Gender and contemporary risk of adverse events in atrial fibrillation.

BACKGROUND AND AIMS: The role of gender in decision-making for oral anticoagulation in patients with atrial fibrillation (AF) remains controversial. METHODS: The population cohort study used electronic healthcare records of 16 587 749 patients from UK primary care (2005-2020). Primary (composite of all-cause mortality, ischaemic stroke, or arterial thromboembolism) and secondary outcomes were analysed using Cox hazard ratios (HR), adjusted for age, socioeconomic status, and comorbidities. RESULTS: 78 852 patients were included with AF, aged 40-75 years, no prior stroke, and no prescription of oral anticoagulants. 28 590 (36.3%) were women, and 50 262 (63.7%) men. Median age was 65.7 years (interquartile range 58.5-70.9), with women being older and having other differences in comorbidities. During a total follow-up of 431 086 patient-years, women had a lower adjusted primary outcome rate with HR 0.89 vs. men (95% confidence interval [CI] 0.87-0.92; P < .001) and HR 0.87 after censoring for oral anticoagulation (95% CI 0.83-0.91; P < .001). This was driven by lower mortality in women (HR 0.86, 95% CI 0.83-0.89; P < .001). No difference was identified between women and men for the secondary outcomes of ischaemic stroke or arterial thromboembolism (adjusted HR 1.00, 95% CI 0.94-1.07; P = .87), any stroke or any thromboembolism (adjusted HR 1.02, 95% CI 0.96-1.07; P = .58), and incident vascular dementia (adjusted HR 1.13, 95% CI 0.97-1.32; P = .11). Clinical risk scores were only modest predictors of outcomes, with CHA2DS2-VA (ignoring gender) superior to CHA2DS2-VASc for primary outcomes in this population (receiver operating characteristic curve area 0.651 vs. 0.639; P < .001) and no interaction with gender (P = .45). CONCLUSIONS: Removal of gender from clinical risk scoring could simplify the approach to which patients with AF should be offered oral anticoagulation.

Pre- and post-procedural cardiac imaging (computed tomography and magnetic resonance imaging) in electrophysiology: a clinical consensus statement of the European Heart Rhythm Association and European Association of Cardiovascular Imaging of the European Society of Cardiology.

Imaging using cardiac computed tomography (CT) or magnetic resonance (MR) imaging has become an important option for anatomic and substrate delineation in complex atrial fibrillation (AF) and ventricular tachycardia (VT) ablation procedures. Computed tomography more common than MR has been used to detect procedure-associated complications such as oesophageal, cerebral, and vascular injury. This clinical consensus statement summarizes the current knowledge of CT and MR to facilitate electrophysiological procedures, the current value of real-time integration of imaging-derived anatomy, and substrate information during the procedure and the current role of CT and MR in diagnosing relevant procedure-related complications. Practical advice on potential advantages of one imaging modality over the other is discussed for patients with implanted cardiac rhythm devices as well as for planning, intraprocedural integration, and post-interventional management in AF and VT ablation patients. Establishing a team of electrophysiologists and cardiac imaging specialists working on specific details of imaging for complex ablation procedures is key. Cardiac magnetic resonance (CMR) can safely be performed in most patients with implanted active cardiac devices. Standard procedures for pre- and post-scanning management of the device and potential CMR-associated device malfunctions need to be in place. In VT patients, imaging-specifically MR-may help to determine scar location and mural distribution in patients with ischaemic and non-ischaemic cardiomyopathy beyond evaluating the underlying structural heart disease. Future directions in imaging may include the ability to register multiple imaging modalities and novel high-resolution modalities, but also refinements of imaging-guided ablation strategies are expected.

Cardioneuroablation for the Treatment of Vasovagal Syncope: Current Status and Impact on Quality of Life.

PURPOSE OF REVIEW: Vasovagal syncope (VVS) is a common entity causing transient loss of consciousness and affecting quality of life. Guideline-recommended therapy involves conservative measures and pacing in selected patients. Cardioneuroablation (CNA) targeting the ganglionated plexi in the heart has been shown to reduce excessive vagal excitation, which plays a major role in the pathophysiology of VVS and functional bradycardia. RECENT FINDINGS: The introduction of CNA has fueled research into its value for the treatment of VVS. Multiple observational studies and one randomized trial have demonstrated the safety and efficacy of CNA and the positive impact on quality of life. This review describes the rationale and CNA procedural techniques and outcomes. Patient selection and future directions have also been described. Cardioneuroablation is a promising treatment for patients with recurrent VVS and functional bradycardia. Further large-scale randomized studies are needed to further verify the safety and efficacy of this approach.

Ongoing substrate-driven atrial fibrillation "boxed" in the left atrial posterior wall with ablation: a case report.

Patients undergoing valve surgery for rheumatic heart disease are expected to develop significant atrial arrhythmogenic substrates outside of the pulmonary veins, which sometimes require complex ablation techniques for the treatment of symptomatic arrhythmias. We describe, herein, the case of a 76-year-old male undergoing endocardial ablation for the treatment of symptomatic persistent atrial fibrillation which developed after aortic and mitral valve replacement with a simultaneous tricuspid ring annuloplasty. Following pulmonary vein isolation, the patient's atrial fibrillation was converted into cavotricuspid isthmus-dependent atrial flutter. After a successful cavotricuspid isthmus ablation, the arrhythmia reverted back to a left atrial tachyarrhythmia originating from the posterior wall. A linear left atrial lesion led to the electrical isolation of a large area, which included the posterior wall, as well as the containment of the ongoing fibrillatory activity, while sinus rhythm was restored in the rest of the atria. In conclusion, successful left atrial posterior wall isolation can be achieved in the setting of severe scarring due to previous atriotomy by creating a linear lesion on the atrial roof, in conjunction with pulmonary vein isolation, sparing the patient from requiring bottom-line ablation, and avoiding possible esophageal injury. Such compartmentalization of the left atrium may effectively contain local fibrillatory activity, while allowing for the restoration of sinus rhythm.

Infections of cardiac implantable electronic devices: Epidemiology, mechanisms, and preventive measures.

Cardiac implantable electronic device (CIED) infections represent a complication associated with high morbidity and mortality. Despite enormous efforts to prevent them, the rates of infections continue to rise out of proportion to the reported increase in CIED implantation rates. Following extensive research of various prevention strategies and new technologies, several organizations have issued recommendations and consensus papers covering this topic. Our narrative review aims to provide a summary of the existing preventive strategies put forward by the European Heart Rhythm Association consensus and European Society of Cardiology guidelines and introduce the most recent developments in the field, including optimized surgical site management and appropriate periprocedural antithrombotic drug use. It also provides an overview of epidemiology, mechanisms, risk factors, and risk stratification approaches. It focuses on the pre-, intra-, and postprocedural actions that should be taken to mitigate CIED infection risks. Future directions in the prevention of CIED infections have also been addressed.

Endocardial, epicardial, and right atrial approach for catheter ablation of premature ventricular contractions from the inferoseptal process of the left ventricle.

Background: Inferoseptal process of the left ventricle (ISP-LV) might be a source of idiopathic ventricular arrhythmias. In these cases, ectopic foci are accessible from the LV endocardium, epicardially from the middle cardiac vein as well as from the right atrium (RA). This study reports a series of patients with premature ventricular contractions (PVCs) arising from the ISP-LV that were successfully ablated following access from different structures. Methods and Results: Five patients (4 males, age 61 ± 12.8 years) with PVCs arising from the ISP-LV were successfully ablated using three different approaches for ablation-endocardial, epicardial (through coronary sinus or its branches), and RA approaches. Endocardial LV mapping, RA, and coronary sinus (CS) mapping were performed in all five cases. PVCs demonstrated RBBB or LBBB-like morphology and left superior axis. The three patients ablated endocardially had a maximum deflection index (MDI) of 0.36, 0.43, and 0.54, whereas in the remaining 2 patients, MDI was 0.57 and both demonstrated QS morphology in the inferior leads. Local activation time at the successful ablation site was 35 ± 8.9 (26-55) msec pre-QRS. Pacemapping at the successful ablation site resulted in a good (11/12) or perfect (12/12) QRS match in all cases. Three of the patients demonstrated frequent monomorphic PVCs of another morphology suggesting a remote exit site. All patients remained arrhythmia-free after a mean follow-up of 21 ± 15 (6-36) months. Conclusion: Successful ablation of PVCs from ISP-LV may require access from the CS or even RA apart from LV endocardial approach. Not infrequently patients demonstrate additional PVC foci.

Fever-Induced Brugada Sign: Clue for Clinical Management with Non-Negligible Risk of Sudden Cardiac Death.

Brugada syndrome (BrS) is a primary electrical disease predisposing to ventricular tachyarrhythmias and sudden cardiac death [...].

Proposing national diagnostic reference levels for electrophysiology studies and catheter ablation procedures in Bulgaria.

INTRODUCTION: The implementation of diagnostic reference levels (DRLs) is an essential tool for optimisation of the routine practice, better management of patient exposure while maintaining sufficient image quality. National DRLs for electrophysiology (EP) procedures are not available in our country. PURPOSE: The main purpose of the study was to propose, for first time in Bulgaria, national DRLs (NDRLs) for EP studies and ablation procedures of two different levels of complexity. The proposed DRLs can be later used to establish NDRLs by the national authority with regulatory functions related to medical exposure. METHOD: A retrospective study was done with the three highest volume Bulgarian EP centers, where over 95% of all cardiac ablations were performed. Data were extracted from the electronic registry for invasive electrophysiology BG-EPHY. Independently of the proposed NDRLs, we also compared the air kerma-area product (KAP) between the participating centers for procedures of the same level of complexity. RESULTS: The proposed NDRL in terms of KAP were: 5.2 Gy.cm2 for diagnostic EP studies, 25.5 Gy.cm2 for simple ablations, and 52.1 Gy.cm2 for complex ablations. There was a significant variation in KAP for procedures with the same degree of complexity within each center. CONCLUSION: This study is the first to propose NDLRs for EP studies and ablation procedures of two levels of complexity in Bulgaria. The results identified EP procedures requiring further optimization of patient protection and provided a basis for future comparisons and standardization with further investigations on the topic. The proposed NDRLs are recommended to be used for better management of radiation exposure during EP procedures of different levels of complexity.