2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation.

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society .

[Endoscopic Ultrasound Drainage of the Gallbladder in Acute Cholecystitis in Patients at High Surgical Risk]. / Endosonografische Drainage der Gallenblase wegen akuter Cholezystitis bei Patienten mit hohem Operationsrisiko.

BACKGROUND: The standard treatment for acute cholecystitis is laparoscopic cholecystectomy. Alternative procedures are used for patients at high surgical risk. Percutaneous drainage is widely available. The alternative of transpapillary drainage of the gallbladder via the ductus cysticus has only limited prospects of success. With the widespread use of interventional endoscopic ultrasound and the development of new stent systems, endoscopic ultrasound gallbladder drainage has proven to be a safe and reliable procedure. MATERIAL AND METHOD: We retrospectively report on our experiences in 11 consecutive patients with endoscopic ultrasound gallbladder drainage in acute cholecystitis between December 2018 and January 2021. RESULTS: 11 patients with acute cholecystitis with a mean age of 84.5 years (70-95 years) are reported. All patients had severe general comorbidities or advanced abdominal tumours or a combination of these conditions. After interdisciplinary debate, the indication for interventional therapy was made. This was carried out in 9 cases by means of endosonographic drainage alone and in 2 cases by means of percutaneous and two-stage endosonographic drainage. Technical success was achieved in 10 cases (91%), clinical success in 9 cases (82%). In 2 cases there were procedural complications that led to the operation. CONCLUSION: In the case of high surgical risks, endosonographic drainage of the gall bladder is a safe and definitive therapy. This can be performed alone or in combination with percutaneous drainage. Endoscopic ultrasound drainage is superior to percutaneous drainage alone, due to its lower complication rates and lower rates of necessary follow-up interventions. Therefore, in cases of relatively high surgical risk, endoscopic ultrasound drainage of the gall bladder should be preferred to percutaneous drainage, especially when definitive therapy is required.

[Prevention of sudden cardiac death]. / Prävention des plötzlichen Herztods.

Sudden cardiac death is a major as yet unsolved public health problem. Prevention of sudden cardiac death is subdivided into two main categories, on the one hand primary prevention (prevention of a first event of sudden cardiac death) and on the other hand secondary prevention (prevention of reoccurring events in survivors of cardiac arrest). This review article summarizes the current state of knowledge on primary and secondary prevention of sudden cardiac death in various clinical settings.

Feasibility and Reliability of Smartwatch to Obtain Precordial Lead Electrocardiogram Recordings.

The Apple Watch is capable of recording single-lead electrocardiograms (ECGs). To incorporate such devices in routine medical care, the reliability of such devices to obtain precordial leads needs to be validated. The purpose of this study was to assess the feasibility and reliability of a smartwatch (SW) to obtain precordial leads compared to standard ECGs. We included 100 participants (62 male, aged 62.8 ± 13.1 years) with sinus rhythm and recorded a standard 12-lead ECG and the precordial leads with the Apple Watch. The ECGs were quantitively compared. A total of 98 patients were able to record precordial leads without assistance. A strong correlation was observed between the amplitude of the standard and SW-ECGs' waves, in terms of P waves, QRS-complexes, and T waves (all p-values < 0.01). A significant correlation was observed between the two methods regarding the duration of the ECG waves (all p-values < 0.01). Assessment of polarity showed a significant and a strong concordance between the ECGs' waves in all six leads (91-100%, all p-values < 0.001). In conclusion, 98% of patients were able to record precordial leads using a SW without assistance. The SW is feasible and reliable for obtaining valid precordial-lead ECG recordings as a validated alternative to a standard ECG.

Use of the Apple Watch iECG in adult congenital heart disease patients.

INTRODUCTION: This study evaluates the accuracy of iECGs in comparison to the gold standard ECG in adult patients with congenital heart disease and recommends the appropriate iECG derivation based on the patient's characteristics. METHODS: In 106 adults (51 female, 55 male) with congenital heart disease, a gold standard 12-lead ECG was recorded, followed by three iECGs with the Apple Watch series 4, which correspond to Einthoven leads I, II, and III. Two experienced and independent cardiologists analyzed the time intervals, amplitudes, and polarities of the ECG parameters as well as the rhythm type and correlated the patient characteristics with the iECG parameters. RESULTS: The iECG parameters of all three iECG leads correlate strongly with those of the gold standard ECG, with exception of the P and T wave durations. We demonstrated that the informative value of the individual iECGs was independent of the patient's characteristics, in particular the heart axis, anatomy, and situs, even if the quality of the Einthoven III-like derivation was partially inadequate. The automatic rhythm analysis of the Apple Watch and the heart rhythm classification of a standard ECG analyzed manually by a cardiologist corresponded in 77%. CONCLUSION: iECG recordings of adults with congenital heart disease provide comparable results with Einthoven recordings I, II, and III of the 12-lead ECG and current data encourage the use of the Apple Watch not only in patients with structurally normal hearts but also in patients with congenital heart disease.

[Current applications of hypnosis in the field of cardiac electrophysiology]. / Aktuelle Anwendungen der Hypnose auf dem Gebiet der kardialen Elektrophysiologie.

With a growing acceptance of clinical hypnosis in medicine, new fields of application are being explored. Data from recent studies support the use of hypnosis for pain management during procedures, such as ablation of arrhythmias and implantation of subcutaneous implantable cardioverter defibrillators, management of preoperative anxiety and reduction of postoperative atrial fibrillation. The aim of this review article is to summarize the findings of investigations showing the application of hypnosis in the field of cardiac electrophysiology, to review the rationale for the efficacy of hypnosis in management of cardiac arrhythmias and to highlight possible future directions in clinical applications and scientific perspectives.

[2020 ESC guidelines on atrial fibrillation : Summary of the most relevant recommendations and innovations]. / ESC-Leitlinien 2020 zum Vorhofflimmern : Zusammenfassung der wichtigsten Empfehlungen und Neuerungen.

The new guidelines for the diagnosis and management of atrial fibrillation (AF) were published by the European Society of Cardiology (ESC) in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) in August 2020. The 2020 guidelines of the ESC on AF summarize the current developments in this field and provide general recommendations for the management of patients with AF based on the principles of evidence-based medicine. Beside the general statements on definition, epidemiology and clinical features of AF, interesting new aspects in screening and diagnosis of AF are also presented. The main novelties of the 2020 guidelines are the proposal of the 4S-AF scheme for a structured characterization of AF that takes the stroke risk, severity of symptoms, severity of AF burden and substrate severity into account. Also new is the ABC approach for improvement of the structured management and treatment results. A further innovation is the introduction of the concept of major risk factors for recurrences in the decision for catheter ablation. This review focuses on the newest and most important recommendations taken from the 2020 ESC guidelines for the diagnosis and management of AF.

Atrial septum biopsy for direct substrate characterization in atrial fibrillation.

INTRODUCTION: The aim of this study was to describe and illustrate the technique of performing interatrial septum biopsy and to demonstrate its use for direct histological substrate characterization in atrial fibrillation (AF). METHODS AND RESULTS: Biopsies were performed in four patients who underwent AF catheter ablation. Bipal 7 bioptome was directed through a steerable sheath directly onto the septum. Fluoroscopic views as well as echocardiography-guided techniques were utilized to confirm that the tip was oriented towards the interatrial septum. The bioptome was then placed on the right atrial (RA) septum and maneuvered to obtain the specimens (at least 1 mm in size) from the posterior septal region of the RA, adjacent to the fossa ovalis. Bioptome placement and sample acquisition were successful in all patients at the first attempt. No patient developed any minor or major complications during the procedure and hospital stay. All the biopsy specimens had proper qualities for histological assessments and revealed a variety of pathologies including fibrosis, inflammation, and fatty infiltration. CONCLUSION: Atrial septum biopsies could be safely performed guided by fluoroscopy and transesophageal echocardiography. The obtained specimens allowed for a detailed localized substrate characterization which is of great interest in AF.

Feasibility and Reliability of SmartWatch to Obtain 3-Lead Electrocardiogram Recordings.

Some of the recently released smartwatch products feature a single-lead electrocardiogram (ECG) recording capability. The reliability of obtaining 3-lead ECG with smartwatches is yet to be confirmed in a large study. This study aimed to assess the feasibility and reliability of smartwatch to obtain 3-lead ECG recordings, the classical Einthoven ECG leads I-III compared to standard ECG. To record lead I, the watch was worn on the left wrist and the right index finger was placed on the digital crown for 30 s. For lead II, the watch was placed on the lower abdomen and the right index finger was placed on the digital crown for 30 s. For lead III, the same process was repeated with the left index finger. Spearman correlation and Bland-Altman tests were used for data analysis. A total of 300 smartwatch ECG tracings were successfully obtained. ECG waves' characteristics of all three leads obtained from the smartwatch had a similar duration, amplitude, and polarity compared to standard ECG. The results of this study suggested that the examined smartwatch (Apple Watch Series 4) could obtain 3-lead ECG tracings, including Einthoven leads I, II, and III by placing the smartwatch on the described positions.

Atrial Fibrillation and Cognitive Impairment: New Insights and Future Directions.

INTRODUCTION: Atrial fibrillation (AF) has been recognised as the most prevalent sustained arrhythmia. Recently, a growing body of evidence has suggested that AF might be involved in the progression of cognitive impairment (CIM), potentially extending into types of dementia. Accordingly, the purpose of the present study was to summarise the findings of investigations examining association between AF and cognitive function as well as highlighting the possible causes of discrepancy between the findings and reviewing the probable mechanisms of CIM in patients affected with AF. METHODS: A systematic search in the literature was conducted in the databases of PubMed, Scopus, Cochrane Library, and Google Scholar with no language restrictions, using specified search terms to identify studies published between 1 January 1990 and 1 April 2018. Then, study designs, participant information, diagnostic approaches used for cognitive assessments, and incidence/prevalence rates of CIM and/or dementia were assessed. RESULTS: Out of the initial 2,364 articles retrieved, a total number of 40 studies were selected for data collection. Most studies had suggested a significant relationship between AF and CIM. In this regard, cerebral hypo-perfusion, altered cerebral blood flow, cerebral micro-bleeds, micro-emboli, vascular inflammation, cerebral small vessel diseases, vascular inflammation, and genetic factors were considered as the possible mechanisms of CIM in patients suffering from AF. It seemed that differences in study settings and designs, variations of diagnostic tools for CIM and AF, as well as underlying conditions such as age groups, concurrent chronic diseases, and therapeutic interventions for AF might be amongst probable factors justifying the diversity of findings across the selected articles. CONCLUSION: Although evidence is much more directed towards an association between AF and CIM, the role of AF in CIM needs to be confirmed in-depth via longer prospective and cohort studies at larger scales using accurate neuropsychological and cognitive function assessments. Moreover, the mechanisms involved in the relationship between AF and Alzheimer's disease (AD) require further studies. To conclude, the effect of different therapeutic strategies of AF on CIM should be investigated in more clinical trials.

Natural course of acquired pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation-Is routine follow-up imaging indicated or not?

INTRODUCTION: Thermal injury during radiofrequency ablation (RFA) of atrial fibrillation (AF) can lead to pulmonary vein stenosis (PVS). The aim of the present study was to analyze the natural course of RFA-induced PVS with regard to the grade of stenosis, clinical symptoms, and mortality during long-term follow-up. METHODS AND RESULTS: All patients with follow-up imaging for radiofrequency-induced untreated PVS were retrospectively assessed. From 2004 to 2017, the total rate of PVS following AF ablation in our center was 0.78% (87 of 11 103). Thirty-eight patients with a total of 54 untreated PVS underwent follow-up including imaging scan. The mean degree of stenosis at the time of diagnosis was 57% ± 27% vs 45% ± 35% (P = .05) after a mean follow-up of 43 ± 31 months. There was a shift in severity of the PVS: 18 of 54 (33%) vs 16 of 54 (30%) severe PVS, 19 of 54 (35%) vs 10 of 54 (18%) moderate PVS, and 17 of 54 (32%) vs 28 of 54 (52%) mild PVS (P = .0001). The mean symptom score decreased significantly during follow-up (1.8 ± 1.0 vs 0.4 ± 0.5, P = .0001). Each of the four patients with progression of PVS underwent another pulmonary vein isolation for AF recurrence following pulmonary vein reconduction during follow-up period. CONCLUSION: This study showed a spontaneous reduction in stenosis grade and symptoms of PVS over a 3.5-year follow-up. Consequently, routine follow-up imaging of PVS seems not to be necessary. However, additional RF energy delivery to stenotic pulmonary veins should be avoided if possible. In case of conduction recovery, the ablation line should be done wide-antrally and follow-up imaging of PVS is recommended.

Atrial fibrillation: is there a role for cardiac troponin?

Atrial fibrillation (AF) is the most common sustained arrhythmia, and its prevalence rate is expected to be doubled over the next decades. Despite the wide use of biomarkers in the management of different cardiac diseases such as myocardial infarction and heart failure, utilization of biomarkers in AF management is not routinely recommended by current guidelines. There is also growing evidence that higher levels of cardiac-specific troponin, as an intracellular protein involved in cardiomyocyte contraction, may be associated with the risk of incident and recurrent AF and its complications. In the present paper, we review the association between troponin and AF and propose clinical suggestions for use of troponin in the management of AF patients.

Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on Acute Admissions at the Emergency and Cardiology Departments Across Europe.

PURPOSE: We evaluated whether the severe acute respiratory syndrome coronavirus 2 (SARS-COV-2) pandemic was associated with changes in the pattern of acute cardiovascular admissions across European centers. METHODS: We set-up a multicenter, multinational, pan-European observational registry in 15 centers from 12 countries. All consecutive acute admissions to emergency departments and cardiology departments throughout a 1-month period during the COVID-19 outbreak were compared with an equivalent 1-month period in 2019. The acute admissions to cardiology departments were classified into 5 major categories: acute coronary syndrome, acute heart failure, arrhythmia, pulmonary embolism, and other. RESULTS: Data from 54,331 patients were collected and analyzed. Nine centers provided data on acute admissions to emergency departments comprising 50,384 patients: 20,226 in 2020 compared with 30,158 in 2019 (incidence rate ratio [IRR] with 95% confidence interval [95%CI]: 0.66 [0.58-0.76]). The risk of death at the emergency departments was higher in 2020 compared to 2019 (odds ratio [OR] with 95% CI: 4.1 [3.0-5.8], P < 0.0001). All 15 centers provided data on acute cardiology departments admissions: 3007 patients in 2020 and 4452 in 2019; IRR (95% CI): 0.68 (0.64-0.71). In 2020, there were fewer admissions with IRR (95% CI): acute coronary syndrome: 0.68 (0.63-0.73); acute heart failure: 0.65 (0.58-0.74); arrhythmia: 0.66 (0.60-0.72); and other: 0.68(0.62-0.76). We found a relatively higher percentage of pulmonary embolism admissions in 2020: odds ratio (95% CI): 1.5 (1.1-2.1), P = 0.02. Among patients with acute coronary syndrome, there were fewer admissions with unstable angina: 0.79 (0.66-0.94); non-ST segment elevation myocardial infarction: 0.56 (0.50-0.64); and ST-segment elevation myocardial infarction: 0.78 (0.68-0.89). CONCLUSION: In the European centers during the COVID-19 outbreak, there were fewer acute cardiovascular admissions. Also, fewer patients were admitted to the emergency departments with 4 times higher death risk at the emergency departments.

Natriuretic peptides: biomarkers for atrial fibrillation management.

In clinical practice, atrial fibrillation (AF) is known as the most common sustained arrhythmia. Therefore, identification of individuals at risk of AF development/recurrence or its associated complications has emerged as a hot topic in the field of cardiology. Recently, several biomarkers have been introduced to predict AF and its consequences; however, use of biomarkers in AF management has not been highly recommended by guidelines yet. While utilization of natriuretic peptides (NPs) including brain (B-type) NPs (BNPs) in heart failure management has been well established, their use in relation to AF has not been fully understood. Accordingly, this review article aimed at presenting an overview of the role of NPs in predicting AF development/recurrence as well as its complications and making suggestions for their use in management of patients with AF in clinical settings.

Is epicardial fat tissue associated with atrial fibrillation recurrence after ablation? A systematic review and meta-analysis.

INTRODUCTION: Although an undoubted association between epicardial fat tissue (EFT) and atrial fibrillation (AF) has been recently approved, the association between EFT and post-ablation AF recurrence is not evident yet. This study aimed to assess the association between EFT and AF recurrence after ablation. METHODS: The present study was a systematic review and meta-analysis using related literature available in electronic databases until July 2018 via "atrial fibrillation" and "epicardial fat" as the main keywords. Considering the different methods of EFT measurement, three different pooled meta-analyses were conducted in this study including: 1) comparison of total EFT volume, 2) left atrium (LA)-EFT volume, and 3) EFT thickness between two groups with and without AF recurrence estimating standardized mean difference (SMD) through a random and non-random effect meta-analysis. Statistical analysis was also performed using Comprehensive Meta-analysis (CMA) Software. RESULTS: Following a search into a total number of 518 articles, the findings of 12 studies published in 10 articles were enrolled in this meta-analysis. Accordingly, the results of meta-analysis showed that LA-EFT and total EFT volumes were higher in recurrent subjects (LA-EFT: SMD = 0.862 ml; I2 = 0.00, 95% confidence interval (CI) = 0.567-1.156; total EFT: SMD = 1.017 ml, I2 = 0.00, 95% CI = 0.748-1.286). Besides, a significant higher EFT thickness in patients with AF recurrence compared to those with no AF recurrence was observed (SMD = 0.808 mm, I2 = 91.07, 95% CI = 0.215-1401). CONCLUSION: The total EFT and LA-EFT volumes, as well as EFT thickness, seemed to be associated with AF recurrence in patients undergoing AF ablation.

Epicardial adipose tissue thickness as an independent predictor of ventricular tachycardia recurrence following ablation.

BACKGROUND: Although several investigations have shown a relationship between increased epicardial adipose tissue (EAT) and atrial fibrillation (AF), the association between EAT and ventricular tachycardia (VT) has not been evaluated. OBJECTIVE: We investigated the association between EAT and postablation VT recurrence. METHODS: Sixty-one consecutive patients (mean age = 62.0 ± 13.9 years) undergoing VT ablation with preprocedural cardiovascular magnetic resonance imaging (CMR) were recruited. EAT thickness was measured using CMR in the right and left atrioventricular grooves (AVGs), right ventricular free wall, and anterior, inferior, and superior interventricular grooves. RESULTS: During a mean follow-up period of 392.9 ± 180.2 days, postablation VT recurrence occurred in 15 (24.6%) patients. EAT thickness was significantly higher in the VT recurrence group than in the nonrecurrent VT group at the right (18.7 ± 5.7 mm vs 14.1 ± 4.4 mm; P = .012) and left (13.3 ± 3.9 mm vs 10.4 ± 4.1 mm; P = .020) AVGs. The best cut-off points for predicting VT recurrence were calculated as 15.5 mm for the right AVG (area under receiver operating characteristic [ROC] curve = 0.74) and 11.5 mm for the left AVG (area under ROC curve = 0.72). Multivariate Cox regression analysis showed that preprocedural right AVG-EAT (hazard ratio: 1.2; 95% confidence interval: [1.06-1.39], P = .004) was the only independent predictor of VT recurrence after adjustment for covariates. Kaplan-Meier analysis showed a difference for postablation VT recurrence between the 2 groups, with right AVG-EAT thickness cut-off value of <15.5 mm vs ≥15.5 mm (log-rank, P = .003). CONCLUSIONS: We suggested a new possible imaging marker for risk stratification of postablation VT recurrence. A higher EAT may be associated with VT recurrence after catheter ablation of VTs.

Diagnostic Value of D-Dimer in Acute Myocardial Infarction Among Patients With Suspected Acute Coronary Syndrome.

BACKGROUND: The role of D-dimer as a diagnostic marker in myocardial infarction (MI) and acute coronary syndrome (ACS) is still a question. The aim of this study was to evaluate the diagnostic value of D-dimer in the diagnosis of AMI in patients suspected with ACS. METHODS: This cross-sectional study was conducted on patients suspected with ACS. Serial standard 12-lead electrocardiogram (ECG), D-dimer, and troponin tests were done for all the patients. According to the examinations, ECG changes, and troponin, patients were allocated into two groups of MI and unstable angina (UA). Chi-square, independent t-test, and Pearson correlation test were used by SPSS ver, 17. Cut-off point of D-dimer for MI diagnosis was evaluated by receiver operating characteristic (ROC) curve analysis. RESULTS: Seventy-five patients with a mean age of 63.1 ± 9.75 years were studied in two groups of MI (n = 34) and UA (n = 41). Patients were homogeneous based on age, gender, and risk factors for diabetes and dyslipidemia. D-dimer in patients with MI patients was higher than in patients with UA (P = 0.001). The optimal cut-off point of D-dimer for diagnosis of MI was 548 mEq/L with sensitivity and specifity of 63.4% and 91.2%, respectively. CONCLUSIONS: Based on the results of this study, it seems that the measurement of D-dimer serum level can be appropriate as a marker with high sensitivity and relatively high specificity for differentiating MI from UA in patients with suspected ACS.

Exercise and Atrial Fibrillation: Some Good News and Some Bad News.

Atrial fibrillation (AF) is considered as the most common sustained arrhythmia in adults, whose incidence rate is on the rise due to the increase in the mean age of the global population. In recent years, many efforts have been made to identify effective factors in the incidence of AF to prevent them and thereby reduce the consequences of AF. Physical activity is one of the topics that attracted much attention in the last two decades. According to some findings, extreme and prolonged exercise itself can be considered as a risk factor for the onset of AF; however, other studies have shown that exercise can be regarded a protective factor against AF in the general population. The present study reviews the findings of studies on the relationship between AF and exercise and discusses possible mechanisms for this relationship. Additionally, we present some recommendations for researchers and physicians about exercise management in association with AF prevention.