Atrial Fibrillation

Introduction-Ablation of high dominant frequency (DF) sources in patients with atrial fibrillation (AF) is an effective treatment option for paroxysmal AF. The aim of this study was to evaluate the accuracy of noninvasive estimation of DF and electrical patterns determination by solving the inverse problem of the electrocardiography. Methods-Four representative AF patients with left-to-right and right-to-left atrial DF patterns were included in the study. For each patient, intracardiac electrograms from both atria were recorded simultaneously together with 67-lead body surface recordings. In addition to clinical recordings, realistic mathematical models of atria and torso anatomy with different DF patterns of AF were used. For both mathematical models and clinical recordings, inverse-computed electrograms were compared to intracardiac electrograms in terms of voltage, phase and frequency spectrum relative errors. Results-Comparison between intracardiac and inverse computed electrograms for AF patients showed 8.8 ± 4.4% errors for DF, 32 ± 4% for voltage and 65 ± 4% for phase determination. These results were corroborated by mathematical simulations showing that the inverse problem solution was able to reconstruct the frequency spectrum and the DF maps with relative errors of 5.5 ± 4.1%, whereas the reconstruction of the electrograms or the instantaneous phase presented larger relative errors (i.e. 38 ±15% and 48 ± 14 % respectively, p<0.01). Conclusions-Non-invasive reconstruction of atrial frequency maps can be achieved by solving the inverse problem of electrocardiography with a higher accuracy than temporal distribution patterns.

Background Despite advancements in secondary cardiovascular prevention, individuals with chronic coronary syndrome (CCS) still experience a lingering risk of adverse ischemic events. To minimize this residual risk by stabilizing and regressing the chronic disease process, there is consensus that antithrombotic therapy is crucial role for secondary cardiovascular prevention. The combination of lowdose rivaroxaban (2.5mg BID) with aspirin, known as dual-pathway inhibition, has emerged as a strategy to mitigate this residual risk and lower major adverse cardiovascular events (MACE). European guidelines, based on ndings of the COMPASS trial, recommend incorporating low-dose rivaroxaban and aspirin into standard secondary prevention in CCS patients. However, real-world data on the impact of this approach are still lacking. Aim The primary objective of the DUTCH-CCS registry is to gather real-world data on the e cacy and safety of low-dose rivaroxaban in combination with aspirin among patients with CCS in the Netherlands. By conducting this registry, the aim is to bridge the gap in knowledge and provide insights into the practical outcomes and potential bene ts or risks associated with the use of dual-pathway inhibition in a real-world clinical setting, beyond the con nes of controlled clinical trials. Methods The DUTCH-CCS registry is a national, multicenter, prospective observational study, and aims to enroll 1000 adult CCS patients who are treated with rivaroxaban 2.5mg BID plus aspirin. The study focuses on high ischemic risk individuals with coronary artery disease (CAD) and/or peripheral artery disease, using a single-arm design. The primary effectiveness endpoint includes major adverse cardiac events (MACE), clinically driven coronary-, peripheral-or carotid revascularization, and stent thrombosis at 1-year follow-up, while the primary safety endpoint is major bleeding at 1-year. The study will collect outcome data at 3-month and 1-year follow-up. Conclusion The DUTCH-CCS registry holds the potential to enhance understanding of the real-world impact of low-dose rivaroxaban plus aspirin as a secondary prevention strategy in CCS patients. The ndings may offer valuable insights into the e cacy and safety of dual-pathway inhibition, providing clinicians and researchers with data for informed treatment decisions and may re ne guidelines for the management of CCS patients in everyday clinical practice.

Cath lab disasters-the interventionalists' nightmares! 1127 segment of left vertebral artery. The patient underwent PTA and stent placement of the left subclavian artery. During one-year follow-up period, he was symptom free, ultrasound showed normal flow in left subclavian artery, and regional wall motion of LV appeared to be normal. Discussion: Clinical manifestation of a coronary-subclavian steal in this patient was unusual with the severe angina but without any symptoms of cerebral ischemia probably due to partly functioning carotid-subclavian graft. Percutaneous revascularization of the subclavian artery was the reasonable treatment option. That lesion was more significant than stenosis of carotid-subclavian graft, more favorable for PTA due to minimal calcification and relatively short stenosis. Conclusions: Coronary-subclavian steal syndrome is a diagnosis that should not be overlooked, especially in patients with known peripheral atherosclerosis. Percutaneous interventions due to their efficacy and low complication rates constitute the first choice treatment in patients with high surgical risk.

Rare co-existance of disease or pathology Background: Coronary artery embolization is an exceedingly rare cause of myocardial infarction, but a few cases in association with prosthetic mechanical valves have been reported. We report a case of embolic myocardial infarction caused by a thrombus in the left atrium with deranged coagulation profile in a patient with critical mitral stenosis under warfarinization. Case Report: A 22-year-old woman was taken to the catheterization lab for early coronary intervention in lieu of non-ST elevation myocardial infarction. Electrocardiography showed T¯ in V 1 to V 4 , and atrial fibrillation with controlled ventricular rate. Coronary angiography showed total occlusion of the mid-left anterior descending artery with thrombus. After upstream treatment with tirofiban, the apparent thrombus was dislodged distally while passing a BMW wire. No abnormalities were seen by intravascular ultrasound study. Echocardiography revealed critical mitral stenosis, and left atrial clot with mild left ventricular dysfunction. Coagulation profile revealed sub-therapeutic international normalized ratio levels. The sequential angiographic images, normal intravascular ultrasound study, and presence of atrial fibrillation are confirmatory of coronary embolism as the cause of myocardial infarction. Anticoagulation and treatment of acute coronary syndrome were initiated and she was referred for closed mitral valvulotomy. Conclusions: Coronary artery thromboembolism as a nonatherosclerotic cause of acute coronary syndrome is rare. The treatment consists of aggressive anticoagulation, antiplatelet therapy, and interventional options, including simple wiring when possible. In this context, primary prevention in the form of patient education on optimal anticoagulation with oral vitamin K antagonist and medical advice about imminent thromboembolic risks are of extreme importance.

Background: Detailed substrate mapping is important for catheter ablation. However, the influence of the electrode spacing of the mapping catheter on the substrate map has not been well clarified. The aim of this study was to investigate the influence of the electrode spacing of the mapping catheter on the voltage of the substrate map. Methods: Protocol 1: We recorded the local atrial potentials of the left atrium (LA) using the ablation catheter during sinus rhythm in six atrial fibrillation (AF) patients. The voltage of each atrial potential was compared between a close-bipolar (1-2 electrode) recording and wide-bipolar (1-4 electrode) recording. Protocol 2: Two voltage-maps of the LA were constructed separately using a 20-pole circular catheter and 10-pole circular catheter during sinus rhythm in 42 AF patients. The low voltage zone (LVZ) (<0.5 mV) areas obtained by 2 voltage maps using the 10-pole and 20-pole circular catheters were compared. Results: Protocol 1: The close-bipolar voltage of the local potentials was significantly smaller than that of the wide-bipolar voltages (0.76 AE 0.39 mV vs. 0.63 AE 0.41 mV, p < 0.0001). Protocol 2: The size of the LVZ areas identified by the 10-pole and 20-pole catheters was 1.12 AE 1.92 cm 2 (1.47 AE 2.78%) and 8.30 AE 7.80 cm 2 (8.83 AE 8.32%), respectively (p < 0.0001). Conclusions: The voltage of the local atrial potential using the close-bipolar catheter was significantly smaller than that using the wide-bipolar catheter. Care should be given to the electrode spacing of mapping catheters when analyzing the voltage of the atrial myocardial potentials.

Background: Research has found atrial fibrillation (AF) to be the primary or a contributing cause of death on 183,321 death certificates, and an underlying cause of death for 26,535 Americans in 2019. Findings indicate an increased AF diagnosis in White people compared to racial and ethnic minorities, contrasting widespread findings of increased prevalence of cardiovascular disease and ischemic strokes in minorities. Significant disparities-by race and socioeconomic status in disease distribution and access to testing and lifesaving treatments-have been documented, specifically associated with social determinants of health (SDOH); i.e., the conditions in which people are born, grow, live, work, and age. The Hispanic population is the second-largest ethnic group, comprising 18.7% of the total population, nonetheless few studies describe AF diagnosis, treatment, and outcomes in Hispanics (Linares et al., 2019). Purpose/Aims: To explore the SDOH, select sociodemographics, and symptom burden in Hispanic/Latino adults compared to non-Hispanic/Latino adults with AF who obtain rhythm and rate control treatment. Methods: A cross-sectional correlational design was used. Data was extracted from the electronic health record of 750 participants receiving treatment for AF between June 2020 and June 2022. Inclusion criteria: Age 21 years and older, gender (males, females, other), and ECG-confirmed AF. Measurements: Age, race, ethnicity, gender, health plan, body mass index, hypertension diagnosis, smoking, alcohol use, admitting/primary/ secondary diagnoses, type of AF diagnosis, employment status, access to healthcare, type of community, AF treatment (rhythm, rate control), reported symptoms. Data Analysis: Descriptive (frequencies, measures of dispersion) and inferential statistics, including bivariate (chi-square tests and t-tests) and multivariate (binomial logistic regression) analyses. Findings: Select clinical findings were not significantly associated with ethnicity (e.g., smoking status, admitting/primary/secondary diagnoses, or diagnoses of hypertension were not associated with ethnicity). Alcohol use was greater in non-Hispanics, and being overweight, obese and morbidly obese was greater in Hispanics. Hispanic participants were younger than non-Hispanic participants. Ethnicity was not significantly associated with any of the AF pharmacological and non-pharmacological care treatments evaluated in this study (i.e., in-hospital antiarrhythmic drugs, in-hospital rate control drugs, prior catheter ablation, prior surgical ablation, and cardioversion). Implications for Research: The American Association of Colleges of Nursing goals for nurses include addressing pervasive inequities in healthcare to meet the needs of all individuals. Studies have found great variability in AF symptomology, and current treatment guidelines recommend clinical treatment decisions based on a patient's symptoms. Findings from this study will inform and guide treatment strategies for Hispanics with AF. The study revealed disparities in healthcare. In this cohort, Hispanics traveled longer distances for care, sought care at an earlier age, and had catheter ablations more frequently than non-Hispanics; obesity was a prevalent comorbidity among Hispanics.

AF (in the absence of LAA thrombus). In the first series of 20 patients with documented paroxysmal or persistent nonrheumatic AF who were operated on preponderantly for degenerative valvular disease or coronary heart disease, we obliterated the mouth of the LAA by an intraatrial running suture. Paradoxically, 2 well-anticoagulated patients, while in sinus rhythm, had a stroke within the first 2 weeks after operation. One died rapidly. In the other patient, transesophageal echocardiography revealed a thrombus inside the LAA and an incompletely obliterated LAA communicating with the left atrium. Transesophageal echocardiography was performed in the 4 subsequent patients. In 1 of them, LAA exclusion was incomplete with thrombus inside the LAA (this patient had no embolic events). In this short retrospective study, there appeared to be a strong relationship between incomplete obliteration of the LAA and the incidence of stroke. Thus, in a second series of 10 patients, we chose to obliterate the LAA using separate mattress stitches. One patient sustained a stroke postoperatively. Transesophageal echocardiography revealed a thrombus in the LAA as well as incomplete LAA obliteration. Therefore, we decided to abandon endocardial suture of the LAA. Currently, obliteration of the LAA is included in some interventions such as the maze procedure [2], and in our opinion, it is also very important for the prevention of stroke. We designed a prospective series with systematic postoperative transesophageal echocardiography control. Thirty patients (27 having mitral valve repair and 3, mitral valve replacement, all with preoperative history of AF) underwent LAA exclusion using an external technique: clamping and ligating the base of the LAA. The ligation was secured by one transfixing mattress suture. The LAA was then excised to check the effectiveness of the obliteration and the absence of leaks. No strokes were observed during a mean follow-up of 110 days, and postoperative transesophageal echocardiography showed complete exclusion of the LAA in all patients. Some case reports [3, 4] and one study [5] have suggested the possibility of incomplete exclusion of the LAA after endocardial suturing. In our experience, intraatrial obliteration of the LAA is dangerous, whereas external obliteration is safe. Is obliteration of the LAA relevant for stroke prevention in patients with AF? A large series with long follow-up is needed to confirm this hypothesis. The aim of this letter is to advise surgical teams who would perform such studies to use safe external method and avoid intraatrial LAA obliteration.

C atheter ablation is an effective treatment for patients with symptomatic, recurrent atrial fibrillation (AF) (1,2). AF recurrences, or the development of new-onset left atrial flutter/ tachycardia (AT), occurring from 2 weeks to 3 months after ablation have been reported in a high percentage of patients (from 15.9% to 65%) regardless of

Background Left atrial appendage closure (LAAC) can be an alternative to oral anticoagulant therapy in patients with non-valvular atrial fibrillation, characterized by high risk of stroke (CHA2D2VASC ≥ two for men and CHA2D2VA2SC ≥ three for women) and high risk of bleeding (HASBLED = 3). Case summary We describe three case reports in which an intracardiac echocardiography probe was used via the oesophageal route as an alternative to traditional transoesophageal echocardiography (TEE) or ICE methods to guide LAAC. Guiding the procedure via conventional TEE, even if feasible, could be difficult in these patients due to different causes: one patient was affected by Brugada syndrome while the other two patients reported oropharyngeal abnormalities. For these reasons, we performed an alternative use of the ICE probe to guide the entire LAAC procedure. Discussion Currently, LAAC is performed using intracardiac or transoesophageal echocardiography. This alternative use of ICE probe via oesophageal (ICE-TEE) is reported in previous studies that describe the feasibility of this technique both in excluding the presence of thrombus in left atrial appendage before cardioversion and in guiding percutaneous foramen ovale closure. Therefore, the ICE probe has been used as an intraoperative transoesophageal echocardiographic probe to repair congenital heart disease in infants or children with oropharyngeal abnormalities. This case series reports the first use of ICE-TEE to guide the entire LAAC procedure, guaranteeing the visualization of all echocardiographic views needed to perform it. The present case series highlights the potential of ICE-TEE to safely perform both preprocedural and intraoperative evaluations in LAAC procedure.

Atrial fibrillation (AF) and renal insufficiency often coexist and are increasingly prevalent with advancing age. Both the risk of thromboembolic events and bleeding propensity are higher in patients with AF and impaired renal function versus those with good renal health. Direct oral anticoagulants (DOACs) are being increasingly preferred over vitamin K antagonists (VKAs) in the treatment of patients with AF and impaired renal function as VKAs may accelerate progression of chronic kidney disease. DOACs, however, are eliminated by the kidneys to varying degrees, and their dosages must be adapted in accordance with renal function. Since creatinine clearance (CrCl) monitoring is recommended in patients with AF receiving DOAC therapy, CrCl must be routinely monitored in patients at the start and during the course of anticoagulation to avoid deviation from Summary of Product Characteristics dosage specifications. This review article provides an overview of current knowledge on the selection and dose of DOACs including apixaban, dabigatran, edoxaban and rivaroxaban in AF patients at different stages of renal insufficiency, with a special focus on elderly patients with comorbidities and receiving multiple medications. The groups discussed in this review include patients with varying levels of CrCl including hyperfiltration or CrCl [ 90 ml/ min, CrCl \ 90-50 ml/min, CrCl \ 50-30 ml/ min, CrCl \ 30-15 ml/min and end-stage renal disease or on dialysis.

BACKGROUND: Atrial fibrillation (AF) is the most common sustained arrhythmia worldwide. However, its pathogenesis is multifactorial and not completely understood. Previous studies have shown that autoantibodies are present in some patients with AF, raising the possibility of an autoimmune etiology. In this study we sought to investigate the association between autoimmune dermatological disorders (ADD) and AF. METHODS: We performed a case-control study using the Olmsted County AF database which included all patients with incident AF from 1980 to 2000 (n=4383) and their age-and sexmatched controls. Prevalence of ADD including bullous pemphigoid, pemphigus vulgaris, psoriasis, vitiligo, idiopathic urticaria, and alopecia areata were compared between the 2 groups. Association between ADD and AF was studied using conditional multivariate logistic regression. Survival curves were compared using log-rank test. RESULTS: The proportion of patients with ADD in the AF group was 7.4% (n=323) and 5.3% (n=232) in the control group, p , 0.0001. Univariate analysis showed that ADD increased the odds of AF by almost 2-fold (OR 1.82, 95% CI 1.54-2.14, p , 0.001). After adjusting for hypertension, diabetes, cardiomyopathy, obstructive sleep apnea, coronary artery disease, peripheral vascular disease, renal insufficiency, congestive heart failure, obesity, malignancy, and smoking, ADD remained independently predictive of the development of AF (OR 1.27, 95% CI 1.05-1.54, p = 0.01). ADD patients with AF were found to have poorer survival compared with those without AF (p , 0.001). CONCLUSIONS: Autoimmune dermatological disorders were found to be independently associated with atrial fibrillation. The development of AF had a negative impact on the survival of patients who had autoimmune dermatological disorders.

It is believed that most of thrombi form in the left atrial appendage (LAA)before they emboli. Different surgical and percutaneouse approaches were suggested to manage the LAA. In this study we are evaluating the safety of clipping the LAA via minithoractotomy approach. All consecutive patients who had minimally invasive mitral valve surgery with concomitant LAA clipping between December 2012 and February 2014 were included in the study. LAA exclusion was performed using AtriClip® LAA Exclusion System (Cincinnati, Ohio, AtriCure®). The patient s&#39; clinical characteristics, intraoperative complications, and in-hospital coarse were obtained by reviewing the medical records. Total of 22 patients(50% males) were included in the study. The median ages was 66.0 years (IQR: 50.8 to 81.3). Eight(36%) had mitral valve replacement and the rest had mitral repair surgery. Five(23%) patients needed blood product transfusion during the surgery. No clip related bleeding was observed and no peri...

The pleiotropic effects of statins have been suggested to prevent atrial fibrillation onset. We conducted a population-based case-control study using medical databases from Northern Denmark (population: 1.8 million) to examine the association between statin use and atrial fibrillation or flutter. We identified 51,374 patients with atrial fibrillation or flutter between 1999 and 2010 and 513,670 matched population controls. We collected data on statin prescriptions redeemed within 90 days (current users) or longer (former users) before the diagnosis date of atrial fibrillation or flutter. We stratified statin users by duration of exposure, determined by the number of days between first and last redeemed prescription before the diagnosis date (,365, 365-1094, and $1095 days). We used conditional logistic regression to compute odds ratios (ORs) and 95% confidence intervals (CIs), controlling for potential confounders. We defined people without previous statin use as never users (reference). A total of 7360 (14.3%) cases and 55,699 (10.8%) controls were current statin users. Among current users (adjusted OR: 0.96, 95% CI, 0.93-0.99), the preventive effect of statins on atrial fibrillation or flutter was related to duration of use: adjusted ORs decreased from 1.35 (95% CI, 1.28-1.42) for users who were prescribed statins for ,365 days to 0.85 (95% CI, 0.81-0.89) for users who were prescribed statins for $1095 days compared with never users. For former users (adjusted OR: 0.94, 95% CI. 0.90-0.98), the ORs did not change with varying lengths of exposure. In conclusion, long-term statin use may reduce the risk of atrial fibrillation or flutter compared with never use.

Atrial Fibrillation (AF) the most commonly occurring type of cardiac arrhythmia is one of the main causes of morbidity and mortality worldwide. The timely diagnosis of AF is an equally important and challenging task because of its asymptomatic and episodic nature. n this paper, state-ofthe-art ECG data-based machine learning models and signal processing techniques applied for auto diagnosis of AF are reviewed. Moreover, key biomarkers of AF on ECG and the common methods and equipment used for the collection of ECG data are discussed. Besides that, the modern wearable and implantable ECG sensing technologies used for gathering AF data are presented briefly. In the end, key challenges associated with the development of auto diagnosis solutions of AF are also highlighted. It is the first review paper of its kind that comprehensively presents a discussion on all these aspects related to AF auto-diagnosis at one place. It is observed that there is dire need of low energy, low cost but accurate auto diagnosis solutions for the proactive management of AF.

Activities carried out in the laboratory provide important contributions to students in terms of developing their research, problem solving, questioning, using hand skills and communication skills. However, providing safety during the studies in the laboratory environment is extremely important. The aim of this study is to determine information level and ideas of prospective chemistry teachers on laboratory safety. Descriptive method is used in study. The sample of the research consists of 58 participants who are studying in Chemistry Teaching department. Questionnaires and informal observations were used as data collection tools. From point of view of the obtained data, scores of the students in different grades in questionnaires were compared with ANOVA. A statistically significant difference was found between the scores obtained from the questionnaire (F(3,57)=10,568; p 0,05). The questionnaire results show that prospective chemistry teacher are aware of the importance of safety ...

Background Atrial fibrillation (AF) represents a growing healthcare challenge, mainly driven by acute hospitalisations. Virtual wards could be the way forward to manage acute AF patients through remote monitoring, especially with the rise in global access to digital telecommunication and the growing acceptance of telemedicine post-COVID-19. Methods An AF virtual ward was implemented as a proof-of-concept care model. Patients presenting acutely with AF or atrial flutter and rapid ventricular response to the hospital were onboarded to the virtual ward and managed at home through remote ECG-monitoring and 'virtual' ward rounds, after being given access to a single-lead ECG device, a blood pressure monitor and pulse oximeter with instructions to record daily ECGs, blood pressure, oxygen saturations and to complete an online AF symptom questionnaire. Data were uploaded to a digital platform for daily review by the clinical team. Primary outcomes included admission avoidance, readmission avoidance and patient satisfaction. Safety outcomes included unplanned discharge from the virtual ward, cardiovascular mortality and allcause mortality. Results There were 50 admissions to the virtual ward between January and August 2022. Twentyfour of them avoided initial hospital admission as patients were directly enrolled to the virtual ward from outpatient settings. A further 25 readmissions were appropriately prevented during virtual surveillance. Patient satisfaction questionnaires yielded 100% positive responses among participants. There were three unplanned discharges from the virtual ward requiring hospitalisation. Mean heart rate on admission to the virtual ward and discharge was 122±26 and 82±27 bpm respectively. A rhythm control strategy was pursued in 82% (n=41) and 20% (n=10) required 3 or more remote pharmacological interventions. Conclusion This is a first real-world experience of an AF virtual ward that heralds a potential means for reducing AF hospitalisations and the associated financial burden, without compromising on patients' care or safety. ⇒ This novel model of healthcare delivery may provide an alternative to the traditional in-patient care for patients with AF, thereby reducing the huge associated economic burden on healthcare without compromising patients' care. Work is still needed to further confirm longitudinal safety and costeffectiveness, to facilitate creating a future blueprint for digitally enabled acute AF virtual wards.

Cardiac implantable electronic devices are increasing in prevalence. The post-implant follow-up is important for monitoring both device function and patient condition. However, practice is inconsistent. For example, ICD follow-up schedules vary from 3 monthly to yearly according to facility and physician preference and availability of resources. Recommended follow-up schedules impose significant burden. Importantly, no surveillance occurs between follow-up visits. In contrast, implantable devices with automatic remote monitoring capability provide a means for performing constant surveillance, with the ability to identify salient problems rapidly. Remote home monitoring reduces the volume of device clinic visits and provides early detection of patient and/or system problems.

To evaluate the impact of Home Monitoring TM (HM) technology on detection and treatment of atrial fibrillation (AF). Methods and results One hundred and sixty-six patients (mean age 73 + 10 years, 112 males) received HM devices [121 pacemakers, 22 implantable cardioverter defibrillators (ICDs), and 23 ICDs combined with cardiac resynchronization therapy]. A nurse consulted the cardioreports on the website and submitted the alerts for AF (new onset AF, persistent AF, and AF burden of .10% for .5 consecutive days) to the physician. During a mean follow-up of 488 + 203 days, 42 patients (26%) had alerts for AF. Twenty-two patients had no history of AF before implant. In nine patients, no further action was taken. For the remaining 33 patients, an unscheduled follow-up was performed: in 16, antiarrhythmic drug therapy was introduced/modified; in 15, anticoagulation was started; in 2, antiplatelet drugs were introduced; in 7, an external cardioversion was performed; in 2 patients, the device was reprogrammed to avoid intermittent atrial undersensing during AF; and in 4 patients, no further action was taken. In four cases the arrhythmia was not confirmed (false positive). The median time to the first intervention for AF was 50 days (148 days before the scheduled follow-up). Conclusion The HM technology allowed early detection of AF in paced patients and early reaction to optimize medical treatment.

We sought to determine whether atrioventricular junction ablation (AVJA) in patients with cardiac resynchronization therapy (CRT) implantable cardioverter-defibrillator (ICD) and with permanent atrial fibrillation (AF) has a positive impact on ICD shocks and hospitalizations compared with rate-slowing drugs. This is a pooled analysis of data from 179 international centres participating in two randomized trials and one prospective observational research. The co-primary endpoints were all-cause ICD shocks and all-cause hospitalizations. Out of 3358 CRT-ICD patients (2720 male, 66.6 years), 2694 (80%) were in sinus rhythm (SR) and 664 (20%) had permanent AF-262 (8%) treated with AVJA (AF + AVJA) and 402 (12%) treated with rate-slowing drugs (AF + Drugs). Median follow-up was 18 months. The mean (95% confidence intervals) annual rate of all-cause ICD shocks per 100 patient years was 8.0 (5.3-11.9) in AF + AVJA, 43.6 (37.7-50.4) in AF + Drugs, and 34.4 (32.5-36.5) in SR patients, resulti...

The discrimination between ventricular (VT) and supraventricular tachycardia (SVT) and the evaluation of their hemodynamic impact are essential issues in the arrhythmia management. A new pacing device features a tachycardia diagnostic system relying on simultaneous recording of the transvalvular impedance (TVI) and a special integrated electric signal derived by the whole set of endocardial electrodes (iECG). The iECG waveform is sensitive to the pattern of ventricular activation, similarly to the surface ECG. The TVI increases in systole and decreases in diastole and the amplitude of this cyclic fluctuation is an expression of the effectiveness of the pump function. In order to test the value of these signals in the analysis of a tachycardia, we have assessed the iECG and TVI modifications induced by different SVTs and tolerated and non-tolerated VTs, during electrophysiological (EP) studies. In case of SVT, the ventricular component of the iECG maintained the same morphology as in...

This study was sponsored by Medtronic Inc, which performed study management and data management tasks and contributed to the review of data analysis report and manuscript contents for technical aspects. The sponsor had no role in the collection of clinical data, in the interpretation of data, and in the decision to submit the article for publication. Dr Padeletti has

Cardiologists often are called to explain electrocardiograms of pacemaker/ implantable cardioverter (PMK/ICD) patients during arrhythmic events. The most frequent arrhythmia is atrial fibrillation (AF) whether in PMK or in ICD patients. Generally, it is not difficult to diagnose, it can affect the quality of life of this subgroup because it can generate inappropriate and painful therapies. Arrhythmias as atrioventricular block or other bradyarrhythmias can show a particular way of presentation specially for the device&#39;s intervention using specific algorithms that cardiologists should know to adequately interpret the phenomenon. For example, Rate Drop Response algorithm (to prevent syncope) or other antiarrhythmic functions for atrial tachyarrhythmias (Post Mode Switching Overdrive Pacing (PMOP) or Atrial Rate Stabilization) can alter surface electrocardiogram after AF or atrial ectopic beats. Ventricular arrhythmias in ICD patients are frequent. Burst, ramp and shock are therapi...

Background Antitachycardia pacing (ATP) therapies may have a r ole to play in treating paroxysmal atrial tachyarrythmias. The Medtronic AT500 is a new DDDRP pacemaker providing automatic ATP therapies and prevention algorithms. Method A total of 131 patients (age 71 ± 9 years, 71 male and 60 female) were enrolled in the AT500 Italian Registry after receiving the device. After implant, diagnostic features were enabled. They classify arrhythmias as atrial fibrillation (AF) or atrial tachycardia (AT) according to their rate, atrioventricular association and regularity. ATP therapies and prevention algorithms were enabled at first month follow-up visit. ATP therapies were programmed to treat episodes classified as AT at their onset or during their progression. Therapies were automatically delivered 1 min after episode detection. Results During a follow up of 3•3 ± 2•9 months, 5593 AT/AF episodes were detected and treated in 21 patients, and 2065 (36%) were classified by the device as successfully terminated. In a subgroup of patients for whom electrogram information was available, the device classified 96 (37•4%) of the 256 recorded episodes as successfully terminated. The effect of ATP on AF burden was closely related to the efficacy of ATP. A reduction in AF burden was more evident in those patients in whom ATP therapy efficacy was greater than 50% in terminating episodes. ATP efficacy was greater (52•6%) in episodes classified at onset as AT than in those classified at onset as AF (28•6%). ATP efficacy was also higher in patients with long pre-therapy P-P cycle interval and in patients with atrial lead implanted at the inter-atrial septum. Conclusion The present study demonstrates the safety and efficacy of automatic ATP therapies for terminating AT/AF, with a sophisticated dual-chamber pacemaker. Atrial ATP terminated 36•9% of treated AT/AF episodes without any proarrhythmic effects in a population of patients with indications for pacemaker implantation and/or a history of AF.

Background Atrial fibrillation has a high incidence in patients wearing an implantable cardioverter defibrillator for ventricular tachyarrhythmias and may lead to palpitations, heart failure, angina, stroke and inappropriate defibrillator discharge. The aim of the study was to evaluate the efficacy of a dual chamber defibrillator with atrial antitachycardia functions in treating spontaneous atrial tachyarrhythmias. Methods One hundred and twelve patients, 88 male, mean age 64 11 years, were enrolled. Seventy-six had ischaemic heart disease, 21 idiopathic dilated cardiomyopathy, nine other heart diseases, six no structural heart disease. The mean left ventricular ejection fraction was 40 11%. Sixty-two had prior atrial tachyarrhythmias. Results Follow-up lasted 11 9 months (range 1-42). Among 933 ventricular tachyarrhythmia episodes, 100% of ventricular fibrillation and 92% of ventricular tachycardia were successfully cardioverted. Among 414 detected sustained atrial tachyarrhythmias, 195 were classified as atrial tachycardia (47•1%), 192 as atrial fibrillation (46•4%) and 27 (6•5%) as sinus rhythm. The detection-positive predictive value was 93•5%. Therapy success rates: anti-tachy pacing on atrial tachycardia=71•3% (crude estimate); 66•1% (adjusted estimate); 50 Hertz on atrial fibril-lation=36•2% (crude estimate); 13•5% (adjusted estimate); atrial shock on atrial fibrillation=62•5% (mean energy 7•8 14•1 J). Shock efficacy was 32% when delivered energy was c2 atrial defibrillation threshold at implant and 92% when >2. Duration of successfully treated atrial episodes was significantly lower than that of unsuccessfully treated (6 26 min vs 42 60). Conclusions Atrial antitachy pacing and shock therapies demonstrated very high efficacy in treating atrial tachyarrhythmias in defibrillator patients.

Aims Several studies have tested non-pharmacological therapies for atrial tachyarrhythmias (ATs) by measuring the cumulative time (burden) the patient spends in arrhythmia. Contradictory results questioned either therapy efficacy or statistical power of the trials. We studied AT burden variability in patients paced for sinus node disease (SND) in order to interpret currently published data appropriately and to evaluate reliable sample sizes. Methods and results One hundred and five patients with AT and SND received a dual chamber pacemaker with antitachyarrhythmia-pacing capability, and were followed for 13 months. Seventy-eight patients (74%) suffered AT recurrences. Device-gathered diagnostic measures were used to simulate results of randomized studies both with crossover and parallel design. The sample size required for statistically significant results was calculated as a function of the expected therapy-induced burden reduction. AT burden intra-patient variability was high: 43% of patients showed intrinsic fluctuations hiding any therapy-induced burden reduction lower than 30%. Demonstrating therapeutic breakthrough through a 6 month study would require 290 patients with crossover design and 5800 patients with parallel design. Doubling the study period requires 400 and 3000 patients, respectively.

Cardiac implantable electronic devices are increasing in prevalence. The post-implant follow-up is important for monitoring both device function and patient condition. However, practice is inconsistent. For example, ICD follow-up schedules vary from 3 monthly to yearly according to facility and physician preference and availability of resources. Recommended follow-up schedules impose significant burden. Importantly, no surveillance occurs between follow-up visits. In contrast, implantable devices with automatic remote monitoring capability provide a means for performing constant surveillance, with the ability to identify salient problems rapidly. Remote home monitoring reduces the volume of device clinic visits and provides early detection of patient and/or system problems.

Aims To evaluate the impact of Home Monitoring TM (HM) remote control on patient medical treatment and on health-care resource utilization. Methods and results One hundred and seventeen patients received HM pacemakers or defibrillators. A pacing expert nurse consulted daily the website and submitted critical cases to physician. During a mean follow-up of 227 + 128 days, 25 210 messages were received (23 545 daily messages and 1665 alert events) resulting in 90.7% of HM supervised days. Fifty-nine minutes/week for the nurse and 12 min/ week for the physician were spent for HM data analysis during 267 web-connections. The mean connection time per patient was 115 + 60 s. The nurse submitted to the physician 133 critical cases in 56 patients. The diagnosis were atrial fibrillation (47%), ventricular tachyarrhythmias (9%), inappropriate implantable cardioverter defibrillator intervention (4%), unsustained ventricular tachycardia (7%), device suboptimal programming (23%), and impending heart failure (10%). Sixty-six unplanned followup in 43 patients led to drug therapy change (44%), device reprogramming (18%), diagnosis confirmation without further intervention (24%), no confirmation (6%), further diagnostic tests (9%). Conclusion HM technology allowed optimization of medical treatment and device programming with low consumption of health-care resource.

To evaluate the impact of Home Monitoring TM (HM) technology on detection and treatment of atrial fibrillation (AF). Methods and results One hundred and sixty-six patients (mean age 73 + 10 years, 112 males) received HM devices [121 pacemakers, 22 implantable cardioverter defibrillators (ICDs), and 23 ICDs combined with cardiac resynchronization therapy]. A nurse consulted the cardioreports on the website and submitted the alerts for AF (new onset AF, persistent AF, and AF burden of .10% for .5 consecutive days) to the physician. During a mean follow-up of 488 + 203 days, 42 patients (26%) had alerts for AF. Twenty-two patients had no history of AF before implant. In nine patients, no further action was taken. For the remaining 33 patients, an unscheduled follow-up was performed: in 16, antiarrhythmic drug therapy was introduced/modified; in 15, anticoagulation was started; in 2, antiplatelet drugs were introduced; in 7, an external cardioversion was performed; in 2 patients, the device was reprogrammed to avoid intermittent atrial undersensing during AF; and in 4 patients, no further action was taken. In four cases the arrhythmia was not confirmed (false positive). The median time to the first intervention for AF was 50 days (148 days before the scheduled follow-up). Conclusion The HM technology allowed early detection of AF in paced patients and early reaction to optimize medical treatment.

The purpose of this study was to evaluate adherence to national guidelines on the non-pharmacologic (ablative) treatment of atrial fibrillation (AF). Methods and results This prospective, observational, transversal study enrolled 1256 consecutive in-and outpatients referred to 43 cardiology departments between 1 and 31 October 2008 for the management of AF as a primary diagnosis. A rhythmcontrol strategy (cardioversion, antiarrhythmic medication, pacemaker implantation, substrate ablation, alone or in combination) was prescribed in 865 (69%) of the patients and a rate-control strategy [drugs, atrioventricular junction ablation and pacemaker implantation (Ablate and Pace)] in 285 (23%). Specifically, substrate catheter ablation was indicated by the attending cardiologist in 187 (14.9%) patients and Ablate and Pace in 29 (2.3%). According to guideline indications, substrate catheter ablation would have been indicated in 183 (14.6%) patients, but only 105 (57%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.49). Atrioventricular junction ablation and pacemaker implantation would have been indicated in 108 (8.6%) patients, but only 29 (27%) of these were correctly identified by the attending cardiologist (K statistics for agreement for indications 0.06). Conclusion About a quarter of patients referred to cardiology departments for AF management have potential indications for non-pharmacological treatment according to the guidelines. Substrate catheter ablation was offered by the attending cardiologist in a percentage similar to that expected, but concordance with guideline indications was moderate. Atrioventricular junction ablation and pacemaker implantation was largely underused.

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Funding Acknowledgements: Type of funding sources: None. Introduction: One of the most significant risk factors for atrial fibrillation is hypertension (HTN) (AF). Although the PR interval is a factor in the Framingham risk score for AF, it has been linked to an elevated risk of incident AF. However, there is a lack of consistency in the findings identifying PR prolongation as a risk factor for AF. Purpose: In a large cohort of HTN patients, we seek to assess the predictive value of the PR interval for the emergence of AF. Methods: The average follow-up time for consecutive individuals with essential hypertension and no known AF at baseline was 5.3 years. Each patient underwent a 12-lead ECG, an echocardiogram examination, and a 24-hour Holter rhythm monitoring in the event of arrhythmia complaints. These tests were done at baseline and once a year. The European Society of Cardiology/European Society of Hypertension guidelines for HTN therapy were followed during the follow-up period, including routine clinical and paraclinical assessments and drug administration. The baseline ECG was used to determine the PR interval and P wave length. Results: We included 1807 hypertensives (mean age 57±11 years; 49% men) with office systolic/diastolic blood pressure of 144±17/89±11 mmHg. A total of 65 occurrences of new-onset AF (3%) were reported during the follow-up period. P wave duration and PR internal time were longer at baseline in patients with new-onset AF (n=67) compared to those without AF (n=1740) (P wave, 115 vs 110 ms) (PR interval, 174 vs 157 ms). A multivariate Cox regression analysis showed that baseline P wave duration had no significant prognostic value for the occurrence of new-onset AF, but baseline PR internal was substantially linked with the development of AF (HR = 1.01, 95% CI = 1.01-1.02; p = 0.01). A greater incidence of AF was linked to baseline elevated diastolic blood pressure (HR 1.05, 95% 1.003-1.091; p=0.037). Conclusions: Baseline PR internal and elevated diastolic blood pressure were significant predictors of new-onset AF in hypertensive patients. PR prolongation may be a marker for cardiovascular degenerative aging caused by vascular inflammation and myocardial fibrosis.

Background: SPRINT trial showed that intensive lowering of systolic blood pressure significantly reduced mortality and morbidity due to cardiovascular diseases. However, despite the fact that hypertension is a major risk factor for stroke, there was no difference in the risk of fatal and non-fatal cerebrovascular events. Purpose: The purpose of the current analysis was to analyze the association between on-treatment DBP and incidence of stroke in patients from SPRINT trial. Methods: We used data of 8944 patients from SPRINT trial obtained from the NHLBI Biologic Specimen and Data Repository Information Coordinating Center. Results: There was 110 stroke events in analyzed period, including 49 in intensive treatment and 61 in standard treated group. In subject with diastolic blood pressure lower than 70 mmHg the risk of stroke was higher than in the others (HR 1.467, 95% CI: 1.009-2.133, p=0.0445). Univariable Cox proportional hazard risk analysis showed that in whole group age >75 years, concomitant cardiovascular and chronic kidney diseases were risk factors for stroke. We found that occurrence of those risk factors was associated with lower values of diastolic blood pressure and higher pulse pressure, however not to the treatment assignment. Multivariable Cox proportional hazard risk model revealed that only age >75 years and cardiovascular diseases were significantly related to stroke events. Stroke-free survival depending on DBP Conclusion: Reduction of diastolic blood pressure below 70 mmHg may be associated with an increased risk of stroke. Therefore, intensive lowering of diastolic blood pressure should be avoided in the elderly with isolated systolic hypertension.

Background: The interaction between cardiorespiratory fitness (CRF) and incidence of atrial fibrillation (AF) and the interaction between obesity and incidence of AF have been explored separately. Therefore, we evaluated the association between CRF, body mass index (BMI), and risk of developing AF in a cohort of middle-aged and older US Veterans. Methods: Symptom limited exercise tests (ETT) were conducted among 16,397 Veterans (97% male) from January 9,1987 to December 31,2017. No history of AF was evident at the time of the ETTs. CRF was expressed as quartiles of peak metabolic equivalents (METs) achieved within each age decile. Weight status was classified as normal (BMI < 25 kg/m 2), overweight (BMI 25-30 kg/m 2), obese (BMI 30-35 kg/m 2), or severely obese (BMI > 35 kg/m 2). Multivariable Cox proportional hazards regression models were used to compare the association between BMI, CRF categories, and incidence of AF. Results: Over a median follow-up of 10.7 years, 2,155 (13.1%) developed AF. Obese and severely obese subjects had 13% and 32% higher risks for incidence of AF, respectively, vs. normal weight subjects. Overweight and obese subjects in the most fit quartile had 50% decline in AF risk compared to the least-fit subjects. Severely obese subjects had marked increases in AF risk (~50-60%) regardless of fitness level. Risk of developing AF increases with higher BMI and lower CRF. Conclusion: Improving CRF should be advocated when assessing those at risk for developing AF.

Background Spatial differences in conduction velocity (CV) are critical for cardiac arrhythmias induction. We propose a method for an automated CV calculation to identify areas of slower conduction during cardiac arrhythmias and sinus rhythm. Methods Color-coded representations of the isochronal activation map using data coming from the RHYTHMIA™ Mapping System were reproduced by applying a temporal isochronal window at 20 ms. Geodesic distances of the 3D mesh were calculated using an algorithm selecting the minimum distance pathway (MDP). The CV estimation was performed considering points on the boundary of two spatially and temporally adjacent isochrones. For each of the boundary points of a given isochrone, the nearest boundary point of the consecutive isochrone was chosen, the MDP was evaluated, and a map of CV was created. The proposed method has been applied to a population of 29 patients. Results In all cases of perimitral atrial flutter (16 pts out of 29 (55%)), areas with significantly low CV (< 30 cm/s) were found. Half of the cases present regions with low CV located in the anterior wall. No case with low CV at the so-called LA isthmus was observed. Right atrial maps during common atrial flutters showed low CV areas mainly located in the inferior inter-atrial septum. No areas of low CV were observed in subjects without a history of atrial arrhythmia while pts affected by paroxysmal AF showed areas with a limited extension of low CV. Conclusions The proposed software for automated CV estimation allows the identification of low CV areas, potentially helping electrophysiologists to plan the ablation strategy.

Atypical form of tako-tsubo cardiomyopathy (TTC) is associated with regional wall motion abnormalities in basal and/or middle segments or only middle segments with sparing of apical segments or apical and basal segments. We described a case of 47-year-old female with atypical form of TTC due to fast atrial fibrillation that converted into ventricular fibrillation in WPW syndrome. The echocardiogram made after direct current cardioversion revealed decreased left ventricular ejection fraction (LVEF 35%) with akinesis of inferior and posterior walls and anterior part of interventricular septum in the middle and the basal segments with hyperkinesis of apical segments. The biochemistry blood samples revealed elevated both troponin T-0.35 ng/mL and NT-proBNP-3550 pg/mL plasma level. The ECG showed sinus rhythm 62 bpm, shortened PQ interval 100 ms, widened QRS duration-115 ms with delta wave, prolonged QT interval-520 ms, QS in leads: II, III, aVF. Negative T waves in leads: I, aVL and positive, symmetrical T waves in leads V 1-V 6. The coronarography revealed normal coronary arteries. The control echocardiography after 10 days showed normal LVEF 70%, without any wall motion abnormalities. TTC was recognised based on: history of sudden stress situation before, ischaemic ECG changes, positive markers of myocardial injury, transient segmental wall motion abnormalities and normal coronary arteries. The ablation of right postero-septal accessory pathway was successfully performed.

The purpose of this study was to determine differences in acute and chronic atrial fibrillation (AF) "organization" in canine models. BACKGROUND Electrophysiologic changes occur during atrial remodeling, but little is known about how remodeling affects AF organization. We hypothesized that atrial remodeling induced by long-term rapid atrial rates heterogeneously decreases AF organization. METHODS In seven dogs, acute AF was induced by atrial burst pacing, and in eight dogs chronic AF was created by six weeks of continuous rapid atrial pacing. Atrial fibrillation was epicardially mapped from the right atria (RA) and left atria (LA). Atrial cycle length (CL), spatial organization and activation maps were compared. Spatial organization was quantified by an objective signal processing measure between multiple electrograms. RESULTS In acute AF, mean CL was slightly shorter in the LA (124 Ϯ 16 ms) than it was in the RA (131 Ϯ 14 ms) (p Ͻ 0.0001). In chronic AF, LA CL (96 Ϯ 14 ms) averaged 24 ms shorter than RA CL (121 Ϯ 18 ms) (p Ͻ 0.0001). Right atria and LA in acute AF had similar levels of organization. In chronic AF, the LA became ϳ25% more disorganized (p Ͻ 0.0001) while the RA did not change. In acute AF, a single broad wave front originating from the posterior and medial atrium dominated LA activation. In chronic AF, LA activation was more complex, sustaining multiple reentrant wavelets in the free wall and lateral appendage. CONCLUSIONS Acute and chronic AF exhibit heterogeneous differences in CL, organization and activation patterns. The LA in chronic AF is faster and more disorganized than it is in acute AF. Differences in the models may be due to heterogeneous electrophysiologic remodeling and anatomic constraints. The design of future AF therapies may benefit by addressing the patient specific degree of atrial remodeling.

Background: Impaired renal function increases the bleeding risk, leading to a conservative prescription and frequent discontinuation of oral anticoagulation in atrial fibrillation patients with chronic kidney disease (CKD). Interventional left atrial appendage closure (LAAC) might be an alternative therapeutic strategy for these patients. Methods: We aimed to prospectively assess cerebrovascular (CE) and bleeding events, as well as peri-procedural and long-term complications in a cohort of consecutive patients undergoing interventional LAAC using the WATCHMAN™ device, with focus on CKD patients. Results: One hundred and eighty-nine consecutive patients undergoing interventional LAAC were included in this analysis; 171 (90.5%) patients had a reduced estimated glomerular filtration rate (eGFR; patients for each CKD stage: II = 66; IIIa = 32; IIIb = 43; IV = 18; V = 12). During a follow-up of 310 patient years three (1.0%) patients suffered a CE (two strokes, one transitory ischemic attack) and five (1.6%) other ones a bleeding complication. The observed stroke rate was more than two-thirds and the bleeding risk more than half lower than expected. Device related thrombi (DRT) were detected in twelve (6.5%) patients; women had significantly more DRT than men (12.5% vs. 2.6%; p = 0.009). Patients with an eGFR< 30 ml/min/1.73m 2 showed a trend to a higher DRT rate as compared to the opposite group (13.3% vs. 5.1%; p = 0.10). Thrombus resolved with temporary oral anticoagulation therapy in ten patients without sequelae; thrombus consolidation was confirmed by serial TEE controls in the remaining two patients. Conclusions: Atrial fibrillation patients with CKD have low CE and bleeding rates after LAAC with the WATCHMAN™ device. DRT risk is higher in female and patients with severe CKD. More frequent post-interventional TEE controls might be justified for early DRT detection and safe management of patients at high DRT risk.

GLORIA-AF (Global Registry on Long-Term Oral Antithrombotic Treatment in Patients with Atrial Fibrillation) is a prospective, global registry program describing antithrombotic treatment patterns in patients with newly diagnosed nonvalvular atrial fibrillation at risk of stroke. Phase 2 began when dabigatran, the first non-vitamin K antagonist oral anticoagulant (NOAC), became available. This study sought to describe phase 2 baseline data and compare these with the pre-NOAC era collected during phase 1. During phase 2, 15,641 consenting patients were enrolled (November 2011 to December 2014); 15,092 were eligible. This pre-specified cross-sectional analysis describes eligible patients&#39; baseline characteristics. Atrial fibrillation disease characteristics, medical outcomes, and concomitant diseases and medications were collected. Data were analyzed using descriptive statistics. Of the total patients, 45.5% were female; median age was 71 (interquartile range: 64, 78) years. Patient...

Chronic kidney disease (CKD) is a major worldwide health problem, affecting a large proportion of the world's population and leading to higher morbidity and death rates. The early stages of CKD sometimes present without visible symptoms, causing patients to be unaware. Early detection and treatments are critical in reducing complications and improving the overall quality of life for people afflicted. In this work, we investigate the use of an explainable artificial intelligence (XAI)-based strategy, leveraging clinical characteristics, to predict CKD. This study collected clinical data from 491 patients, comprising 56 with CKD and 435 without CKD, encompassing clinical, laboratory, and demographic variables. To develop the predictive model, five machine learning (ML) methods, namely logistic regression (LR), random forest (RF), decision tree (DT), Naïve Bayes (NB), and extreme gradient boosting (XGBoost), were employed. The optimal model was selected based on accuracy and area under the curve (AUC). Additionally, the SHAP (SHapley Additive exPlanations) and LIME (Local Interpretable Model-agnostic Explanations) algorithms were utilized to demonstrate the influence of the features on the optimal model. Among the five models developed, the XGBoost model achieved the best performance with an AUC of 0.9689 and an accuracy of 93.29%. The analysis of feature importance revealed that creatinine, glycosylated hemoglobin type A1C (HgbA1C), and age were the three most influential features in the XGBoost model. The SHAP force analysis further illustrated the model's visualization of individualized CKD predictions. For further insights into individual predictions, we also utilized the LIME algorithm. This study presents an interpretable ML-based approach for the early prediction of CKD. The SHAP and LIME methods enhance the interpretability of ML models and help clinicians better understand the rationale behind the predicted outcomes more effectively.