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There are limited data on trends in nationwide cardiac electrophysiology (EP) procedures in the US before and during the global COVID-19 pandemic.We aimed to understand contemporary EP procedural trends, and how the COVID-19 pandemic impacted them.Trends were obtained from publicly reported Centers for Medicare and Medicaid Services data from 2013 to 2020 (latest available). Rates of catheter-based EP procedures (EP studies and ablations) and cardiac implantable electronic device (CIED) procedures were analyzed. All procedural rates were calculated per 100,000 Medicare beneficiaries (year specific). Procedure physician subspecialty was also reported.From 2013 to 2019, annual rate of all cardiac EP procedures increased from 817.91 to 1089.68 per 100,000 beneficiaries. Catheter-based EP procedures increased from 323.73 to 675.01, while CIED rates decreased from 494.18 to 414.67. While all ablation procedures increased over time, relative proportion of ablation procedures being pulmonary vein isolation (PVI) increased (9.9% of ablations in 2013, to 18.2% in 2019). In 2020, rates of both catheter-based EP procedures and CIED procedures decreased; however, PVI share of ablation continued to increase in 2020 comprising 25.2% of ablation procedures.Rates of EP procedures have increased among Medicare beneficiaries, with catheter-based procedures now eclipsing CIEDs. Additionally, a greater proportion of catheter-based EP procedures are PVI, but they still represent a minority of all ablations. In 2020, rates of EP procedures were attenuated, yet proportion of PVI ablations increased to over one-fourth of ablation procedures. These data have important implications for the EP workforce.

Atrial fibrillation (AF) is associated with an increased risk of dementia. Emerging evidence suggests AF suppression is associated with reduced risk of dementia, but the optimal strategy to achieve this is unknown. We sought to compare the risk of dementia in patients with AF who underwent catheter ablation (CA) versus anti-arrhythmic drug (AAD) treatment. METHODS AND RESULTS: Using the 2000 to 2021 Optum Clinformatics database, patients with AF who underwent CA versus AAD treatment (≥1 prescription fill for ≥2 different AADs) were identified and propensity score matched overall and within sex subgroups. A cause-specific hazard model was performed to assess dementia overall and in sex-specific subgroups. After matching, there were 19,088 patients per group. CA was associated with a 41% lower risk of dementia compared with AAD alone (1.9% vs 3.3%; hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.52-0.67, log-rank P.0001). When examined by sex, dementia risk reduction associated with CA versus AAD use alone was observed among both males (HR 0.55, 95% CI 0.46-0.66) and females (HR 0.60, 95% CI 0.50-0.72). Though not studied as a primary outcome, patients treated with CA were also observed to have 49% lower associated risk of mortality compared with AAD only (HR 0.51 95% CI 0.46-0.55, P.0001). CONCLUSIONS: Among patients treated for AF, CA was associated with significantly lower risk of dementia and death compared with AADs only. These reductions in risk associated with CA versus AAD were seen in both males and females.

To determine if health-related quality of life (HRQoL) improvement after cardiac resynchronization therapy (CRT) correlates with improved left-ventricular ejection fraction (EF).CRT was reported to improve EF and HRQoL in clinical trials of heart failure with reduced EF (HFrEF). It is unknown if improvements in HRQoL reflect EF response to CRT.We included HFrEF patients who underwent CRT and had both pre- and post-CRT HRQoL assessment. EF response was categorized as absent (0% change or decrease), modest (0%-19% increase), or significant (20% increase). We examined the associations between EF response and generic (PROMIS) and HF-specific (KCCQ-12) HRQoL.The group included 115 patients with mean age of 65 years and baseline EF of 31%; 39% were female (n = 45). Nineteen percent (n = 22) had significant, 57% (n = 66) modest, and 23% (n = 27) absent EF responses. AF burden across significant (8.9%), modest (4.8%), and absent EF responders (1.4%) was similar ( P = 0.20). Significant improvements in KCCQ-12 (43.4-57.5, P = 0.003), current health visual analog scale (49.1-55.9, P = 0.042), PROMIS fatigue (58.9-55.1, P = 0.026), and PROMIS satisfaction (42.7-46.4, P = 0.020) resulted following CRT across all groups. There was no association between significant EF improvement and HRQoL by KCCQ-12 (nonresponse, 44.4%; modest response, 33.3%; and significant response, 22.2%) at 1 year ( P = 0.52 across all groups).CRT was associated with a modest to significant EF response in a majority of patients. However, EF response did not significantly correlate with generic or HF-specific HRQoL measures. Further investigations are warranted into determinants of improved HRQoL following CRT.

We aimed to measure patient-reported outcomes (PROs) and costs associated with same-day discharge (SDD) for atrial fibrillation (AF) ablation and vascular closure device implantation in clinical practice.PROs were prospectively measured in 50 AF ablation patients, comparing complete vascular device closure (n = 25) versus manual compression hemostasis (n = 25). Health-system costs for SDD patients receiving vascular device closure were compared to matched controls with one-night stays who did not receive any closure device.Prospectively enrolled patients receiving vascular device closure for AF ablation had a mean age of 65 years, 17% were female, with a mean CHAVascular closure for AF ablation improves patient experience in routine care. The use of vascular closure and SDD after AF ablation reduces several components of healthcare system costs, without an overall increase.

Background Burden of atrial fibrillation (AF), as a continuous measure, is an emerging alternative classification often assumed to increase linearly with progression of disease. Yet there are no descriptions of AF burden distributions across populations. Methods We examined patterns of AF burden (% time in AF) across 3 different cohorts: outpatients with AF undergoing Holter monitoring in a national registry (ORBIT-AF II), routine outpatients undergoing Holter monitoring in a tertiary healthcare system (UHealth), and patients >=65 years with cardiac implantable electronic devices (Merlin.netTM linked to Medicare). Results We included 2,058 ORBIT-AF II patients, 4,537 UHealth patients, and 39,710 from Merlin.netTM. Mean age ranged from 56 to 77 years, sex ranged from 40% to 61% male, and mean CHA2DS2-VASc scores ranged from 2.2 to 4.9. Across all cohorts, AF burden demonstrated skewed frequency towards the extremes, with the vast majority of patients having either very low or very high AF burden. This bimodal distribution was consistent across cohorts, across clinically-documented AF types (paroxysmal vs. persistent), patients with or without a known AF diagnosis, and among patients with different types of cardiac implantable electronic devices. Conclusions Across 3 broad, diverse cohorts with continuous monitoring, distribution of AF burden was consistently skewed towards the extremes without an even, linear distribution or progression. As AF burden is increasingly recognized as a descriptor and potential risk-stratifier, these findings have important implications for future research and patient care.

Atrial fibrillation (AF) frequently complicates heart failure (HF), and each is associated with lower overall health-related quality of life. We aimed to quantify the incremental burden of AF on the health-related quality of life of patients with HF in clinical practice.We used data from the Utah mEVAL program to analyze patient-reported outcomes (PROs) among patients with HF with and without AF. The primary outcome was the HF-specific Kansas City Cardiomyopathy Questionnaire, with generic PROs as secondary outcomes. Among 1707 patients with HF, 36% had AF (n = 616). Those with HF and AF were older (mean age 69 years vs 58 years, P.001), more likely to have prior stroke (29% vs 17%, P.001) and ischemic cardiomyopathy (28% vs 23%, P = .01), but had similar ejection fractions (mean 44% each, P = .6). After adjustment, and compared with HF alone, HF with AF was associated with worse Kansas City Cardiomyopathy Questionnaire scores (adjusted mean difference -3.45, 95% confidence interval [CI] -6.24 to -0.65), and worse Patient-Reported Outcomes Measurement Information System physical function scores (adjusted mean difference -1.63, 95% CI -2.59 to -0.67). The difference in visual analog scale general health was borderline (adjusted mean difference -2.01, 95% CI -4.51 to 0.49), and Patient-Reported Outcomes Measurement Information System depression scores were similar (adjusted mean difference 0.54, 95% CI -0.48 to 1.57).AF complicates nearly one-third of HF cases, and patients with HF and AF are substantially older and sicker. After adjustment, AF was independently associated with worse disease-specific and overall health-related quality of life than HF alone. Whether maintaining sinus rhythm can improve the HF-related health status of patients with HF in clinical practice should be explored further.

Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF).The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure.Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight.In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.

The role of the sports cardiologist has evolved into an essential component of the medical care of athletes. In addition to the improvement in health outcomes caused by reductions in cardiovascular risk, exercise results in adaptations in cardiovascular structure and function, termed exercise-induced cardiac remodeling. As diagnostic modalities have evolved over the last century, we have learned much about the healthy athletic adaptation that occurs with exercise. Sports cardiologists care for those with known or previously unknown cardiovascular conditions, distinguish findings on testing as physiological adaptation or pathological changes, and provide evidence-based and "best judgment" assessment of the risks of sports participation. We review the effects of exercise on the heart, the approach to common clinical scenarios in sports cardiology, and the importance of a patient/athlete-centered, shared decision-making approach in the care provided to athletes.

Background Radiofrequency catheter ablation for cardiac arrhythmias has traditionally been guided by fluoroscopy. Fluoroscopy exposes the patient, operator, and staff to ionizing radiation which has no safe dose void of stochastic and deterministic biologic risks. Zero fluoroscopy (ZF) approaches for catheter ablation have been advocated to eliminate these risks. We conducted a meta-analysis comparing acute procedure success, recurrence-free survival, complications, and procedure times between the approaches. Methods We conducted a literature search from inception through December 2020 in the databases of EMBASE and MEDLINE. We included randomized controlled trials and cohorts that compared the outcomes of interest in ZF and conventional/low fluoroscopy (CF/LF) approaches. The outcomes sought were acute procedure success, recurrence-free survival, complications, and procedure times. Effect estimates were combined, using the random-effects, generic inverse variance method of DerSimonian and Laird. Results Sixteen studies from 2013 to 2020, including 6,052 patients (2,219 ZF, 3,833 CF/LF) were included. There were no significant differences in acute procedure success rate (odds ratio [OR] 1.10, 95% CI 0.75-1.59), recurrence-free survival (OR 1.08, 95% CI 0.78-1.49), periprocedural complication rate (OR 0.72, 95% CI 0.45-1.16), or total procedure time (weighted mean difference 2.32 minutes, 95% CI -2.85-7.50) between ZF and CF/LF approaches, respectively. Overall, only 1.26% of patients crossed over from ZF to CF/LF arm. Conclusions Peri- and post-procedural outcomes with a ZF approach compared favorably with traditional fluoroscopic guidance without increasing procedural times. As comfort with ZF grows, coupled with evolving mapping technologies, this method has potential to become the standard approach for catheter ablation. This article is protected by copyright. All rights reserved.

OBJECTIVES: This study sought to evaluate atrial fibrillation (AF) ablation outcomes based on scar patterns and contiguous area available for AF wavefronts to propagate. BACKGROUND: The relevance of ablation scar pattern acting as a barrier for electrical propagation in recurrence after catheter ablation for persistent AF is unknown. METHODS: Three-month post-ablation atrial cardiac magnetic resonance was used to determine post-ablation scar. The left atrium (LA) was divided into 5 areas based on anatomical landmarks and scar patterns. The length of gaps in scar on the area boundaries was used to calculate fibrillatory areas (FAs) by adding the weighted contribution of adjacent areas. Cylindrical as well as patient-specific computational models were used to further confirm findings. RESULTS: A total of 75 patients that underwent an initial ablation for AF with 2 years of follow-up were included. The average maximum FA was 7,896 ± 1,988 mm(2) in patients with recurrence (n = 40) and 6,559 ± 1,784 mm(2) in patients without recurrence (n = 35) (p < 0.008). After redo ablation in 19 patients with recurrence, average maximum FA was 7,807 ± 1,392 mm(2) in 9 patients with recurrence and 5,030 ± 1,765 mm(2) in 10 without recurrence (p < 0.007). LA volume and total scar were not significant predictors of recurrence after the first ablation. In the cylindrical model, AF self-terminated after reducing the FAs. In the patient-specific models, simulation matched the clinical outcomes with larger FAs associated with post-ablation arrhythmia recurrences. CONCLUSIONS: This data provides mechanistic insights into AF recurrence, suggesting that post-ablation scar pattern dividing the atria into smaller regions is an important and better predictor than LA volume and total scar, with improved long-term outcomes in persistent AF. (J Am Coll Cardiol EP 2020;■:■–■) © 2020 by the American College of Cardiology Foundation.