Background: Patients with Marfan syndrome (MFS) are at an increased risk of ventricular arrythmia (VA) and death. Objective: This retrospective observational study aimed to assess the role of electrocardiographic parameters of repolarization and dispersion in risk stratification. Methods: Baseline 12-lead electrocardiograms were obtained from consecutive patients with MFS treated at a tertiary care specialized outpatient clinic and from age- and sex-matched controls. In patients with MFS, we studied the association of established parameters of repolarization and dispersion with a combined primary end point of VA or all-cause mortality using Cox regression analysis. Results: A total of 89 patients with MFS (mean age 42 ± 14 years; 54 (61%) women) and 92 controls were included in the analysis. The mean QRS duration (97 ms vs 87 ms) was longer, and the mean corrected QT interval (411 ms vs 379 ms) and T-peak–T-end interval (67 ms vs 62 ms) were also longer in patients with MFS. During a median follow-up of 5.05 years (interquartile range 3.43–10.0 years), 11 patients with MFS (12%) had VA or died. In univariable analyses, male sex (hazard ratio [HR] 5.01; 95% confidence interval [CI] 1.051–23.87), history of atrial fibrillation (HR 9.51; 95% CI 2.51–36.01), larger left atrial volume (HR 1.35 per 10-mL increase; 95% CI 1.12–1.64 per 10-mL increase), and higher N-terminal pro–B-type brain natriuretic peptide levels (HR 1.05 per 100-pg/mL increase; 95% CI 1.03–1.07 per 100-pg/mL increase) were associated with the primary end point, but QRS duration, corrected QT interval, and T-peak–T-end interval or their derivatives were not associated with the primary end point. Conclusion: Electrocardiographic parameters of repolarization and dispersion are altered in patients with MFS, but their role in risk stratification may be limited.

Evidence is limited on an early treatment strategy for any type of recent-onset atrial fibrillation (AF), comparing anti-arrhythmic drug (AAD) therapy to catheter ablation of patients presenting to the emergency department (ED). The purpose of the EMERGE Cryo study is to investigate the impact of early catheter ablation in patients presenting to the ED with recent-onset AF.The EMERGE Cryo study is a prospective, 2-arm, randomized, open-label, blinded endpoint, multicentre study to investigate the impact of first-line ablation vs AAD in patients presenting to the ED (within the preceding 2 weeks) with recent-onset (≤ 1 year) paroxysmal or persistent AF (longest AF episode < 6-month duration). All study participants receive an implantable loop recorder. Randomization is based on a 1:1 ratio into 2 study arms: (i) cryo-AF-ablation: pulmonary vein isolation performed with cryoballoon; and (ii) usual care: AAD therapy, including electrical cardioversion, if necessary. A total of 350 patients will be randomized.Both arms have a blanking period or an AAD optimization period of 3 months, during which adapting the therapy will be allowed. This trial is designed to elaborate whether early AF ablation is superior to usual care. The primary effectiveness endpoint is freedom from any atrial tachyarrhythmia (> 30 seconds) through 3-12 months of follow-up on implantable loop recorder monitoring. Patients will be followed up for 36 months in total.EMERGE Cryo aims to determine the value of early catheter ablation in AF patients presenting with any type of AF to the ED. Clinical Trial Registration:NCT05294445.

Background: The automated NavX Ensite Precision latency-map (LM) algorithm aims to identify atrial tachycardia (AT) mechanisms. However, data on a direct comparison of this algorithm with conventional mapping are scarce. Methods: Patients scheduled for AT ablation were randomized to mapping with the LM-algorithm (LM group) or to conventional mapping (conventional only group: ConvO), using entrainment and local activation mapping techniques. Several outcomes were exploratively analyzed. Primary endpoint was intraprocedural AT Termination. If AT termination with only automated 3D-Mapping failed, additional conventional methods were applied (conversion). Results: A total of 63 patients (mean 67 years, 34 % female) were enrolled. In the LM group (n = 31), the correct AT mechanism was identified in 14 patients (45 %) using the algorithm alone compared to 30 patients (94 %) with conventional methods. Time to termination of the first AT was not different between groups (LM group 34 & PLUSMN; 20 vs. ConvO 43.1 & PLUSMN; 28.3 min; p = 0.2). However, when AT termination did not occur with LM algorithm, time to termination prolonged significantly (65 & PLUSMN; 35 min; p = 0.01). After applying conventional methods (conversion), procedural termination rates did not differ between LM group (90 %) vs. ConvO (94 %) (p = 0.3). During a follow-up time of 20 & PLUSMN; 9 months, no differences were observed in clinical outcomes. Conclusion: In this small prospective, randomized study, the use of the LM algorithm alone may lead to AT termination, but less accurate than conventional methods.

Marfan´s syndrome caused by FBN1 mutation is associated with sudden cardiac death and ventricular arrhythmias. Data evaluating predictors for these events is scarse. We evaluated predictors of rhythm events and sudden cardiac death in patients with Marfan`s syndrome. In this prospective study 94 adult marfan patients (60 % male, 42 ± 15 years) with FBN1 mutation and a follow up of at least 1 months (median: 5 years, IQR: 3.1 - 10) were included. Baseline serum N-terminal pro-brain natriuretic peptide (NT-proBNP), transthoracic echocardiogram, 12-lead resting ECG and epidemiological parameters were assessed for further analysis and predictor selection. Primary endpoint was composed of ventricular tachycardia, arrhythmogenic syncope or sudden cardiac death. In a mean follow-up time of 6.1 ± 4 years 15 (16 %) marfan patients suffered from rhythm event or sudden cardiac death.Left atrial volume, age, mitral-valve prolaps, impaired left ventricular ejection fraction, NT-proBNP, gender, QRS duration, T-peak-T-end intervals with derivatives and aortic bulbus diameter index were included in further model selection process. We then performed statistical learning methods with best subset selection for model evaluation to identify predictors of composite endpoint. Subsequent multivariate Cox-regression analysis revealed hazard ratios. LA volume (ml) (HR 1.03 per ml, p<0.001), impaired left ventricular ejection fraction (HR: 41.7, p<0.001), male-gender (HR: 4.5, p=0.06), QRS duration (HR: 1.03 per ms, p=0.02) and TpTe maximum (HR: 1.08 per ms, p=0.02) were identified as independent predictors for the combined primary endpoint. NT-proBNP was highly correlated to LA volume and therefore was not significant in the multivariate model. In a statistical learning model combination of echocardiographic and electrocardiographic parameters performed best in prediction power of rhythm events and sudden cardiac death in patients with Marfan´s syndrome.

Abstract Background Atrioventricular conduction disturbance may rarely be caused by cardiac involvement of sarcoidosis. Case summary A 20-year-old Caucasian female with exertional dyspnoea was admitted to the hospital. Electrocardiogram revealed intermittent complete atrioventricular block with ventricular escape rhythm. Laboratory findings indicated no obvious cause for the complete heart block, and echocardiography showed no abnormalities with normal systolic left ventricular function. However, in gadolinium-enhanced cardiovascular magnetic resonance imaging, a mass at the basal septum with high intensity of T2-weighted signal was found, and 18-fluorodeoxyglucose positron emission tomography revealed severe enhancement in this area and in the mediastinal lymph nodes. The diagnosis of cardiac sarcoidosis was established by the detection of non-caseating epithelioid granulomas in the endobronchial lymph node biopsy. Corticosteroid therapy with oral administration of 30 mg prednisolone was initiated, and complete recovery of atrioventricular block was observed within several weeks, obviating the need for permanent pacemaker implantation. Discussion Cardiac sarcoidosis can cause complete atrioventricular block and should always be considered, especially in younger patients. Early diagnosis and initiation of corticosteroid therapy may lead to complete recovery of conduction system without the need for permanent pacemaker implantation.

Left atrial (LA) thrombus formation is the presumed origin of thromboembolic complications in patients with atrial fibrillation (AF). Beyond clinical risk factors, the factors causing formation of LA thrombi are not well known. In this case-control study, we analyzed clinical characteristics and genetic thrombophilia markers (factor V Leiden (FVL), prothrombin G20210A (FIIV), Tyr2561 variant of von Willebrand factor (VWF-V)) in 42 patients with AF and LA thrombus (LAT) and in 68 control patients with AF without LAT (CTR). Patients with LAT had more clinical conditions predisposing to stroke (mean CHA 2 DS 2 -VASc-score 3.4 ± 1.5 vs. 1.9 ± 1.4; P < 0.001), a higher LA volume (96 ± 32 vs. 76 ± 21 ml, P = 0.002) and lower LA appendage emptying velocity (0.21 ± 0.11vs. 0.43 ± 0.19 m/s, P < 0.001). Prevalence of FVL, FIIV and VWF-V mutations was not different, but in the subgroup of patients <65 years (y) there was a tendency for a higher incidence of VWF-V with a prevalence of 27% (LAT <65 y) vs. 7% (CTR <65 y, P = 0.066). These findings warrant further investigation of the VWF-V as a risk factor for LA thrombogenesis in younger patients.

Background Complex ablation for persistent atrial fibrillation (AF) aims to modify the arrhythmogenic substrates to become incapable to perpetuate the arrhythmia. Ablation-associated determinants of atrial tachycardia (AT) rather than AF recurrences are unknown. The aim of the study was to evaluate the association between the type of arrhythmia recurrence and electrophysiological findings during redo procedures. Methods A total number of 384 consecutive patients with persistent AF underwent complex ablation consisting of PV isolation (PVI), biatrial electrogram-guided ablation, and linear ablation with the desired procedural endpoint of AF termination. Electrophysiological findings during redo procedures and its relation to AR type are the subject of this study. Results Overall, 177 (46%) patients underwent a second procedure. Patients with AT recurrences had significantly more often persistent PVI (47 vs. 25%; P = 0.002). Moreover, a higher number of recovered PVs were associated with AF recurrence (3 PVs recovered, AF = 16.1% vs. AT = 5.2%; P = 0.02; 4 PVs recovered, AF = 18.5% vs. AT = 6.3%; P = 0.01), regardless of the extent of substrate ablation during the first procedure. Conclusions Durable PV isolation but not the extent of atrial substrate ablation determines the type of arrhythmia recurrence. Thus, the PVs may represent dominant perpetuators (and not only triggers) of persistent AF even in the presence of a significantly modified atrial substrate.

Aims Weight management seems to be beneficial for obese atrial fibrillation (AF) patients; however, randomized data are sparse. Thus, this study aimed to investigate the influence of weight reduction on AF ablation outcomes. Methods and results SORT-AF is an investigator-sponsored, prospective, randomized, multicentre, and clinical trial. Patients with symptomatic AF (paroxysmal or persistent) and body mass index (BMI) 30-40 kg/m(2) underwent AF ablation and were randomized to either weight-reduction (group 1) or usual care (group 2), after sleep-apnoea-screening and loop recorder (ILR) implantation. The primary endpoint was defined as AF burden between 3 and 12 months after AF ablation. Overall, 133 patients (60 +/- 10 years, 57% persistent AF) were randomized to group 1 (n = 67) and group 2 (n =66), respectively. Complications after AF-ablation were rare (one stroke and no tamponade). The intervention led to a significant reduction of BMI (34.9 +/- 2.6-33.4 +/- 3.6) in group 1 compared to a stable BMI in group 2 (P <0.001). Atrial fibrillation burden after ablation decreased significantly (P < 0 .001), with no significant difference regarding the primary endpoint between the groups (P = 0 .815, odds ratio: 1.143, confidence interval: 0.369-3.613). Further analyses showed a significant correlation between BMI and AF recurrence for patients with persistent AF compared with paroxysmal AF patients (P = 0.032). Conclusion The SORT-AF study shows that AF ablation is safe and successful in obese patients using continuous monitoring via ILR. Although the primary endpoint of AF burden after ablation did not differ between the two groups, the effects of weight toss and improvement of exercise activity were beneficial for obese patients with persistent AF demonstrating the relevance of life-style management as an important adjunct to AF ablation in this setting.

Background Catheter ablation of non-reentrant, commonly termed “idiopathic” ventricular arrhythmias (VA) is highly effective in patients without structural heart disease (SHD). Meanwhile, the outcome of catheter ablation of these arrhythmias in patients with SHD remains unclear. This study sought to characterize the outcome of patients with and without SHD undergoing catheter ablation of non-reentrant VA. Methods In this single-centre study the acute and long-term outcome of 266 consecutive patients undergoing catheter ablation of non-reentrant VA was investigated. In 41.0% of patients a SHD was present ( n = 109, 80.7% male, age 59.1 ± 14.7 years), 59.0% had no SHD ( n = 157; 44.0% male, age 49.9 ± 16.5 years). Results Acute procedural success (absence of spontaneous or provoked VA at the end of procedure and within 48 h after the procedure) was achieved in 89.9% of patients with SHD vs. 94.3% without SHD ( p = 0.238). During a mean follow-up of 34.7 ± 15.1 months a repeat catheter ablation was performed in 19.6% of patients with SHD vs. 13.0% without SHD ( p = 0.179). Patients with dilated cardiomyopathy (DCM) were the most likely to require a repeat ablation procedure (32.0% of patients with DCM vs. 13.0% without SHD; p = 0.022). Periprocedural complications occurred in 5.5% of patients with SHD vs. 5.7% without SHD ( p > 0.999). All complications were managed without sequelae. Conclusions The outcome of catheter ablation of non-reentrant VA in patients with SHD appears good and is comparable to patients without SHD. A slightly higher rate of repeat ablations was observed in patients with DCM.

BACKGROUND:Arterial stiffness is a strong predictor of atrial fibrillation in the community. Whether noninvasively measured conduit artery function and peripheral vascular reactivity are related to atrial fibrillation remains unknown. METHODS AND RESULTS:In 15 010 individuals of the population-based Gutenberg Health Study, mean age 55 ± 11 years, 50.5% men, we determined noninvasive vascular function by flow-mediated dilation (FMD) and peripheral arterial tonometry (PAT) in relation to manifest atrial fibrillation (N = 466). Patients with atrial fibrillation exhibited a higher mean brachial artery diameter [4.81 mm (4.17, 5.33) in atrial fibrillation vs. 4.31 mm (3.67, 4.93)] and baseline pulse amplitude in arbitrary units [6.35 (5.76, 6.78) in atrial fibrillation vs. 6.09 (5.36, 6.71)] as well as a reduced FMD in arbitrary units [1.29 (1.26, 1.33) in atrial fibrillation vs. (1.31 (1.26, 1.37)] and PAT ratio [0.42 (0.19, 0.77) in atrial fibrillation vs. 0.67 (0.33, 0.94)] compared with individuals without atrial fibrillation (all PWilcoxon rank-sum test). In age-adjusted and sex-adjusted logistic regression analyses, only baseline brachial artery diameter [odds ratio (OR) per standard deviation 1.19; 95% confidence interval (CI), 1.04-1.37; P = 0.012] and PAT ratio (OR 0.83; 0.74-0.94; P = 0.0029) were associated with atrial fibrillation. In risk factor and heart rate-adjusted models, there was no statistically significant correlation of atrial fibrillation and brachial artery diameter, FMD and PAT ratio while baseline pulse amplitude was reduced in individuals with atrial fibrillation (OR 0.81; 95% CI 0.71-0.93; P = 0.0034). CONCLUSION:In our large contemporary cohort, peripheral vascular function was compromised in individuals with atrial fibrillation. However, observed associations were mediated by age and classical risk factors. Noninvasive vascular function measures did not improve discriminatory ability for atrial fibrillation.

Long‐term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long‐term follow‐up using continuous atrial rhythm monitoring (CARM).

Procedural atrial fibrillation (AF) termination is considered as a predictor of long‐term success after catheter ablation for persistent AF (persAF). However, some patients remain free of arrhythmia recurrences despite failure to achieve AF termination. The objective of this study was to assess long‐term outcome and prognostic factors in patients undergoing complex ablation without procedural AF termination.

Introduction Comparative data of early recurrence rates of atrial fibrillation (ERAF) following second-generation cryoballoon (CB-G2) and radiofrequency current (RFC) ablation for pulmonary vein isolation (PVI) in paroxysmal AF (PAF) are rare. We randomized PAF patients into either PVI with CB-G2 (group 1) or PVI with a combined RFC-approach applying contact force (CF) with the endpoint of unexcitability (group 2) to investigate ERAF. Methods and results In group 1 (n = 30), CB-G2-PVI was performed. After CF-PVI in group 2 (n = 30), bipolar pacing on the ablation line and additional ablation until unexcitability was conducted. Follow-up included 48 h of in-hospital monitoring followed by 5-day Holter ECGs 1, 2, 3, 6, 12 months postablation to evaluate ERAF. Acute PVI was reached in 100% of group 2 and in 99% of group 1. Shorter procedure durations (98.0 ± 21.9 vs. 114.3 ± 18.7 min, P < 0.05) but extended fluoroscopy times (15.4 ± 3.9 vs. 10.0 ± 4.3 min, P < 0.05) were found in the CB-G2 group. Ten non-severe complications occurred (6 vs. 4 in group 1 and 2, P = 0.73). In group 2, five patients suffered from ERAF vs. seven patients in group 1 (P = 0.67). The time until the occurrence of ERAF was shorter in group 2 (1 day (q1-q3: 1-4.5)) when compared with group 1 (22 (q1-q3: 6-54) days, P = 0.025). Conclusion ERAF rates were equal among groups; however, they occurred earlier in the initial phase after RFC ablation when compared with CB-G2. PVI utilizing cryoablation is associated with shorter procedure durations but extended fluoroscopy time while being similarly secure.

Sex differences in cardiovascular risk factors, cardiac structure and function, and disease and symptom burden in the common arrhythmia atrial fibrillation (AF) have not been investigated systematically at the population level. Cross-sectional data of 14,796 subjects (age range 35 to 74 years, 50.5% men) from the population-based Gutenberg Health Study were examined to show the distribution of cardiovascular risk factors by AF status and sex, and to determine sex-specific predictors for AF. The prevalence of AF was higher in men (4.3%) than in women (1.9%). Men had a worse cardiovascular risk factor profile, a higher prevalence of cardiovascular disease, but fewer symptoms than women. Age-adjusted Cox regressions showed sex interactions in the association of high-density lipoproteincholesterol, triglycerides, diabetes mellitus, coronary artery disease, myocardial infarction, generalized anxiety disorder, and heart rate with AF. After multivariable adjustment, sex interactions were seen for thickness of interventricular end-diastolic septum, odds ratio (OR) per standard deviation (SD), 95% confidence interval women: 0.9 (0.8,1.1), men: 1.2 (1.1, 1.4), interaction p value = 0.02; left atrial diameter index, OR per SD women: 1.5 (1.3,1.8), men: 1.9 (1.7, 2.1), interaction p value = 0.03; and myocardial infarction, OR women: 2.7 (1.3, 5.6), men: 0.7 (0.5,1.1), interaction p value = 0.002. In conclusion, in our large cohort, we observed substantial sex differences in AF distribution and clinical characteristics including comorbidities, symptom burden, and structural cardiac changes. (C) 2018 Elsevier Inc. All rights reserved. (Am J Cardiol 2018;122:76-82)

AIMS:To evaluate the incidence of newly diagnosed intracardiac thrombi (ICT) in respect to the mode of OAC in patients undergoing cardioversion (CV). METHODS AND RESULTS:We prospectively assessed transesophageal echocardiography (TEE) and OAC therapy prior to CV in AF patients with ≥48-hour duration scheduled for CV. A total of 60 first-time ICT (4.7%) were diagnosed in 1,286 TEE, with highest rate in patients without OAC (9.6% vs. OAC 4.1%, P  =  0.009) and an apparently lower rate in nonvitamin K antagonist anticoagulants (NOAC) therapy compared to vitamin K antagonist (VKA) (2.5% vs. 5.3%, P  =  0.02). VKA therapy control 4 weeks prior to CV was overall average (time in therapeutic range 60%) and patients showed more frequently clinical characteristics and TEE parameters associated with risk for ICT. Even among patients with effective OAC therapy (uninterrupted NOAC and VKA therapy with international normalized ratio (INR) ≥2.0 for 3 weeks), ICT occurred in 2.7%, but with no difference between both groups (P  =  0.22). There was no difference between different types of NOAC. Independent predictors for ICT were history of embolism, hypertension, BMI, absence of OAC, renal function, reduced atrial appendage flow, and presence of spontaneous echo contrast. CONCLUSION:NOAC therapy seems favorable in the overall prevention of ICT, although this is likely to be caused by suboptimal VKA therapy control and differences in the overall health status between VKA and NOAC patients. ICT occurred even with effective OAC therapy suggesting individual TEE-guided cardioversion in patients at risk.

Background: Fingolimod can lead to increased risk of cardiac events such as bradycardia or atrioventricular (AV) block. Objective: Evaluate acute and long-term effects of fingolimod on heart rhythm (HR), heart rate variability (HRV) and development of AV-blocks. Methods: In 64 patients with relapsing-remitting multiple sclerosis Holter ECG monitoring (HEM) and HRV analysis were performed 24 h before, six h during and 72 h after initiation of fingolimod. We additionally analyzed a 24 h HEM after a follow up of >= three months. Results: Heart rate (HR) decreased significantly (p < 0.001) under fingolimod treatment with nadir at five hours after starting and maintained decreased for 72 h. Five (7.8%) patients suffered from new-onset AV-block requiring cessation of treatment. In four of five patients (80%), the AV-block could only be documented in the 72 h-HEM with a median time of occurrence at 14 h. The mean heart rate was still significant lower after a mean follow up time of 14.1 +/- 9.6 months (85.0 +/- 9.8 vs. 75.3 +/- 16.2 bpm; p = 0.002) in comparison to baseline. Conclusion: The treatment with fingolimod leads to an increase of vagal activation which persists even after 14 months of treatment. These changes did not return to baseline levels on treatment with fingolimod. Based on our data an additional at least 24 h hour-HEM after the initiation of fingolimod therapy should be considered.

AimsDuring ablation in the vicinity of the coronary arteries establishing a safe distance from the catheter tip to the relevant vessels is mandatory and usually assessed by fluoroscopy alone. The aim of the study was to investigate the feasibility of an image integration module (IIM) for continuous monitoring of the distance of the ablation catheter tip to the main coronary arteries during ablation of ventricular arrhythmias (VA) originating in the sinus of valsalva (SOV) and the left ventricular summit part of which can be reached via the great cardiac vein (GCV).Methods and resultsOf 129 patients undergoing mapping for outflow tract arrhythmias from June 2014 till October 2015, a total of 39 patients (52.4 ± 18.1 years, 17 female) had a source of origin in the SOV or the left ventricular summit. Radiofrequency (RF) ablation was performed when a distance of at least 5 mm could be demonstrated with IIM. A safe distance in at least one angiographic plane could be demonstrated in all patients with a source of origin in the SOV, whereas this was not possible in 50% of patients with earliest activation in the summit area. However, using the IIM a safe position at an adjacent site within the GCV could be obtained in three of these cases and successful RF ablation performed safely without any complications. Ablation was successful in 100% of patients with an origin in the SOV, whereas VAs originating from the left ventricular summit could be abolished completely in only 60% of cases.ConclusionImage integration combining electroanatomical mapping and fluoroscopy allows assessment of the safety of a potential ablation site by continuous real-time monitoring of the spatial relations of the catheter tip to the coronary vessels prior to RF application. It aids ablation in anatomically complex regions like the SOV or the ventricular summit providing biplane angiograms merged into the three-dimensional electroanatomical map.

Slow pathway modulation is the treatment of choice in patients with atrioventricular nodal reentrant tachycardia (AVNRT). No comparative data on ablation strategies exist. Therefore, we sought to compare two common ablation approaches.