2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Effect of pacing site on P wave parameters: Within-patient comparison of right atrial appendage and Bachmann's bundle.

BACKGROUND: Conventional right atrial appendage pacing (RAAp) is associated with adverse clinical outcomes mediated in part by electromechanical atrial delays. Bachmann's bundle pacing (BBp) offers more physiologic atrial activation; however, detailed analysis of pacing site on paced P wave parameters is lacking. METHODS: Intraprocedural electrocardiograms of 21 consecutive patients undergoing atrial lead implantation were retrospectively analyzed and within-patient comparisons of 7 P wave parameters (P wave duration, P wave voltage, P wave area, PR interval, PR segment, PTFV1 and P wave axis) during sinus rhythm, RAAp and BBp performed. RESULTS: The median basal P wave duration was prolonged at 134.5 ms (Q1,Q3: 120.5, 150.5) and similarly prolonged during RAAp at 144.0 ms (127.0, 176.0) but was significantly reduced with BBp at 98.0 ms (93.0, 116.0; p = 0.005 and p < 0.001, respectively). The median basal P wave voltage in lead II was normal at 0.11 mV (0.08, 0.15) but significantly reduced during RAAp at 0.08 mV (0.04, 0.11) and greatest during BBp at 0.16 mV (0.09, 0.19; p < 0.001 and p = 0.003, respectively). The median basal PR interval was top normal at 185.0 ms (163.0, 213.0) and similarly prolonged during RAAp at 204.0 ms (166.5, 221.0) but was significantly shortened during BBp at 163.0 ms (142.0, 208.0; p = 0.03 and p = 0.001, respectively). CONCLUSIONS: BBp has favorable effects on the paced P wave parameters including marked shortening in P wave duration, increase in P wave voltage in lead II and increase in PR segment which may offer significant hemodynamic advantages over conventional RAAp.

Alternative atrial pacing site to improve cardiac function: focus on Bachmann's bundle pacing.

Pacing from the right atrial appendage (RAA) prolongs the P wave duration and can induce interatrial and especially left-sided atrio-ventricular dyssynchrony. Pacing from Bachmann's bundle closely reproduces normal physiology and has the potential to avoid the electromechanical dysfunction associated with conventional RAA pacing. Interatrial conduction delay is associated with an increased risk of stroke, heart failure, and death. In addition to a reduction in atrial fibrillation, Bachmann's bundle pacing has emerging applications as a hemodynamic pacing modality. This review outlines the pathophysiology of atrial conduction disturbances and their potential remedies and provides the reader with a practical guide to implementing Bachmann's bundle pacing with an emphasis on the recapitulation of normal electrical and mechanical function.

Racial and ethnic differences in left atrial appendage occlusion wait time, complications, and periprocedural management.

PURPOSE: Non-white patients are underrepresented in left atrial appendage occlusion (LAAO) trials, and racial disparities in LAAO periprocedural management are unknown. METHODS: We assessed sociodemographics and comorbidities of consecutive patients at our institution undergoing LAAO between 2015 and 2020, then in adjusted analyses, compared procedural wait time, procedural complications, and post-procedure oral anticoagulation (OAC) use in whites versus non-whites. RESULTS: Among 109 patients undergoing LAAO (45% white), whites had lower CHA2 DS2 VASc scores, on average, than non-whites (4.0 vs. 4.8, p = .006). There was no difference in median time from index event (IE) or initial outpatient cardiology encounter to LAAO procedure (whites 10.5 vs. non-whites 13.7 months, p = .9; 1.9 vs. 1.8 months, p = .6, respectively), and there was no difference in procedural complications (whites 4% vs. non-whites 5%, p = .33). After adjusting for CHA2 DS2 VASc score, OAC use at discharge tended to be higher in whites (OR 2.4, 95% CI [0.9-6.0], p = .07). When restricting the analysis to those with prior gastrointestinal (GI) bleed, adjusting for CHA2 DS2 VASc score and GI bleed severity, whites had a nearly five-fold odds of being discharged on OAC (OR 4.6, 95% CI [1-21.8], p = 0.05). The association between race and discharge OAC was not mediated through income category (total mediation effect 19% 95% CI [-.04-0.11], p = .38). CONCLUSION: Despite an increased prevalence of comorbidities amongst non-whites, wait time for LAAO and procedural complications were similar in whites versus non-whites. Among those with prior GI bleed, whites were nearly five-fold more likely to be discharged on OAC than non-whites, independent of income.

2021 ISHNE/ HRS/ EHRA/ APHRS collaborative statement on mHealth in Arrhythmia Management: Digital Medical Tools for Heart Rhythm Professionals: From the International Society for Holter and Noninvasive Electrocardiology/Heart Rhythm Society/European Heart Rhythm Association/Asia Pacific Heart Rhythm Society.

This collaborative statement from the International Society for Holter and Noninvasive Electrocardiology/ Heart Rhythm Society/ European Heart Rhythm Association/ Asia Pacific Heart Rhythm Society describes the current status of mobile health ("mHealth") technologies in arrhythmia management. The range of digital medical tools and heart rhythm disorders that they may be applied to and clinical decisions that may be enabled are discussed. The facilitation of comorbidity and lifestyle management (increasingly recognized to play a role in heart rhythm disorders) and patient self-management are novel aspects of mHealth. The promises of predictive analytics but also operational challenges in embedding mHealth into routine clinical care are explored.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Hypokalemia unmasking underlying premature ventricular contraction induced polymorphic ventricular tachycardia: Low potassium is not always the culprit!

Hypokalemia is prevalent in patients resuscitated from out-of-hospital cardiac arrest and can contribute to polymorphic ventricular tachycardia (PMVT) by prolonging the QT interval. We present an interesting scenario of malignant ventricular arrythmia initially attributed to moderate hypokalemia that persisted after correction of potassium. Subsequent electrophysiological study showed two frequent PMVT-triggering PVCs mapped to the base of the antero-lateral papillary muscle and the para-Hisian region of the right side of the interventricular septum. The patient underwent catheter ablation to prevent further recurrences and dual chamber ICD implantation for secondary prevention.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias.

Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.

Estimating the incidence of atrial fibrillation in single-chamber implantable cardioverter defibrillator patients.

BACKGROUND: Atrial arrhythmias are associated with major adverse cardiovascular events. Recent reports among implantable cardioverter defibrillator (ICD) patients have demonstrated a high prevalence of atrial fibrillation (AF), predominantly in dual-chamber recipients. AF incidence among patients with single-chamber systems (approximately 50% of all ICDs) is currently unknown. The objective was to estimate the prevalence of new-onset AF among single-chamber ICD patients by observing the rates of new atrial tachycardia (AT)/AF among a propensity scoring matched cohort of dual-chamber ICD patients from the PainFree SmartShock technology study, to better inform screening initiatives. METHODS: Among 2770 patients enrolled, 1862 single-chamber, dual-chamber, and cardiac resynchronization therapy subjects with no prior history of atrial tachyarrhythmias were included. Daily AT/AF burden was estimated using a propensity score weighted model against data from dual-chamber ICDs. RESULTS: Over 22 ± 9 months of follow-up, the estimated incidence of AT/AF-lasting at least 6 min, 6 h, and 24 h per day -in the single-chamber cohort was 22.0, 9.8, and 6.3%, whereas among dual-chamber patients, the prevalence was 26.6, 13.1, and 7.1%, respectively. Initiation of oral anticoagulation was estimated to occur in 9.8% of the propensity matched single-chamber cohort, which was higher than the actual observed rate of 6.0%. Stroke and transient ischemic attack occurred at low rates in all device subgroups. CONCLUSIONS: Atrial arrhythmias occur frequently, and significant underutilization of anticoagulation is suggested in single-chamber ICD recipients. Routine screening for AF should be considered among single-chamber ICD recipients.

Coronary Sinus Lead Extraction.

Expanded indications for cardiac resynchronization therapy and the increasing incidence of cardiac implantable electronic device infection have led to an increased need for coronary sinus (CS) lead extraction. The CS presents unique anatomical obstacles to successful lead extraction. Training and facility requirements for CS lead extraction should mirror those for other leads. Here we review the indications, technique, and results of CS lead extraction. Published success rates and complications are similar to those reported for other leads, although multiple techniques may be required. Re-implantation options may be limited, which should be incorporated into pre-procedural decision making.

Arrhythmias in Patients with Pulmonary Hypertension and Right Ventricular Failure: Importance of Rhythm Control Strategies.

Arrhythmias frequently complicate the course of advanced pulmonary hypertension, often leading to hemodynamic compromise, functional impairment, and mortality. Given the importance of right atrial function in this physiology, the restoration and maintenance of sinus rhythm are of critical importance. In this review, we outline the pathophysiology of arrhythmias and their impact on right heart performance; describe considerations for antiarrhythmic drug selection, anesthetic and periprocedural management; and discuss the results of catheter ablation techniques in this complex and challenging patient population.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines.

AIM: The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Safety of repetitive nerve stimulation in patients with cardiac implantable electronic devices.

INTRODUCTION: Pacemakers and implantable cardioverter-defibrillators (ICDs) are vulnerable to inappropriate sensing of electromagnetic interference (EMI), such as from nerve conduction studies. We conducted a prospective study to assess the safety of repetitive nerve stimulation (RNS). METHODS: Fourteen patients undergoing insertion of 10 ICDs and 4 pacemakers under general anesthesia received RNS of the median, axillary, and spinal accessory nerves at 2 HZ and 50 HZ. We recorded detection of EMI and whether or not this resulted in an arrhythmia diagnosis or change in pacing output. RESULTS: EMI was visible in 2 ICDs, without spurious tachyarrhythmia detection. EMI was observed in 3 of the 4 pacemakers, which led to pacing inhibition and a pause in 2, both of which were programmed to a unipolar sensing configuration. CONCLUSIONS: RNS is safe in patients with ICDs. In pacemaker patients, RNS appears safe during bipolar sensing, but caution is recommended in pacemaker patients with unipolar sensing.

Real-time guidewire localization using impedance-based electroanatomic mapping: experimental results and clinical validation during cryoballoon ablation of atrial fibrillation.

AIMS: Cryoballoon ablation is an emerging therapy for atrial fibrillation (AF). However, the Arctic Front cryoballoon (Medtronic) cannot be localized on current electroanatomic mapping (EAM) systems. We describe a technique to visualize guidewires in an impedance-based EAM system. METHODS AND RESULTS: A novel technique for real-time guidewire localization in an EAM (Ensite Velocity, St Jude Medical) was prospectively evaluated among patients referred for cryoballoon AF ablation. The guidewire was visualized as an 'orb' on the EAM and localization in each of the pulmonary veins (PVs) compared with orthogonal fluoroscopy, contrast venography, and intra-cardiac echocardiography. Application of the technique in 21 consecutive patients [median age 58 (interquartile range 21); 71.4% male; 85.7% paroxysmal AF] demonstrated agreement with respect to guidewire localization in 82 of 82 (100%) PVs. Discrimination of guidewire position in the left atrial appendage from the left PVs was also demonstrated. When compared with 21 consecutive cryoballoon procedures over the same time period in which the technique was not used, fluoroscopy time was reduced [median 53.2 (25.9) vs. 72.3 (47.6) min, P = 0.008], and a trend towards reduced radiation exposure [median 372 (656.0) vs. 581 (849.9) mGy, P = 0.08] was noted, without effect on acute procedural or mid-term endpoints. Ex vivo assessment of the technique in a saline bath left atrial model demonstrated that the 'orb' localizes to the centroid of the exposed portion of the guidewire. CONCLUSION: This simple, novel technique provides real-time, accurate guidewire localization to enable guidewire and catheter navigation during cryoballoon AF ablation.

Defining the distance between the His bundle and first septal perforator: implications for left bundle branch pacing.

BACKGROUND: Left bundle branch pacing (LBBP) is a developing method of native conduction pacing, but cases of injury to the septal perforator arteries during implantation have been reported. Knowing the distance between the His bundle and the first septal perforator artery can help operators implant LBBP leads more safely. METHODS: Using previously performed coronary CT angiography (CCTA) studies, the distance between the His bundle and the first septal perforator was measured. RESULTS: A total of 50 CCTA studies were included. The mean distance from the His bundle to the first septal perforator (His-SP) along the line connecting the His bundle to the RV apex (His-RV apex) was 27.17 ± 7.7 mm with a range of 13.0 to 44.7 mm. The distance was greater than 2.0 cm in 84% of patients. To standardize this distance among patients with varying cardiac structures, the ratio between the His-SP distance and the His-RV Apex distance was also measured. The mean His-SP:His-RV Apex was 0.302 and the median was 0.298. Eighty-six percent of patients had a ratio of greater than 0.20. CONCLUSION: Using this information, operators can aim to implant LBBP leads within 2.0 cm of the His bundle or 20% of the distance between the His bundle and the RV apex with minimal risk of causing vascular injury.

Performance of alert transmissions from cardiac implantable electronic devices to the CareLink network: A retrospective analysis.

Background: Remote monitoring of cardiac implantable electric devices improves patient outcomes and experiences. Alert-based systems notify physicians of clinical or device issues in near real-time, but their effectiveness is contingent upon device connectivity. Objective: To assess patient connectivity by analyzing alert transmission times from patient transceivers to the CareLink network. Methods: Alert transmissions were retrospectively gathered from a query of the United States de-identified Medtronic CareLink database. Alert transmission time was defined as the duration from alert occurrence to arrival at the CareLink network and was analyzed by device type, alert event, and alert type. Using data from previous studies, we computed the benefit of daily connectivity checks. Results: The mean alert transmission time was 14.8 hours (median = 6 hours), with 90.9% of alert transmissions received within 24 hours. Implantable pulse generators (17.0 ± 40.2 hours) and cardiac resynchronization therapy-pacemakers (17.2 ± 42.5 hours) had longer alert transmission times than implantable cardioverter-defibrillators (13.7 ± 29.5 hours) and cardiac resynchronization therapy-defibrillators (13.5 ± 30.2 hours), but the median time was 6 hours for all 4 device types. There were differences in alert times between specific alert events. Based on our data and previous studies, daily connectivity checks could improve daily alert transmission success by 8.5% but would require up to nearly 800 additional hours of staff time on any given day. Conclusion: Alert transmission performance from Medtronic devices was satisfactory, with some delays likely underscored by patient connectivity issues. Daily connectivity checks could provide some improvement in transmission success at the expense of increased clinic burden.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure.

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

2023 HRS/APHRS/LAHRS guideline on cardiac physiologic pacing for the avoidance and mitigation of heart failure.

Cardiac physiologic pacing (CPP), encompassing cardiac resynchronization therapy (CRT) and conduction system pacing (CSP), has emerged as a pacing therapy strategy that may mitigate or prevent the development of heart failure (HF) in patients with ventricular dyssynchrony or pacing-induced cardiomyopathy. This clinical practice guideline is intended to provide guidance on indications for CRT for HF therapy and CPP in patients with pacemaker indications or HF, patient selection, pre-procedure evaluation and preparation, implant procedure management, follow-up evaluation and optimization of CPP response, and use in pediatric populations. Gaps in knowledge, pointing to new directions for future research, are also identified.

Magnetic resonance imaging conditional pacemakers: rationale, development and future directions.

Pacemakers and other cardiac implantable electronic devices (CIEDs) have long been considered an absolute contraindication to magnetic resonance imaging (MRI), a crucial and growing imaging modality. In the last 20 years, protocols have been developed to allow MR scanning of CIED patients with a low complication rate. However, this practice has remained limited to a relatively small number of centers, and many pacemaker patients continue to be denied access to clinically indicated imaging. The introduction of MRI conditional pacemakers has provided a widely applicable and satisfactory solution to this problem. Here, the interactions of pacemakers with the MR environment, the results of MR scanning in patients with conventional CIEDs, the development and clinical experience with MRI conditional devices, and future directions are reviewed.

Simultaneous Leadless Pacemaker and Subcutaneous ICD Implantation With Intraoperative Screening: Workflow in Two Patients.

A communicating subcutaneous implantable cardioverter-defibrillator (ICD) and leadless pacemaker system is being developed for patients who require both pacing and ICD therapy. It is important to ensure that the paced morphology from the leadless pacemaker will be sensed appropriately by the subcutaneous ICD. We present 2 cases illustrating our approach and workflow. (Level of Difficulty: Intermediate.).