Emergency out-of-hours catheter ablation for ventricular arrhythmia storm: a UK and Australian experience.

AIMS: There are limited data on emergency catheter ablation (CA) for ventricular arrhythmia (VA) storm. We describe the feasibility and safety of performing emergency CA in an out-of-hours setting for VA storm refractory to medical therapy at 2 tertiary hospitals. METHODS AND RESULTS: Twenty-five consecutive patients underwent out-of-hours (5pm-8am [weekday] or Friday 5pm-Monday 8am [weekend]) CA for VA storm refractory to anti-arrhythmic drugs and sedation. Baseline and procedural characteristics along with outcomes were compared to 91 consecutive patients undergoing weekday daytime-hours (8am-5pm) CA for VA storm. More patients undergoing out-of-hours CA had a left ventricular ejection fraction ≤35% (68% vs. 42%, P = 0.022), chronic kidney disease (60% vs. 20%, P < 0.001), and presented following a resuscitated out-of-hospital cardiac arrest (56% vs. 5%, P < 0.001), compared to the daytime-hours group. During median follow-up (377 [interquartile range 138-826] days), both groups experienced similar survival free from recurrent VA and VA storm. Survival free from cardiac transplant and/or mortality was lower in the out-of-hours group (44% vs. 81%, P = 0.007), but out-of-hours CA was not independently associated with increased cardiac transplant and/or mortality (hazard ratio 1.34, 95% confidence interval 0.61-2.96, P = 0.47). Of the 11 patients in the out-of-hours group who survived follow-up, VA-free survival was 91% and VA storm-free survival was 100% at 1-year after CA. CONCLUSION: Out-of-hours CA may occasionally be required to control VA storm and can be safe and efficacious in this scenario. During follow-up, cardiac transplant and/or mortality is common but undergoing out-of-hours CA was not predictive of this composite endpoint.

Convergent approach to persistent atrial fibrillation ablation: long-term single-centre safety and efficacy.

Background: Efforts to maintain sinus rhythm in patients with persistent atrial fibrillation (PsAF) remain challenging, with suboptimal long-term outcomes. Methods: All patients undergoing convergent PsAF ablation at our centre were retrospectively analysed. The Atricure Epi-Sense® system was used to perform surgical radiofrequency ablation of the LA posterior wall followed by endocardial ablation. Results: A total of 24 patients underwent convergent PsAF ablation, and 21 (84%) of them were male with a median age of 63. Twelve (50%) patients were obese. In total, 71% of patients had a severely dilated left atrium, and the majority (63%) had preserved left ventricular function. All were longstanding persistent. Eighteen (75%) patients had an AF duration of >2 years. There were no endocardial procedure complications. At 36 months, all patients were alive with no new stroke/transient ischaemic attack (TIA). Freedom from documented AF at 3, 6, 12, 18, 24, and 36 months was 83%, 78%, 74%, 74%, 74%, and 61%, respectively. There were no major surgical complications, with five minor complications recorded comprising minor wound infection, pericarditic pain, and hernia. Conclusions: Our data suggest that convergent AF ablation is effective with excellent immediate and long-term safety outcomes in a real-world cohort of patients with a significant duration of AF and evidence of established atrial remodelling. Convergent AF ablation appears to offer a safe and effective option for those who are unlikely to benefit from existing therapeutic strategies for maintaining sinus rhythm, and further evaluation of this exciting technique is warranted. Our cohort is unique within the published literature both in terms of length of follow-up and very low rate of adverse events.

Can C-Reactive Protein Be Used to Predict Acute Septic Arthritis in the Adult Population?

OBJECTIVES: The objective of this study was to establish whether C-reactive protein (CRP) could be used to predict native joint septic arthritis (SA) in the adult population. METHODS: All patients who underwent native joint aspiration in accident and emergency settings between April 2012 and September 2016 were identified from laboratory microbiology records. Patients were divided into three groups for analysis: patients with SA, patients with crystal arthropathy, and patients with normal or osteo/inflammatory arthritic joints. RESULTS: Fifteen patients (7.9%) were deemed to have SA, 18 patients had crystal arthropathy (9.5%), and 157 patients (82.6%) were deemed to have normal or osteo/inflammatory arthritic joints. All of the patients with CRP >200 mg/L had SA. Patients with CRP 90 to 200 mg/L had a mix of crystal arthropathy and SA, and patients with CRP <90 mg/L had either normal or osteo/inflammatory arthritic joints or crystal arthropathy. The mean CRP in patients with a normal or osteo/inflammatory arthritic joint was 25 mg/L. This was compared with 100 mg/L (P ≤ 0.001) in patients with crystal arthropathy and 308 mg/L (P ≤ 0.001) in patients with SA. CONCLUSIONS: We demonstrated CRP to be a reliable independent marker to help differentiate among SA, crystal arthropathy, and normal/arthritic joints in an adult population. No patients with CRP <90 mg/L had SA.

Signal Reconstruction of Pulmonary Vein Recordings Using a Phenomenological Mathematical Model: Application to Pulmonary Vein Isolation Therapy.

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, is commonly initiated by ectopic beats originating from a small myocardial sleeve extending over the pulmonary veins. Pulmonary vein isolation therapy attempts to isolate the pulmonary veins from the left atrium by ablating tissue, commonly by using radiofrequency ablation. During this procedure, the cardiologist records electrical activity using a lasso catheter, and the activation pattern recorded is used as a guide toward which regions to ablate. However, poor contact between electrode and tissue can lead to important regions of electrical activity not being recorded in clinic. We reproduce these signals through the use of a phenomenological model of the cardiac action potential on a cylinder, which we fit to post-AF atrial cells, and model the bipolar electrodes of the lasso catheter by an approximation of the surface potential. The resulting activation pattern is validated by direct comparison with those of clinical recordings. A potential application of the model is to reconstruct the missing electrical activity, minimizing the impact of the information loss on the clinical procedure, and we present results to demonstrate this.

Increasing age does not affect time to appropriate therapy in primary prevention ICD/CRT-D: a competing risks analysis.

Aims: To evaluate the impact of age on the clinical outcomes in a primary prevention implantable cardioverter defibrillator (ICD)/cardiac resynchronization therapy defibrillator (CRT-D) population. Methods and Results: A retrospective, multicentre analysis of patients aged 60 years and over with primary prevention ICD/CRT-D devices implanted between 1 January 2006 and 1 November 2014 was performed. Survival to follow-up with no therapy (T1), death prior to follow-up with no therapy (T2), delivery of appropriate therapy with survival to follow-up (T3), and delivery of appropriate therapy with death prior to follow-up (T4) were measured. In total, 424 patients were eligible for inclusion in the analysis, mean follow-up of 32.6 months during which time 44 patients (10.1%) received appropriate therapy. The sub-hazard ratio (SHR) for the cumulative incidence of appropriate therapy (T3) according to age at implant was 1.00 (P = 0.851; 95% CI 0.96­1.04). The SHR for cumulative incidence of death (T2) according to age at implant was 1.06 (P < 0.001; 95% CI 1.03­1.01). Age at implant, ischaemic aetiology, baseline haemoglobin, and the presence of diabetes mellitus were predictors of all-cause mortality. Conclusion: Age has no impact on the time to appropriate therapy, but risk of death prior to therapy increases by 6% for every year increment. As the ICD population ages, the proportion who die without receiving appropriate therapy increases due to competing risks. Characterizing competing risks predictive of death independent of ICD indication would focus therapy on those with potential to benefit and reduce unnecessary exposure to ICD-related morbidity.

Safety and mid-term outcome of catheter ablation of ventricular tachycardia in octogenarians.

AIMS: Radiofrequency (RF) catheter ablation (CA) is superior to standard medical therapy in controlling recurrent ventricular tachycardia (VT). The majority of procedures have been performed in a middle-aged population. The outcome of VT ablation in the elderly has not been described. METHODS AND RESULTS: We retrospectively studied the outcome and safety of CA of VT in octogenarians performed in four European centres. The population consisted of patients presenting with recurrent VT refractory to medical therapy. Patients aged over 80 years were compared with younger patients undergoing CA. Clinical characteristics, procedural data, complications, and outcomes were examined. Implantable cardioverter-defibrillator (ICD) therapy data were collected. A total of 54 consecutive octogenarian patients underwent RF CA of VT and represented the study group (42 males, age 82.8 ± 2.7 years) compared with a control group of 104 younger patients (85 males, age 66.7 ± 8.9 years). Mean follow-up was 33 ± 48 months. Implantable cardioverter-defibrillators were present in 81 and 86% of patients, respectively (P = 0.93). Left ventricular ejection fraction was 29% ± 8.2 in octogenarians vs. 34% ± 10.2 in the younger group (P < 0.01). More major complications occurred in octogenarians (18 vs. 2%, P < 0.01). During follow-up, there were more ICD shocks in the octogenarians (28 vs. 15%, P < 0.01). The Kaplan-Meier curve of survival after VT ablation confirms comparable survival rates at 1 year, but the elderly have poor survival in the mid-term. Survival in the elderly post VT ablation is comparable with that in an age-matched cohort with ICDs but no VT storm. CONCLUSION: Octogenarians undergoing CA of VT have more risk factors, higher risk of complications and ICD shocks, but demonstrate comparable short-term survival rates.

Catheter ablation of atrial fibrillation in patients with heart failure: impact of maintaining sinus rhythm on heart failure status and long-term rates of stroke and death.

AIMS: Catheter ablation of atrial fibrillation (AF) in patients with heart failure (HF) can improve left ventricular (LV) function and HF symptoms. We aimed to investigate whether long-term maintenance of sinus rhythm impacts on hard outcomes such as stroke and death. METHODS AND RESULTS: An international multicentre registry was compiled from seven centres for consecutive patients undergoing catheter ablation of AF. Long-term freedom from AF was examined in patients with and without HF. The impact of maintaining sinus rhythm on rates of stroke and death was also examined. A total of 1273 patients were included: 171 with HF and 1102 without. Median follow-up was 3.1 years (IQR 2.0-4.3). The final procedure success rate was no different for paroxysmal AF (PAF) (78.7 vs. 85.7%, P = 0.186), but significantly different for persistent AF (57.3 vs. 75.8%, P < 0.001). Multivariate analysis showed that HF independently predicted recurrent arrhythmia [hazard ratio (HR) 1.7, 95% confidence interval (CI) 1.2-2.4, P = 0.002]. New York Heart Association class decreased from 2.3 ± 0.7 at baseline to 1.5 ± 0.8 at follow-up (P < 0.001). Left ventricular ejection fraction (LVEF) increased from 34.3 ± 9.0 to 45.8 ± 12.8% (P < 0.001). Recurrent AF was strongly predictive of stroke or death in HF patients (HR 8.33, 95% CI 1.86-37.7, P = 0.001). CONCLUSION: Long-term success rates for persistent (but not paroxysmal) AF ablation are significantly lower in HF patients. Left ventricular function and HF symptoms were improved following ablation. In HF patients, recurrent arrhythmia strongly predicted stroke and death during follow-up.

Epicardial ablation of ventricular tachycardia in a patient with arrhythmogenic right ventricular dysplasia after failed conventional endocardial ablation: A case for remote navigation with functional image integration.

Arrhythmogenic right ventricular dysplasia (ARVD) is an inheritable heart muscle disease that predominantly affects the right ventricle (RV) and predisposes to ventricular arrhythmias and sudden cardiac death (SCD)1. The natural history is predominantly related to ventricular electric instability which may lead to arrhythmic SCD, mostly in young people and athletes2,3, but may progress with significant RV muscle disease and left-ventricular (LV) involvement and can result in right or biventricular heart failure4. We report on a 54-year-old male with ARVD who underwent an epicardial ventricular tachycardia (VT) ablation using remote magnetic navigation (RMN) after functional imaging from a nuclear perfusion study was fused with a 3D segmentation from computed tomography (CT) imaging.

Catheter ablation of atrial fibrillation in patients with diabetes mellitus: a systematic review and meta-analysis.

AIMS: Diabetes mellitus (DM) and atrial fibrillation (AF) share pathophysiological links, as supported by the high prevalence of AF within DM patients. Catheter ablation of AF (AFCA) is an established therapeutic option for rhythm control in drug resistant symptomatic patients. Its efficacy and safety among patients with DM is based on small populations, and long-term outcome is unknown. The present systematic review and meta-analysis aims to assess safety and long-term outcome of AFCA in DM patients, focusing on predictors of recurrence. METHODS AND RESULTS: A systematic review was conducted in MEDLINE/PubMed and Cochrane Library. Randomized controlled trials, clinical trials, and observational studies including patients with DM undergoing AFCA were screened and included if matching inclusion and exclusion criteria. Fifteen studies were included, adding up to 1464 patients. Mean follow-up was 27 (20-33) months. Overall complication rate was 3.5 (1.5-5.0)%. Efficacy in maintaining sinus rhythm at follow-up end was 66 (58-73)%. Meta-regression analysis revealed that advanced age (P < 0.001), higher body mass index (P < 0.001), and higher basal glycated haemoglobin level (P < 0.001) related to higher incidence of arrhythmic recurrences. Performing AFCA lead to a reduction of patients requiring treatment with antiarrhythmic drugs (AADs) from 55 (46-74)% at baseline to 29 (17-41)% (P < 0.001) at follow-up end. CONCLUSIONS: Catheter ablation of AF safety and efficacy in DM patients is similar to general population, especially when performed in younger patients with satisfactory glycemic control. Catheter ablation of AF reduces the amount of patients requiring AADs, an additional benefit in this population commonly exposed to adverse effects of AF pharmacological treatments.

Premature ventricular beats initiate recurrent ventricular fibrillation in early repolarization syndrome.

An early repolarization (ER) pattern on electrocardiography was historically considered a benign finding; however, this finding in the inferior and lateral leads has recently been associated with idiopathic ventricular fibrillation (VF). Here we describe a case of a 29-year-old man with an ER pattern, who experienced recurrent implantable cardioverter-defibrillator (ICD) shocks for ventricular tachycardia (VT) and VF. An ICD interrogation demonstrated how VF and VT were repeatedly initiated by closely coupled premature ventricular beats.

Vagal atrial fibrillation: What is it and should we treat it?

Vagal atrial fibrillation (AF) remains an under-recognised entity, affecting younger patients often with structurally normal hearts. Although there remains no universal definition or diagnostic criteria, in this review we describe recognised triggers and associated features, including a well-established association with athletic training. We explore potential mechanisms, including the role of the autonomic nervous system and ganglionated plexi in initiating and maintaining arrhythmia. We discuss the limited evidence base addressing the question of progression to persistent AF, and debate the merits of anti-arrhythmic treatment, as well as uncertainty regarding the risk of stroke. Differences in suggested pharmacological therapy are highlighted and as is the emerging promise of radiofrequency catheter ablation as a therapeutic option. As we recognise the emerging burden of vagal AF, we hope to explore the important similarities and differences crucial to developing our understanding of the disorder, and highlight some significant questions which remain unanswered.

Demographic and Clinical Characteristics to Predict Paroxysmal Atrial Fibrillation: Insights from an Implantable Loop Recorder Population.

BACKGROUND: There is growing interest in detecting paroxysmal atrial fibrillation (PAF) to identify patients at high risk of thromboembolic stroke. The implantable loop recorder (ILR) is emerging as a powerful new tool in the diagnosis of PAF. Widespread implantation has significant cost implications and their use must be targeted at those patients at most risk. METHODS: We retrospectively studied a population of 200 adult patients who underwent ILR implantation for the investigation of syncope or palpitations. Clinical data, baseline electrocardiogram (ECG) characteristics, and echocardiographic data were collected. All ECGs and electrograms (EGMs) were scrutinized by two blinded investigators. PAF incidence was defined as episodes lasting >30 seconds on EGMs recorded in ILR memory. RESULTS: Our ILR population consists of 200 patients, 111 (56%) male, with a mean age of 61.4 years (range 19-95). PAF was detected in 42 patients. The following factors were significant predictors of PAF by multivariate logistic regression analysis: cigarette smoking (odds ratio [OR] = 3.73, 95% confidence interval [CI] = 1.40-10.24, P = 0.009) and incomplete right bundle branch block (IRBBB; OR = 9.04, 95% CI = 2.51-34.64, P = 0.00088). Significant differences included incidence of IRBBB (P = 0.012), cigarette smoking (P = 0.026), hypercholesterolemia (P = 0.015), age (P = 0.002), estimated glomerular filtration rate (P = 0.031), left atrial volume (P = 0.019), and PR interval (P = 0.031). The PAF group had significantly higher CHA2 DS2 -VASc scores (P = 0.01). CONCLUSIONS: Our study reports predictive factors for PAF in an ILR population. We suggest that cigarette smoking and IRBBB are independently associated with paroxysmal AF in patients presenting with palpitations or syncope.

Clinical Predictors of Pacemaker Implantation in Patients with Syncope Receiving Implantable Loop Recorder with or without ECG Conduction Abnormalities.

BACKGROUND: Implantable loop recorders (ILR) allow prolonged cardiac rhythm monitoring and improved diagnostic yield in syncope patients. Predictive factors for pacemaker (PM) implantation in the ILR population with unexplained syncope have not been adequately investigated. In this single center, retrospective, observational study we investigated factors that predict PM implantation in this population. METHODS: We retrospectively analyzed our ILR database of patients aged over 18 years who underwent ILR implantation for unexplained syncope between January 2009 and June 2013. Patient case notes were examined for demographics, history, electrocardiogram (ECG) abnormalities, investigations, and events during follow-up. The primary end-point was the detection of a symptomatic or asymptomatic bradycardia requiring PM implantation. RESULTS: During a period of 4.5 years, 200 patients were implanted with ILR for unexplained syncope, of who n = 33 (16.5%) had clinically significant bradycardia requiring PM implantation. After multivariable analysis, history of injury secondary to syncope was found to be the strongest independent predictor for PM implantation (odds ratio [OR]:9.1; P < 0.001; 95% confidence interval [CI]: (3.26-26.81). Other significant predictors included female sex, PR interval > 200msec, and age >75 years. In patients without conduction abnormalities on the ECG, history of injury secondary to syncope was found to be the strongest independent predictor for PM implantation (OR: 8.16; P = 0.00027; 95% [CI]: (2.67-26.27). CONCLUSIONS: A history of injury secondary to syncope and female sex were independent predictive factors for bradycardia necessitating PM implantation in patients receiving an ILR for syncope with or without ECG conduction abnormalities.

The use of hip radiographs in primary care: the inter-observer agreement of reporting native hip pathology.

INTRODUCTION: Plain radiographs are often the first line investigation in identifying the cause of hip pain, though they do not differentiate all morphologically normal and abnormal hips. Interpretation of radiographs is subjective, depending on the patient history and physical signs. A radiological report can be misleading and may lead to, unnecessary radiation exposure, a delay in referral and a delay to definitive treatment. This study was to investigate the inter-observer reliability in the reporting of plain radiographs. METHODS: Sixty-one consecutive antero-posterior (AP) radiographs of native hips were identified that had been referred to one of the senior authors from the community with "hip pain". Images were anonymised within PACS (picture archiving and communication system) and reviewed by a consultant orthopaedic surgeon, two consultant musculoskeletal radiologists, one senior orthopaedic registrar and one senior radiology registrar. Each reviewer was given a pre-constructed proforma, and asked to report the radiographs. RESULTS: There is a varying degree of 'agreement' for many of the commonly used terms on a hip radiograph. Agreement between all observers varied, by description, between 23.3% (CAM Lesion) to 93.3% (AVN). Multi-rater agreement showed Kappa values ranging from 0.12 (poor) to 0.6 (moderate). Overall there were widespread inconsistencies, even amongst the most widely used terms. CONCLUSION: There is variable agreement amongst musculoskeletal radiology and orthopaedic experts when analysing plain radiographs of the native hip. This has implications for utility of reporting and therefore treatment in the community setting.

Development, implementation, and preliminary evaluation of a recovery-based curriculum for community navigation specialists working with individuals with serious mental illnesses and repeated hospitalizations.

A recovery-oriented curriculum for training the Community Navigation Specialists (CNSs) of the new Opening Doors to Recovery in Southeast Georgia program was developed, implemented, and preliminarily evaluated. This new mental health program provides mobile, community-based support services to individuals with serious mental illnesses and a history of psychiatric inpatient recidivism (and commonly past incarcerations and homelessness). Teams of CNSs include a licensed social worker, a family member of an individual with a serious mental illness, and a peer specialist with lived experience. In two courses held in February and June of 2011, 14 newly hired CNSs participated in the new training. A pre-training/post-training evaluation demonstrated statistically significant improvements in pertinent knowledge and self-efficacy for working in a community navigation role. As the recovery paradigm continues to be implemented in diverse real-world mental health treatment settings, recovery-based training curricula should be carefully constructed and evaluated.

Epicardial catheter ablation for ventricular tachycardia in heparinized patients.

AIMS: In patients undergoing epicardial catheter ablation of ventricular tachycardia (VT), current guidelines recommend obtaining pericardial access prior to heparinization to minimize bleeding complications. Consequently, access is obtained before endocardial mapping (leading to unnecessary punctures) or during an additional procedure. We present our experience of obtaining pericardial access during the index procedure in heparinized patients. METHODS AND RESULTS: Patients undergoing catheter ablation of VT in whom pericardial access was performed after heparinization were included. Clinical and procedural data and complications were recorded. Electrocardiograms (ECGs) were analysed for published criteria suggesting an epicardial ablation target and compared with patients (matched for substrate) undergoing successful endocardial ablation. Seventeen patients (13 males, age 58 ± 16 years, 8 (47%) ischaemic) were evaluated. Pericardial access was achieved in 16 (94%), including 2 patients with prior epicardial ablation. The mean activated clotting time was 273 ± 36 s. No bleeding complications occurred. In three patients, inadvertent puncture of the right ventricle caused no adverse consequences. An epicardial ablation target was found in nine of which three (33%) had ECG criteria, suggesting an epicardial circuit. In comparison 5 of 17 patients undergoing successful endocardial ablation had at least one ECG criterion suggesting an epicardial ablation target. CONCLUSION: Obtaining pericardial access for epicardial catheter ablation for VT appears to be safe in heparinized patients. Electrocardiogram criteria suggesting an epicardial ablation target lack the sensitivity and specificity accurately to predict which patients might need epicardial ablation. Performing pericardial access in heparinized patients therefore may reduce unnecessary punctures and reduce the number of additional procedures in some patients.

A randomised comparison of Cartomerge vs. NavX fusion in the catheter ablation of atrial fibrillation: the CAVERN Trial.

PURPOSE: Integration of a 3D reconstruction of the left atrium into cardiac mapping systems can aid catheter ablation of atrial fibrillation (AF). The two most widely used systems are NavX Fusion and Cartomerge. We aimed to compare the clinical efficacy of these systems in a randomised trial. METHODS: Patients undergoing their first ablation were randomised to mapping using either NavX fusion or CartoMerge. Pulmonary vein isolation by wide area circumferential ablation was performed for paroxysmal AF with additional linear and fractionated potential ablation for persistent AF. Seven-day Holter monitoring was used for confirmation of sinus rhythm maintenance at 6 months. RESULTS: Ninety-seven patients were randomised and underwent a procedure. There was no difference in the primary endpoint of freedom from arrhythmia at 6 months (51% in the Cartomerge group vs. 48% in the NavX Fusion group, p = 0.76). 3D image registration was faster with Cartomerge (24 vs. 33 min, p = 0.0001), used less fluoroscopic screening (11 vs. 15 min, p = 0.039) with a lower fluoroscopic dose (840 vs. 1,415 mGyCm(2), p = 0.043). There was a strong trend to lower ablation times in the Cartomerge group, overall RF time (3,292 s vs. 4,041, p = 0.07). Distance from 3D lesion to 3D image shell was smaller in the Cartomerge group (2.7 ± 1.9 vs. 3.3 ± 3.7 mm, p < 0.001). CONCLUSIONS: Cartomerge appears to be faster and uses less fluoroscopy to achieve registration than NavX Fusion, but overall procedural times and clinical outcomes are similar.

Maintenance of sinus rhythm with an ablation strategy in patients with atrial fibrillation is associated with a lower risk of stroke and death.

OBJECTIVE: To investigate whether catheter ablation of atrial fibrillation (AF) reduces stroke rate or mortality. METHODS: An international multicentre registry was compiled from seven centres in the U.K. and Australia for consecutive patients undergoing catheter ablation of AF. Long-term outcomes were compared with (1) a cohort with AF treated medically in the Euro Heart Survey, and (2) a hypothetical cohort without AF, age and gender matched to the general population. Analysis of stroke and death was carried out after the first procedure (including peri-procedural events) regardless of success, on an intention-to-treat basis. RESULTS: 1273 patients, aged 58±11 years, 56% paroxysmal AF, CHADS(2) score 0.7±0.9, underwent 1.8±0.9 procedures. Major complications occurred in 5.4% of procedures, including stroke/TIA in 0.7%. Freedom from AF following the last procedure was 85% (76% off antiarrhythmic drugs) for paroxysmal AF, and 72% (60% off antiarrhythmic drugs) for persistent AF. During 3.1 (1.0-9.6) years from the first procedure, freedom from AF predicted stroke-free survival on multivariate analysis (HR=0.30, CI 0.16 to 0.55, p<0.001). Rates of stroke and death were significantly lower in this cohort (both 0.5% per patient-year) compared with those treated medically in the Euro Heart Survey (2.8% and 5.3%, respectively; p<0.0001). Rates of stroke and death were no different from those of the general population (0.4% and 1.0%, respectively). CONCLUSION: Restoration of sinus rhythm by catheter ablation of AF is associated with lower rates of stroke and death compared with patients treated medically.