Diagnostic yield of implantable loop recorders: Results from the Hellenic registry.

AIMS: Implantable loop recorders (ILRs) are increasingly being used for long-term cardiac monitoring in different clinical settings. The aim of this study was to investigate the real-world performance of ILRs-including the time to diagnosis- in unselected patients with different ILR indications. METHODS AND RESULTS: In this multicenter, observational study, 871 patients with an indication of pre-syncope/syncope (61.9%), unexplained palpitations (10.4%), and atrial fibrillation (AF) detection with a history of cryptogenic stroke (CS) (27.7%) underwent ILR implantation. The median follow-up was 28.8 ± 12.9 months. In the presyncope/syncope group, 167 (31%) received a diagnosis established by the device. Kaplan-Meier estimates indicated that 16.9% of patients had a diagnosis at 6 months, and the proportion increased to 22.5% at 1 year. Of 91 patients with palpitations, 20 (22%) received a diagnosis based on the device. The diagnosis established at 12.2% of patients at 6 months, and the proportion increased to 13.3% at 1 year. Among 241 patients with CS, 47 (19.5%) were diagnosed with AF. The diagnostic yield of the device was 10.4% at 6 months and 12.4% at 1 year. In all cases, oral anticoagulation was initiated. Overall, ILR diagnosis altered the therapeutic strategy in 26.1% in presyncope/syncope group, 2.2% in palpitations group, and 3.7% in CS group in addition to oral anticoagulation initiation. CONCLUSIONS: In this real-world patient population, ILR determines diagnosis and initiates a new therapeutic management in nearly one fourth of patients. ILR implantation is valuable in the evaluation of patients with unexplained presyncope/syncope, CS and palpitations.

Cardiac contractility modulation in patients with heart failure - A review of the literature.

Experimental in vivo and in vitro studies showed that electric currents applied during the absolute refractory period can modulate cardiac contractility. In preclinical studies, cardiac contractility modulation (CCM) was found to improve calcium handling, reverse the foetal myocyte gene programming associated with heart failure (HF), and facilitate reverse remodeling. Randomized control trials and observational studies have provided evidence about the safety and efficacy of CCM in patients with HF. Clinically, CCM therapy is indicated to improve the 6-min hall walk, quality of life, and functional status of HF patients who remain symptomatic despite guideline-directed medical treatment without an indication for cardiac resynchronization therapy (CRT) and have a left ventricular ejection fraction (LVEF) ranging from 25 to 45%. Although there are promising results about the role of CCM in HF patients with preserved LVEF (HFpEF), further studies are needed to elucidate the role of CCM therapy in this population. Late gadolinium enhancement (LGE) assessment before CCM implantation has been proposed for guiding the lead placement. Furthermore, the optimal duration of CCM application needs further investigation. This review aims to present the existing evidence regarding the role of CCM therapy in HF patients and identify gaps and challenges that require further studies.

When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer.

Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.

Hyperacute synchronous cardiocerebral infarction in a patient with new-onset atrial fibrillation: a case of myocardial infarction with nonobstructive coronary arteries.

Hyperacute synchronous cardiocerebral infarction (CCI) is an extremely rare condition with an incidence of 0.009%. In the acute stage of ischemic stroke, there is a high prevalence of ECG abnormalities. Prolonged QTc, atrial fibrillation (AF) and ECG changes indicative of ischemic heart disease, such as Q waves, ST depression, and T wave inversion, were the most prevalent changes. There are three types of simultaneous CCI: cardiac conditions that cause cerebral infarction, cerebral infarction caused by cardiac conditions, and (c) dysregulation of the brain-heart axis or cerebral infarction causing myocardial infarction. Herein, we present a case of hyperacute synchronous CCI in an elderly patient with new-onset AF and myocardial infarction with nonobstructive coronary arteries (MINOCA).

Implantable Cardiac Defibrillator-Related Culture-Negative Infection: A Case of Coxiella burnetii Infection.

Coxiella burnetii is one of the most common causes of blood culture-negative infective endocarditis (IE). However, only a few cases of cardiac implantable electronic devices (CIED) infection have been reported in the literature. Herein, we present a case of CIED-related blood culture-negative infection attributed to C. burnetii. A 54-year-old male was admitted to our hospital due to prolonged fatigue, a low-grade fever lasting more than a month, and weight loss. Three years ago, he received an implantable cardiac defibrillator (ICD) as a primary prevention measure against sudden cardiac death. An initial transthoracic and transesophageal echocardiography showed a dilated left ventricle with severely impaired systolic function, while the ventricular pacing wire was inside the right ventricle with a large echogenic mass (2.2 × 2.5 cm) adherent to it. Repeated blood cultures were negative. The patient underwent transvenous lead extraction. A transesophageal echocardiography after the extraction revealed multiple vegetations on the tricuspid valve with moderate to severe valve regurgitation. A surgical replacement of the tricuspid valve was determined after a multidisciplinary heart team approach. Serology tests showed increased IgG antibodies in phase I (1:16,394) and phase II (1:8192), and a definite diagnosis of CIED infection was made based on the serological tests.

A rare complication: Right ventricular lead perforation abutting the left anterior descending artery through the left ventricle and the septum.

BACKGROUND: Cardiac perforation is an uncommon complication of transvenous pacemaker implantation typically occurring through the apex. CASE SUMMARY: We report a case of patient, in whom ventricular lead perforation was confirmed 6 days after implantation of a dual chamber pacemaker. The ventricular lead was perforating the ventricular septum, near the left anterior descending artery, exiting the left ventricle. The patient underwent cardiac surgery due to the lead perforation as also as aortic valve replacement due to concomitant severe aortic valve stenosis. DISCUSSION: The presented case report is a rare case of lead perforation through the LV and illustrates that lead perforation can still occur even after placement of the RV lead in septal position and even through the thick ventricular wall.

Chronic Thoracic Aortic Dissection: How to Treat, When to Intervene.

Thoracic aortic dissection (AD) is associated with increased morbidity and mortality. Acute aortic syndrome is the first presentation of the disease in most cases. While acute AD management follows concrete guidelines because of its urgent and life-threatening nature, chronic AD is usually overlooked, although it concerns a wide spectrum of patients surviving an acute event. Acute AD survivors ultimately enter a chronic aortic disease course. Patients with chronic thoracic AD (CTAD) require lifelong surveillance and a proportion of them may present with symptoms and late complications demanding further surgical or endovascular treatment. However, the available data concerning the management of CTAD is sparse in the literature. The management of patients with CTAD is challenging as far as determining the best medical therapy and deciding on intervention are concerned. Until recently, there were no guidelines or recommendations for imaging surveillance in patients with chronic AD. The diagnostic methods for imaging aortic diseases have been improved, while the data on new endovascular and surgical approaches has increased significantly. In this review, we summarize the current evidence in the diagnosis and management of CTAD and the latest recommendations for the surgical/endovascular aortic repair of CTAD.

The RV1-V3 transition ratio: A novel electrocardiographic criterion for the differentiation of right versus left outflow tract premature ventricular complexes.

BACKGROUND: Several electrocardiographic (ECG) indices have been proposed to predict the origin of premature ventricular complexes (PVCs) with precordial transition in lead V3. However, the accuracy of these algorithms is limited. OBJECTIVES: We sought to evaluate a new ECG criterion differentiating the origin of outflow tract with precordial transition in lead V3. METHODS: We included in our study patients exhibiting outflow tract PVCs with precordial transition in lead V3 referred for ablation. We analyzed a novel new ECG criterion, RV1-V3 transition ratio, for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3. The RV1-V3 transition ratio was defined as (RV1+RV2+RV3) PVC / (RV1+RV2+RV3) SR (sinus rhythm). RESULTS: We included 58 patients in our study. The ratio was lower for right ventricular outflow tract origins than left ventricular outflow tract (LVOT) origins (median [interquartile range], 0.6953 [0.4818-1.0724] vs 1.5219 [1.1582-2.4313], P < .001). Receiver operating characteristic analysis revealed an area under the curve of 0.856 for the ratio, and a cut-off value of ≥0.9 predicting LVOT origin with 94% sensitivity and 73% specificity. This ratio was superior to any previously proposed ECG criterion for differentiating right from left outflow tract PVCs. CONCLUSION: The RV1-V3 transition ratio is a simple and accurate novel ECG criterion for distinguishing right from left idiopathic outflow tract PVCs with precordial transition in lead V3.

The management of atrial fibrillation in heart failure: an expert panel consensus.

Heart failure (HF) and atrial fibrillation (AF) often coexist, being closely interrelated as the one increases the prevalence and incidence and worsens the prognosis of the other. Their frequent coexistence raises several challenges, including under-diagnosis of HF with preserved ejection fraction in AF and of AF in HF, characterization and diagnosis of atrial cardiomyopathy, target and impact of rate control therapy on outcomes, optimal rhythm control strategy in the era of catheter ablation, HF-related thromboembolic risk and management of anticoagulation in patients with comorbidities, such as chronic kidney disease or transient renal function worsening, coronary artery disease or acute coronary syndromes, valvular or structural heart disease interventions and cancer. In the present document, derived by an expert panel meeting, we sought to focus on the above challenging issues, outlining the existing evidence and identifying gaps in knowledge that need to be addressed.

An uncommon cause of inappropriate ICD shock.

In cases of electromagnetic interference (EMI), if the source of the inappropriate EMI cannot be identified, then the sensitivity of the device could be decreased, or the cycle length of the VF detection trigger zone changed.

Catheter ablation of anteroseptal accessory pathways from the aortic cusps: A case series and a review of the literature.

Data regarding catheter ablation of anteroseptal accessory pathways through the aortic cusps are limited. We describe two cases of true para-Hisian accessory pathways successfully ablated from the aortic cusps (right coronary cusp and non-coronary cusp, respectively) along with a review of the current literature. Due to the close proximity to the atrioventricular node and the high risk of complication, mapping of the aortic cusps should always be considered in the case of anteroseptal accessory pathways. Anteroseptal accessory pathways can be safely and effectively ablated from the aortic cusps with good long-term outcomes.

Prediction of atrial fibrillation development and progression: Current perspectives.

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice. Several conventional and novel predictors of AF development and progression (from paroxysmal to persistent and permanent types) have been reported. The most important predictor of AF progression is possibly the arrhythmia itself. The electrical, mechanical and structural remodeling determines the perpetuation of AF and the progression from paroxysmal to persistent and permanent forms. Common clinical scores such as the hypertension, age ≥ 75 years, transient ischemic attack or stroke, chronic obstructive pulmonary disease, and heart failure and the congestive heart failure, hypertension, age ≥ 75 years, diabetes mellitus, stroke/transient ischemic attack, vascular disease, age 65-74 years, sex category scores as well as biomarkers related to inflammation may also add important information on this topic. There is now increasing evidence that even in patients with so-called lone or idiopathic AF, the arrhythmia is the manifestation of a structural atrial disease which has recently been defined and described as fibrotic atrial cardiomyopathy. Fibrosis results from a broad range of factors related to AF inducing pathologies such as cell stretch, neurohumoral activation, and oxidative stress. The extent of fibrosis as detected either by late gadolinium enhancement-magnetic resonance imaging or electroanatomic voltage mapping may guide the therapeutic approach based on the arrhythmia substrate. The knowledge of these risk factors may not only delay arrhythmia progression, but also reduce the arrhythmia burden in patients with first detected AF. The present review highlights on the conventional and novel risk factors of development and progression of AF.

Immunosenescence in patients with chronic systolic heart failure.

AIM: Chronic heart failure (CHF) is characterized by hemodynamic compromise, neurohormonal and immune activation. We sought to examine the presence and severity of immunosenescence and its relation with the stages of CHF. METHODS: We enrolled 86 consecutive stable systolic CHF patients and examined the relationship of leukocyte and lymphocyte subpopulation counts by flow cytometry with their functional status according to New York Heart Association (NYHA) class. RESULTS: Patients with advanced heart failure were characterized by significantly increased neutrophil and reduced lymphocyte counts. T-helper cells were increased, whereas B-cells and T cytotoxic cells were decreased. T-helper cells exhibited significant differentiation and aging across the NYHA classes; naïve T-cells, CD4 + CD45RA +, were significantly reduced in NYHA Class IV and memory T-cells, CD4 + CD45RO +, were significantly increased. CONCLUSION: Patients with CHF develop intense T-cell differentiation and aging. The presence of significant immunosenescence in advanced CHF may indicate a population at increased risk for adverse events.

Catheter Ablation of Ventricular Arrhythmias Arising from the Distal Great Cardiac Vein.

Catheter ablation of idiopathic ventricular arrhythmias arising from the distal great cardiac vein represents a great challenge. We report data regarding the electrocardiographic and electrophysiologic characteristics in two patients with ventricular arrhythmias arising from the distal great cardiac vein. The technical difficulties to advance and navigate the ablation catheter within the coronary venous system as well as the close proximity to the major coronary vessels are discussed.

Differences in quality of life, anxiety and depression in patients with paroxysmal atrial fibrillation and common forms of atrioventricular reentry supraventricular tachycardias.

INTRODUCTION: The aim of this study was to evaluate the differences in quality of life and psychosocial stress parameters among patients with paroxysmal atrial fibrillation (AF) and common forms of atrioventricular reentry supraventricular tachycardias (SVTs). METHODS AND RESULTS: The total study population included 106 patients, 54 patients with paroxysmal AF (32 males, age 56.64±12.50 years) and 52 with SVTs (25 males, age 40.46±14.96 years). General health (p<0.01), physical function (p=0.004), role emotion (p=0.002) and role physical (p<0.01) scores were lower in patients who suffered AF. SF-36 physical and mental health summary measures were also significantly lower in the AF group compared to those in SVT group (p<0.01 and p=0.001, respectively). Lower SF-36 total score was observed in patients with AF compared to those with SVTs (p<0.01). Comparing the anxiety and depression scores all the values were higher in patients with AF. Higher STAI-state scores (p<0.01), STAI-trait scores (p=0.039) and BDI scores (p=0.077) were seen in patients who suffered AF comparing to those with SVTs. CONCLUSIONS: Quality of life is significantly impaired and the level of anxiety is significantly higher in patients with AF comparing to those with common forms of SVTs.

CHADS2 and CHA2DS2-VASc scores as predictors of left atrial ablation outcomes for paroxysmal atrial fibrillation.

AIMS: The selection of patients with atrial fibrillation (AF) that will benefit most by left atrial ablation remains suboptimal. CHADS2 score has been shown to be associated with post-ablation AF recurrences. However, data regarding the CHA2DS2-VASc score are lacking. In addition, there is paucity of data regarding the exact predictive value, in terms of sensitivity and specificity, of each of these scores as to AF recurrence. This study aimed to evaluate the merit of the CHADS2 and CHA2DS2-VASc scores in predicting arrhythmia recurrence after a single ablation procedure for paroxysmal AF. METHODS AND RESULTS: One hundred and twenty-six patients (78 males, median age 61 years) with symptomatic paroxysmal AF underwent left atrial ablation. Over 16 months (interquartile range: 10.8-26.0), 89 patients were recurrence-free (70.6%). Larger left atrial volume (P: 0.039), diabetes (P: 0.001), dyslipidemia (P: 0.003), coronary artery disease (P: 0.003), class III antiarrhythmic drugs (P: 0.017), CHADS2 (P: 0.006), and CHA2DS2-VASc (P: 0.016) scores were univariately associated with recurrence. In the multivariate analysis, both CHADS2 (hazard ratio: 1.91, 95% confidence interval 1.09-3.36, P: 0.023) and CHA2DS2-VASc (hazard ratio: 1.97, 95% confidence interval 1.16-3.33, P: 0.012) were independently associated with AF recurrence. Cut-off analysis showed that a score ≥2 for both the CHADS2 (sensitivity = 46% and specificity = 79%, area under the Receiver's operating characteristic curve, AUC = 0.644) and CHA2DS2-VASc score (sensitivity = 57% and specificity = 65%, AUC = 0.627) showed the highest predictive value for AF recurrence. CONCLUSIONS: CHA2DS2-VASc score is an independent predictor of left atrial ablation outcomes for paroxysmal AF, with a similar predictive value to CHADS2. However, the predictive accuracy of both is mediocre.

The impact of vagotonic, adrenergic, and random type of paroxysmal atrial fibrillation on left atrial ablation outcomes.

BACKGROUND: Accumulating data have shown that the autonomic nervous system is strongly implicated in the genesis of atrial fibrillation (AF). The aim of this study was to assess the efficacy of a single ablation procedure in patients with vagotonic, adrenergic and random type of paroxysmal AF. METHODS AND RESULTS: The clinical records of consecutive patients with symptomatic, drug-refractory paroxysmal AF who underwent pulmonary vein antral isolation were analysed. The study population consisted of 104 patients (64 males, mean age 57.9 ± 10.9 years) with paroxysmal AF. Based on AF triggers, patients were classified in those with vagotonic (31.7%), adrenergic (17.3%) and random AF (51%). Subjects with adrenergic and random AF tended to be older (p: 0.104) and displayed a higher incidence of hypertension (p: 0.088) compared with those with vagotonic AF. Following a mean follow-up period of 14.7 ± 7.4 months, 74 patients were free from arrhythmia recurrence (71.2%). Late arrhythmia recurrence (>3 months from the index procedure) occurred in 33.3%, 16.7% and 30.2% of patients with vagotonic, adrenergic and random AF, respectively (p: 0.434). Cox regression analysis showed that early AF recurrence [hazard ratio (HR) 15.76; 95% confidence interval (CI) 5.456-45.566, p: <0.001], left atrial volume (HR 0.969; 95% CI 0.942-0.996, p: 0.025) and statin use (HR 6.828; 95% CI 2.078-22.437 p: 0.002) were independent predictors of late arrhythmia recurrence. CONCLUSIONS: In this study cohort, the type of paroxysmal AF was not associated with arrhythmia recurrence following left atrial ablation.