A New Player in the Game: Can Exergame Be of Support in the Management of Atrial Fibrillation?

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, currently affecting 2-3% of the world's population. Traditional exercise and physical activity interventions have been successfully implemented in the management of AF, with the aim of improving patients' quality of life and their exercise capacity, as well as reducing their mortality rate. Currently, new technology-mediated approaches to exercise, defined as exergame, have been shown to be successful in the delivery of exercise home-based interventions in patients with cardiovascular diseases. However, data on the effects of exergame on AF are not yet available. In this paper, we summarise the current literature on the role of traditional exercise in AF and how it affects the pathophysiology of this condition. We also review the current literature on exergame and its employment in cardiac rehabilitation and suggest its potential role in the management of AF patients. A review of the evidence suggests that traditional exercise (of light-to-moderate intensity) is beneficial in patients with AF. Additionally, exergame seems to be a promising approach for delivering exercise interventions in patients with cardiovascular diseases. Exergame may be a promising tool to improve the quality of life and exercise capacity in patients with AF, with the additional advantage of being remotely delivered, and the potential to increase patients' engagement. Proper guidelines are required to prescribe exergame interventions, considering the principles of traditional exercise prescription and applying them to this new e-health approach. Further studies are needed to validate the use of exergame in patients with AF.

Impact of cryoballoon application abortion due to phrenic nerve injury on reconnection rates: a YETI subgroup analysis.

AIMS: Cryoballoon (CB)-based pulmonary vein isolation (PVI) is an effective treatment for atrial fibrillation (AF). The most frequent complication during CB-based PVI is right-sided phrenic nerve injury (PNI) which is leading to premature abortion of the freeze cycle. Here, we analysed reconnection rates after CB-based PVI and PNI in a large-scale population during repeat procedures. METHODS AND RESULTS: In the YETI registry, a total of 17 356 patients underwent CB-based PVI in 33 centres, and 731 (4.2%) patients experienced PNI. A total of 111/731 (15.2%) patients received a repeat procedure for treatment of recurrent AF. In 94/111 (84.7%) patients data on repeat procedures were available. A total of 89/94 (94.7%) index pulmonary veins (PVs) have been isolated during the initial PVI. During repeat procedures, 22 (24.7%) of initially isolated index PVs showed reconnection. The use of a double stop technique did non influence the PV reconnection rate (P = 0.464). The time to PNI was 140.5 ± 45.1 s in patients with persistent PVI and 133.5 ± 53.8 s in patients with reconnection (P = 0.559). No differences were noted between the two populations in terms of CB temperature at the time of PNI (P = 0.362). The only parameter associated with isolation durability was CB temperature after 30 s of freezing. The PV reconnection did not influence the time to AF recurrence. CONCLUSION: In patients with cryoballon application abortion due to PNI, a high rate of persistent PVI rate was found at repeat procedures. Our data may help to identify the optimal dosing protocol in CB-based PVI procedures. CLINICAL TRIAL REGISTRATION: https://clinicaltrials.gov/ct2/show/NCT03645577?term=YETI&cntry=DE&draw=2&rank=1 ClinicalTrials.gov Identifier: NCT03645577.

Peripheral microcirculation alteration as cause of posterosuperior rotator cuff tear: the possible indirect contribution of nailfold capillaroscopy.

BACKGROUND: Most of the recent literature regarding rotator cuff tear etiology identifies in peripheral microcirculation disorders the probable main cause of tissue degeneration, and consequently of tendon rupture. Nailfold capillaroscopy is a practical and inexpensive diagnostic technique used to evaluate the health status of peripheral microcirculation, and recently, its use has found other indications in addition to that of diagnosing connective tissue diseases and Raynaud phenomenon. We verified the possible indirect contribution of nailfold capillaroscopy in the identification of peripheral microcirculation disturbances in a group of patients with rotator cuff tear and whether these possible alterations could be related to rotator cuff tear size. MATERIALS AND METHODS: A case-control study was performed. One hundred patients (56 male, 44 female; mean age ± standard deviation [SD]: 60.46 ± 5.46 years) with different-sized posterosuperior cuff tears and 100 healthy controls (38 male, 62 female; mean age ± SD: 60.40 ± 6.34 years) were submitted to capillaroscopic examination. The following parameters were examined: capillary morphology and density, avascular areas, visibility of the subpapillary venous plexus, enlarged and giant capillaries, ectasias and microaneurysms, neoangiogenesis, hemosiderin deposits, pericapillary edema, and capillary blood flow. Severe exclusion criteria were applied. Statistical analysis was performed. RESULTS: Visibility of subpapillary venous plexus (P < .001), pericapillary edema (P < .001), capillary blood flow (P < .001), ectasias and microaneurysms (P < .001), and neoangiogenesis (P = .04) were significantly associated with presence of a rotator cuff tear. CONCLUSIONS: Our results support the hypothesis that microcirculation disorder has a relevant role in the genesis of cuff degeneration and, consequently, of tendon rupture. However, these alterations do not seem to be related to rotator cuff tear size.

Three Years of COVID-19 on Orthopaedic Trauma; Are We Going Back to Normality?

Background and Objective: On March 2020, our country became a protected area due to the COVID-19 pandemic. The consequences of COVID-19 on trauma surgery were great. We aimed to evaluate the activity of the Trauma Centre of a highly populated suburban area over 30 days starting from the first day of restrictions, to compare it with the same period of 2019 and 2022 and to evaluate whether a progressive return to normality has taken place. Materials and Methods: All patients older than 18 years managed in our Trauma Unit between 8 March 2020 and 8 April 2020 (the first COVID-19 period) were compared to the same period of 2019 (a COVID-19 free period) and 2022 (the second COVID-19 period). Clinical records were examined. Five categories of diagnoses and six mechanisms of injury were distinguished. Results: There were 1351 patients [M:719-F:632; mean age (SD):49.9 (18.7)], 451 [M:228-F:223; mean age (SD):55.9 (18.4)] and 894 [M:423-F:471;mean age (SD):54.1 (16.7)] in the COVID-19 free and in the first and second COVID-19 periods, respectively (p < 0.05). In 2020, the most significant decrease was registered for sprains/subluxations (80%); contusions decrease by 77% while fractures decrease only by 37%. The lowest reduction was found for dislocations (26%). In 2022, dislocations decreased by only 16% and both fractures and sprains decreased by about 30% with respect to the pre-pandemic period. Patients with minor trauma (contusions) were half compared to 2019. Accidental falls remain the most frequent mechanism of injury. The incidence of proximal femur, proximal humerus and distal radius fractures remained almost unchanged during both pre-pandemic and pandemic periods. Conclusions: COVID-19 has markedly altered orthopaedic trauma. Injuries related to sports and high energy trauma/traffic accidents drastically reduced in 2020; however, we are slowly going back to normality: the same injuries increased in 2022 due to the progressive easing of restrictions. Elderly fractures related to accidental falls remained unchanged.

Add-on Therapy With Sacubitril/Valsartan and Clinical Outcomes in CRT-D Nonresponder Patients.

ABSTRACT: No data on the add-on sacubitril/valsartan (S/V) therapy among cardiac resynchronization therapy with a defibrillator (CRT-D) nonresponder patients are currently available in literature. We conducted a prospective observational study including 190 CRT-D nonresponder patients with symptomatic heart failure with reduced ejection fraction despite the optimal medical therapy from at least 1 year. The primary endpoint was the rate of additional responders (left ventricular end-systolic volume reduction >15%) at 12 months from the introduction of S/V therapy. At the end of the 12 months follow-up, 37 patients (19.5%) were deemed as "additional responders" to the combination use of CRT + S/V therapy. The only clinical predictor of additional response was a lower left ventricular ejection fraction [OR 0.881 (0.815-0.953), P = 0.002] at baseline. At 12 months follow-up, there were significant improvements in heart failure (HF) symptoms and functional status [New York Heart Association 2 (2-3) vs. 1 (1-2), P < 0.001; physical activity duration/day: 10 (8-12) vs. 13 (10-18) hours, P < 0.001]. Compared with the 12 months preceding S/V introduction, there were significant reductions in the rate of HF rehospitalization (35.5% vs. 19.5%, P < 0.001), in atrial tachycardia/atrial fibrillation burden [6.0 (5.0-8.0) % vs. 0 (0-2.0) %, P < 0.001] and in the proportions of patients experiencing ventricular arrhythmias (21.6% vs. 6.3%; P < 0.001). Our results indicate that S/V add-on therapy in CRT-D nonresponder patients is associated with 19.5% of additional responders, a reduction in HF symptoms and rehospitalizations, AF burden, and ventricular arrhythmias.

Intraprocedural PRAETORIAN score for early assessment of S-ICD implantation: A proof-of-concept study.

INTRODUCTION: The PRAETORIAN score (PS) was developed to assess the implant position and predict defibrillation success of the subcutaneous implantable cardioverter defibrillators (S-ICD). The main critique moved to the routine use of PS has been its postprocedural timing, that limits its usefulness on procedure guidance. The aim of this proof-of-concept study was to assess the feasibility of an intraprocedural use of PS. METHODS: Forty consecutive patients undergoing S-ICD implantation were enrolled. Intraprocedural PS (IP-PS) obtained with fluoroscopy before closure of the pocket and postprocedural PS (PP-PS) obtained with two-views chest X-ray were compared. Intraprocedural data and PS were compared with the historic cohorts of the involved institutions. RESULTS: When assessing IP-PS and PP-PS, a complete overall agreement was observed (100%, 1.00-κ; p < .001). When assessing a per-step agreement, a very high-degree of concordance in evaluating Step 1 of the PS was observed (95%, 0.81-κ; p < .001). A complete agreement in Step 2-3 (100%, 1.00-κ; p < .001) of the PS was reported. In comparison with our historical cohort, procedural time in the IP-PS cohort did not increase (45 [41-52] vs. 45 [39-49] min; p = .351) while the expected increase in fluoroscopy time resulted scarce (15 [10-15] s). CONCLUSION: An IP-PS can be reliably obtained using fluoroscopy guidance during S-ICD implantation, without a significant increase in procedural duration and may serve as guidance for implanting physicians, to avoid postprocedural S-ICD repositioning, leading to patient discomfort and significantly enhancing infective risks. IP-PS showed a very high agreement with the PP-PS obtained from two-views chest X-ray.

Bottom-up and top-down modulation of route selection in imitation.

The cognitive system selects the most appropriate action imitative process: a semantic process - relying on long-term memory representations for known actions, and low-level visuomotor transformations for unknown actions. These two processes work in parallel; however, how context regularities and cognitive control modulate them is unclear. In this study, process selection was triggered contextually by presenting mixed known and new actions in predictable or unpredictable lists, while a cue on the forthcoming action triggered top-down control. Known were imitated faster than the new actions in the predictable lists only. Accuracy was higher and reaction times faster in the uncued conditions, and the predictable faster than the unpredictable list in the uncued condition only. In the latter condition, contextual factors modulate process selection, as participants use statistical regularities to perform the task at best. With the cue, the cognitive system tries to control response selection, resulting in more errors and longer reaction times.

Zero-fluoroscopy approach for ablation of supraventricular tachycardia using the Ensite NavX system: a multicenter experience.

BACKGROUND: Three-dimensional electroanatomic mapping systems have demonstrated a significant reduction in radiation exposure during radiofrequency catheter ablation procedures. We aimed to investigate the safety, feasibility and efficacy of a completely zero-fluoroscopy approach for catheter ablation of supraventricular tachycardia using the Ensite NavX navigation system compared with a conventional fluoroscopy approach. METHODS: A multicenter prospective non-randomized registry study was performed in seven centers from January 2013 to February 2018. Consecutive patients referred for catheter ablation of supraventricular tachycardia were assigned either to a completely zero-fluoroscopic approach (ZF) or conventional fluoroscopy approach (CF) according to the operator's preference. Patients with atrial tachycardia were excluded. RESULTS: Totally, 1020 patients were enrolled in ZF group; 2040 patients ablated by CF approach were selected for controls. There was no significant difference between the zero-fluoroscopy group and conventional fluoroscopy group as to procedure time (60.3 ± 20.3 vs. 59.7 ± 22.6 min, P = 0.90), immediate success rate of procedure (98.8% vs. 99.2%, P = 0.22), arrhythmia recurrence (0.4% vs. 0.5%, P = 0.85), total success rate of procedure (98.4% vs. 98.8%, P = 0.39) or complications (1.1% vs. 1.5%, P = 0.41). Compared with the conventional fluoroscopy approach, the zero-fluoroscopy approach provided similar outcomes without compromising the safety or efficacy of the procedure. CONCLUSION: The completely zero-fluoroscopy approach demonstrated safety and efficacy comparable to a conventional fluoroscopy approach for catheter ablation of supraventricular tachycardia, and mitigated radiation exposure to both patients and operators. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT03042078; first registered February 3, 2017; retrospectively registered.

The impact of COVID-19 on shoulder and elbow trauma: an Italian survey.

BACKGROUND: Because of the rapid spread of COVID-19, on March 8, 2020 Italy became a "protected area": people were told not to leave their homes unless it was essential. The aim of this study was to evaluate the activity of our trauma center, relative to shoulder and elbow, in the 30 days starting from March 8, 2020, the first day of restrictions in Italy, and to compare it with the same days of 2019 to weigh the impact of COVID-19 on shoulder and elbow trauma. MATERIALS AND METHODS: Patients managed in our trauma center between March 8, 2020, and April 8, 2020 (COVID period), for shoulder and elbow trauma were retrospectively included and compared to patients admitted in the same period of 2019 (no-COVID period). Clinical records of all participants were examined to obtain information regarding age, sex, mechanism of injury, and diagnosis. RESULTS: During the no-COVID period, 133 patients were admitted for a shoulder or elbow trauma; in the COVID period, there were 47 patients (65% less first aid). In the no-COVID and COVID period, patients with shoulder contusion totaled 60 (14.78% of all; male [M]: 34; female [F]: 26; mean age 51.8 years, range 18-88) and 11 (12.09% of all contusions; M: 7, F: 4; mean age 43 years, range 24-60), respectively. In the no-COVID period, 27 fractures (9.34% of all fractures) involved the shoulder, whereas 18 fractures (8.69%) were registered in the COVID period. In the no-COVID period, 14 elbow fractures were treated (4.8% of all fractures), compared with 4 in the COVID period. In the no-COVID and COVID periods, 6 patients (M: 5, F: 1; mean age 42 years, range 21-64) and 2 patients (M: 1, F: 1; mean age 29.5 years, range 24-35) reported having a feeling of momentary post-traumatic shoulder instability, and 0 and 1 patients (M: 1, F: 0; age 56 years), respectively, reported similar symptoms at the elbow. Finally, first or recurrent dislocations in the no-COVID period were 10, and in the COVID period, 7; elbow dislocations in the no-COVID period were 2, and in the COVID period, there were 3. CONCLUSIONS: During the COVID period, we provided a reduced number of health services, especially for patients with low-energy trauma and for those who underwent sports and traffic accidents. However, during the COVID period, elderly subjects remain exposed to shoulder and elbow trauma due to low-energy (domestic) falls. The subsequent hospitalization of these patients has contributed to making it more difficult to manage the hospital wards that are partly occupied by COVID-19 patients.

Stroke, Dementia, and Atrial Fibrillation: From Pathophysiologic Association to Pharmacological Implications.

The impact of stroke and dementia on disability and death is a major contemporary health issue [...].

Anticoagulation after catheter ablation of atrial fibrillation: An unnecessary evil? A systematic review and meta-analysis.

BACKGROUND: Anticoagulation in patients with atrial fibrillation (AF) is currently based on clinical parameters (CHA2 DS 2 -VASc score) that have been shown to predict cerebrovascular events (CVE). Controversy exists as to whether CVE risk persists unmodified after successful catheter ablation, as observational studies suggest a lower risk of CVE. Current guidelines recommend continued oral anticoagulation (OAC) based on the CHA 2 DS 2 -VASc score risk profile. METHODS: We conducted a systematic literature review of all studies published up to July 31, 2018, that reported CVE after catheter ablation of AF and compared patients on or off OAC. Random-effects models were used to demonstrate the risk of CVE and major bleeding in on-OAC vs off-OAC patients. This analysis was further stratified by CHADS2 and CHA 2 DS 2 -VASc score. RESULTS: We retained 16 studies, 10 prospective cohort and 6 retrospective cohort, that met inclusion criteria, and which enrolled 25 177 patients: 13 166 off-OAC and 12 011 on-OAC. No significant difference in the incidence of CVE emerged between on-OAC and off-OAC patients after AF ablation (risk ratio, 0.66; confidence interval [CI], 0.38, 1.15). Similar results were found after stratification by CHADS2 and CHA 2 DS 2 -VASc score. Off-OAC patients suffered significantly less bleeding than those on OAC (RR, 0.17; CI, 0.09, 0.34). Of note, the percentage of patients with AF recurrence impacts the treatment effect in the two groups ( P = 0.001). CONCLUSIONS: In this metanalysis, the risk-benefit ratio favored the suspension of OAT after successful AF ablation even in patients at moderate-high risk. Whether the reported results can be extended also to non-vitamin K antagonist oral anticoagulants warrants further investigations.

Anti-arrhythmic therapy in patients with non-ischemic cardiomyopathy.

Implantable cardiac defibrillators (ICD) are the foundation of therapy for the prevention of sudden cardiac death. While ICDs prevent SCD, they do not prevent the occurrence of ventricular arrhythmias which are usually symptomatic. Though catheter ablation has been successful in substrate modification of ventricular tachycardia in patients with ischemic cardiomyopathy, there is much less evidence to support its use in non-ischemic cardiomyopathy. Therefore, anti-arrhythmic drugs (AADs) are an essential adjunctive therapy for secondary prevention of ventricular arrhythmias in patients with non-ischemic cardiomyopathy. In patients with hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM), the prevalence of ventricular arrhythmias correlates with the volume of scar as characterized by late gadolinium enhancement. Beta-blockers forms the cornerstone of treatment to prevent ventricular arrhythmias in both HCM and DCM. Disopyramide is an important therapeutic option in HCM as it provides both negative inotropy which reduces obstruction as well as lass I anti-arrhythmic action. In DCM sotalol, through is combined beta-blocking and class III AD effects, significantly reduces the burden of ventricular arrhythmias. Though amiodarone is efficacious in the prevention of ventricular arrhythmias in both HCM and DCM, its use is limited by its side-effects profile. Evidence for AAD therapy for arrhythmogenic right ventricular dysplasia (ARVD) is limited by its low prevalence and lack of studies. ICDs have been shown to reduce SCD regardless of whether patients are receiving AAD therapy.

Anti-arrhythmic drug therapy in implantable cardioverter-defibrillator recipients.

Implantable cardioverter-defibrillators (ICDs) have revolutionized the primary and secondary prevention of patients with ventricular arrhythmias. However, the adverse effects of appropriate or inappropriate shocks may require the adjunctive use of anti-arrhythmic drugs (AADs). Beta blockers are the cornerstone of pharmacological primary and secondary prevention of ventricular arrhythmias. In addition to their established efficacy at reducing the incidence of ventricular arrhythmias, beta-blockers are safe with few side effects. Amiodarone is superior to beta blockers and sotalol for the prevention of ventricular arrhythmia recurrence. However, long-term amiodarone use is associated with significant side effects that limit its utility. Sotalol and mexiletine are the main alternatives to amiodarone with a better side effect profile though they are less efficacious at preventing ventricular arrhythmia recurrence. Dofetilide, azimilide and ranolazine are emerging as therapeutic options for secondary prevention; more studies are needed to assess efficacy and safety in comparison to currently used agents. Beta blockers and amiodarone are the mainstay of therapy in patients experiencing electrical storm; their use reduces the frequency of ventricular arrhythmias and ICD intervention as well as affording time until catheter ablation can be considered.

Efficacy and Safety of Cryoballoon Ablation in Patients With Heart Failure and Reduced Left Ventricular Ejection Fraction　- A Multicenter Study.

BACKGROUND: Second-generation cryoballoon (CB2)-based pulmonary vein isolation (PVI) has demonstrated encouraging results in the treatment of atrial fibrillation (AF). This study sought to assess data on the safety, efficacy and clinical success of CB2-based PVI in patients with heart failure (HF) and reduced ejection fraction (HFrEF).Methods and Results:CB2-based PVI was performed in 551 consecutive patients in 3 highly experienced EP centers. Patients with HF and LVEF ≤40% were included (HFrEF group, n=50/551, 9.1%). Data were compared with propensity score-matched patients without HF and preserved left ventricular EF (LVEF) (n=50, control group). The median LVEF was HFrEF: 37% (35, 40) and control: 55% (55, 55), P<0.0001. Major periprocedural complications were registered in 4/50 (8%, HFrEF group) and 3/50 (6%, control group), P=0.695. The 12-month freedom from AF recurrence was 73.1% (95% confidence interval (CI): 61-88, HFrEF group) and 72.6% (95% CI: 61-87, control group), P=0.25. NYHA class decreased from 2.4±0.8 (baseline) to 1.7±0.8 at 12-month follow-up (P<0.0001). LVEF improved from a median of 37% (35, 40) prior to ablation to a median of 55% (40, 55), P<0.0001. CONCLUSIONS: CB2-based PVI in patients with HFrEF appeared to be safe, was associated with comparable periprocedural complications and showed promising clinical success rates equal to those for patients with preserved LVEF. NYHA class and LVEF significantly improved at 12-month follow-up.

Catheter ablation for atrial fibrillation in heart failure with reduced ejection fraction: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Previous randomized controlled trials (RCT)s showed similar outcomes in patients with atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) treated with anti-arrhythmic drugs (AAD) compared to rate control therapy. We sought to evaluate whether catheter ablation is superior to medical therapy in patients with AF and HFrEF. METHODS: We searched electronic databases for all RCTs that compared catheter ablation and medical therapy (with or without use of AAD). We used random-effects models to summarize the studies. The primary end-point was all-cause mortality. Secondary outcomes included heart failure-related hospitalizations and change in left ventricular ejection fraction (LVEF). RESULTS: We retrieved and summarized 7 randomized controlled trials, enrolling 856 patients (429 in the catheter ablation arm and 427 in the medical therapy arm). Compared with medical therapy (including use of AAD), AF catheter ablation was associated with a significant reduction in mortality (risk ratio 0.50; 95% confidence interval [CI]: 0.34 to 0.74; P = 0.0005) and heart failure-related hospitalizations (risk ratio 0.56; 95% CI: 0.44 to 0.71; P < 0.0001). Furthermore, catheter ablation led to significant improvements in LVEF (weighted mean difference, 7.48; 95% CI: 3.71 to 11.26; P < 0.0001). CONCLUSIONS: Compared to medical therapy, including use of AAD, catheter ablation for AF was associated with a significant reduction in mortality and heart failure-related hospitalizations as well as an improvement in LVEF in patients with HFrEF. Larger trials are needed to confirm whether rhythm control with ablation is superior to rate control in patients with AF and heart failure.

Predicting response to cardiac resynchronization therapy: Use of strict left bundle branch block criteria.

BACKGROUND: Cardiac resynchronization therapy (CRT) reduces morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). CRT efficacy is greater in left bundle branch block (LBBB). This study aimed to determine if strict LBBB criteria predict an improved QRS duration and left ventricular ejection fraction (LVEF) response after CRT. METHODS: HFrEF patients who received a CRT device at a single quaternary center were included. Patients were divided into three groups based on baseline QRS morphology. Group 1 consisted of patients with strict LBBB. Group 2 had conventional LBBB, and group 3 had non-LBBB morphology. Outcomes assessed included change in QRS duration after CRT, change in LVEF, and all-cause mortality. RESULTS: In 231 patients, 56% of patients were in group 1, 29% were in group 2, and 15% were in group 3. Patients with strict LBBB had a significant reduction in QRS duration (-20.9 ± 12.4 ms) compared to conventional LBBB (6.7 ± 19.4 ms; P < 0.0001) and non-LBBB (3.9 ± 29.3 ms; P < 0.0001). Patients with strict LBBB had a significant increase in LVEF (19.5 ± 10.2) compared to conventional LBBB (5.3 ± 12.6; P < 0.0001) and non-LBBB (-1.3 ± 10.9; P < 0.0001). There was moderate negative correlation between changes in QRS duration and LVEF (correlation coefficient = -0.63, P < 0.0001). Strict LBBB criteria were associated with a significant reduction in mortality compared to conventional LBBB (odds ratio 0.49, 95% confidence interval 0.24 to 0.99; P = 0.046). CONCLUSIONS: Strict LBBB predicted a reduction in QRS duration and an increase in LVEF compared to conventional LBBB and non-LBBB morphology in patients with HFrEF who received CRT.

Subclinical Atrial Fibrillation and Risk of Stroke: Past, Present and Future.

Subclinical atrial fibrillation (SCAF) describes asymptomatic episodes of atrial fibrillation (AF) that are detected by cardiac implantable electronic devices (CIED). The increased utilization of CIEDs renders our understanding of SCAF important to clinical practice. Furthermore, 20% of AF present initially as a stroke event and prolonged cardiac monitoring of stroke patients is likely to uncover a significant prevalence of SCAF. New evidence has shown that implanting cardiac monitors into patients with no history of atrial fibrillation but with risk factors for stroke will yield an incidence of SCAF approaching 30-40% at around three years. Atrial high rate episodes lasting longer than five minutes are likely to represent SCAF. SCAF has been associated with an increased risk of stroke that is particularly significant when episodes of SCAF are greater than 23 h in duration. Longer episodes of SCAF are incrementally more likely to progress to episodes of SCAF >23 h as time progresses. While only around 30-40% of SCAF events are temporally related to stroke events, the presence of SCAF likely represents an important risk marker for stroke. Ongoing trials of anticoagulation in patients with SCAF durations less than 24 h will inform clinical practice and are highly anticipated. Further studies are needed to clarify the association between SCAF and clinical outcomes as well as the factors that modify this association.

The Role of Cardiovascular and Metabolic Comorbidities in the Link between Atrial Fibrillation and Cognitive Impairment: An Appraisal of Current Scientific Evidence.

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice with implications on long-term outcomes. Metabolic disorders including diabetes mellitus and obesity are independent predictors of atrial fibrillation and present therapeutic targets to reduce both the incidence and duration burden of atrial fibrillation. The presence of pericardial fat in direct contact with cardiac structures, as well the subsequent release of proinflammatory cytokines, may play an important role in this connection. Atrial fibrillation is an independent predictor of cognitive impairment and dementia. While clinical stroke is a major contributor, other factors such as cerebral hypoperfusion and microbleeds play important roles. New evidence suggests that atrial fibrillation and cognitive impairment may be downstream events of atrial cardiomyopathy, which may be caused by several factors including metabolic syndrome, obesity, and obstructive sleep apnea. The mechanisms linking these comorbidities to cognitive impairment are not yet fully elucidated. A clearer understanding of the association of AF with dementia and cognitive impairment is imperative. Future studies should focus on the predictors of cognitive impairment among those with AF and aim to understand the potential mechanisms underlying these associations. This would inform strategies for the management of AF aiming to prevent continued cognitive impairment.

Targeting nonpulmonary vein triggers during atrial fibrillation ablation: is the game worth the candle?

PURPOSE OF REVIEW: Triggers for atrial fibrillation are found outside the pulmonary veins in 12-20% of cases. The role of addressing these triggers during catheter ablations has not been well defined. Therefore, the aim of this review is to summarize the effect of ablation of nonpulmonary vein triggers in addition to pulmonary vein isolation across the spectrum of atrial fibrillation in patients receiving catheter ablation. RECENT FINDINGS: In paroxysmal atrial fibrillation, an inducible nonpulmonary vein trigger is an independent predictor of recurrence. These triggers are inducible by adenosine and isoproterenol infusion. Nonpulmonary vein triggers cause a significant proportion of atrial fibrillation recurrence seen during repeat procedure and addressing them decreases such recurrence. Targeting inducible nonpulmonary vein triggers also decreases recurrence in persistent atrial fibrillation and was associated with a 25-30% relative reduction in arrhythmia recurrence compared with pulmonary vein isolation alone. In persistent atrial fibrillation, the addition of left atrial appendage isolation was associated with 55% reduction in arrhythmia recurrence. There was no benefit to the empirical ablation of the superior vena cava and the addition of extensive linear lines. There was insufficient evidence to assess the effects of empirical ablation of the coronary sinus, crista terminalis, left atrial posterior wall and the vein of Marshall on arrhythmia recurrence. SUMMARY: Evidence suggests that the presence of an inducible nonpulmonary vein trigger is a strong predictor of arrhythmia recurrence. Efforts to detect and ablate nonpulmonary vein triggers are warranted. Further studies are required to fully identify the role nonpulmonary vein trigger ablation.