of passive SFL only with very long mean follow-up of more than 6 years. Methods Patients in whom a passive SFL was implanted in two large Swiss centers were followed. We excluded eight (5.5%) patients with a follow-up of <6 months. Patients who died or were lost during follow-up were censored at death or last device check, all others on January 31, 2014. We employed two different definitions of failure: strict = fracture with inappropriate discharge; sudden increase in impedance >1,500 or high-voltage impedance >100 Ohm; >300 nonphysiological short interventricular-intervals. Lenient = any of the above plus a linear increase in impedance >1,500 Ohm or a linear decrease in sensing to a level that treating cardiologists considered inappropriate. Results We included 137 patients. Age was 60 ± 12 years. Mean and median follow-up were 6.2 ± 2.1 and 6.8 (interquartile range 4.8-7.8) years. Applying the strict definition, 12 leads (8.8%) were replaced after 4.9 ± 2.4 years (range 1.2-8.1). Applying the lenient definition, 14 leads (10.2%) failed. Cumulative lead survival was 98.5% at 3, 96.9% at 4, 94.2% at 5, and 93.1% at 6 years. Leads 'at risk' were: n = 122 (89%), 115 (84%), 101 (74%), and 88 (64%). Conclusions In this population with passive SFLs, 5-year lead survival is impaired with 94.2% based on 74% of leads 'at risk' at this time point. [ABSTRACT FROM AUTHOR]

Background Although radiofrequency (RF) and cryoballoon (CB) based technologies for pulmonary vein isolation (PVI) have both individually been demonstrated to be effective and safe for the treatment of paroxysmal AF, head-to-head comparisons are lacking. The purpose of this study was to compare the outcome of cryoballoon versus radiofrequency ablation in patients with paroxysmal atrial fibrillation undergoing pulmonary vein isolation. Methods Out of a prospective registry of 327 patients undergoing PVI, 208 patients (age 58 ± 11 years, ejection fraction 59 ± 6%, left atrial size 39 ± 6 mm) with paroxysmal AF were identified. The presented dataset was obtained by 1:1 propensity score matching and contained 142 patients undergoing CB-PVI or RF-PVI in conjunction with a 3D mapping system, respectively. We compared single procedure efficacy of the two methods using a Cox proportional hazards model. Results After a mean follow-up of 28 months and a single procedure, AF recurred in 37 of 71 (52%) in the CB-PVI group and in 31 of 71 patients (44%) in the RF-PVI group (HR [95% CI] = 1.19 [0.74, 1.92], p = 0.48). Recurrence of AF for PVI using solely the CB was observed in 23 of 51 (45%) patients and in 23 of 51 (45%) patients in the corresponding RF-PVI group (HR [95% CI] = 0.93 [0.52, 1.66], p = 0.81). Complication rate was not different between the groups. Conclusion A propensity score matched comparison between CB-PVI and RF-PVI using a 3D-mapping system for AF ablation showed similar long-term success rates. [ABSTRACT FROM AUTHOR]

Role of Defibrillation Threshold Testing. Introduction: Defibrillation threshold (DFT) testing has been performed to prove functionality of the implantable cardioverter defibrillator (ICD). Over the past years it has become increasingly controversial because of possible morbidity and mortality. The goal of this study was to determine unsuccessful shock testing and report strategies used to overcome these problems. Methods and Results: A total of 314 patients with a de novo implantation of an ICD and 127 patients receiving a generator exchange were identified retrospectively. All patients underwent defibrillation threshold testing after induction of VF using a low-energy T-wave shock during the intervention, 2 shock tests after de novo implantations, 1 after generator change. A safety margin of 10 J or more was requested. Seven (2.3%) patients in the de novo group and 2 patients (1.4%) in the generator exchange group could not be defibrillated using the standard approach. All of those patients had either chronic amiodarone therapy, secondary prevention or a cardiac resynchronization therapy device (CRT). In univariate analysis, amiodarone therapy, dilated cardiomyopathy, and lower ejection fraction were predictors of failure. Conclusion: Our study's results as well as a review of the current literature favor shock testing, especially in patients with specific risk factors as mentioned above. (J Cardiovasc Electrophysiol, Vol. 24, pp. 437-441, April 2013) [ABSTRACT FROM AUTHOR]

Background: Loss of left ventricular capture in patients with cardiac resynchronization devices may account for worsening heart failure and can be difficult to diagnose without a programmer. Objective: To determine whether distinct morphologic changes on the surface electrocardiogram indicate loss of left ventricular capture. Design: After analysis of the R-S spike ratio in the 12-lead electrocardiogram during right ventricular and biventricular pacing in 10 patients, an algorithm to detect loss of left ventricular capture was developed. Setting: University hospital. Patients: 54 patients with a cardiac resynchronization device and underlying left bundle-branch block. Measurements: Leads V1 and I of a 12-lead electrocardiogram were assessed after biventricular pacing was confirmed and after the device was programmed to right ventricular pacing only (simulating loss of left ventricular capture). Results: The sensitivity of the algorithm to correctly identify loss of left ventricular capture was 94% (95% CI, 88.2% to 97.7%), and the specificity was 93% (CI, 86.3% to 95.8%). The likelihood ratio of a positive test result was 12.8 (CI, 6.443 to 23.310), and the likelihood ratio of a negative test result was 0.06 (CI, 0.024 to 0.137). Limitations: The algorithm was tested in patients in whom the right ventricular electrode was placed in the apex of the right ventricle only. Conclusion: Presence of biventricular capture the prerequisite for successful cardiac resynchronization therapy-and loss of left ventricular capture can be accurately detected by an algorithm based on analysis of the R-S ratio on leads V1 and I of the surface electrocardiogram. [ABSTRACT FROM AUTHOR]

Discusses gender and age differences in induced atrial fibrillation (AF). Overview on studies on effects of verapamil, procainamide or digoxin on AF-induced changes in atrial refractoriness; Mean effective refractory period (ERP) after autonomic blockade in women; Explanation on significant attenuation of the shortening of the ERP in response to a brief episode of AF in young women.

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: Stereotactic arrhythmia radioablation (STAR) is delivered with a planning target volume (PTV) prescription dose of 25 Gy, mostly to the surrounding 75–85% isodose line. This means that the average and maximum dose received by the target is less than 35 Gy, which is the minimum threshold required to create a homogenous transmural fibrosis. Similar to catheter ablation, the primary objective of STAR should be transmural fibrosis to prevent heterogenous intracardiac conduction velocities and the occurrence of sustained ventricular arrhythmias (sVA) caused by reentry. We hypothesize that the current dose prescription used in STAR is inadequate for the long-term prevention of sVA and that a significant increase in dose is necessary to induce transmural scar formation. Objective: A single arm, multi-center, phase II, dose escalation prospective clinical trial employing the i3 + 3 design is being conducted to examine the safety of a radiation dose-escalation strategy aimed at inducing transmural scar formation. The ultimate objective of this trial is to decrease the likelihood of sVA recurrence in patients at risk. Methods: Patients with ischemic or non-ischemic cardiomyopathy and recurrent sVA, with an ICD and history of ≥ 1 catheter ablation for sVA will be included. This is a prospective, multicenter, one-arm, dose-escalation trial utilizing the i3 + 3 design, a modified 3 + 3 specifically created to overcome limitations in traditional dose-finding studies. A total of 15 patients will be recruited. The trial aims to escalate the ITV dose from 27.0 Gy to an ITV prescription dose-equivalent level of maximum 35.1 Gy by keeping the PTV prescription dose constant at 25 Gy while increasing the dose to the target (i.e. the VT substrate without PTV margin) by step-wise reduction of the prescribing isodose line (85% down to 65%). The primary outcome of this trial is safety measured by registered radiation associated adverse events (AE) up to 90 days after study intervention including radiation associated serious adverse events graded as at least 4 or 5 according to CTCAE v5, radiation pneumonitis or pericarditis requiring hospitalization and decrease in LVEF ≥ 10% as assessed by echocardiography or cardiac MRI at 90 days after STAR. The sample size was determined assuming an acceptable primary outcome event rate of 20%. Secondary outcomes include sVA burden at 6 months after STAR, time to first sVA recurrence, reduction in appropriate ICD therapies, the need for escalation of antiarrhythmic drugs, non-radiation associated safety and patient reported outcome measures such as SF-36 and EQ5D. Discussion: DEFT-STAR is an innovative prospective phase II trial that aims to evaluate the optimal radiation dose for STAR in patients with therapy-refractory sVA. The trial has obtained IRB approval and focuses on determining the safe and effective radiation dose to be employed in the STAR procedure. Trial registration: NCT05594368. [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]

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.

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]

Considers the patient with known coronary artery disease and the effects of angiography. The coronary angiography given because of progressive dyspnoea and angina; The patient having had coronary bypass surgery with three vein grafts; The resulting confusion and loss of vision after the angiography; The suspicion of bilateral cortical blindness.

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]

Fragmented QRS (fQRS) is an electrocardiographic (ECG) marker of myocardial conduction abnormality, characterized by additional notches in the QRS complex. The presence of fQRS has been associated with an increased risk of all-cause mortality and arrhythmia in patients with cardiovascular disease. However, current binary visual analysis is prone to intra- and inter-observer variability and different definitions are problematic in clinical practice. Therefore, objective quantification of fQRS is needed and could further improve risk stratification of these patients. We present an automated method for fQRS detection and quantification. First, a novel robust QRS complex segmentation strategy is proposed, which combines multi-lead information and excludes abnormal heartbeats automatically. Afterwards extracted features, based on variational mode decomposition (VMD), phase-rectified signal averaging (PRSA) and the number of baseline-crossings of the ECG, were used to train a machine learning classifier (Support Vector Machine) to discriminate fragmented from non-fragmented ECG-traces using multi-center data and combining different fQRS criteria used in clinical settings. The best model was trained on the combination of two independent previously annotated datasets and, compared to these visual fQRS annotations, achieved Kappa scores of 0.68 and 0.44, respectively. We also show that the algorithm might be used in both regular sinus rhythm and irregular beats during atrial fibrillation. These results demonstrate that the proposed approach could be relevant for clinical practice by objectively assessing and quantifying fQRS. The study sets the path for further clinical application of the developed automated fQRS algorithm. [ABSTRACT FROM AUTHOR]

Sustained forms of atrial fibrillation (AF) may be associated with a higher risk of adverse outcomes, but few if any long-term studies took into account changes of AF type and co-morbidities over time. We prospectively followed 3843 AF patients and collected information on AF type and co-morbidities during yearly follow-ups. The primary outcome was a composite of stroke or systemic embolism (SE). Secondary outcomes included myocardial infarction, hospitalization for congestive heart failure (CHF), bleeding and all-cause mortality. Multivariable adjusted Cox proportional hazards models with time-varying covariates were used to compare hazard ratios (HR) according to AF type. At baseline 1895 (49%), 1046 (27%) and 902 (24%) patients had paroxysmal, persistent and permanent AF and 3234 (84%) were anticoagulated. After a median (IQR) follow-up of 3.0 (1.9; 4.2) years, the incidence of stroke/SE was 1.0 per 100 patient-years. The incidence of myocardial infarction, CHF, bleeding and all-cause mortality was 0.7, 3.0, 2.9 and 2.7 per 100 patient-years, respectively. The multivariable adjusted (a) HRs (95% confidence interval) for stroke/SE were 1.13 (0.69; 1.85) and 1.27 (0.83; 1.95) for time-updated persistent and permanent AF, respectively. The corresponding aHRs were 1.23 (0.89, 1.69) and 1.45 (1.12; 1.87) for all-cause mortality, 1.34 (1.00; 1.80) and 1.30 (1.01; 1.67) for CHF, 0.91 (0.48; 1.72) and 0.95 (0.56; 1.59) for myocardial infarction, and 0.89 (0.70; 1.14) and 1.00 (0.81; 1.24) for bleeding. In this large prospective cohort of AF patients, time-updated AF type was not associated with incident stroke/SE. [ABSTRACT FROM AUTHOR]

Background: An action potential duration (APD) restitution curve with a steep slope ≥1 has been associated with increased susceptibility for malignant ventricular arrhythmias. We aimed to evaluate the "restitution hypothesis" and tested ventricular APD restitution slope as well as effective refractory period (ERP)/APD ratio for long-term prognostic value in patients with ischemic (ICM) or dilated cardiomyopathy (DCM). Methodology/Principal Findings: Monophasic action potentials were recorded in patients with ICM (n = 32) and DCM (n = 42) undergoing routine programmed ventricular stimulation (PVS). Left ventricular ejection fraction was 32±7% and 28±9%, respectively. APD and ERP were measured at baseline stimulation (S1) and upon introduction of one to three extrastimuli (S2-S4). ERP/APD ratios and the APD restitution curve were calculated and the maximum restitution slope was determined. After a mean follow-up of 6.1±3.0 years, the combined end-point of mortality and and/or implantable cardioverter-defibrillator shock was not predicted by restitution slope or ERP/APD ratios. Comparing S2 vs. S3 vs. S4 extrastimuli for restitution slope (1.5±0.6 vs. 1.4 plusmn;0.4 vs. 1.3 plusmn;0.5;p = NS), additional extrastimuli did not lead to a steepening restitution slope. ERP/APD ratio decreased with additional extrastimuli (0.98 plusmn;0.09 [S1] vs. 0.97 plusmn;0.10 [S2] vs. 0.93 plusmn;0.11 [S3]; p = 0.03 S1 vs. S3). Positive PVS was strongly predictive of outcome (p = 0.006). Conclusions/Significance: Neither ventricular APD restitution slope nor ERP/APD ratios predict outcome in patients with ICM or DCM. [ABSTRACT FROM AUTHOR]

Cryoballoon ablation has emerged as a novel tool to perform pulmonary vein isolation. The aim of this paper is to review the advantages, drawbacks as well as possible complications and clinical outcomes of this technology and to discuss some important technical issues. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the diagnostic yield of Holter monitoring in very old adults (≥80) with syncope. DESIGN: A Holter study was considered diagnostic if the arrhythmia explained syncope (atrioventricular (AV) block, sinus node dysfunction, atrial fibrillation with severe bradycardia or tachycardia, supraventricular or ventricular tachycardia). SETTING: A tertiary care center in Switzerland over a period of 10 years. PARTICIPANTS: Four hundred seventy-five Holter studies were performed in individuals aged 80 and older (median age 84, 65% female, mean left ventricular ejection fraction (LVEF) 0.56 0.1%). MEASUREMENTS AND RESULTS: Fifty-three Holter studies (11%) were diagnostic. The detected arrhythmias were AV block (n=13), sinus node dysfunction (n=13), binodal disease (n=2), atrial fibrillation with slow or rapid ventricular response (n=21), ventricular tachycardia (n=3) and supraventricular tachycardia (n=1). Forty participants (8%) received a pacemaker, and one received an implantable cardioverter-defibrillator because of the results of Holter monitoring. The yield of Holter monitoring was significantly greater (all P<.01) in the presence of heart disease (17%) and low LVEF (22%), in men (17%) and in participants aged 90 and older (20%). Heart disease (odds ratio (OR)=3.2, 95% confidence interval (CI)=1.7–6.1), male sex (OR=2.1, 95% CI51.1–3.8), and aged 90 and older (OR=2.4, 95% CI=1.2–5.1) remained independent predictors for a high diagnostic yield of Holter monitoring. Furthermore, Holter monitoring was helpful in excluding arrhythmias as a cause of syncope in an additional 10% of cases. CONCLUSION: The diagnostic value of Holter monitoring in participants aged 80 and older with syncope was 11.2%. Its yield was higher in men and in the presence of structural heart disease and was 20% in individuals aged 90 and older. [ABSTRACT FROM AUTHOR]

Current guidelines have indicated an implantable cardioverter-defibrillator (ICD) for patients with severe idiopathic dilated cardiomyopathy, for both primary and secondary prevention. Compared to coronary artery disease, the overall benefit has been smaller. A more refined risk assessment, using the left ventricular ejection fraction (LVEF) and prevention mode (primary/secondary), is still needed to guide ICD implantation. Patients included in 2 large ICD registers were analyzed regarding the appropriate therapies and improvement of LVEF, overall and in subgroups of prevention mode and LVEF <20% versus >20%. Overall, 349 patients were included; 70% were men, the mean age was 54 years, and the mean follow-up was 33 months. Cardiac resynchronization therapy (CRT) was used in 57%, and secondary prevention was present in 30%. ICD therapies were delivered to 33% of the patients, in most for ventricular tachycardia. Patients receiving an ICD for secondary prevention and non-CRT were more likely to have arrhythmic events (both p <0.05). The cumulative event rates at 5 years were 53% for secondary and 33% for primary prevention (p <0.001). Depending on the prevention mode and LVEF status (<20% vs >20%), the event rates ranged from 30% to 76%. The mean LVEF improved by 10%, independently of the stimulation mode (CRT 22% to 31%, non-CRT 26% to 35%; p <0.0001). A persistent improvement to >35% was seen in only 25% of CRT patients but in 45% of non-CRT patients (p = 0.004). In conclusion, the results from the present study have demonstrated that in patients with idiopathic dilated cardiomyopathy, the potential for LVEF improvement is considerable and that the rate of ICD interventions strongly depends on the prevention mode and LVEF. These findings could be the basis for additional risk stratification tools. [ABSTRACT FROM AUTHOR]

Abstract: Background: The value of an implantable cardioverter defibrillator (ICD) for primary prevention in dilated cardiomyopathy (DCM) is unclear, as randomized trials could not show a survival benefit compared to drug therapy. It has not been investigated if patients with a very poor left ventricular function (LVEF) could profit from an ICD. Methods: Consecutive patients with DCM who received an ICD between December 1996 and November 2003 were included in this analysis. Patients were divided in group A (secondary prevention) and group B (primary prevention). Both groups were stratified in subgroups with left ventricular ejection fraction (LVEF) below and above 20%. Results: Fifty eight patients were included (male 50, age 56.4±12.7 years). Follow-up was 34±19 months. There was no difference regarding death (18% vs. 11%), but significant differences (p value <0.05) regarding any adverse events (55% vs. 22%), any ICD intervention (48% vs. 17%) and ICD interventions for life-threatening arrhythmias (27% vs. 0%) between group A and B. LVEF was not predictive for events in group A, whereas in group B only patients with a LVEF <20% had events (p value 0.02). Over time there was an increase of the LVEF of more than 15% determined by echocardiography in 36% of patients, significantly more often in group B. Conclusions: Indication for primary prevention with an ICD in DCM should be made with caution. Larger studies are needed to determine if patients with LVEF of <20% might benefit from an ICD. [Copyright &y& Elsevier]

Objectives: We aimed to compare the hemodynamic effects of right-atrial-paced (DDD) and right-atrial-sensed (VDD) biventricular paced rhythm on cardiac resynchronization therapy (CRT). Background: Cardiac resynchronization therapy improves hemodynamics in patients with severe heart failure and left ventricular (LV) dyssynchrony. However, the impact of active right atrial pacing on resynchronization therapy is unknown. Methods: Seventeen CRT patients were studied 10 months (range: 1 to 46 months) after implantation. At baseline, the programmed atrioventricular delay was optimized by timing LV contraction properly at the end of atrial contraction. In both modes the acute hemodynamic effects were assessed by multiple Doppler echocardiographic parameters. Results: Compared to DDD pacing, VDD pacing resulted in much better improvement of intraventricular dyssynchrony assessed by the septal-to-posterior wall motion delay (VDD 106 ± 83 ms vs. DDD 145 ± 95 ms; p = 0.001), whereas the interventricular mechanical delay (difference between onset of pulmonary and aortic outflow) did not differ (VDD 20 ± 21 ms vs. DDD 18 ± 17 ms; p = NS). Furthermore, VDD pacing significantly prolonged the rate-corrected LV filling period (VDD 458 ± 123 ms vs. DDD 371 ± 94 ms; p = 0.0001) and improved the myocardial performance index (VDD 0.60 ± 0.18 vs. DDD 0.71 ± 0.23; p &#60; 0.01). Conclusions: Our findings suggest that avoidance of right atrial pacing results in a higher degree of LV resynchronization, in a substantial prolongation of the LV filling period, and in an improved myocardial performance. Thus, the VDD mode seems to be superior to the DDD mode in CRT patients. [Copyright &y& Elsevier]

Immediate Recurrence of Atrial Fibrillation. Introduction: An immediate recurrence of atrial fibrillation (IRAF) appears to be more common after early restoration of sinus rhythm with an implantable atrial defibrillator than after elective transthoracic cardioversion, which suggests that the probability of IRAF may be related to the duration of AF. Methods and Results: Transthoracic cardioversion was performed 85 ± 187 days (range 7 minutes to 8 years) after the onset of atrial fibrillation in 315 patients (mean age 61 ± 13 years). IRAF was defined as a recurrence of AF within 60 seconds after restoration of sinus rhythm. IRAF occurred in 56% of patients when cardioversion was performed within 1 hour of the onset of AF compared with 12% of patients when cardioversion was performed after 24 hours of AF (P < 0.001) . The duration of AF was the only independent predictor of IRAF among the clinical variables of age, gender, structural heart disease, antiarrhythmic drug therapy, and cardioversion energy (P < 0.01) . Conclusion: IRAF is more likely to occur when the duration of AF is <1 hour than when the duration is >24 hours. This observation has clinical implications for the most appropriate timing of cardioversion, particularly in patients who receive device therapy for AF. (J Cardiovasc Electrophysiol, Vol. 14, pp. 182-185, February 2003). [ABSTRACT FROM AUTHOR]

Introduction: Cardiac resynchronization defibrillator (CRT‐D) as primary prevention is known to reduce mortality. At the time of replacement, higher age and comorbidities may attenuate the benefit of implantable cardioverter‐defibrillator (ICD) therapy. The purpose of this study was to evaluate the progression of comorbidities after implantation and their association with mortality following CRT‐D generator replacement. In addition, a risk score was developed to identify patients at high risk for mortality after replacement. Methods and Results: We identified patients implanted with a primary prevention CRT‐D (n = 648) who subsequently underwent elective generator replacement (n = 218) from two prospective ICD registries. The cohort consisted of 218 patients (median age: 70 years, male gender: 73%, mean left ventricular ejection fraction [LVEF]: 36 ± 11% at replacement). Median follow‐up after the replacement was 4.2 years during which 64 patients (29%) died and 11 patients (5%) received appropriate ICD shocks. An increase in comorbidities was observed in 77 patients (35%). The 5‐year mortality rate was 41% in patients with ≥2 comorbidities at the time of replacement. A risk score incorporating age, gender, LVEF, atrial fibrillation, anemia, chronic kidney disease, and history of appropriate ICD shocks at time of replacement accurately predicted 5‐year mortality (C‐statistic 0.829). Patients with a risk score of greater than 2.5 had excess mortality at 5‐year postreplacement compared with patients with a risk score less than 1.5 (57% vs. 6%; p <.001). Conclusion: A simple risk score accurately predicts 5‐year mortality after replacement in CRT‐D patients, as patients with a risk score of greater than 2.5 are at high risk of dying despite ICD protection. [ABSTRACT FROM AUTHOR]

The Heart Failure (HF) Meta-score may be useful in predicting prognosis in patients with primary prevention cardiac resynchronization defibrillators (CRT-D) considering the competing risk of appropriate defibrillator shock versus mortality. Data from 648 consecutive patients from two centers were used for the evaluation of the performance of the HF Meta-score. The primary endpoint was mortality and the secondary endpoint was time to first appropriate implantable cardioverter-defibrillator (ICD) shock or death without prior appropriate ICD shock. Fine-Gray model was used for competing risk regression analysis. In the entire cohort, 237 patients died over a median follow-up of 5.2 years. Five-year cumulative incidence of mortality ranged from 12% to 53%, for quintiles 1 through 5 of the HF Meta-score, respectively (log-rank P < 0.001). Compared with the lowest quintile, mortality risk was higher in the highest quintile (HR 6.9; 95%CI 3.7–12.8). The HF Meta-score had excellent calibration, accuracy, and good discrimination in predicting mortality (C -statistic 0.76 at 1-year and 0.71 at 5-year). The risk of death without appropriate ICD shock was higher in risk quintile 5 compared to quintile 1 (sub HR 5.8; 95%CI 3.1–11.0, P < 0.001). Our study demonstrated a good ability of the HF Meta-score to predict survival in HF patients treated with CRT-D as primary prevention. The HF Meta-score proved to be useful in identifying a subgroup with a significantly poor prognosis despite a CRT-D. • The Heart Failure Meta-score reliably predicts survival in patients who received a CRT-D as primary prevention of SCD. • The Heart Failure Meta-score is able to discriminate between patients with a low or high risk for mortality • The majority of patients died without experiencing an appropriate ICD shock • The Heart Failure Meta-score can be used to identify a subgroup with a significantly poor prognosis despite a CRT-D [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: 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]

Single-shot devices are increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). The Arctic Front cryoballoon (Medtronic) is the most frequently used single-shot technology. A recently developed novel cryoballoon has been introduced (PolarX, Boston Scientific) with the aim to address limitations of the Arctic Front system. COMPARE CRYO is a multicentre, randomized, controlled trial with blinded endpoint adjudication by an independent clinical events committee. A total of 200 patients with paroxysmal AF undergoing their first PVI are randomized 1:1 between PolarX cryoballoon ablation and Arctic Front cryoballoon ablation. Continuous monitoring during follow-up is performed using an implantable cardiac monitor (ICM) in all patients. The primary endpoint is time to first recurrence of any atrial tachyarrhythmia (AF, atrial flutter, and/or atrial tachycardia) ≥ 120 s between days 91 and 365 post ablation as detected on the (ICM). Procedural safety is assessed by a composite of cardiac tamponade, persistent phrenic nerve palsy >24 h, vascular complications requiring intervention, stroke/transient ischemic attack, atrioesophageal fistula or death occurring during or up to 30 days after the procedure. Key secondary endpoints include (1) procedure and fluoroscopy times, (2) AF burden, (3) proportion of patients with recurrence in the blanking period, (4) proportion of patients undergoing repeat ablation, and (5) quality of life changes at 12 months compared to baseline. COMPARE CRYO will compare the efficacy and safety of the novel PolarX cryoballoon and the standard-of-practice Arctic Front cryoballoon for first PVI performed in patients with symptomatic paroxysmal AF. Trial registration : (ClinicalTrials.gov ID: NCT04704986). Comparison of the PolarX and the Arctic Front Cryoballoon for Pulmonary Vein Isolation in Patients with Symptomatic Paroxysmal Atrial Fibrillation (COMPARE CRYO) – study protocol for a randomized controlled trial. Abbreviations: AF = atrial fibrillation; PVI = pulmonary vein isolation [Display omitted] [ABSTRACT FROM AUTHOR]

Abnormal 12-lead electrocardiogram (ECG) can predict cardiovascular events, including sudden cardiac death. We tested the hypothesis that ECG provides useful information on guiding implantable cardioverter defibrillator (ICD) therapy into individuals with impaired left ventricular ejection fraction (LVEF). Retrospective data of primary prevention ICD implantations from 14 European centers were gathered. The registry included 5111 subjects of whom 1687 patients had an interpretable pre-implantation ECG available (80.0% male, 63.3 ± 11.4 years). Primary outcome was survival without appropriate ICD shocks or heart transplantation. A low-risk ECG was defined as a combination of ECG variables that were associated with the primary outcome. A total of 1224 (72.6%) patients survived the follow-up (2.9 ± 1.7 years) without an ICD shock, 224 (13.3%) received an appropriate shock and 260 (15.4%) died. Low-risk ECG defined as QRS duration <120 ms, QTc interval <450 ms for men and <470 ms for women, and sinus rhythm, were met by 515 patients (30.5%). Multivariable Cox regression showed that the hazard (HR) for death, heart transplantation or appropriate shock were reduced by 42.5% in the low-risk group (HR 0.575; 95% CI 0.45–0.74; p < 0.001), compared to the high-risk group. The HR for the first appropriate shock was 42.1% lower (HR 0.58; 95% CI 0.41–0.82; p = 0.002) and the HR for death was 48.0% lower (HR 0.52; 95% CI 0.386–0.72; p < 0.001) in the low-risk group. Sinus rhythm, QRS <120 ms and normal QTc in standard 12-lead ECG provides information about survival without appropriate ICD shocks and might improve patient selection for primary prevention ICD therapy. • 12-lead ECG identifies the patients who may not benefit from primary prophylactic ICD patients. • Low risk ECG is defined as QRS duration <120 ms, sinus rhythm, and normal QTc duration. • 12-lead ECG can be used together with other risk variables in identifying the candidate for prophylactic ICD therapy. [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]

Objective: Diabetes increases the risk of all-cause mortality and sudden cardiac death (SCD). The exact mechanisms leading to sudden death in diabetes are not well known. We compared the incidence of appropriate shocks and mortality in patients with versus without diabetes with a prophylactic implantable cardioverter defibrillator (ICD) included in the retrospective EU-CERT-ICD registry.Research Design and Methods and Results: A total of 3,535 patients from 12 European EU-CERT-ICD centers with a mean age of 63.7 ± 11.2 years (82% males) at the time of ICD implantation were included in the analysis. A total of 995 patients (28%) had a history of diabetes. All patients had an ICD implanted for primary SCD prevention. End points were appropriate shock and all-cause mortality. Mean follow-up time was 3.2 ± 2.3 years. Diabetes was associated with a lower risk of appropriate shocks (adjusted hazard ratio [HR] 0.77 [95% CI 0.62-0.96], P = 0.02). However, patients with diabetes had significantly higher mortality (adjusted HR 1.30 [95% CI 1.11-1.53], P = 0.001).Conclusions: All-cause mortality is higher in patients with diabetes than in patients without diabetes with primary prophylactic ICDs. Subsequently, patients with diabetes have a lower incidence of appropriate ICD shocks, indicating that the excess mortality might not be caused primarily by ventricular tachyarrhythmias. These findings suggest a limitation of the potential of prophylactic ICD therapy to improve survival in patients with diabetes with impaired left ventricular function. [ABSTRACT FROM AUTHOR]

Background: A small proportion of patients undergoing primary prophylactic implantation of implantable cardioverter defibrillators (ICDs) experiences malignant arrhythmias. We postulated that periodic repolarisation dynamics, a novel marker of sympathetic-activity-associated repolarisation instability, could be used to identify electrically vulnerable patients who would benefit from prophylactic implantation of ICDs by way of a reduction in mortality.Methods: We did a prespecified substudy of EUropean Comparative Effectiveness Research to Assess the Use of Primary ProphylacTic Implantable Cardioverter Defibrillators (EU-CERT-ICD), a prospective, investigator-initiated, non-randomised, controlled cohort study done at 44 centres in 15 EU countries. Patients aged 18 years or older with ischaemic or non-ischaemic cardiomyopathy and reduced left ventricular ejection fraction (≤35%) were eligible for inclusion if they met guideline-based criteria for primary prophylactic implantation of ICDs. Periodic repolarisation dynamics from 24-h Holter recordings were assessed blindly in patients the day before ICD implantation or on the day of study enrolment in patients who were conservatively managed. The primary endpoint was all-cause mortality. Propensity scoring and multivariable models were used to assess the interaction between periodic repolarisation dynamics and the treatment effect of ICDs on mortality.Findings: Between May 12, 2014, and Sept 7, 2018, 1371 patients were enrolled in our study. 968 of these patients underwent ICD implantation, and 403 were treated conservatively. During follow-up (median 2·7 years [IQR 2·0-3·3] in the ICD group and 1·2 years [0·8-2·7] in the control group), 138 (14%) patients died in the ICD group and 64 (16%) patients died in the control group. We noted a 43% reduction in mortality in the ICD group compared with the control group (adjusted hazard ratio [HR] 0·57 [95% CI 0·41-0·79]; p=0·0008). Periodic repolarisation dynamics significantly predicted the treatment effect of ICDs on mortality (adjusted p=0·0307). The mortality benefits associated with ICD implantation were greater in patients with periodic repolarisation dynamics of 7·5 deg or higher (n=199; adjusted HR 0·25 [95% CI 0·13-0·47] for the ICD group vs the control group; p<0·0001) than in those with periodic repolarisation dynamics less than 7·5 deg (n=1166; adjusted HR 0·69 [95% CI 0·47-1·00]; p=0·0492; pinteraction=0·0056). The number needed to treat was 18·3 (95% CI 10·6-4895·3) in patients with periodic repolarisation dynamics less than 7·5 deg and 3·1 (2·6-4·8) in those with periodic repolarisation dynamics of 7·5 deg or higher.Interpretation: Periodic repolarisation dynamics predict mortality reductions associated with prophylactic implantation of ICDs in contemporarily treated patients with ischaemic or non-ischaemic cardiomyopathy. Periodic repolarisation dynamics could help to guide treatment decisions about prophylactic ICD implantation.Funding: The European Community's 7th Framework Programme. [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: Patients with atrial fibrillation (AF) have an increased risk of cognitive decline, potentially resulting from clinically unrecognized vascular brain lesions.Objectives: This study sought to assess the relationships between cognitive function and vascular brain lesions in patients with AF.Methods: Patients with known AF were enrolled in a multicenter study in Switzerland. Brain magnetic resonance imaging (MRI) and cognitive testing using the Montreal Cognitive Assessment (MoCA) were performed in all participants. Large noncortical or cortical infarcts (LNCCIs), small noncortical infarcts (SNCIs), microbleeds, and white matter lesions were quantified by a central core laboratory. Clinically silent infarcts were defined as infarcts on brain MRI in patients without a clinical history of stroke or transient ischemic attack.Results: The study included 1,737 patients with a mean age of 73 ± 8 years (28% women, 90% taking oral anticoagulant agents). On MRI, LNCCIs were found in 387 patients (22%), SNCIs in 368 (21%), microbleeds in 372 (22%), and white matter lesions in 1715 (99%). Clinically silent infarcts among the 1,390 patients without a history of stroke or transient ischemic attack were found in 201 patients with LNCCIs (15%) and 245 patients with SNCIs (18%). The MoCA score was 24.7 ± 3.3 in patients with and 25.8 ± 2.9 in those without LNCCIs on brain MRI (p < 0.001). The difference in MoCA score remained similar when only clinically silent LNCCIs were considered (24.9 ± 3.1 vs. 25.8 ± 2.9; p < 0.001). In a multivariable regression model including all vascular brain lesion parameters, LNCCI volume was the strongest predictor of a reduced MoCA (β = -0.26; 95% confidence interval: -0.40 to -0.13; p < 0.001).Conclusions: Patients with AF have a high burden of LNCCIs and other brain lesions on systematic brain MRI screening, and most of these lesions are clinically silent. LNCCIs were associated with worse cognitive function, even among patients with clinically silent infarcts. Our findings raise the question of MRI screening in patients with AF. [ABSTRACT FROM AUTHOR]

Background: To date, there are no data from randomized controlled studies on the benefit of cardiac resynchronization therapy (CRT) when implanted as an upgrade in patients with a previous device as compared to de novo CRT. In the CRT Survey II we compared the baseline data of patients upgraded to CRT (CRT-P/CRT-D) from a previous pacemaker (PM) or implantable cardioverter-defibrillator (ICD) to de novo CRT implantation.Methods and Results: In the European CRT Survey II, clinical practice data of patients undergoing CRT and/or ICD implantation across 42 European Society of Cardiology (ESC) countries were collected between October 2015 and December 2016. Out of a total of 11 088 patients, 2396 (23.2%) were upgraded from a previous PM or ICD and 7933 (76.8%) underwent de novo implantation. Compared to de novo implantations, upgraded patients were older, more often male, more frequently had ischaemic heart failure aetiology, atrial fibrillation, reduced renal function, worse heart failure symptoms, and higher N-terminal pro-B-type natriuretic peptide levels. Upgraded patients were more often PM-dependent and less frequently received CRT-D. Total peri-procedural, in-hospital complications and length of hospital stay were similar. Upgraded patients were less frequently treated with heart failure medication at discharge.Conclusion: Despite a lack of evidenced-based data, close to one quarter of all CRT implantations across 42 ESC countries were upgrades from a previous PM or ICD. Despite older age and worse symptoms, the CRT implantation procedures in upgraded patients were equally frequently successful and complications similar to de novo implantations. These results call for more studies. [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]

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]

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]

Background: Some but not all prior studies have shown that women receiving a primary prophylactic implantable cardioverter defibrillator (ICD) have a lower risk of death and appropriate shocks than men. Purpose: To evaluate the effect of gender on the risk of appropriate shock, all-cause mortality and inappropriate shock in contemporary studies of patients receiving a primary prophylactic ICD. Data Source: PubMed, LIVIVO, Cochrane CENTRAL between 2010 and 2016. Study Selection: Studies providing at least 1 gender-specific risk estimate for the outcomes of interest. Data Extraction: Abstracts were screened independently for potentially eligible studies for inclusion. Thereby each abstract was reviewed by at least two authors. Data Synthesis: Out of 680 abstracts retained by our search strategy, 20 studies including 46’657 patients had gender-specific information on at least one of the relevant endpoints. Mean age across the individual studies varied between 58 and 69 years. The proportion of women enrolled ranged from 10% to 30%. Across 6 available studies, women had a significantly lower risk of first appropriate shock compared with men (pooled multivariable adjusted hazard ratio 0.62 (95% CI [0.44; 0.88]). Across 14 studies reporting multivariable adjusted gender-specific hazard ratio estimates for all-cause mortality, women had a lower risk of death than men (pooled hazard ratio 0.75 (95% CI [0.66; 0.86]). There was no statistically significant difference for the incidence of first inappropriate shocks (3 studies, pooled hazard ratio 0.99 (95% CI [0.56; 1.73]). Limitations: Individual patient data were not available for most studies. Conclusion: In this large contemporary meta-analysis, women had a significantly lower risk of appropriate shocks and death than men, but a similar risk of inappropriate shocks. These data may help to select patients who benefit from primary prophylactic ICD implantation. [ABSTRACT FROM AUTHOR]

Background Clinical guidelines on implantable cardioverter defibrillator (ICD) therapy changed significantly in the last decades with potential inherent effects on therapy efficacy. We aimed to study therapy rates in time and the association between therapies and mortality. Methods All patients receiving an ICD, primary and secondary prevention, were included in a single-center retrospective registry. Information on first appropriate and inappropriate therapies was documented. Dates of implant were divided in P1: 1996-2001, P2: 2002-2008, and P3: 2009-2014. Results A total of 727 patients, 84.9% male-66.4% ischemic cardiomyopathy (ICM)-56% primary prevention-mean follow-up 5.2 ± 4.1 years, were included. There was a shift from secondary to primary prevention indications, from ischemic to non-ICM, and from single chamber to cardiac resynchronization therapy defibrillator devices. The annual 1- and 3-year appropriate shock (AS) rate declined from 29.4% and 15.1% in P1, over 13.3% and 9.2% in P2 to 7.8% and 5.7% in P3 (log-rank P < 0.001), while inappropriate shock (IAS) rates remained unchanged (log-rank P = 0.635). After multivariate regression analysis a higher age at implant, lower left ventricular ejection fraction, history of stroke, diabetes mellitus, intake of loop diuretics or digitalis, higher creatinine, and longer QTc were independent predictors of mortality. Conclusion These changes in clinical practice with a shift to primary prevention and rise in non-ICM implants caused a significant decrease in AS incidence, while IAS remained stable. Receiving AS or IAS was not an independent predictor of mortality in our real-life cohort. [ABSTRACT FROM AUTHOR]

Imaging of the heart anatomy plays an important role, especially in catheter ablation for the treatment of arrhythmias in adults with congenital heart disease (ACHD). We present a comprehensive overview of the current state‐of‐the‐art modalities available to plan and guide catheter ablation in an ACHD patient. In addition to the clinical assessment of the computed tomography and the integration of 3D reconstructions into the electroanatomical mapping system, 3D printing and virtual reality assessment showed its value in preprocedural planning of the intervention. [ABSTRACT FROM AUTHOR]

The article presents a case study of 57-year-old patient presented with drug-refractory atrial fibrillation and referred to hospital for pulmonary vein isolation (PVI). Topics discussed include revealing a large persistent foramen ovale in transesophageal echocardiography, using irrigated multielectrode ablation (IMEA) catheter for performing PVI, and feasibility of using an IMEA catheter and a 3D mapping system without using fluoroscopy for patients with persistent foramen ovale.

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: 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]

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]

Background To categorize indications of permanent pacemaker (PPM) implantation after transcatheter aortic valve implantation (TAVI), to determine predictors for conduction disturbances and to quantify the need for ventricular pacing during follow-up. Method We studied 97 patients (median age 83 years, 58% female) undergoing TAVI using the Medtronic CoreValve Revalving System (MCRS; Medtronic Inc., Minneapolis, MN, USA) or Edwards-Sapien Valve (Edwards Lifesciences, Irvine, CA, USA). During follow-up, no need for ventricular pacing was defined as <1% ventricular pacing and intrinsic 1:1 atrioventricular (AV) conduction. Results In the 35 patients (36.1%) undergoing PPM implantation three indication categories were identified: (1) high-grade AV block (Mobitz 2 or higher), (2) new-onset left bundle branch block (LBBB) with a prolonged PR interval, and (3) new-onset LBBB. The only independent predictors of high-grade AV block were the use of MCRS (odds ratio [OR] 79.25; 95% confidence interval [CI] 4.57-1373.31) and the presence of preprocedural right bundle branch block (OR 81.95; 95% 95% CI 8.72-770.46). Whereas high-grade AV block resolved only in 17% of cases, none of the patients receiving a PPM due to LBBB with or without PR prolongation required ventricular pacing during follow-up. Conclusion Our findings justify early PPM implantation in patients with high-grade AV block and may suggest a more conservative approach to PPM implantation in patients with new-onset LBBB after TAVI. [ABSTRACT FROM AUTHOR]

Background To compare the feasibility and efficiency of atrioventricular junction (AVJ) ablation and device implantation in patients with drug-refractory atrial fibrillation using three different approaches. Methods Sixty-nine patients (57% male; age 72 ± 10; ejection fraction 45 ± 15%) undergoing device implantation and AVJ ablation were retrospectively studied at a tertiary referral center. In 20 patients (29%) AVJ ablation was performed via the femoral vein immediately following device implantation (group 1), whereas 33 patients (48%) underwent a staged procedure with AVJ ablation via the femoral vein >3 weeks after device implantation (group 2). In a third group of 16 patients (23%), AVJ ablation was performed during device implantation through the pocket using the same axillary vein access site (group 3). The main outcome measures were: procedure time, fluoroscopy time, laboratory occupancy time, and success rate. Results There was a significant difference in procedure time (118 ± 45 minutes. in group 1, 133 ± 32 minutes in group 2, and 87 ± 26 minutes in group 3, P < 0.001) and the laboratory occupancy time (175 ± 48 minutes in group 1, 200 ± 32 minutes in group 2, and 121 ± 27 minutes in group 3, P < 0.001). There was no difference in fluoroscopy time (group 1: 20 ± 15 minutes, group 2: 27 ± 22 minutes, and group 3: 24 ± 9 minutes P = 0.4). The procedure was successfully completed in all patients, but cross-over to a femoral approach was required in one patient in group 3. Conclusion The alternative approach of AVJ ablation during permanent pacemaker implantation from the same axillary vein access site is feasible and more efficient compared to the femoral approach. [ABSTRACT FROM AUTHOR]