Electrophysiological cardiovascular MR: procedure-ready mesh model generation for interventional guidance based on non-selective excitation compressed sensing whole heart imaging.

Fully CMR-guided electrophysiological interventions (EP-CMR) have recently been introduced but data on the optimal CMR imaging protocol are scarce. This study determined the clinical utility of 3D non-selective whole heart steady-state free precession imaging using compressed SENSE (nsWHcs) for automatic segmentation of cardiac cavities as the basis for targeted catheter navigation during EP-CMR cavo-tricuspid isthmus ablation. Fourty-two consecutive patients with isthmus-dependent right atrial flutter underwent EP-CMR radiofrequency ablations. nsWHcs succeeded in all patients (nominal scan duration, 98 ± 10 s); automatic segmentation/generation of surface meshes of right-sided cavities exhibited short computation times (16 ± 3 s) with correct delineation of right atrium, right ventricle, tricuspid annulus and coronary sinus ostium in 100%, 100%, 100% and 95%, respectively. Point-by-point ablation adhered to the predefined isthmus line in 62% of patients (26/42); activation mapping confirmed complete bidirectional isthmus block (conduction time difference, 136 ± 28 ms). nsWHcs ensured automatic and reliable 3D segmentation of targeted endoluminal cavities, multiplanar reformatting and image fusion (e.g. activation time measurements) and represented the basis for precise real-time active catheter navigation during EP-CMR ablations of isthmus-dependent right atrial flutter. Hence, nsWHcs can be considered a key component in order to advance EP-CMR towards the ultimate goal of targeted substrate-based ablation procedures.

Long-term outcomes after catheter ablation for idiopathic atypical atrial flutter.

BACKGROUND: Idiopathic atypical (non-cavotricupid isthmus [CTI]-dependent) atrial flutter (IAAFL) may be seen in patients without structural heart disease and without previous cardiac surgery or ablation. OBJECTIVE: This study sought to determine the patient characteristics, electrophysiological and electroanatomic properties, and clinical outcomes after ablation in patients with IAAFL. METHODS: We retrospectively compared IAAFL patients to CTI-dependent AFL (C-AFL) patients undergoing catheter ablation. The primary outcome was a composite of death from cardiovascular causes, ischemic stroke, and hospitalization for worsening of heart failure. RESULTS: Among 180 patients who underwent catheter ablation for AFL, 89 were included in this study (22 IAAFL and 67 C-AFL). Electrophysiological study showed significantly longer intra-atrial conduction time, lower atrial voltage during sinus rhythm in the IAAFL group compared to the C-AFL group. The atrial scar was observed in all 22 IAAFL patients, with the most common sites being the posterior or lateral wall of RA in 10 (45.5 %) and the anterior wall of LA in 8 (36.4 %). During 3.5 ± 2.8 years of follow-up, the composite primary endpoint occurred significantly more frequently in the IAAFL group (hazard ratio [HR] 3.45, 95 % confidence interval [CI] 1.20-9.89, P=0.015). In multivariable analysis, brain natriuretic peptide (BNP) levels (HR 1.01, 95 % CI 1.00-1.01, per 1 pg/mL, P=0.01) and IAAFL (HR 4.14, 95% CI 1.21-14.07, P=0.02) were independently associated with the primary outcome. CONCLUSIONS: IAAFL in patients had distinct electrophysiologic features suggestive of atrial cardiomyopathy. These patients are at risk of developing cardiovascular adverse events after ablation.

Mortality and rehospitalization in patients with pre-existing implantable pacemakers undergoing catheter ablation are related to increased comorbidity burden-data from the German Ablation Registry.

BACKGROUND: Catheter ablation of atrial fibrillation and atrial flutter is routinely performed in patients with implantable devices. The aim of the present study was to assess success rates and potential complications in a large registry cohort of patients with cardiac pacemakers. METHODS AND RESULTS: The German Ablation Registry is a nationwide, prospective registry with a 1-year follow-up investigating patients who underwent catheter ablation of supraventricular arrhythmias in 51 German centers. The present analysis focussed on the presence of cardiac pacemakers in 591 patients undergoing catheter ablation of atrial fibrillation or atrial flutter. These were compared to 7393 patients without a pacemaker. Patients with pacemakers were significantly older and presented more comorbidities like diabetes, renal failure, cardiovascular disease, or previous stroke. One-year mortality (2.4% vs. 1.3%, p = 0.022) and a combined endpoint of death, myocardial infarction, and stroke (3.6% vs. 2.1%, p = 0.014) were significantly elevated in patients with pacemakers. Re-hospitalization was also more common in patients with a pacemaker (53.3% vs. 45.0%, p < 0.01). After adjustment for important comorbidities, pre-existing pacemaker systems did not show any negative effect. Procedural success was reported in 98.8% vs. 98.4% (p = 0.93). Device-related complications were only observed in 0.4% of patients with pacemakers. CONCLUSION: Patients with pacemaker systems undergoing catheter ablation of atrial fibrillation or atrial flutter demonstrate an increased risk of death, cardiovascular events, and re-hospitalization. This observation can be largely attributed to an older patient population and an increased rate of comorbidities.

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

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

Electrophysiological evidence of right atrial epicardial connections in a case with recurrent common atrial flutter.

The majority of the cavotricuspid isthmus (CTI) region consists of discretely arranged muscle bundles separated by connective tissue. Heterogeneity in the anatomic arrangement of the muscle bundles results in differences in the endocardial and epicardial activation patterns. We present a case of recurrent atrial flutter (AFL) despite the presence of a complete endocardial CTI block. We found epicardial-endocardial breakthrough (EEB) sites on the right atrial high septum. In addition, the epicardial excitation confirmed by endocardial activation mapping was detected as far-field potentials. Radiofrequency ablation was performed at the EEB site. No AFL has recurred for 12 months after the present procedure.

Cryoballoon pulmonary vein isolation as first-line treatment of typical atrial flutter: long-term outcomes of the CRAFT trial.

BACKGROUND: CRAFT was an international, multicentre, randomised controlled trial across 11 sites in the United UK and Switzerland. Given the evidence that pulmonary vein triggers may be responsible for atrial flutter (AFL) as well as atrial fibrillation (AF), we hypothesised that cryoballoon pulmonary vein isolation (PVI) would provide greater symptomatic arrhythmia reduction than cavotricuspid isthmus (CTI) ablation, whilst also reducing the subsequent burden of AF. Twelve-month outcomes were previously reported. In this study, we report the extended outcomes of the CRAFT study to 36 months. METHODS: Patients with typical AFL and no evidence of AF were randomised 1:1 to cryoballoon PVI or radiofrequency CTI. All patients received an implantable loop recorder (ILR) for continuous cardiac rhythm monitoring. The primary outcome was time-to-symptomatic arrhythmia recurrence > 30 s. Secondary outcomes included time-to-first-AF episode ≥ 2 min. The composite safety outcome included death, stroke and procedural complications. RESULTS: A total of 113 patients were randomised to cryoballoon PVI (n = 54) or radiofrequency CTI ablation (n = 59). Ninety-one patients reconsented for extended follow-up beyond 12 months. There was no difference in the primary outcome between arms, with the primary outcome occurring in 12 PVI vs 11 CTI patients (HR 0.97; 95% CI 0.43-2.20; p = 0.994). AF ≥ 2 min was significantly less frequent in the PVI arm, affecting 26 PVI vs 36 CTI patients (HR 0.48; 95% CI 0.29-0.79; p = 0.004). The composite safety outcome occurred in 5 PVI and 6 CTI patients (p = 0.755). CONCLUSION: Cryoballoon PVI shows similar efficacy to radiofrequency CTI ablation in reducing symptomatic arrhythmia recurrence in patients presenting with isolated typical AFL but significantly reduces the occurrence of subsequent AF.

Intravenous Landiolol for Rate Control in Supraventricular Tachyarrhythmias in Patients with Left Ventricular Dysfunction: A Systematic Review and Meta-Analysis.

Background: This systematic review explores the effects of landiolol administration in individuals presenting with supraventricular tachyarrhythmia (SVT) and concurrent left ventricular dysfunction, without being septic or in a peri-operative period. Methods: We systematically searched PubMed, Cochrane, Web of Science, and Scopus databases, retrieving a total of 15 eligible studies according to prespecified eligibility criteria. Results: Patients treated with landiolol experienced a substantial reduction in heart rate (HR) (mean HR reduction: 42 bpm, 95% confidence intervals (CIs): 37-47, I2 = 82%) and were more likely to achieve the target HR compared to those receiving alternative antiarrhythmic therapy (pooled odds ratio (OR): 5.37, 95% CIs: 2.87-10.05, I2 = 0%). Adverse events, primarily hypotension, occurred in 14.7% of patients receiving landiolol, but no significant difference was observed between the landiolol and alternative antiarrhythmic receiving groups (pooled OR: 1.02, 95% CI: 0.57-1.83, I2 = 0%). No significant difference was observed between the two groups concerning sinus rhythm restoration (pooled OR: 0.97, 95% CI: 0.25-3.78, I2 = 0%) and drug discontinuation due to adverse events (pooled OR: 5.09, 95% CI: 0.6-43.38, I2 = 0%). Conclusion: While further research is warranted, this systematic review highlights the potential benefits of landiolol administration in the management of SVTs in the context of left ventricular dysfunction.

Navigating the fine line between focal atrial tachycardia and atrial flutter?

Focal atrial tachycardia (FAT) is an organized atrial rhythm >100 beats per minute initiated from a discrete origin and spreading over both atria in a centrifugal pattern. The arrhythmia may be sustained or incessant. Dynamic forms with recurrent interruptions and reinitiating may be frequent. In this report, we present a 36-year-old man who came to the emergency room complaining of palpitation and shortness of breath. All laboratory evaluations were normal. With an initial electrocardiogram (ECG) the patient was admitted with the initial diagnosis of atrial flutter. Finally, after the electrophysiologist's examination, with the diagnosis of FAT, ablation was successfully performed. Atrial tachycardia (AT), excluding atrial fibrillation (AF) and cavotricuspid isthmus-dependent atrial flutter (AFL), account for 10% of supraventricular tachycardia referred for ablation procedures. More than 70% of these cases are focal and occur in patients with no records of cardiac surgery or ablation of AF. FAT originating from the right pulmonary veins (PV) can be challenging to differentiate from atrial flutter due to their proximity and overlapping symptoms. The right PV is close to the right atrium, and the abnormal electrical activity in FAT may mimic the organized circuit found in atrial flutter. Distinguishing between FAT and atrial flutter is crucial for choosing the best therapeutic option. This can be done most of the time by focusing on the differences in the pattern of their P and QRS waves, R-R wave intervals, and also their baseline changes on ECG, as well as their cycle duration, response to adenosine and risk factors of the patient.

Validation of a novel smartphone-based photoplethysmographic method for ambulatory heart rhythm diagnostics: the SMARTBEATS study.

AIMS: In the current guidelines, smartphone photoplethysmography (PPG) is not recommended for diagnosis of atrial fibrillation (AF), without a confirmatory electrocardiogram (ECG) recording. Previous validation studies have been performed under supervision in healthcare settings, with limited generalizability of the results. We aim to investigate the diagnostic performance of a smartphone-PPG method in a real-world setting, with ambulatory unsupervised smartphone-PPG recordings, compared with simultaneous ECG recordings and including patients with atrial flutter (AFL). METHODS AND RESULTS: Unselected patients undergoing direct current cardioversion for treatment of AF or AFL were asked to perform 1-min heart rhythm recordings post-treatment, at least twice daily for 30 days at home, using an iPhone 7 smartphone running the CORAI Heart Monitor PPG application simultaneously with a single-lead ECG recording (KardiaMobile). Photoplethysmography and ECG recordings were read independently by two experienced readers. In total, 280 patients recorded 18 005 simultaneous PPG and ECG recordings. Sufficient quality for diagnosis was seen in 96.9% (PPG) vs. 95.1% (ECG) of the recordings (P < 0.001). Manual reading of the PPG recordings, compared with manually interpreted ECG recordings, had a sensitivity, specificity, and overall accuracy of 97.7%, 99.4%, and 98.9% with AFL recordings included and 99.0%, 99.7%, and 99.5%, respectively, with AFL recordings excluded. CONCLUSION: A novel smartphone-PPG method can be used by patients unsupervised at home to achieve accurate heart rhythm diagnostics of AF and AFL with very high sensitivity and specificity. This smartphone-PPG device can be used as an independent heart rhythm diagnostic device following cardioversion, without the requirement of confirmation with ECG.

Peak frequency mapping of atypical atrial flutter.

INTRODUCTION: Peak frequency (PF) mapping is a novel method that may identify critical portions of myocardial substrate supporting reentry. The aim of this study was to describe and evaluate PF mapping combined with omnipolar voltage mapping in the identification of critical isthmuses of left atrial (LA) atypical flutters. METHODS AND RESULTS: LA omnipolar voltage and PF maps were generated in flutter using the Advisor HD-Grid catheter (Abbott) and EnSite Precision Mapping System (Abbott) in 12 patients. Normal voltage was defined as ≥0.5 mV, low-voltage as 0.1-0.5 mV, and scar as <0.1 mV. PF distributions were compared with ANOVA and post hoc Tukey analyses. The 1 cm radius from arrhythmia termination was compared to global myocardium with unpaired t-testing. The mean age was 65.8 ± 9.7 years and 50% of patients were female. Overall, 34 312 points were analyzed. Atypical flutters most frequently involved the mitral isthmus (58%) or anterior wall (25%). Mean PF varied significantly by myocardial voltage: normal (335.5 ± 115.0 Hz), low (274.6 ± 144.0 Hz), and scar (71.6 ± 140.5 Hz) (p < .0001 for all pairwise comparisons). All termination sites resided in low-voltage regions containing intermediate or high PF. Overall, mean voltage in the 1 cm radius from termination was significantly lower than the remaining myocardium (0.58 vs. 0.95 mV, p < .0001) and PF was significantly higher (326.4 vs. 245.1 Hz, p < .0001). CONCLUSION: Low-voltage, high-PF areas may be critical targets during catheter ablation of atypical atrial flutter.

SuperMap algorithm: an efficient, safe and accurate modality for mapping and eliminating challenging cardiac arrhythmias.

Even with the development of advanced catheter-based mapping systems, there remain several challenges in the electrophysiological evaluation and elimination of atrial arrhythmias. For instance, atrial tachycardias with irregular rates cannot be reliably mapped by systems that require stability in order to sequentially gather data points to be organized thereafter. Separately, these arrhythmias often arise following initial ablation for atrial fibrillation, posing logistic challenges. Here, we present the available literature summarizing the use of a non-contact mapping catheter, the AcQMap catheter, in conjunction with SuperMap, an algorithm that compiles a large number of non-contact data points from multiple catheter positions within the atria. These studies demonstrate the efficiency, safety and accuracy of this technology.

Irregular heart rhythms (arrhythmias) are often treatable with medications, but sometimes require expert evaluation in a cardiac electrophysiology laboratory. They are often studied and treated using thin, flexible catheters which enter the body through blood vessels in the leg and reach the internal walls of the heart. Time, expertise and specialized equipment are necessary to identify characteristics specific to each patient's arrhythmia. For each arrhythmia, a unique electrical blueprint is created before trying to eliminate it. The fleeting nature of certain arrhythmias can make it difficult to generate these blueprints, and many take a lot of time to accurately identify, leading to procedural challenges. Here we evaluate studies discussing the use of a new catheter (AcQMap) and its accompanying strategy for identifying arrhythmias. Unlike traditional catheters that require direct contact with the internal walls of the heart, the AcQMap catheter floats within these blood-filled chambers and does not touch the walls when obtaining data points. Instead, using ultrasound waves and electrical signals, it can generate data points to create blueprints. This technology also uses a new algorithm that enables the catheter to move freely within the heart, obtaining numerous data points and grouping them together to create maps efficiently and safely, even for fleeting or challenging arrhythmias.

How well do ED physician practices align with the CAEP acute atrial fibrillation checklist for stroke prevention and disposition?

OBJECTIVES: Acute atrial fibrillation (AF)/flutter (AFL) is a common emergency department (ED) presentation. In 2021, an updated version of CAEP's Acute AF/AFL Best Practices Checklist was published, seeking to guide management. We assessed the alignment with and safety of application of the Checklist, regarding stroke prevention and disposition. METHODS: This health records review included adults presenting to two tertiary care academic EDs between January and August 2022 with a diagnosis of acute AF/AFL. Patients were excluded if their initial heart rate was < 100 or if they were hospitalized. Data extracted included: demographics, CHADS-65 score, clinical characteristics, ED treatment and disposition, and outpatient prescriptions and referrals. Our primary outcome was the proportion of patient encounters with one or more identified safety issues. Each case was assessed according to seven predetermined criteria from elements of the CAEP Checklist and either deemed "safe" or to contain one or more safety issues. We used descriptive statistics with 95% confidence intervals. RESULTS: 358 patients met inclusion criteria. The mean age was 66.9 years, 59.2% were male and 77.4% patients had at least one of the CHADS-65 criteria. 169 (47.2%) were not already on anticoagulation and 99 (27.6%) were discharged home with a new prescription for anticoagulation. The primary outcome was identified in 6.4% (95% CI 4.3-9.5) of encounters, representing 28 safety issues in 23 individuals. The safety concerns included: failure to prescribe anticoagulation when indicated (n = 6), inappropriate dosing of a direct oral anticoagulant (DOAC) (n = 2), inappropriate prescription of rate or rhythm control medication (n = 9), and failure to recommend appropriately timed follow-up for new rate control medication (n = 11). CONCLUSIONS: There was a very high level of ED physician alignment with CAEP's Best Practices Checklist regarding disposition and stroke prevention. There are opportunities to further improve care with respect to recommendation of anticoagulation and reducing inappropriate prescriptions of rate or rhythm medications.

RéSUMé: OBJECTIFS: La fibrillation auriculaire aiguë (FA)/flutter (FAT) est une présentation courante aux urgences (SU). En 2021, une version mise à jour de la liste de vérification des pratiques exemplaires en matière de FA/FAT aiguë du CAEP a été publiée, dans le but de guider la direction. Nous avons évalué l'harmonisation et la sécurité de l'application de la liste de contrôle en ce qui concerne la prévention et la disposition des AVC. MéTHODES: Cet examen des dossiers de santé comprenait des adultes qui se sont présentés à deux urgences universitaires de soins tertiaires entre janvier et août 2022 avec un diagnostic d'AF/AFL aigu. Les patients étaient exclus si leur fréquence cardiaque initiale était inférieure à 100 ou s'ils étaient hospitalisés. Les données extraites comprenaient les données démographiques, le score CHADS-65, les caractéristiques cliniques, le traitement et la disposition des urgences, ainsi que les prescriptions et les références ambulatoires. Notre résultat principal était la proportion de patients qui rencontraient un ou plusieurs problèmes de sécurité identifiés. Chaque cas a été évalué selon sept critères prédéterminés à partir des éléments de la liste de vérification du PPVE et jugé « sécuritaire ¼ ou comportant un ou plusieurs problèmes de sécurité. Nous avons utilisé des statistiques descriptives avec des intervalles de confiance de 95 %. RéSULTATS: 358 patients répondaient aux critères d'inclusion. L'âge moyen était de 66.9 ans, 59.2% étaient des hommes et 77.4% des patients avaient au moins un des critères CHADS-65. 169 (47.2%) n'étaient pas déjà sous anticoagulation et 99 (27.6%) ont été renvoyés à la maison avec une nouvelle prescription d'anticoagulation. Le critère de jugement principal a été identifié dans 6.4 % (IC à 95 % 4.3­9.5) des rencontres, ce qui représente 28 problèmes d'innocuité chez 23 personnes. Parmi les préoccupations en matière d'innocuité, mentionnons l'omission de prescrire un anticoagulant lorsque cela est indiqué (n = 6), l'administration inappropriée d'un anticoagulant oral direct (n = 2), la prescription inappropriée d'un médicament pour contrôler le rythme ou le rythme (n = 9), et l'omission de recommander un suivi bien chronométré vers le haut pour le nouveau médicament de contrôle de taux (n = 11). CONCLUSIONS: Il y avait un très haut niveau d'harmonisation des médecins de l'urgence avec la liste de vérification des pratiques exemplaires de l'ACMU en ce qui concerne la disposition et la prévention des accidents vasculaires cérébraux. Il est possible d'améliorer davantage les soins en ce qui concerne la recommandation d'anticoagulation et de réduire les prescriptions inappropriées de médicaments à taux ou à rythme.

Predictors of atrial fibrillation detection in embolic stroke of undetermined source patients with implantable loop recorder.

Background: Covert atrial fibrillation (AF) is a predominant aetiology of embolic stroke of undetermined source (ESUS). Evidence suggested that AF is more frequently detected by implantable loop recorder (ILR) than by conventional monitoring. However, the predictive factors associated with occult AF detected using ILRs are not well established yet. In this study we aim to investigate the predictors of AF detection in patients with ESUS undergoing an ILR. Methods: This observational multi-centre study included consecutive ESUS patients who underwent ILR implantation. The infarcts were divided in deep, cortical infarcts or both. The infarction sites were categorized as anterior and middle cerebral artery, posterior cerebral artery with and without brainstem/cerebellum involvement. Multivariable logistic regression analysis was performed to investigate variables associated with AF detection. Results: Overall, 3,000 patients were initially identified. However, in total, 127 patients who consecutively underwent ILR implantation were included in our analysis. AF was detected in 33 (26%) out of 127 patients. The median follow-up was 411 days. There were no significant differences in clinical characteristics and comorbidities between patients with and without AF detected. AF was detected more often after posterior cerebral artery infarct with brainstem/cerebellum involvement (p < 0.001) whereas less often after infarction in the anterior and middle cerebral artery (p = 0.021). Multivariable regression analysis demonstrated that posterior cerebral artery infarct with brainstem/cerebellum involvement was an independent predictor of AF detection. Conclusion: Our study showed that posterior circulation infarcts with brainstem/cerebellum involvement are associated with AF detection in ESUS patients undergoing ILR. Larger prospective studies are needed to validate our findings.

Atrial Arrhythmias in Patients With Pulmonary Hypertension.

TOPIC IMPORTANCE: Atrial arrhythmia (AA) are common in patients with pulmonary hypertension (PH) and contribute to morbidity and mortality. Given the growing PH population, understanding the pathophysiology, clinical impact, and management of AA in PH is important. REVIEW FINDINGS: AA occurs in PH with a 5-year incidence of 10% to 25%. AA confers a higher morbidity and mortality, and restoration of normal sinus rhythm improves survival and functionality. AA is thought to develop because of structural alterations of the right atrium caused by changes to the right ventricle (RV) due to elevated pulmonary artery pressures. AA can subsequently worsen RV function. Current guidelines do not provide comprehensive recommendations for the management of AA in PH. Robust evidence to favor a specific treatment approach is lacking. Although the role of medical rate or rhythm control, and the use of cardioversion and ablation, can be inferred from other populations, evidence is lacking in the PH population. Much remains to be determined regarding the optimal management strategy. We present here our institutional approach and discuss areas for future research. SUMMARY: This review highlights the epidemiology and pathophysiology of AA in patients with PH, describes the relationship between AA and RV dysfunction, and discusses current management practices. We outline our institutional approach and offer directions for future investigation.

Effect of SGLT-2 inhibitors on arrhythmia events: insight from an updated secondary analysis of > 80,000 patients (the SGLT2i-Arrhythmias and Sudden Cardiac Death).

OBJECTIVE: We aimed to assess the effect of SGLT2i on arrhythmias by conducting a meta-analysis using data from randomized controlled trials(RCTs). BACKGROUND: Sodium-glucose co-transporter 2 inhibitors (SGLT2i) have shown cardioprotective effects via multiple mechanisms that may also contribute to decrease arrhythmias risk. METHODS: We searched in databases (PubMed, Embase, Cochrane Library, and clinicaltrials.gov) up to April 2023. RCTs comparing SGLT2i with placebo were included. The effects of SGLT2i on atrial fibrillation(AF), atrial flutter(AFL), composite AF/AFL, ventricular fibrillation(VF), ventricular tachycardia(VT), ventricular extrasystoles(VES), sudden cardiac death(SCD) and composite VF/VT/SCD were evaluated. RESULTS: 33 placebo-controlled RCTs were included, comprising 88,098 patients (48,585 in SGLT2i vs. 39,513 in placebo). The mean age was 64.9 ± 9.4 years, 63.0% were male. The mean follow-up was 1.4 ± 1.1 years. The pooled-results showed that SGLT2i was associated with a significantly lower risk of AF [risk ratio(RR): 0.88, 95% confidence interval(CI) 0.78-1.00, P = 0.04] and composite AF/AFL (RR: 0.86, 95%CI 0.77-0.96, P = 0.01). This favorable effect appeared to be substantially pronounced in patients with HFrEF, male gender, dapagliflozin, and > 1 year follow-up. For SCD, only in heart failure patients, SGLT2i were found to be associated with a borderline lower risk of SCD (RR: 0.67, P = 0.05). No significant effects of SGLT2i on other ventricular arrhythmic outcomes were found. CONCLUSIONS: SGLT2i lowers the risks of AF and AF/AFL, and this favorable effect appeared to be particularly pronounced in patients with HFrEF, male gender, dapagliflozin, and longer follow-up (> 1 year). SGLT2i lowers the risk of SCD only in heart failure patients.