Results from the prospective, multicenter AMBULATE-CAP trial: Reduced use of urinary catheters and protamine with hemostasis via the Mid-Bore Venous Vascular Closure System (VASCADE® MVP) following multi-access cardiac ablation procedures.

INTRODUCTION: Manual compression (MC), historically the most common method to achieve hemostasis after percutaneous vascular procedures, is time consuming, requires prolonged bedrest, and is uncomfortable for patients and clinicians. Recent studies demonstrate the efficacy and safety of vascular closure devices and suggest shorter times to hemostasis and patient ambulation compared with MC. The current study evaluated the feasibility of the VASCADE® venous vascular closure system (VVCS) while allowing for urinary catheter (UC) elimination, and elimination of protamine and/or same calendar day discharge (SCDD). METHODS AND RESULTS: In this prospective, multicenter trial, patients were enrolled and assigned to the following groups: no UC, no protamine, and/or SCDD (no co-enrollment in no protamine and SCDD). After completing the catheter-based cardiac procedure, access sites were closed using the VVCS. Outcomes included final hemostasis (all sites) without major access site-related complications at 30 days, rates of access site closure-related complications, device success, and study group success. All 168 patients had hemostasis without major access site-related complications through 30 days. In the no UC group, 160 out of 164 (97.6%) patients did not receive a UC. Additionally, 39 out of 41 (95.1%) patients received heparin without protamine reversal and no access site bleeding-related ambulation delays, and 18 out of 18 (100%) patients were discharged on the same day. There were no major access site closure-related complications, few minor complications, and adverse events were generally mild and well managed. CONCLUSION: The VVCS was effective for achieving hemostasis following catheter-based procedures; access site closure-related complications and adverse events were well managed.

Comparative safety of periablation anticoagulation strategies for atrial fibrillation: data from a large multicenter study.

BACKGROUND: There are a variety of periprocedural anticoagulation strategies for atrial fibrillation (AF) ablation, including the use of dabigatran. It is unclear which strategy is superior. OBJECTIVE: To compare the safety and efficacy of anticoagulation with uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing ablation of AF at four experienced centers. METHODS AND RESULTS: In this retrospective analysis, 882 patients (mean age: 61 ± 11 years) underwent ablation of AF using uninterrupted warfarin (n = 276), dabigatran (n = 374), or warfarin with heparin bridging (n = 232) for periprocedural anticoagulation. The rate of total complications was 23/276 (8.3%) in the uninterrupted warfarin group, 30/374 (8.0%) in the dabigatran group, and 29/232 (12.5%) in the bridged group (P = 0.15). Major complications were more frequent in the uninterrupted warfarin group 12/276 (4.3%) compared with 3/374 (0.8%) in dabigatran and 6/232 (2.6%) in the bridged group (P = 0.01). The most common major complication was the need for transfusion or occurrence of major bleeding. Minor complications did not differ among the three groups. On multivariate analysis, female gender (odds ratio [OR] 1.93, confidence interval [CI] 1.16-3.19, P = 0.011), bridging heparin (OR 2.13, CI 1.100-3.941, P = 0.016), use of triple antithrombotic therapy (OR 1.77, CI 1.05-2.98, P = 0.033), and prior myocardial infarction (OR 2.40, CI 1.01-5.67, P = 0.046) independently predicted total complications. CONCLUSIONS: When comparing the use of uninterrupted warfarin, dabigatran, and warfarin with heparin bridging in patients undergoing catheter ablation of AF, dabigatran was not associated with increased risk, major complications were more common in the uninterrupted warfarin group, and after adjustment, warfarin with bridging increased total complications.

Defining the blanking period, using continuous ECG monitoring, after cryoballoon pulmonary vein isolation.

BACKGROUND: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. A blanking period (BP) of 3 months is used in clinical trials and practice. However, the optimal BP duration after PVI remains undefined. OBJECTIVE: The aim of this study was to objectively define, using continuous monitoring by an implantable loop recorder, the optimal BP duration after cryoballoon PVI. METHODS: We enrolled consecutive patients who had cryoballoon PVI and an implantable loop recorder. We determined the time of the last confirmed episode of AF within the blanking period. This was then correlated with AF recurrence in the first year after ablation. RESULTS: There were 210 patients (66 ± 9 years; 138 [66%] male; 116 [55%] paroxysmal AF; CHA2DS2-VASc score, 2.5 ± 1.6). We defined 4 distinct groups based on the last AF episode within the BP: no AF days 0-90 (n = 96 [46%]) and last AF 0-30 days (n = 46 [22%]), 31-60 days (n = 18 [9%]), and 61-90 days (n = 50 [24%]). After the 3-month BP, 101 (48%) patients had AF recurrence at 160 ± 86 days. Compared with patients with no AF in the BP, those with recurrent AF and AF burden >0% 30 days after ablation had a significantly greater AF recurrence during long-term follow-up (P = .001). CONCLUSION: Our data show that the approximately one-third of patients in whom AF occurs and who have a burden of >0% after the first month that follows PVI are at significantly higher risk of long-term recurrent AF. We therefore suggest that the blanking period be limited to a month after cryoballoon PVI.

Incidence and Predictors of Very Late Recurrence of Atrial Fibrillation Following Cryoballoon Pulmonary Vein Isolation.

BACKGROUND: A very late recurrence (VLR) of atrial fibrillation (AF) is considered present when the first recurrence of AF occurs ≥12 months following ablation. Prior studies characterizing VLR have not used an implantable loop recorder for ECG monitoring. Thus, it is unknown whether VLR truly occurs or whether these patients have simply had unrecognized AF. Our objective was to assess the incidence and predictors of VLR in patients who underwent cryoballoon pulmonary vein isolation alone, had an implantable loop recorder, and were confirmed AF free for at least 1 year. METHODS: We enrolled consecutive patients with paroxysmal or persistent AF who underwent cryoballoon pulmonary vein isolation and had an implantable loop recorder implanted <3 months post-ablation. Patients free of AF 1 year post-ablation were followed prospectively for recurrent AF. All AF episodes were adjudicated. RESULTS: We included 188 patients (66±10 years; 116 [62%] men; 102 [54%] paroxysmal AF; CHA2DS2-VASc, 2.6±1.7). After 1 year post-pulmonary vein isolation, 93 (49%) patients remained AF free. During subsequent follow-up, 30 (32%) patients had VLR of AF. The only independent risk factor for VLR was an elevated CHA2DS2-VASc score (hazard ratio, 1.317 [95% CI, 1.033-1.6979]; P=0.026). Patients with CHA2DS2-VASc score ≥4 represented a quarter of the population and were at the highest risk. CONCLUSIONS: Our data using implantable loop recorders for continuous ECG monitoring post-AF ablation show that VLR occurs in a third of patients after an apparently successful cryoballoon pulmonary vein isolation procedure. Additional strategies are needed to ensure long-term freedom from AF recurrences in these high-risk patients.

Incidence, duration, pattern, and burden of de novo atrial arrhythmias detected by continuous ECG monitoring using an implantable loop recorder following ablation of the cavotricuspid isthmus.

Background: Following cavotricuspid isthmus (CTI) ablation, many patients with atrial flutter (AFL) are diagnosed with atrial fibrillation (AF). The incidence, duration, pattern, and burden of AF remain undefined. These may have implications for the management of these patients. Objective: To classify the incidence, duration, pattern, and burden of AF/AFL using an implantable loop recorder (ILR) after CTI ablation. Methods: We enrolled consecutive patients with CTI-dependent AFL, no known history of AF, and CHA2DS2-VASc ≥ 2. An ILR was implanted before or within 90 days of ablation. The time to first AF/AFL, pattern, duration, and burden of longest AF/AFL were determined. Five distinct AF/AFL cohorts were identified: no AF/AFL and those with recurrences of isolated, clustered, frequent, or persistent AF/AFL. Results: Fifty-two patients (81% male; 73 ± 9 years; CHA2DS2-VASc 3.7 ± 1.2) were followed for 784 (interquartile range [IQR] 263, 1150) days. AF/AFL occurred in 44 (85%) patients at 64 (IQR 8, 189) days post-CTI ablation and was paroxysmal in 31 (70%) patients (burden 0.6% [IQR 0.1, 4.8]). AF/AFL was isolated (n = 5, 11%), clustered (n =7, 16%), frequent (n =19, 43%), and persistent (n =13, 30%). The longest AF episode was <24 hours in 27 (61%) patients. Conclusion: Following CTI ablation in AFL patients, although AF/AFL occurs in most patients, the burden is low and episodes were <24 hours in the majority of patients. Additional studies are needed to determine whether long-term electrocardiographic monitoring can help guide management of patients undergoing CTI ablation.

Detection of atrial fibrillation using an implantable loop recorder following cryptogenic stroke: implications for post-stroke electrocardiographic monitoring.

PURPOSE: Approximately 10-40% of strokes are cryptogenic (CS). Long-term electrocardiographic (ECG) monitoring has been recommended in these patients to search for atrial fibrillation (AF). An unresolved issue is whether ambulatory ECG (AECG) monitoring should be performed first, followed by an implantable loop recorder (ILR) if AECG monitoring is non-diagnostic, or whether long-term ECG monitoring should be initiated using ILRs from the onset. The purpose of this study was to assess, using an ILR, AF incidence in the first month after CS. METHODS: We enrolled consecutive CS patients referred for an ILR. All patients were monitored via in-hospital continuous telemetry from admission until the ILR (Medtronic [Minneapolis, MN] LINQ™) was implanted. The duration and overall burden of all AF episodes ≥ 2 min was determined. RESULTS: The cohort included 343 patients (68 ± 11 years, CHA2DS2-VASc 3.5 ± 1.7). The time between stroke and ILR was 3.7 ± 1.5 days. During the first 30 days, only 18 (5%) patients had AF. All episodes were paroxysmal, lasting from 2 min to 67 h and 24 min. The median AF burden was 0.85% (IQR 0.52, 10.75). During 1 year of follow-up, 67 (21%) patients had AF. CONCLUSION: The likelihood of AF detection by an ILR in the first month post-CS is low. Thus, the diagnostic yield of 30 days of AECG monitoring is likely to be limited. These data suggest a rationale for proceeding directly to ILR implantation prior to hospital discharge in CS patients, as many have AF detected during longer follow-up.

The Efficacy of His Bundle Pacing: Lessons Learned From Implementation for the First Time at an Experienced Electrophysiology Center.

OBJECTIVES: This study sought to evaluate the clinical and procedural characteristics impacting outcomes during implementation of a His bundle pacing (HBP) program in a real-world setting. BACKGROUND: Right ventricular pacing is associated with an elevated risk of heart failure, but device reprogramming and upgrades have significant challenges. HBP has emerged as an alternative and is reported to be highly successful in the hands of highly experienced centers. METHODS: All patients referred for permanent pacemaker implantation at the Valley Hospital (Ridgewood, New Jersey) between October 2015 and October 2017 were evaluated; a subset of 24% was selected for HBP. RESULTS: Permanent HBP was feasible with an acute implant success rate of 75%. HBP in the presence of bundle branch block (64% vs. 85%; p = 0.05) or complete heart block (56% vs. 83%; p = 0.03) was significantly less successful. The pattern of atrioventricular block in combination with bundle branch block (BBB) further affects outcomes. HBP is highly successful across the spectrum of atrioventricular block pattern severity in the absence of BBB. In the presence of BBB, Mobitz II AV block and complete heart block significantly attenuated HBP success compared with Mobitz I atrioventricular block (62% vs. 100%; p = 0.02). A rising threshold was observed in 30%, and 8% required lead intervention. CONCLUSIONS: HBP was feasible and readily learned with a high implant success in the hands of experienced electrophysiologists without prior exposure to the technique. BBB and atrioventricular block pattern appears to affect success. The technique is limited by a high rate of rising thresholds and lead intervention. These data have important implications for patient selection.

Value of EP Study and Other Cardiac Investigations.

With the advent of implantable loop recorders capable of prolonged electrocardiographic monitoring, and following studies demonstrating the benefit of implantable cardioverter-defibrillator therapy in subgroups of patients with structural heart disease and depressed left ventricular function, the role of invasive cardiac electrophysiologic (EP) studies in patients with unexplained syncope has been substantially reduced. Nonetheless, in select high-risk patients presenting with unexplained syncope, EP studies still play an important role in identifying a diagnosis in these patients and assessing long-term risk of mortality.

Very long-term outcome after initially successful catheter ablation of atrial fibrillation.

BACKGROUND: The ablation of atrial fibrillation (AF) using pulmonary vein isolation is indicated when patients do not respond favorably to medical therapy. Successful procedures are accomplished in the majority of patients, but the outcome after many years of follow-up after ablation is unknown. OBJECTIVE: To describe the long-term recurrence rate and pattern of AF after successful ablation. METHODS: A prospectively identified cohort of 445 patients who demonstrated freedom from AF for at least 1 year postablation (single procedure in 391 [87.9%]) was followed for 66.0 ± 34.0 months. Patients were seen at least annually as outpatients and underwent regular electrocardiographic monitoring. RESULTS: At 40.7 ± 27.0 months postablation, 97 (21.8%) patients experienced at least 1 episode of recurrent AF. The vast majority of events were symptomatic, and no serious clinical events were associated with AF recurrence (eg, stroke). There was a steady attrition rate reaching 16.3% and 29.8% at 5 and 10 years, respectively. In 29 patients (29.5%) of the patients, recurrences were self-limited; the remainder required either medical therapy or repeat ablation. By multivariate analysis, persistent AF (hazard ratio 3.08; P < .0001) and hypertension (hazard ratio 1.08; P = .009) were independent risk factors for the recurrence of AF. The presence of both factors placed the patient at high risk of recurrence: 37.6% at 5 years and 68.8% at 10 years. CONCLUSIONS: Over the decade after a successful ablation of AF, most patients continue to demonstrate freedom from AF. At the highest risk of very late recurrence is the subset of patients with hypertension and prior persistent AF.

Prophylactic pulmonary vein isolation during isthmus ablation for atrial flutter: the PReVENT AF Study I.

BACKGROUND: Although catheter ablation of isthmus-dependent atrial flutter (AFL) is successful at eliminating the target arrhythmia, many patients subsequently experience new-onset atrial fibrillation (AF). OBJECTIVE: The aim of this study was to determine whether AF can be prevented by prophylactic pulmonary vein ablation in patients with AFL. METHODS: A prospective, single-blind, randomized clinical trial in patients whose sole arrhythmia was AFL without AF was conducted. Patients were randomized to cavotricuspid isthmus ablation alone or with concomitant pulmonary vein isolation. All patients received an implantable cardiac monitor. RESULTS: Fifty patients completed the trial, and patients were well matched. Isthmus ablation was successful in all patients; pulmonary vein isolation was successful in 25 (100%) randomized patients. Procedure (P < .0001) and fluoroscopy (P < .0001) times were longer in the combined ablation group. More patients in the isthmus ablation-only group experienced new-onset AF during follow-up (52% vs. 12%; P = .003). The 1-year AF burden also favored the combined ablation group compared with the isthmus ablation-only group (8.3% vs. 4.0%; P = .034). In the isthmus ablation-only group, 8 (32%) patients subsequently underwent another ablation for AF. The performance of pulmonary vein isolation and male sex were independent predictors of freedom from AF. CONCLUSION: In the PREVENT-AF Study I randomized clinical trial of patients in whom only typical AFL had been observed clinically, the addition of pulmonary vein isolation to cavotricuspid isthmus ablation resulted in a marked reduction of new-onset AF during clinical follow-up as assessed with a continuous implantable cardiac monitor.

Safety and efficacy of renal denervation as a novel treatment of ventricular tachycardia storm in patients with cardiomyopathy.

BACKGROUND: Modulation of the autonomic nervous system has been used to treat refractory ventricular tachycardia (VT). Renal artery denervation (RDN) is under investigation for the treatment of sympathetic-driven cardiovascular diseases. OBJECTIVE: The purpose of this study was to report the largest case series to date using RDN as adjunctive therapy for refractory VT in patients with underlying cardiomyopathy. METHODS: Four patients with cardiomyopathy (2 nonischemic, 2 ischemic) with recurrent VT despite maximized antiarrhythmic therapy and prior endocardial (n = 2) or endocardial/epicardial (n = 2) ablation underwent RDN ± repeat VT ablation. RDN was performed spirally along each main renal artery with either a nonirrigated (6 W at 50°C for 60 seconds) or an open irrigated ablation catheter (10-12 W for 30-60 seconds). Renal arteriography was performed before and after RDN. RESULTS: RDN was well tolerated acutely and demonstrated no clinically significant complications during follow-up of 8.8 ± 2.6 months (range 5.0-11.0 months). No hemodynamic deterioration or worsening of renal function was observed. The number of VT episodes was decreased from 11.0 ± 4.2 (5.0-14.0) during the month before ablation to 0.3 ± 0.1 (0.2-0.4) per month after ablation. All VT episodes occurred in the first 4 months after ablation (2.6 ± 1.5 months). The responses to RDN were similar for ischemic and nonischemic patients. CONCLUSION: This case series provides promising preliminary data on the safety and effectiveness of RDN as an adjunctive therapy in the treatment of patients with cardiomyopathy and VT resistant to standard interventions.

Comparison of endovascular versus epicardial lead placement for resynchronization therapy.

Cardiac resynchronization therapy (CRT) has been shown to improve survival and symptoms in patients with severe left ventricular (LV) dysfunction, congestive heart failure, and prolonged QRS duration. LV lead placement is achieved by placing the lead in the coronary sinus, an endovascular approach, or by a minimally invasive robotic-assisted thoracoscopic epicardial approach. There are no data directly comparing the 2 methods. Patients eligible for CRT were randomized to the endovascular and epicardial arms. Coronary sinus lead placement was achieved using the standard technique, and epicardial leads were placed using a minimally invasive robotic-assisted thoracoscopic approach. The primary end point was a decrease in LV end-systolic volume index at 6 months. The secondary end points included 30-day mortality rate, measures of clinical improvement, 1-year electrical lead performance, and 1-year survival rate. The relative improvement of LV end-systolic volume index from baseline to 6 months was similar between the arms (28.8% for the transvenous [n = 12] vs 30.5% for the epicardial (n = 9) arm, p = 0.93). There were no significant differences in the secondary end points between the 2 groups. In conclusion, there were no differences in echocardiographic and clinical outcomes comparing a conventional endovascular approach versus robotic-assisted surgical epicardial LV lead placement for CRT in patients with heart failure. Surgical approaches are still a viable alternative when a transvenous procedure has failed or is not technically feasible.

Cardiac implantable electronic device infections: incidence, risk factors, and the effect of the AigisRx antibacterial envelope.

BACKGROUND: Cardiac implantable electronic device (CIED) infection is associated with morbidity and mortality. OBJECTIVES: To determine the incidence and risk factors for CIED infection, to develop a scoring index for risk stratification, and to analyze the effect of the AIGISRx envelope on infection rates. METHODS: Consecutive patients who underwent a CIED procedure were identified and surveyed for 6 months for the development of an infection necessitating removal of all implanted hardware. RESULTS: In the pre-envelope era, an infection occurred in 25 (1.5%) of 1651 patients. After its availability, an envelope was used in 275 (22%) of 1240 patients; an infection occurred in 8 (0.6%) patients in this era (P = .029 vs pre-envelope). In the overall cohort of 2891 patients, the infection rate was 1.2% and 3.5% in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device, respectively (P = .018); in these patients, 7 independent risk factors predicted infection: early pocket re-exploration, male sex, diabetes, upgrade procedure, heart failure, hypertension, and glomerular filtration rate < 60 mL/min. A composite risk score (0-25; C index 0.72; 95% confidence interval 0.61-0.83) was created by weight, adjusting these 7 factors: 3 groups emerged-low risk (score 0-7; 1% infection), medium risk (score 8-14; 3.4% infection), and high risk (score ≥15; 11.1% infection). The envelope reduced infections by 79% and 100% in the medium- and high-risk groups, respectively. CONCLUSIONS: CIED infection most commonly occurred in patients with an implantable cardioverter-defibrillator device and those with a cardiac resynchronization therapy defibrillator device. A composite score based on clinical variables appeared feasible for infection risk stratification. The AIGISRx envelope significantly lowered the risk of CIED infection. Randomized clinical data are warranted.

ABCC9 is a novel Brugada and early repolarization syndrome susceptibility gene.

BACKGROUND: Genetic defects in KCNJ8, encoding the Kir6.1 subunit of the ATP-sensitive K(+) channel (I(K-ATP)), have previously been associated with early repolarization (ERS) and Brugada (BrS) syndromes. Here we test the hypothesis that genetic variants in ABCC9, encoding the ATP-binding cassette transporter of IK-ATP (SUR2A), are also associated with both BrS and ERS. METHODS AND RESULTS: Direct sequencing of all ERS/BrS susceptibility genes was performed on 150 probands and family members. Whole-cell and inside-out patch-clamp methods were used to characterize mutant channels expressed in TSA201-cells. Eight ABCC9 mutations were uncovered in 11 male BrS probands. Four probands, diagnosed with ERS, carried a highly-conserved mutation, V734I-ABCC9. Functional expression of the V734I variant yielded a Mg-ATP IC50 that was 5-fold that of wild-type (WT). An 18-y/o male with global ERS inherited an SCN5A-E1784K mutation from his mother, who displayed long QT intervals, and S1402C-ABCC9 mutation from his father, who displayed an ER pattern. ABCC9-S1402C likewise caused a gain of function of IK-ATP with a shift of ATP IC50 from 8.5 ± 2 mM to 13.4 ± 5 µM (p<0.05). The SCN5A mutation reduced peak INa to 39% of WT (p<0.01), shifted steady-state inactivation by -18.0 mV (p<0.01) and increased late I(Na) from 0.14% to 2.01% of peak I(Na) (p<0.01). CONCLUSION: Our study is the first to identify ABCC9 as a susceptibility gene for ERS and BrS. Our findings also suggest that a gain-of-function in I(K-ATP) when coupled with a loss-of-function in SCN5A may underlie type 3 ERS, which is associated with a severe arrhythmic phenotype.

Correlation of QT interval correction methods during atrial fibrillation and sinus rhythm.

The calculation of the corrected QT interval (QTc) is particularly problematic in patients during atrial fibrillation (AF). The aims of this study were to compare the QTc calculated using Bazett's formula in AF and sinus rhythm (SR) and determine whether alternative methods for QT correction were superior to Bazett's, in an effort to define the optimal method for QT correction in patients with AF. We evaluated consecutive patients with persistent AF admitted for initiation of dofetilide. The QT interval was corrected according to the following formulas: Bazett's, Fridericia, and Framingham. We compared the QTc interval on the last electrocardiogram in AF to the first electrocardiogram in SR. The cohort included 54 patients (age 60 ± 10 years, 80% men) with persistent AF for a median of 36 months. Bazett's overestimated QTc during AF compared with SR (464 ± 34 vs 445 ± 38 ms, p = 0.008); in contrast, Framingham underestimated it (385 ± 48 vs 431 ± 40 ms, p <0.001, respectively). However, there was no significant difference between the QTc interval in AF and SR when assessed by Fridericia (435 ± 33 vs 440 ± 35 ms, p = 0.46). There were 24 dofetilide dose reductions based on Bazett's QTc; this would have been avoided in 33% of patients had Fridericia been used. In conclusion, the commonly used Bazett's formula leads to an overestimation of the QTc during AF. This may result in unnecessary reduction in antiarrhythmic doses and thus drug efficacy. These data suggest that the Fridericia most closely approximates the QTc during AF to QTc during SR.

Long-term ECG monitoring using an implantable loop recorder for the detection of atrial fibrillation after cavotricuspid isthmus ablation in patients with atrial flutter.

BACKGROUND: In patients with atrial flutter who undergo cavotricuspid isthmus ablation, long-term electrocardiographic (ECG) monitoring may identify new onset of atrial fibrillation (AF). OBJECTIVES: To ascertain, through the use of an implantable loop recorder (ILR) with a dedicated AF detection algorithm, the incidence, duration, and burden of new AF in these patients and to develop an optimal postablation ECG monitoring strategy. METHODS: We enrolled 20 patients with flutter, a CHADS2 score of 2-3, and no prior episode of AF. After cavotricuspid isthmus ablation, we implanted an ILR, which was interrogated routinely; all stored ECGs were adjudicated. RESULTS: During a mean follow-up of 382 ± 218 days, 3 patterns were observed. First, in 11 (55%) patients, stored ECGs confirmed AF at 62 ± 38 days after ablation. Second, in 4 (20%) patients, although the ILR suggested AF, episodes actually represented sinus rhythm with frequent premature atrial contractions and/or oversensing. Third, in 5 (25%) patients, no AF was observed. Episodes <4 hours were associated with low AF burden (<1%) or false detections. The 1-year freedom from any episode of AF >4 and >12 hours was 52% and 83%, respectively. CONCLUSIONS: Our data show that many (but not all) patients develop new AF within the first 4 months of flutter ablation. Since external ECG monitoring for this duration is impractical, the ILR has an important role for long-term AF surveillance. Future research should be directed toward identifying the relationship between duration/burden of AF and stroke and improving existing ILR technology.