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Background: Severe aortic valve stenosis (AS) and atrial fibrillation (AF) are risk factors of hemodynamic instability in heart failure (HF) management due to low cardiac output, respectively. Therefore, the treatment of HF due to severe AS complicated with AF is anticipated to be difficult. Tolvaptan, a vasopressin V2 receptor inhibitor, is effective in controlling acute decompensated heart failure (ADHF) with hemodynamic stability. However, its clinical efficacy against ADHF caused by AS with AF remains to be determined. Methods: Clinical information (from September 2014 to December 2017) of 59 patients diagnosed with ADHF due to severe AS (20 patients with AF; 39 patients with sinus rhythm [SR]) was obtained from the LOHAS registry. The registry collected data from seven hospitals and assessed the short-term effects of tolvaptan in patients hospitalized for ADHF with severe AS. We attempted to identify clinical differences from baseline up to 4 days, comparing patients with AF (AF group) versus those with SR (SR group). Results: There were no significant differences between the groups in age (83.7 ± 4.5 vs. 85.8 ± 6.9 years, respectively; p = 0.11) and aortic valve area (0.60 [0.46–0.73] vs. 0.56 [0.37–0.70] cm2, respectively; p = 0.50). However, left atrial volume was larger (104 [85–126] vs. 87 [64–103] mL, respectively; p < 0.01), whereas stroke volume was lower (51.6 ± 14.8 vs. 59.0 ± 18.7 mL, respectively; p = 0.08) in the AF group versus the SR group. Body weight decreased daily from baseline up to day 4 in both groups (from 55.4 to 53.2 kg [p < 0.01] and from 53.5 to 51.0 kg [p < 0.01], respectively) without change in heart rate. Notably, the systolic blood pressure decreased slightly in the AF group after 2 days of treatment with tolvaptan. Conclusions: Short-term treatment with tolvaptan improved HF in patients hospitalized for severe AS, regardless of the presence of AF or SR. After achieving sufficient diuresis, a slight decrease in blood pressure was observed in the AF group, suggesting an appropriate timeframe for safe and effective use of tolvaptan. [ABSTRACT FROM AUTHOR]

Background: Recent advancements in artificial intelligence (AI) have significantly improved atrial fibrillation (AF) detection using electrocardiography (ECG) data obtained during sinus rhythm (SR). However, the utility of printed ECG (pECG) records for AF detection, particularly in developing countries, remains unexplored. This study aims to assess the efficacy of an AI-based screening tool for paroxysmal AF (PAF) using pECGs during SR. Methods: We analyzed 5688 printed 12-lead SR-ECG records from 2192 patients admitted to Beijing Chaoyang Hospital between May 2011 to August 2022. All patients underwent catheter ablation for PAF (AF group) or other electrophysiological procedures (non-AF group). We developed a deep learning model to detect PAF from these printed SR-ECGs. The 2192 patients were randomly assigned to training (1972, 57.3% with PAF), validation (108, 57.4% with PAF), and test datasets (112, 57.1% with PAF). We developed an applet to digitize the printed ECG data and display the results within a few seconds. Our evaluation focused on sensitivity, specificity, accuracy, F1 score, the area under the receiver-operating characteristic curve (AUROC), and precisionrecall curves (PRAUC). Results: The PAF detection algorithm demonstrated strong performance: sensitivity 87.5%, specificity 66.7%, accuracy 78.6%, F1 score 0.824, AUROC 0.871 and PRAUC 0.914. A gradient-weighted class activation map (Grad-CAM) revealed the model’s tailored focus on different ECG areas for personalized PAF detection. Conclusions: The deep-learning analysis of printed SR-ECG records shows high accuracy in PAF detection, suggesting its potential as a reliable screening tool in real-world clinical practice. [ABSTRACT FROM AUTHOR]

Severe left ventricular dysfunction and ventricular wall motion abnormalities predispose individuals to thrombosis and thromboembolism. Thromboembolism is one of the main causes of increased mortality in patients with heart failure and reduced ejection fraction (HFrEF). However, regarding thromboembolism due to HFrEF in sinus rhythm, most cases to date have reported ischemic strokes, and repeated embolization of peripheral arteries has been reported not uncommon. Herein, we report the case of a 48-year-old man with a definite diagnosis of sinus rhythm HFrEF and recurrent peripheral arterial embolization within a short period. The condition is caused by severe left ventricular systolic dysfunction and abnormal left ventricular wall motion, resulting in blood stasis and abnormal blood composition, with or without left ventricular thrombosis, and can lead to thromboembolism. Current guidelines state that patients with heart failure and clear indication(s) for anticoagulation (e.g., atrial fibrillation, heart valve replacement) should be administered appropriate anticoagulation therapy. However, controversy persists regarding whether patients with HFrEF in sinus rhythm can benefit from anticoagulation therapy. This case highlights the utility and necessity of anticoagulation for the prevention of intracardiac thrombosis and the treatment of peripheral arterial embolism in patients with HFrEF in sinus rhythm.

Objective: To analyze the results of biatrial (BA) Cox-Maze IV cryoablation during combined heart surgeries Methods: The study involved 88 patients who underwent BA cryoablation and concomitant cardiac surgery. The inclusion criteria were patients who underwent BA cryoablation and concomitant cardiac surgery between 2019 and 2021. The types of atrial fibrillation (AF) observed were as follows: persistent – 39 (44.3%) and long-term persistent – 49 (55.7%) cases Results: The following procedures were performed: coronary artery bypass grafting (CABG) in 5 cases (5.7%), isolated valve repair in 67 cases (76.1%), and valve repair combined with CABG in 16 cases (18.2%). The aortic cross-clamping (ACC) time was 143 minutes [range: 120.5-161.5], and the cardiopulmonary bypass time was 193.5 minutes [range: 168.5-210]. BA Cox-Maze IV cryoablation was performed in all cases. The hospital mortality rate was 1.1%. Sinus rhythm was restored at the time of discharge in 81 patients (92%). Two patients (2.3%) received a permanent pacemaker. The survival rates at 1, 2, 3, and 4 years were 88.9%, 88.9%, 82.2%, and 73.5%, respectively. The rates of remaining free from AF at 1, 2, 3, and 4 years were 87.5%, 80.7%, 68.3%, and 38.6%, respectively. Conclusion: Cryoablation using the maze procedure as a concomitant step during cardiac surgery is a safe procedure with a high likelihood of restoring sinus rhythm.

Background: Amiodarone is an anti-arrhythmic drug that has extensive tissue distribution and substantial storage in the fat tissue. Different studies have described some implications of body fat composition in its pharmacokinetics and pharmacodynamics. However, no clinical studies have described its implications for clinical efficacy. Methods: We studied 878 patients with persistent atrial fibrillation (AF) treated with a regimen of amiodarone and referred to electrical cardioversion (ECV), included prospectively in two Spanish registries. We analyzed the influence of body mass index (BMI), as well as overweight and obesity, in the efficacy of amiodarone for achieving pharmacologic cardioversion to sinus rhythm (SR) before ECV. Results: A total of 185 patients (21.1%) reverted to SR before ECV. Patients who reverted to SR had a lower BMI than those who did not revert (27.45 ± 4.36 kg/m2 vs. 29.11 ± 4.09 kg/m2; p < 0.001). We observed a progressively lower probability of reverting to SR in overweight and obese patients (normal weight 28.3%, overweight 21.3%, obesity 13.1%; p < 0.001). In the logistic regression, BMI (kg/m2) adjusted for other related variables remained as the main factor inversely related to reversion to SR (OR = 0.904 × kg/m2); CI 75% 0.864–0.946). Conclusions: We observed a negative relationship between an increased BMI and the efficacy of amiodarone for reversion to SR, suggesting a negative clinical impact of excess body fat in its efficacy. [ABSTRACT FROM AUTHOR]

Aims Human induced pluripotent stem cell–derived atrial cardiomyocytes (hiPSC-aCM) could be a helpful tool to study the physiology and diseases of the human atrium. To fulfil this expectation, the electrophysiology of hiPSC-aCM should closely resemble the situation in the human atrium. Data on the contribution of the slowly activating delayed rectifier currents (I Ks) to repolarization are lacking for both human atrium and hiPSC-aCM. Methods and results Human atrial tissues were obtained from patients with sinus rhythm (SR) or atrial fibrillation (AF). Currents were measured in human atrial cardiomyocytes (aCM) and compared with hiPSC-aCM and used to model I Ks contribution to action potential (AP) shape. Action potential was recorded by sharp microelectrodes. HMR-1556 (1 µM) was used to identify I Ks and to estimate I Ks contribution to repolarization. Less than 50% of hiPSC-aCM and aCM possessed I Ks. Frequency of occurrence, current densities, activation/deactivation kinetics, and voltage dependency of I Ks did not differ significantly between hiPSC-aCM and aCM, neither in SR nor AF. β-Adrenoceptor stimulation with isoprenaline did not increase I Ks neither in aCM nor in hiPSC-aCM. In tissue from SR, block of I Ks with HMR-1556 did not lengthen the action potential duration, even when repolarization reserve was reduced by block of the ultra-rapid repolarizing current with 4-aminopyridine or the rapidly activating delayed rectifier potassium outward current with E-4031. Conclusion I Ks exists in hiPSC-aCM with biophysics not different from aCM. As in adult human atrium (SR and AF), I Ks does not appear to relevantly contribute to repolarization in hiPSC-aCM. [ABSTRACT FROM AUTHOR]

Objectives: The study aimed to develop a deep learning-based edge AI model deployed on electrocardiograph (ECG) devices for the real-time detection of atrial fibrillation (AF) risk during sinus rhythm (SR) using standard 10 s, 12-lead electrocardiograms (ECGs). Methods: A novel approach was used to convert standard 12-lead ECGs into binary images for model input, and a lightweight convolutional neural network (CNN)-based model was trained using data collected by the Japan Agency for Medical and Research Development (AMED) between 2019 and 2022. Patients over 40 years old with digital, SR ECGs were retrospectively enrolled and divided into AF and non-AF groups. The data labeling was supervised by cardiologists. The dataset was randomly allocated into training, validation, and internal testing datasets. External testing was conducted on data collected from other hospitals. Results: The best-trained model achieved an AUC of 0.82 and 0.80, sensitivity of 79.5% and 72.3%, specificity of 77.8% and 77.7%, precision of 78.2% and 76.4%, and overall accuracy of 78.6% and 75.0% in the internal and external testing datasets, respectively. The deployed model and app package utilized 2.5 MB and 40 MB of the available ROM and RAM capacity on the edge ECG device, correspondingly. The processing time for AF risk detection was approximately 2 s. Conclusions: The model maintains comparable performance and improves its suitability for deployment on resource-constrained ECG devices, thereby expanding its potential impact to a wide range of healthcare settings. Its successful deployment enables real-time AF risk detection during SR, allowing for timely intervention to prevent AF-related serious consequences like stroke and premature death. [ABSTRACT FROM AUTHOR]

• Clinical settings influence stroke prediction scores in HFrEF with sinus rhythm. • Rivaroxaban is associated with a reduced stroke risk in HFrEF with sinus rhythm and high D-dimer. • The predictive value of stroke risk score should be evaluated further. Patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm have a heightened risk of stroke. Whether anticoagulation benefits these patients is uncertain. In this post hoc analysis of the A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure (COMMANDER-HF) trial we evaluated how a previously validated risk model consisting of 3 variables (history of prior stroke, insulin-treated diabetes, and N-terminal pro-B-type natriuretic peptide level) would perform, compared with plasma d -dimer, for stroke prediction and estimation of the benefit of low-dose rivaroxaban. Stroke risk and treatment effect were computed across risk score and plasma d -dimer tertiles. Risk score was available in 58% of the COMMANDER-HF population (n = 2928). Over a median follow-up of 512 days (range 342–747 days), 60 patients experienced a stroke (14.6 per 1000 patient-years). The risk model did not identify patients at higher risk of stroke and showed a low overall prognostic performance (C-index = 0.53). The effect of rivaroxaban on stroke was homogeneous across risk score tertiles (P -interaction =.67). Among patients in whom the risk score was estimated, d -dimer was available in 2343 (80%). d -dimer had an acceptable discrimination performance for stroke prediction (C-index = 0.66) and higher plasma d -dimer concentrations were associated with higher rates of stroke (ie, tertile 3 vs tertile 1, hazard ratio 3.65, 95% confidence interval 1.59–8.39, P =.002). Treatment with low-dose rivaroxaban reduced the incidence of stroke in patients at highest risk by d -dimer levels (ie, >515 ng/mL, hazard ratio 0.42, 95% confidence interval 0.18–0.95, P -interaction =.074), without any safety concerns. In our analysis, plasma d -dimer concentrations performed better than a previously described 3-variable risk score for stroke prediction in patients with heart failure with reduced ejection fraction, a recent clinical worsening and sinus rhythm as enrolled in the COMMANDER-HF trial. In these patients, a raised plasma d -dimer concentration identified patients who might benefit most from rivaroxaban. [ABSTRACT FROM AUTHOR]

(1) Background: Structural remodeling plays an important role in the pathophysiology of atrial fibrillation (AF). It is likely that structural remodeling occurs transmurally, giving rise to electrical endo-epicardial asynchrony (EEA). Recent studies have suggested that areas of EEA may be suitable targets for ablation therapy of AF. We hypothesized that the degree of EEA is more pronounced in areas of transmural conduction block (T-CB) than single-sided CB (SS-CB). This study examined the degree to which SS-CB and T-CB enhance EEA and which specific unipolar potential morphology parameters are predictive for SS-CB or T-CB. (2) Methods: Simultaneous endo-epicardial mapping in the human right atrium was performed in 86 patients. Potential morphology parameters included unipolar potential voltages, low-voltage areas, potential complexity (long double and fractionated potentials: LDPs and FPs), and the duration of fractionation. (3) Results: EEA was mostly affected by the presence of T-CB areas. Lower potential voltages and more LDPs and FPs were observed in T-CB areas compared to SS-CB areas. (4) Conclusion: Areas of T-CB could be most accurately predicted by combining epicardial unipolar potential morphology parameters, including voltages, fractionation, and fractionation duration (AUC = 0.91). If transmural areas of CB indeed play a pivotal role in the pathophysiology of AF, they could theoretically be used as target sites for ablation. [ABSTRACT FROM AUTHOR]

Aims Guidelines recommend opportunistic screening for atrial fibrillation (AF), using a 30 s single-lead electrocardiogram (ECG) recorded by a wearable device. Since many patients have paroxysmal AF, identification of patients at high risk presenting with sinus rhythm (SR) may increase the yield of subsequent long-term cardiac monitoring. The aim is to evaluate an AI-algorithm trained on 10 s single-lead ECG with or without risk factors to predict AF. Methods and results This retrospective study used 13 479 ECGs from AF patients in SR around the time of diagnosis and 53 916 age- and sex-matched control ECGs, augmented with 17 risk factors extracted from electronic health records. AI models were trained and compared using 1- or 12-lead ECGs, with or without risk factors. Model bias was evaluated by age- and sex-stratification of results. Random forest models identified the most relevant risk factors. The single-lead model achieved an area under the curve of 0.74, which increased to 0.76 by adding six risk factors (95% confidence interval: 0.74–0.79). This model matched the performance of a 12-lead model. Results are stable for both sexes, over ages ranging from 40 to 90 years. Out of 17 clinical variables, 6 were sufficient for optimal accuracy of the model: hypertension, heart failure, valvular disease, history of myocardial infarction, age, and sex. Conclusion An AI model using a single-lead SR ECG and six risk factors can identify patients with concurrent AF with similar accuracy as a 12-lead ECG-AI model. An age- and sex-matched data set leads to an unbiased model with consistent predictions across age groups. [ABSTRACT FROM AUTHOR]

AbstractBackground It is unknown which features of unipolar atrial electrogram (U-AEGM) morphology are affected by ageing and whether age-related changes in U-AEGM morphology are equally distributed throughout the right and left atria.Patients and methods Epicardial high-resolution mapping was performed in patients undergoing coronary artery bypass grafting surgery during sinus rhythm (SR). Mapping areas include the right atrium (RA), left atrium (LA), pulmonary vein area (PVA) and Bachmann’s bundle (BB). Patients were categorized into a young (age < 60) and aged (age ≥ 60) group. U-AEGM were classified as single potentials (SPs, one deflection), short double potentials (SDPs, deflection interval ≤ 15ms), long double potentials (LDPs, deflection interval > 15ms) and fractionated potentials (FPs, ≥3 deflections).Results A total of 213 patients (age: 67 (59–73) years; young group N = 58, aged group N = 155) were included. Only at BB, the proportion of SPs (p = 0.007) was significantly higher in the young group, while the proportion of SDPs (p = 0.051), LDPs (p = 0.004) and FPs (p = 0.006) was higher in the aged group. After adjusting for potential confounders, older age was associated with a reduction in SPs [regression coefficient (β): −6.33, 95% confident interval (CI): −10.37 to −2.30] at the expense of an increased proportion of SDPs (β: 2.49, 95% CI: 0.09 to 4.89), LDPs (β: 1.94, 95% CI: 0.21 to 3.68) and FPs (β: 1.90, 95% CI: 0.62 to 3.18).Conclusions Age-related remodeling particularly affects BB as indicated by the decreased amount of non-SP at this location in the elderly.Key MessagesAgeing preferentially affects the morphology of unipolar atrial electrograms recorded at Bachmann’s bundle.At Bachmann’s bundle, the proportion of short double-, long double- and fractionated potentials increase during ageing at the expense of a decrease in the proportion of single potentials, reflecting aggravation of abnormalities in conduction.The increase in abnormal unipolar atrial electrograms at Bachmann’s bundle during ageing supports the concept that Bachmann’s bundle may play an important role in development of age-related arrhythmias such as atrial fibrillation.

It is unknown which features of unipolar atrial electrogram (U-AEGM) morphology are affected by ageing and whether age-related changes in U-AEGM morphology are equally distributed throughout the right and left atria. Epicardial high-resolution mapping was performed in patients undergoing coronary artery bypass grafting surgery during sinus rhythm (SR). Mapping areas include the right atrium (RA), left atrium (LA), pulmonary vein area (PVA) and Bachmann's bundle (BB). Patients were categorized into a young (age < 60) and aged (age ≥ 60) group. U-AEGM were classified as single potentials (SPs, one deflection), short double potentials (SDPs, deflection interval ≤ 15ms), long double potentials (LDPs, deflection interval > 15ms) and fractionated potentials (FPs, ≥3 deflections). A total of 213 patients (age: 67 (59–73) years; young group N = 58, aged group N = 155) were included. Only at BB, the proportion of SPs (p = 0.007) was significantly higher in the young group, while the proportion of SDPs (p = 0.051), LDPs (p = 0.004) and FPs (p = 0.006) was higher in the aged group. After adjusting for potential confounders, older age was associated with a reduction in SPs [regression coefficient (β): −6.33, 95% confident interval (CI): −10.37 to −2.30] at the expense of an increased proportion of SDPs (β: 2.49, 95% CI: 0.09 to 4.89), LDPs (β: 1.94, 95% CI: 0.21 to 3.68) and FPs (β: 1.90, 95% CI: 0.62 to 3.18). Age-related remodeling particularly affects BB as indicated by the decreased amount of non-SP at this location in the elderly. Ageing preferentially affects the morphology of unipolar atrial electrograms recorded at Bachmann's bundle. At Bachmann's bundle, the proportion of short double-, long double- and fractionated potentials increase during ageing at the expense of a decrease in the proportion of single potentials, reflecting aggravation of abnormalities in conduction. The increase in abnormal unipolar atrial electrograms at Bachmann's bundle during ageing supports the concept that Bachmann's bundle may play an important role in development of age-related arrhythmias such as atrial fibrillation. [ABSTRACT FROM AUTHOR]

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Background: Substrate‐based ablation can treat uninducible or hemodynamically instability scar‐related ventricular tachycardia (VT). However, whether a correlation exists between the critical VT isthmus and late activation zone (LAZ) during sinus rhythm (SR) is unknown. Objective: To demonstrate the structural and functional properties of abnormal substrates and analyze the link between the VT circuit and abnormal activity during SR. Methods: Thirty‐six patients with scar‐related VT (age, 50.0 ± 13.7 years and 86.1% men) who underwent VT ablation were reviewed. The automatic rhythmia ultrahigh resolution mapping system was used for electroanatomic substrate mapping. The clinical characteristics and mapping findings, particularly the LAZ characteristics during SR and VT, were analyzed. To determine the association between the LAZ during the SR and VT circuits, the LAZ was defined as five activation patterns: entrance, exit, core, blind alley, and conduction barrier. Results: Forty‐five VTs were induced in 36 patients, 91.1% of which were monomorphic. The LAZ of all patients was mapped during the SR and VT circuits, and the consistency of the anatomical locations of the LAZ and VT circuits was analyzed. Using the ultrahigh resolution mapping system, interconversion patterns, including the bridge, T, puzzle, maze, and multilayer types, were identified. VT ablation enabled precise ablation of abnormal late potential conduction channels. Conclusion: Five interconversion patterns of the LAZ during the SR and VT circuits were summarized. These findings may help formulate more precise substrate‐based ablation strategies for scar‐related VT and shorter procedure times. [ABSTRACT FROM AUTHOR]

Introduction: Although there is a high prevalence of atrial arrythmias in patients with cardiovascular implantable electronic devices (CIED), few studies have compared the efficacy of cardioversion modalities for the restoration of sinus rhythm. The primary aim of this study is to compare the efficacy of internal and external first-time cardioversion for the treatment of atrial arrythmias in patients with an implantable cardioverter defibrillator (ICD), including the relative efficacy of dual and single coil leads. Methods: Demographic and clinical information was collected and analysed from consecutive electronic records of patients with a CIED who received atrial cardioversion at a single NHS trust between 2008 and 2023. Non-parametric statistical analyses were undertaken to enable the relative success of first-time cardioversion for different modalities to be determined. Results: Out of 163 patients who were identified, 71 received external and 92 received internal cardioversion. External cardioversion had the highest first-time efficacy (90.1%) with a statistically significant difference in first-time success between the external and combined internal cohorts (p = .002). Dual coil leads had superior first-time efficacy (80.4%) compared to single coil leads (56.1%), with a statistically significant difference between them (p = .022). Conclusions: First-time internal cardioversion success is superior for patients with dual coil leads compared to patients with single coil leads. There is no statistical difference between first time success for dual coil internal and external cardioversions, making an initial attempt at internal cardioversion a potentially credible clinical option for patients with dual coil leads. [ABSTRACT FROM AUTHOR]

Aims Areas of conduction inhomogeneity (CI) during sinus rhythm may facilitate the initiation and perpetuation of atrial fibrillation (AF). Currently, no tool is available to quantify the severity of CI. Our aim is to develop and validate a novel tool using unipolar electrograms (EGMs) only to quantify the severity of CI in the atria. Methods and results Epicardial mapping of the right atrium (RA) and left atrium, including Bachmann's bundle, was performed in 235 patients undergoing coronary artery bypass grafting surgery. Conduction inhomogeneity was defined as the amount of conduction block. Electrograms were classified as single, short, long double (LDP), and fractionated potentials (FPs), and the fractionation duration of non-single potentials was measured. The proportion of low-voltage areas (LVAs, <1 mV) was calculated. Increased CI was associated with decreased potential voltages and increased LVAs, LDPs, and FPs. The Electrical Fingerprint Score consisting of RA EGM features, including LVAs and LDPs, was most accurate in predicting CI severity. The RA Electrical Fingerprint Score demonstrated the highest correlation with the amount of CI in both atria (r = 0.70, P < 0.001). Conclusion The Electrical Fingerprint Score is a novel tool to quantify the severity of CI using only unipolar EGM characteristics recorded. This tool can be used to stage the degree of conduction abnormalities without constructing spatial activation patterns, potentially enabling early identification of patients at high risk of post-operative AF or selection of the appropriate ablation approach in addition to pulmonary vein isolation at the electrophysiology laboratory. [ABSTRACT FROM AUTHOR]

Background: “Ablate and pace” strategy is a reasonable treatment option in refractory atrial fibrillation (AF) when sinus rhythm (SR) cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), with left bundle branch pacing (LBBP) or His bundle pacing (HBP), is gaining recognition since it offers the most physiological activation of the left ventricle. However, the incidence of conversion to SR after AVNA with CSP is not known. The purpose of the investigation was to determine the incidence of spontaneous conversion to SR and its predicting factors in patients undergoing CSP and AVNA. Methods: Consecutive refractory symptomatic AF patients undergoing AVNA with CSP at our institution between June 2018 and December 2022 were retrospectively analyzed. Twelve lead electrocardiogram (ECG) recordings were analyzed at each outpatient follow-up visit. Echocardiographic and clinical parameters were assessed at baseline and six months after the implantation. Results: Sixty-eight patients (male 42.6%, age 71 ± 8 years, left ventricular ejection fraction 40 ± 15%) were included. Thirty-seven patients (54.4%) received HBP and 31 (45.6%) LBBP. During follow-up, spontaneous conversion to SR was registered in 6 patients (8.8%); 3 in the HBP group and 3 in the LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was significantly smaller in the SR group (45 mL/m² (41–51) vs. 60 mL/m² (52–75); p = 0.002). Multiple regression model confirmed an inverse association between LAVI and conversion to SR even after considering other clinically relevant covariates (odds ratio 1.273, p = 0.028). At follow-up, LAVI did not change in any group (SR: p = 0.345; NSR: p = 0.508). Improvement in New York Heart Association (NYHA) class was comparable in both groups. Conclusions: Spontaneous conversion to SR after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Further studies are warranted to clarify which patients should be considered for initial dual-chamber device implantation to provide atrio-ventricular synchrony in case of SR restoration. [ABSTRACT FROM AUTHOR]

Background: Reentrant atrial tachycardias (ATs) utilize critical isthmus (CI) for the maintenance of the circuit. The electrophysiological characteristics and clinical implications of the targeted CI regions of reentrant ATs during sinus rhythm (SR) were not clear. Therefore, our research aims at studying the electrical properties of the CI sites for scar-related reentrant ATs and the functional substrate mapping identified during SR. Methods: Patients mapped with high-density catheters during SR and reentrant ATs were retrospectively analyzed. The CI regions of the reentrant ATs were confirmed by the combination of the activation map and the entrainment. The substrate mapping was analyzed for wavefront propagation, conduction velocity, and electrogram patterns. Results: Twenty patients with 22 reentrant ATs that underwent high-density maps were analyzed at 2 hospitals. Mapping performed during SR identified a scar region of 23.0 ± 13.6% of the left atrium. Regions of the CI in SR were characterized by low voltage (0.3 ± 0.2 mV), conduction slowing (0.4 ± 0.2 m/s), and fractionated electrogram (duration 62.5 ± 13.9 ms). Substrate mapping during SR showed that the regions of the CI located with the low-voltage zone in 16 out of 22 CI (72.7%), the deceleration zone in 15 out of 22 CI (68.2%), and late atrial activation in 12 out of 22 CI (54.5%). Targeting regions of CI achieve 94% of termination or change of the reentrant circuit. At 6.2 ± 7.1 months, there was 75% freedom from atrial arrhythmia. Conclusions: Novel high-density mapping can identify the functional substrates during SR and guide ablation. Low-voltage areas with conduction slowing are putative predictors of the CI for the maintenance of the reentrant ATs. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is the most common heart rhythm disorder. AF ablation based on endovascular or surgical techniques is a standard of care in everyday practice. Early recurrence of atrial arrhythmias is a significant problem after ablative procedures. Prophylactic use of antiarrhythmic drugs has become a possible solution. Materials and methods: We performed a retrospective observational cohort study of 59 patients with heart disease requiring surgery under extracorporeal circulation (ECC) and have received radiofrequency ablation (RFA) for chronic or persistent AF with a successful conversion to sinus rhythm. Patients were divided into two groups: 36 were treated with amiodarone for three months postoperatively (treatment group), and 23 had no concomitant amiodarone therapy (control group). We compared the groups regarding freedom from recurrent atrial arrhythmia and the frequency of conduction disorders requiring permanent pacemaker implantation. Results: No differences between the groups were found regarding demographic characteristics, risk profile, and heart diseases indicating cardiac surgery. During follow-up, a significantly higher proportion of patients with sinus rhythm in the group receiving amiodarone was found (80.56% vs. 52.17%; p < 0.041). No cases of premature discontinuation of amiodarone for side effects or noncompliance were registered in the treatment group. Conclusion: Three months of amiodarone therapy post-surgical RFA of AF is an effective and safe strategy for relapse prevention. [ABSTRACT FROM AUTHOR]

Background: Amiodarone is an anti-arrhythmic drug that has extensive tissue distribution and substantial storage in the fat tissue. Different studies have described some implications of body fat composition in its pharmacokinetics and pharmacodynamics. However, no clinical studies have described its implications for clinical efficacy. Methods: We studied 878 patients with persistent atrial fibrillation (AF) treated with a regimen of amiodarone and referred to electrical cardioversion (ECV), included prospectively in two Spanish registries. We analyzed the influence of body mass index (BMI), as well as overweight and obesity, in the efficacy of amiodarone for achieving pharmacologic cardioversion to sinus rhythm (SR) before ECV. Results: A total of 185 patients (21.1%) reverted to SR before ECV. Patients who reverted to SR had a lower BMI than those who did not revert (27.45 ± 4.36 kg/m2 vs. 29.11 ± 4.09 kg/m2; p < 0.001). We observed a progressively lower probability of reverting to SR in overweight and obese patients (normal weight 28.3%, overweight 21.3%, obesity 13.1%; p < 0.001). In the logistic regression, BMI (kg/m2) adjusted for other related variables remained as the main factor inversely related to reversion to SR (OR = 0.904 × kg/m2); CI 75% 0.864–0.946). Conclusions: We observed a negative relationship between an increased BMI and the efficacy of amiodarone for reversion to SR, suggesting a negative clinical impact of excess body fat in its efficacy.

Objectives: The study aimed to develop a deep learning-based edge AI model deployed on electrocardiograph (ECG) devices for the real-time detection of atrial fibrillation (AF) risk during sinus rhythm (SR) using standard 10 s, 12-lead electrocardiograms (ECGs). Methods: A novel approach was used to convert standard 12-lead ECGs into binary images for model input, and a lightweight convolutional neural network (CNN)-based model was trained using data collected by the Japan Agency for Medical and Research Development (AMED) between 2019 and 2022. Patients over 40 years old with digital, SR ECGs were retrospectively enrolled and divided into AF and non-AF groups. The data labeling was supervised by cardiologists. The dataset was randomly allocated into training, validation, and internal testing datasets. External testing was conducted on data collected from other hospitals. Results: The best-trained model achieved an AUC of 0.82 and 0.80, sensitivity of 79.5% and 72.3%, specificity of 77.8% and 77.7%, precision of 78.2% and 76.4%, and overall accuracy of 78.6% and 75.0% in the internal and external testing datasets, respectively. The deployed model and app package utilized 2.5 MB and 40 MB of the available ROM and RAM capacity on the edge ECG device, correspondingly. The processing time for AF risk detection was approximately 2 s. Conclusions: The model maintains comparable performance and improves its suitability for deployment on resource-constrained ECG devices, thereby expanding its potential impact to a wide range of healthcare settings. Its successful deployment enables real-time AF risk detection during SR, allowing for timely intervention to prevent AF-related serious consequences like stroke and premature death.

Background. The stage 4 mitral stenosis is accompanied by atrial fibrillation which significantly worsens the prognosis due to the possibility of thromboembolic complications. However, sinus rhythm does not exclude the possibility of thrombosis which sometimes requires differential diagnosis with heart tumors. The aim. To present a case of unusual thrombus formation in a patient with significant mitral stenosis on the background of sinus rhythm and describe the specifics of determining indications for surgical intervention. Case report. Female patient K., 42 years old, who was admitted on January 12, 2023 to the National Amosov Institute of Cardiovascular Surgery, had been suffering from rheumatism for the past 20 years. In this case, the clinical course of mitral stenosis could be classified as stage 4, since there were signs of severe heart failure (shortness of breath on light exertion, peripheral edema, right-sided pleuritis, pulmonary thrombosis). However, the patient had sinus rhythm, which is more characteristic of the stage 3 mitral stenosis. The patient underwent mitral valve prosthetic surgery and removal of an unusual thrombus from the pulmonary valve cavity on January 23, 2023. Conclusions. The course of mitral stenosis, despite its thorough study, may have unusual clinical and instrumental manifestations, which requires differential diagnosis with heart tumors and other diseases. In some cases, the mechanism of thrombus formation can be extremely unusual, which can be a subject for discussion by cardiologists.

Objective: To assess outcome of Left Atrial reduction plasty and sinus rhythm restoration in patients undergoing Mitral valve surgery with chronic Atrial Fibrillation. Study Design: Longitudinal study. Place and Duration of Study: Adult Cardiac Surgery Unit, Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Jan 2017-Jun 2022. Methodology: Thirty three (n=33) patients with mitral valve disease were recruited via convenience sampling, all of whom exhibited an enlarged left atrium and pre-operative Atrial Fibrillation (AF). Pre-operative cardiac evaluations were performed using Transthoracic Echocardiography (TTE). Pre- and post-surgery trans-esophageal echocardiography studies were conducted as a routine procedure. Follow-up echocardiographic assessments were carried out at intervals of 1 month, 3 months, and 6 months, alongside Electrocardiograms (ECGs). During surgery, median sternotomy was done. Cardiopulmonary Bypass (CPB) time was established followed by cardiac arrest. After Mitral valve Repair/Replacement (MVR), Left Atrial (LA) plication was done by a double needle. Results: Out of thirty three (n=33) patients, 25(75.7%) females and 8(24.2%) male patients, with mean age of 44.3±15.5 years, underwent mitral valve surgery(repair/replacement) followed by LA reduction & sinus rhythm restoration procedure. Complete restoration of sinus rhythm with re-appearance of “a” wave on echocardiography, signifying LA transport function through mitral valve was observed in 31(93.9%) patients on 3rd month and only 1(3.0%) individual continued to have persistent AF after 6 months. (83.70±2.50 mm vs. 47.50±1.08 mm) (p

Introduction: Sinus node location, function, and atrial activation are often abnormal in patients with congenital heart disease (CHD), due to anatomical, surgical, and acquired factors. We aimed to perform noninvasive electrocardiographic imaging (ECGI) of the intrinsic atrial pacemaker and atrial activation in patients with surgically repaired or palliated CHD, compared with control patients with structurally normal hearts. Methods and Results: Atrial ECGI was performed in eight CHD patients with prespecified diagnoses (Fontan circulation, dextro transposition of the great arteries post Mustard/Senning, tetralogy of Fallot), and three controls. Activation and propagation maps were constructed in presenting rhythm. Wavefront propagation was analyzed to identify (1) intrinsic atrial pacemaker breakout site, (2) morphological right atrial (RA) activation pattern, (3) morphological left atrial (LA) breakout sites (i.e., interatrial connections), (4) LA activation pattern, and (5) putative lines of block. Physiologically appropriate atrial activation and propagation maps were able to be constructed. In the majority of patients, atrial breakouts were in keeping with the sinus node, observed in a crescent‐shaped distribution from the anterior superior vena cava to the posterior RA. Ectopic atrial pacemaker sites were demonstrated in the atriopulmonary (AP) Fontan patient (very diffuse posterolateral RA) and Mustard patient (very posterior RA competing with a low RA focus). RA propagation was laminar in controls, but suggested either a line of block or conduction slowing consistent with an atriotomy scar in the tetralogy of Fallot (TOF) patients. Putative lines of block were more complex and RA propagation more abnormal in the atrial switch and AP Fontan patients, compared with the TOF patients. RA activation in the extracardiac Fontan patients was relatively laminar. Earliest LA breakout was most commonly observed in the region of Bachmann's Bundle in both controls and CHD patients, except for posterior LA breakouts in two patients. LA activation was typically more homogeneous than RA activation in CHD patients. Conclusion: ECGI can be utilized to create a noninvasive mapping model of atrial activation in postsurgical CHD, demonstrating atrial pacemaker location, putative lines of block and interatrial connections. Once validated invasively, this may have clinical implications in predicting risk of sinus node dysfunction and atrial arrhythmias, or in guiding catheter ablation. [ABSTRACT FROM AUTHOR]

Objective: Atrial fibrillation is one of the most common arrhythmias. The mechanism of atrial fibrillation is not yet clear. A number of previous studies have shown that adipokines, including leptin, visfatin, are closely related to cardiovascular diseases.In this study, the relationship between leptin, visfatin and atrial fibrillation was investigated. Methods: In this study, the secretion levels of leptin and visfatin in peripheral blood and epicardial adipose tissue of AF group and control group were detected. To explore the relationship between leptin, visfatin and AF. Results: The average concentration of visfatin in peripheral blood serum of atrial fibrillation group was 15.95±10.44 ng/mL, and the sinus rhythm group was 20.28±12.90 ng/mL, and there was not statistically significant (P=0.169); The average concentration of leptin in peripheral blood in the atrial fibrillation group was 1.48 ng/mL, and in the sinus rhythm group was 2.56ng/mL. The comparison between the two was statistically significant (P=0.0027). Serum leptin levels in the sinus group were significantly higher than those in the atrial fibrillation group; In epicardial adipose tissue, the expression of leptin in the atrial fibrillation group was significantly lower than that in the control group (P=0.032), while the expression of visfatin was not statistically different between the two groups (P=0.06). Conclusions: The incidence of atrial fibrillation can be reduced by high levels of leptin in peripheral blood serum and epicardial adipose tissue. The levels of visfatin in peripheral blood serum and epicardial adipose tissue in patients with atrial fibrillation was not significantly different from those with sinus rhythm. Therefore there may not be a correlation between visfatin and atrial fibrillation. [ABSTRACT FROM AUTHOR]

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Background and aims Atrial extrasystoles (AES) provoke conduction disorders and may trigger episodes of atrial fibrillation (AF). However, the direction- and rate-dependency of electrophysiological tissue properties on epicardial unipolar electrogram (EGM) morphology is unknown. Therefore, this study examined the impact of spontaneous AES on potential amplitude, -fractionation, -duration, and low-voltage areas (LVAs), and correlated these differences with various degrees of prematurity and aberrancy. Methods and results Intra-operative high-resolution epicardial mapping of the right and left atrium, Bachmann's Bundle, and pulmonary vein area was performed during sinus rhythm (SR) in 287 patients (60 with AF). AES were categorized according to their prematurity index (>25% shortening) and degree of aberrancy (none, mild/opposite, moderate and severe). In total, 837 unique AES (457 premature; 58 mild/opposite, 355 moderate, and 154 severe aberrant) were included. The average prematurity index was 28% [12–45]. Comparing SR and AES, average voltage decreased (−1.1 [−1.2, −0.9] mV, P < 0.001) at all atrial regions, whereas the amount of LVAs and fractionation increased (respectively, +3.4 [2.7, 4.1] % and +3.2 [2.6, 3.7] %, P < 0.001). Only weak or moderate correlations were found between EGM morphology parameters and prematurity indices (R 2 < 0.299, P < 0.001). All parameters were, however, most severely affected by either mild/opposite or severely aberrant AES, in which the effect was more pronounced in AF patients. Also, there were considerable regional differences in effects provoked by AES. Conclusion Unipolar EGM characteristics during spontaneous AES are mainly directional-dependent and not rate-dependent. AF patients have more direction-dependent conduction disorders, indicating enhanced non-uniform anisotropy that is uncovered by spontaneous AES. [ABSTRACT FROM AUTHOR]

Introduction: Improved sinus rhythm (SR) maintenance rates have been achieved in patients with persistent atrial fibrillation (AF) undergoing pulmonary vein isolation plus additional ablation of low voltage substrate (LVS) during SR. However, voltage mapping during SR may be hindered in persistent and long‐persistent AF patients by immediate AF recurrence after electrical cardioversion. We assess correlations between LVS extent and location during SR and AF, aiming to identify regional voltage thresholds for rhythm‐independent delineation/detection of LVS areas. (1) Identification of voltage dissimilarities between mapping in SR and AF. (2) Identification of regional voltage thresholds that improve cross‐rhythm substrate detection. (3) Comparison of LVS between SR and native versus induced AF. Methods: Forty‐one ablation‐naive persistent AF patients underwent high‐definition (1 mm electrodes; >1200 left atrial (LA) mapping sites per rhythm) voltage mapping in SR and AF. Global and regional voltage thresholds in AF were identified which best match LVS < 0.5 mV and <1.0 mV in SR. Additionally, the correlation between SR‐LVS with induced versus native AF‐LVS was assessed. Results: Substantial voltage differences (median: 0.52, interquartile range: 0.33–0.69, maximum: 1.19 mV) with a predominance of the posterior/inferior LA wall exist between the rhythms. An AF threshold of 0.34 mV for the entire left atrium provides an accuracy, sensitivity and specificity of 69%, 67%, and 69% to identify SR‐LVS < 0.5 mV, respectively. Lower thresholds for the posterior wall (0.27 mV) and inferior wall (0.3 mV) result in higher spatial concordance to SR‐LVS (4% and 7% increase). Concordance with SR‐LVS was higher for induced AF compared to native AF (area under the curve[AUC]: 0.80 vs. 0.73). AF‐LVS < 0.5 mV corresponds to SR‐LVS < 0.97 mV (AUC: 0.73). Conclusion: Although the proposed region‐specific voltage thresholds during AF improve the consistency of LVS identification as determined during SR, the concordance in LVS between SR and AF remains moderate, with larger LVS detection during AF. Voltage‐based substrate ablation should preferentially be performed during SR to limit the amount of ablated atrial myocardium. [ABSTRACT FROM AUTHOR]

Aims: Chronic rheumatic heart disease (RHD) is prevalent in India. The mitral valve in isolation or combination with the aortic or tricuspid valve is involved in 31.6% and 52.8% of chronic RHD patients, respectively. The left atrium (LA) functions as a reservoir during the cardiac cycle. Therefore, the LA enlargement leads to longitudinal lengthening, measured as a positive strain, permitting the measurement of the longitudinal strain of LA. This study aimed to assess the LA functions using peak atrial longitudinal strain (PALS) in patients with severe rheumatic mitral stenoses (MS) in sinus rhythm who underwent successful percutaneous transvenous mitral commissurotomy (PTMC). Material and Methods: We recruited 56 patients with severe rheumatic MS for the study, of which 06 PTMC procedures were considered unsuccessful. So, 50 patients of chronic severe rheumatic MS in sinus rhythm undergoing PTMC were enrolled in a tertiary care centre of the Armed Forces from August 2017 to May 2019. Patients included in the study were not consecutive, and patients with atrial fibrillation (AF) were excluded. Results: PALS improved post‑PTMC (P <.001) in this study, effectively concluding that PALS is impaired in patients with severe symptomatic MS and is acutely enhanced after treatment. Conclusions: PALS is a good indicator of LA function and may predict the success of PTMC on the rheumatic mitral valve. [ABSTRACT FROM AUTHOR]

Background: Treating arrhythmia adequately is crucial to prevent cardiac morbidity and mortality. Previous studies report that ivabradine may increase the risk of atrial fibrillation; however, emerging evidence shows that the drug may have beneficial effect in treatment of arrhythmia. Purpose: The present research explored the clinical evidence regarding the clinical efficacy and safety of ivabradine to treat arrhythmias. Method: A comprehensive literature search was conducted using MEDLINE, EMBASE, Scopus, Google Scholar and Web of Science databases. Full text articles that report on the use of ivabradine in human subjects with arrhythmia are included. Studies not written in English language and those not published in the period between 2016 and May 2021 were excluded. Results and discussion: Eight articles were included in the current review after screening a total of 1100 articles. The studies depicted that ivabradine is effective in improving ventricular rate, heart rate, and sinus rhythm in atrial fibrillation and has limited or no side effects. In addition, the findings indicate that combining ivabradine with other medications is more effective for improving the ventricular rate and maintain sinus rhythm than when used alone. Conclusion: Ivabradine alone or in combination with other medications can therefore be used as a potential treatment for arrhythmias. [ABSTRACT FROM AUTHOR]

Background: Paroxysmal atrial fibrillation (AF) often eludes early diagnosis, resulting in significant morbidity and mortality. Artificial intelligence (AI) has been used to predict AF from sinus rhythm electrocardiograms (ECGs), but AF prediction using sinus rhythm mobile electrocardiograms (mECG) remains unexplored. Objective: The purpose of this study was to investigate the utility of AI to predict AF events prospectively and retrospectively using sinus rhythm mECG data. Methods: We trained a neural network to predict AF events from sinus rhythm mECGs obtained from users of the Alivecor KardiaMobile 6L device. We tested our model on sinus rhythm mECGs within ±0–2 days, ±3–7 days, and ±8–30 days from AF events to determine the optimal screening window. Finally, we tested our model on mECGs from before an AF event to determine whether AF can be predicted prospectively. Results: We included 73,861 users with 267,614 mECGs (mean age 58.14 years; 35% women). Users with paroxysmal AF contributed 60.15% of mECGs. Model performance on the test set comprising control and study samples across all windows of interest showed an area under the curve (AUC) score of 0.760 (95% confidence interval [CI] 0.759–0.760), sensitivity of 0.703 (95% CI 0.700–0.705), specificity of 0.684 (95% CI 0.678–0.685), and accuracy of 69.4% (95% CI 0.692–0.700). Model performance was better on ±0–2 day samples (sensitivity 0.711; 95% CI 0.709–0.713) and worse on the ±8–30 day window (sensitivity 0.688; 95% CI 0.685–0.690), with performance on the ±3–7 day window falling in between (sensitivity 0.708; 95% CI 0.704–0.710). Conclusion: Neural networks can predict AF using a widely scalable and cost-effective mobile technology prospectively and retrospectively.

(1) Background: Structural remodeling plays an important role in the pathophysiology of atrial fibrillation (AF). It is likely that structural remodeling occurs transmurally, giving rise to electrical endo-epicardial asynchrony (EEA). Recent studies have suggested that areas of EEA may be suitable targets for ablation therapy of AF. We hypothesized that the degree of EEA is more pronounced in areas of transmural conduction block (T-CB) than single-sided CB (SS-CB). This study examined the degree to which SS-CB and T-CB enhance EEA and which specific unipolar potential morphology parameters are predictive for SS-CB or T-CB. (2) Methods: Simultaneous endo-epicardial mapping in the human right atrium was performed in 86 patients. Potential morphology parameters included unipolar potential voltages, low-voltage areas, potential complexity (long double and fractionated potentials: LDPs and FPs), and the duration of fractionation. (3) Results: EEA was mostly affected by the presence of T-CB areas. Lower potential voltages and more LDPs and FPs were observed in T-CB areas compared to SS-CB areas. (4) Conclusion: Areas of T-CB could be most accurately predicted by combining epicardial unipolar potential morphology parameters, including voltages, fractionation, and fractionation duration (AUC = 0.91). If transmural areas of CB indeed play a pivotal role in the pathophysiology of AF, they could theoretically be used as target sites for ablation.

Patients with hypertrophic cardiomyopathy (HCM) are at increased risk of stroke, but the incidence and factors associated with cardioembolic events in HCM patients without atrial fibrillation (AF) remain unresolved. We determined the incidence of stroke in patients in sinus rhythm (SR) monitored with a cardiac implantable electronic device (CIED). All consecutive patients diagnosed with HCM and referred to CIED implantation with >16 years at diagnosis and ≥ 1 year follow-up post CIED implantation were retrospectively reviewed. Severe LA dilatation was defined as ≥48 mm. Patients were stratified by rhythm as: Pre-existing AF (AF present prior to CIED); De novo AF (AF present after CIED implantation); SR : no episodes of AF. Of 1651 patients, 185 (11.2%) implanted with a CIED were included (57% men, age: 54 ± 17 years). Baseline, pre-existing AF was present in 73 (39%) patients. Ischemic stroke was reported in 19 (10.3%, 1.78%/year) patients and was similar across the three groups (2.3%/year vs 1.1%/year vs 0.6%/year in patients in SR vs pre-existing AF vs de novo AF , respectively, p = 0.235). In SR patients, a LAD≥48 mm posed the greatest risk of stroke (Hazard Ratio: 10.03,95% Confidence-Interval 2.79–16.01). At Cox multivariable analysis, after adjustment for oral anticoagulation, LA was independently associated with stroke while rhythm was not. in HCM patients with CIED long-term monitoring and no prior history of AF, stroke rates were similar in those with de novo AF or stable SR. Severe LA dilatation was a powerful risk factor, irrespective of AF. CIED: Cardiac Implantable Electronic Device, HCM: Hypertrophic Cardiomyopathy, HR: Hazard Ratio, P/LP pathogenic/likely pathogenic variant. [Display omitted] • Incidence of cardioembolic events in HCM patients with atrial fibrillation (AF) and sinus rhythm (SR) remains unresolved. • Whether left atrial (LA) disease could predispose to cardioembolic events in patients with SR is undetermined. • In patients with HCM and long-term monitoring stroke rates were similar in those with AF and SR. LA dilatation was a powerful risk factor. [ABSTRACT FROM AUTHOR]

Patients undergoing ablation for atrial fibrillation may be at increased risk of developing gastroesophageal reflux disease. We prospectively studied the presence of symptomatic gastroesophageal reflux disease in naïve patients who underwent atrial fibrillation ablation. Methods: The presence of typical symptoms suggestive of gastroesophageal reflux disease was clinically assessed by the gastroenterologist at baseline and at 3 months after ablation. In addition to that, all patients underwent upper gastrointestinal endoscopy. Results: Seventy-five patients were included in two groups: 46 patients who underwent atrial fibrillation ablation (study group) and 29 patients without ablation (control group). Patients with atrial fibrillation ablation were younger (57.76 ± 7.66 years versus 67.81 ± 8.52 years; p = 0.001), predominantly male (62.2% versus 33.3%; p = 0.030) and with higher body mass index (28.96 ± 3.12 kg/m2 versus 26.81 ± 5.19 kg/m2; p = 0.046). At three months after the ablation, in the study and control groups, there were 88.9% and 57.1% patients in sinus rhythm, respectively, (p = 0.009). Symptomatic gastroesophageal reflux disease was not more frequent in the study group (42.2% versus 61.9%; p = 0.220). There was no difference in terms of sinus rhythm prevalence in patients with versus without symptomatic gastroesophageal reflux disease (89.5% versus 88.5%; p = 0.709). Conclusion: In this small prospective study, typical symptoms suggestive of gastroesophageal reflux disease were not more frequent three months following atrial fibrillation ablation. [ABSTRACT FROM AUTHOR]

Introduction: Heart failure (HF) is a major public health issue associated with significantly increased risk of stroke. It remains uncertain whether oral anticoagulation (OAC) in patients with heart failure and sinus rhythm (HF-SR) could improve prognosis. Methods: We performed a systematic search of PubMed and Embase databases for randomized controlled clinical trials assessing oral anticoagulants versus antiplatelets or placebo in patients with HF or ventricular dysfunction/cardiomyopathy without clinical HF and SR. The outcomes assessed were stroke/systemic embolism, major bleeding, myocardial infarction, all-cause mortality, and HF hospitalization. Results: Seven trials of 15,794 patients were eligible for our analyses. The overall follow-up duration was 32,367 patient-years corresponding to a mean follow-up of 2.05 years per patient. Four trials included patients treated with warfarin and three included patients treated with rivaroxaban. OAC was associated with reduced rate of stroke or systemic embolism compared to control (odds ratio (OR): 0.57, 95% confidence interval (CI): 0.44, 0.73, number needed to treat (NNT): 71.9) but higher rate of major bleeding (OR: 1.92, 95% CI: 1.47, 2.50, number needed to harm (NNH): 57.1). In the subgroup analysis according to the type of OAC, rivaroxaban was associated with significantly reduced rate of stroke or systemic embolism (1.24 vs 1.97 events per 100 patient-years, respectively, OR: 0.63, 95% CI: 0.45, 0.88, NNT: 82) and higher risk of major bleeding (OR: 1.66, 95% CI: 1.26, 2.20) compared to antiplatelets or placebo. There was no significant differences between groups for the outcomes of myocardial infarction, all-cause mortality, and HF hospitalization. Conclusion: This analysis shows that any benefit of OAC for stroke prevention may be offset by an increased risk of major bleeding in HF-SR patients. A well-designed randomized controlled trial of newer safer OACs is needed in this population. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for atrial fibrillation (AF) is a common therapeutic strategy for patients with either paroxysmal AF (PAF) or persistent AF (persAF), but long‐term ablation success rates are imperfect. Maintenance of sinus rhythm immediately before ablation with antiarrhythmic drug (AAD) therapy has been associated with improved outcomes in patients undergoing ablation. Amiodarone has superior efficacy relative to other AADs. Whether failure of amiodarone to maintain sinus rhythm before ablation for either PAF or persAF is associated with poor outcomes is unknown. Methods: A total of 307 patients who received amiodarone in a 1‐year window before undergoing catheter ablation for AF were included. Patients were divided into amiodarone success (n = 183) and amiodarone failure (n = 124) groups based on the response to pre‐ablation amiodarone treatment. Analysis of procedural outcomes as a function of response to amiodarone therapy was performed. Patients were followed for at least 12 months postablation, to assess outcomes (adverse events and arrhythmia recurrence). Procedural success was defined by the absence of documented arrhythmia (>30 s) without any antiarrhythmic agents beyond a 90‐day blanking period. Results: Following ablation for either PAF or persAF, freedom from any recurrent atrial arrhythmia at 1 year was 57.7% for the entire cohort. One‐year freedom from recurrent arrhythmia in the amiodarone success group was comparable to that in the amiodarone failure group (55.7% vs. 60.5%; p =.54). Success rates following ablation did not vary by the response to amiodarone when analyzed for PAF or persAF subgroups. Conclusion: Failure to restore and maintain sinus rhythm with amiodarone before ablation for either PAF or persAF is not a predictor of ablation procedural failure. Amiodarone failure alone should not deter practitioners from considering ablation therapy for patients with AF. [ABSTRACT FROM AUTHOR]

A patient with bradycardia and an idioventricular rhythm was observed. According to cardiologists, there is no reliable drug treatment for bradycardia with an idioventricular rhythm; instead, the sole treatment is a pacemaker. In the course of this case, it was shown that acupuncture can restore the heart rhythm from bradycardia to normocardia, and from idioventricular with third-degree atrioventricular node block and an average heart rate of 34 BPM, to normal sinus rhythm with a heart rate of 71 BPM. Additionally, at the end of the treatment, the patient’s number of episodes of ventricular extrasystole decreased 36 times (3289 versus 91 episodes). These results show that research on this technique should be continued.

Magnesium sulphate (MgSO4) has been proven as an analgesic, neuromuscular blocker agent, and treatment of acute asthma.

Aims Loss of cell-to-cell communication results in local conduction disorders and directional heterogeneity (LDH) in conduction velocity (CV) vectors, which may be unmasked by premature atrial contractions (PACs). We quantified LDH and examined differences between sinus rhythm (SR) and spontaneous PACs in patients with and without atrial fibrillation (AF). Methods and results Intra-operative epicardial mapping of the right and left atrium (RA, LA), Bachmann's bundle (BB) and pulmonary vein area (PVA) was performed in 228 patients (54 with AF). Conduction velocity vectors were computed at each electrode using discrete velocity vectors. Directions and magnitudes of individual vectors were compared with surrounding vectors to identify LDH. Five hundred and three PACs [2 (1–3) per patient; prematurity index of 45 ± 12%] were included. During SR, most LDH were found at BB and LA [11.9 (8.3–14.9) % and 11.3 (8.0–15.2) %] and CV was lowest at BB [83.5 (72.4–94.3) cm/s, all P < 0.05]. Compared with SR, the largest increase in LDH during PAC was found at BB and PVA [+13.0 (7.7, 18.3) % and +12.5 (10.8, 14.2) %, P < 0.001]; CV decreased particularly at BB, PVA and LA [−10.0 (−13.2, −6.9) cm/s, −9.3 (−12.5, −6.2) cm/s and −9.1 (−11.7, −6.6) cm/s, P < 0.001]. Comparing patients with and without AF, more LDH were found during SR in AF patients at PVA and BB, although the increase in LDH during PACs was similar for all sites. Conclusion Local directional heterogeneity is a novel methodology to quantify local heterogeneity in CV as a possible indicator of electropathology. Intra-operative high-resolution mapping indeed revealed that LDH increased during PACs particularly at BB and PVA. Also, patients with AF already have more LDH during SR, which becomes more pronounced during PACs. [ABSTRACT FROM AUTHOR]