INTRODUCTION:Catheter ablation of persistent atrial fibrillation yields sub-optimal success rates partly due to the considerable heterogeneity within the patient population. Identifying distinct patient phenotypes based on post-ablation prognosis could improve patient selection for additional therapies and optimize treatment strategies. METHODS:We studied all patients who underwent catheter ablation of persistent atrial fibrillation in the DECAAF II trial. Out of 44 participating centers, 25% were randomly chosen as a validation set. A Gradient Boosting Method determined essential features for arrhythmia recurrence prediction and the number of clusters was determined according to the average silhouette width. K-medoids cluster analysis identified subgroups based on these features, and Kaplan-Meier curves were further compared among different clusters. RESULTS:Among 815 patients, 570 served as a training set and 245 as a validation set. Using the training set, the GBM model achieved an AUC of 0.874. K-medoids cluster analysis used LA volume, BMI, baseline fibrosis, and age, resulting in two clusters. Cluster 1 patients were older, had higher baseline fibrosis, higher BMI, and greater LA volume compared to Cluster 2. Atrial arrhythmia recurrence rates were significantly higher in Cluster 1 (51.7% vs. 35.0%, p = 0.0002), and survival analysis showed a significant difference in primary recurrence outcomes (HR = 1.71, p < 0.0001). The validation set confirmed these findings. CONCLUSION:Utilizing machine learning, we identified a high-risk cluster for procedural failure in catheter ablation of persistent atrial fibrillation within the DECAAF II trial population. The primary differentiating factors of this high-risk cluster include older age, high left atrial fibrosis, elevated BMI, and increased left atrial volume.

Reverse takotsubo cardiomyopathy is triggered by emotional or physical stress and has a presentation similar to that of acute coronary syndrome. A 39-year-old woman with a history of heroin use disorder presented with intractable nausea, vomiting, and diarrhea. She was diagnosed with heroin withdrawal and started on buprenorphine-naloxone. On day 2 of her hospitalization, she developed chest heaviness and had an elevated troponin I level of 3.2 ng/mL (reference range, 0.015-0.045 ng/mL); electrocardiography showed new T-wave inversions in the anterior and inferior leads. Emergent coronary angiography showed patent coronary arteries, and left ventriculography showed basal hypokinesis and apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy secondary to heroin withdrawal. She was started on antihypertensive agents, and her buprenorphine-naloxone dose was increased. At her 3-month follow-up visit, she reported no symptoms consistent with angina or heart failure. This appears to be the first report of heroin withdrawal causing reverse takotsubo cardiomyopathy. Awareness of this association can lead to earlier recognition and treatment of reverse takotsubo cardiomyopathy.

Objective Early atrial arrhythmia recurrence following atrial fibrillation (AF) ablation is common. Current guidelines promulgate a 3-month blanking period. We hypothesize that early atrial arrhythmia recurrence during the blanking period may predict longer-term ablation outcomes. Methods and results A total of 688 patients with persistent AF undergoing catheter ablation were included in the DECAAF II trial database. The primary endpoint of the study was the first confirmed recurrence of atrial arrhythmia. Recurrence was also monitored during the 90-day blanking period. A total of 287 patients experienced recurrent atrial arrhythmia during the blanking period, while 401 remained in sinus rhythm. Rates of longer-term arrhythmia recurrence were substantially higher among those who developed recurrence during the blanking period compared to those who remained in sinus rhythm throughout the blanking period (68% vs. 32%, P < 0.001). The study cohort was divided into three groups according to the timing of arrhythmia recurrence during the blanking period. Of those who had recurrent arrhythmia during the first month of the blanking period (Group 1), 43.9% experienced longer-term recurrence, compared to 61.6% who recurred during the second month of the blanking period (Group 2), and 93.3% of those who had arrhythmia recurrence during the third month (Group 3, P < 0.001). The risk of recurrent arrhythmia was highest in Group 3 (HR = 10.15), followed by Group 2 (HR = 2.35) and Group 1 (HR = 1.5). Receiver operating characteristic analysis was performed to assess the relationship between the timing of arrhythmia recurrence and the primary outcome (AUC = 0.746, P < 0.001). The optimal blanking period duration was identified as 34 days. Atrial fibrillation burden determined by smartphone electrocardiogram technology over the 18 months follow-up period was significantly higher in Group 3 (29%) compared to Groups 1 (6%) and 2 (7%) and in patients who stayed in sinus rhythm during the blanking period (5%) (P < 0.0001). Conclusion Early atrial arrhythmia recurrence during the blanking period, particularly during the third month, is significantly associated with later recurrence. Although a blanking period is warranted, it should be abbreviated.

Conclusion:Although AP-map allowed us to acquire higherresolution maps in shorter time without changing activation pattern, amplitude and frequency of electrograms may be reduced as the cycle length of AP becomes shorter.

Introduction: Pulmonary vein isolation (PVI) using radiofrequency (RF) and cryoballoon (Cryo) ablation are standard approaches for rhythm control of symptomatic atrial fibrillation. Both strategies involve scar formation of the left atrium (LA). There have been few studies investigating the differences in residual fibrosis and scar formation in patients undergoing RF and Cryo using cardiac magnetic resonance imaging (CMR). Methods: The current study is a sub-analysis of the control arm of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation study (DECAAF II). The study was a multicenter, randomized, controlled, single blinded trial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus CMR atrial fibrosis guided ablation. Pre-ablation CMR and 3–6-month post ablation CMR were obtained to assess baseline LA fibrosis and scar formation respectively. Results: Of the 843 patients randomized in the DECAAF II trial, we analyzed the 408 patients in the primary analysis control arm that received standard PVI. Five patients received combined RF and Cryo ablations so were excluded from this sub-analysis. Of the 403 patients analyzed, 345 underwent RF and 58 Cryo. The average procedure duration was 146 minutes for RF and 103 minutes for Cryo (p = 0.001). The rate of AAR at ~15 months occurred in 151 (43.8%) patients in the RF group and 28 (48.3%) patients in the Cryo group (p = 0.62). On 3-month post CMR the RF arm had significantly more covered fibrosis (3.6% vs. 3.0%, p = 0.04) and scar (8.8% vs. 6.4%, p = 0.001) compared to Cryo. Patients with ≥ 6.5% LA scar on 3-month post CMR had less AAR independent of ablation technique (RF p = 0.009, Cryo p = 0.02). Cryo caused a greater percentage of right and left pulmonary vein (PV) scar (p = 0.04, p = 0.02) and less non-PV scar (p = 0.009) compared to RF. On Cox regression Cryo patients free of AAR had a greater percentage of left PV scar (p = 0.01) and less non-PV scar (p = 0.004) compared to RF free of AAR. Conclusion: In this sub-analysis of the control arm of the DECAAF II trial, there was no significant difference in the rate of AAR in patients undergoing PVI alone between RF vs. Cryo. Post ablation LA scar ≥ 6.5% predicted freedom from AAR, independent of ablation technique. Cryo formed a greater percentage of PV scar and less non-PV scar compared to RF, which may have prognostic implications.

Medium to long term effects of catheter ablation (CA) on left atrial (LA) function in patients with paroxysmal atrial fibrillation (AF) using cardiac magnetic resonance (CMR) are not well studied. Moreover, the changes in left ventricular(LV) diastolic filling patterns (by CMR) after CA have not been studied.

BACKGROUND Atrial fibrillation (AF) recurrence during the blanking period is under investigated. With the rise of smartphone-based electrocardiogram (ECG) monitoring, there's potential for better prediction and understanding of AF recurrence trends.OBJECTIVES In this study the authors hypothesize that AF burden derived from a single-lead Smartphone ECG during the blanking period predicts recurrence of atrial arrhythmias after ablation. METHODS 630 patients with persistent AF undergoing ablation were included from the DECAAF II (Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) trial. Patients recorded daily ECG strips using a smartphone device. AF burden was defined as the ratio of ECG strips with AF to the total number of strips submitted. The primary outcome was the recurrence of atrial arrhythmia.RESULTS Recurrence occurred in 301 patients during the 18-month follow-up period. In patients who developed recurrent arrhythmia after 90 days of follow-up, AF burden during the blanking period was significantly higher when compared with patients who remained in sinus rhythm (31.3% vs 7.5%; P < 0.001). AF burden during the blanking period was an independent predictor of arrhythmia recurrence (HR: 1.41; 95% CI: 1.36-1.47; P < 0.001). Through grid searching, an AF burden of 18% best discriminates between recurrence and no-recurrence groups, yielding a C-index of 0.748. After a follow-up period of 18 months, recurrence occurred in 33.7% of patients (147 of 436) with an AF burden <18% and in 79.4% of patients (154 of 194) with an AF burden >18% (HR: 4.57; 95% CI: 3.63-5.75; P < 0.001).CONCLUSIONS A high AF burden derived from a smartphone ECG during the blanking period is a strong predictor of atrial arrhythmia recurrences after ablation. (J Am Coll Cardiol EP 2023;9:2085-2095) (c) 2023 The Authors. Published by Elsevier on behalf of the American College of Cardiology Foundation. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

The presence of atrial fibrillation (AF) in heart failure (HF), especially HF with reduced ejection fraction (HFrEF), increases mortality and hospitalization. Little is known regarding outcomes of HF patients with preserved ejection fraction (HFpEF).

A 70-year-old man with a history of smoking presented at the emergency department with dyspnea and a 24-hour history of intermittent chest pain that had acutely worsened. His heart rate was 128 beats/min; blood pressure, 114/81 mmHg; respiratory rate, 24 breaths/min; and oxygen saturation, 85% on 4 L of oxygen. He had bibasilar crackles and a grade 3/6 holosystolic murmur over the left sternal border. A basic metabolic panel showed nothing unusual. A coronavirus nasopharyngeal swab test was negative. The patient's N-terminal pro-brain-type natriuretic peptide level was 1,583 pg/mL (normal, <100 pg/mL), and his cardiac troponin I level was 39 ng/mL (normal, ≤0.04 ng/mL). He became hypoxic and needed intubation. He was started on intravenous vasopressors and was taken to the cardiac catheterization laboratory, where an intra-aortic balloon pump was placed. His presenting electrocardiogram (ECG) is shown below (Fig. 1).In addition to ST-segment-elevation myocardial infarction (STEMI), what diagnosis should be suspected from this ECG?B) Ventricular septal ruptureIn cases of delayed STEMI, mechanical complications can occur. The differential diagnosis in acute myocardial infarction (AMI) complicated by a holosystolic murmur includes papillary muscle rupture (PMR) and ventricular septal rupture (VSR). Free wall rupture would not present with a holosystolic murmur, and aortic dissection resulting in aortic regurgitation would cause a diastolic murmur. Patients with acute PMR typically present with shock and acute pulmonary edema. In acute PMR, the systolic murmur may be soft or absent, given pressure equalization between the left ventricle and left atrium; conversely, in VSR, there is hemodynamic compromise and a harsh systolic precordial murmur.Inferior and anterior STE with inferior Q waves, such as in our patient's ECG, should raise suspicion for VSR.1 Hayashi and colleagues2 observed STE in the inferior and anterior leads in 42.9% of patients who had VSR, but in only 3.6% of patients without VSR. Moreover, abnormal Q waves appeared in all inferior leads (II, III, and aVF) in 44.4% of patients with VSR but in only 4% of those without.2 Whereas the ventricular septum receives a dual blood supply from the left anterior descending coronary artery (LAD) and right coronary artery, in a dominant “wrap-around” LAD, the ventricular apex is supplied only by the LAD. Occlusion of the LAD (Fig. 2, arrow) results in necrosis of the anterior and inferior walls, leading to STE in the anterior and inferior leads, and a risk of VSR (Fig. 3, arrow) if reperfusion is delayed.3 This case highlights that, in AMI, an ECG showing STE in the anterior and inferior leads with inferior Q waves should raise suspicion for VSR.Conflicts of interest: NoneFunding: None

Introduction: Radiofrequency (RFA) and cryoballon ablation are standard approaches for rhythm control of atrial fibrillation. Both strategies involve scar formation of the left atrial tissue. To date there have been no studies using post ablation cardiac magnetic resonance imaging (MRI) to assess residual fibrosis and scar created by standard radiofrequency and cryoballoon ablation. Methods: The current study is a sub analysis of the control group of the Delayed-Enhancement MRI Determinant of Successful Catheter Ablation of Atrial Fibrillation trial (DECAAF II). This was a multicenter, randomized, controlled, single blindedtrial that evaluated atrial arrhythmia recurrence (AAR) between PVI alone and PVI plus fibrosis guided ablation. Baseline MRI and 3-month post ablation MRI were obtained to assess lesion and scar formation. Results: Of the 843 patients randomized in the trial, 428 patients were in the control arm that received standard PVI alone. Of those 428 patients, 367 patients (85.7%) underwent RFA and 61 (14.3%) underwent cryoballoon ablation. Average procedure duration was 147 minutes for RFA and 107 minutes for cryoballoon (p = 0.001). The rate of AAR at 451 days was 42.0% in the RFA group and 45.9% in the cryoballoon group (p = 0.66). At the 3-month post MRI the RFA arm had significantly more left atrial scar formation compared to cryoballoon arm (8.8% vs. 6.4%, p = 0.001). Also, the RFA arm had more covered fibrosis (3.6% vs. 2.9%, p = 0.02) and less non-covered fibrosis (14.9% vs. 17.2%, p = 0.05) compared to the cryoballoon arm. The amount of scar formation did not predict AAR (p = 0.07). Conclusions: In this subanalysis of the DECAAF II trial, there was no significant difference in the rate of AAR between RFA and cryoballoon ablation. However, RFA caused significantly more left atrial scar compared to cryoballoon ablation on 3-month post MRI.

We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.

Background: Cardiogenic shock (CS) is a highly fatal condition characterized by cardiac dysfunction leading to inadequate tissue perfusion.Few studies have sought to clarify the rate of mortality among different patient populations hospitalized with CS, and none have investigated CS patients transferred for a higher level of care.Hypothesis: We hypothesized that transfer patients would experience a higher mortality rate compared to inpatients initially admitted to an academic medical center.Methods: Studied patients were hospitalized at an academic medical center with an ICD-9/10 discharge diagnosis of CS between 12/2015 and 8/2017.A chart review identified admission status: to the academic medical center or transferred from a referring facility.Mortality was defined as death in the hospital or as a discharge to hospice.Patient characteristics stratified by admission status were compared.Univariate and multivariate logistic regression analysis were performed.All variables reported as significant had a two-sided p-value ≤0.01, unless otherwise stated.Results: 508 patients were included in this analysis: 62% were male, 73% were Caucasian and mean age was 63 years.Presentation with STEMI was seen in 13% and ACS in 25% of patients.31% of patients were transferred from another facility.Transfer patients had a higher rate of mortality than non-transfer patients (43.6% vs 33.5%, p=0.03).Univariate predictors of mortality included admission post cardiac arrest, respiratory failure, acute renal failure, need for dialysis, lower SBP or MAP and elevated direct bilirubin, lactic acid or creatinine.Multivariate regression analysis identified admission post cardiac arrest, respiratory failure, acute renal failure, need for dialysis and elevated lactic acid as predictors of mortality.Transfer status was not an independent predictor when adjusted for comorbidities.Conclusion: In the study population, transfer patients have a higher severity of illness.This explains the increased mortality observed in this group, and indicates the need for early aggressive therapy in this population.A-2 Prolonged Impella 5.0 support is Safe and Used as a Bridge to Clinical Decision Making

Mortality from cardiogenic shock remains a significant clinical challenge. Short term mechanical circulatory support devices have the potential to improve outcomes. The Impella 5.0 is currently FDA approved for up to 10 days. We report our institutional experience with the Impella 5.0 as a means to improve survival and expand treatment options in patients presenting with severely decompensated end stage heart failure (HF) and cardiogenic shock. The Impella 5.0 can serve as an effective bridge to recovery or as an optimization tool for long-term support in patients with cardiogenic shock. A retrospective review was performed on all consecutive patients supported with Impella 5.0 from August 2017 to February 2018 at Froedtert and the Medical College of Wisconsin. A total of 19 Impella 5.0 devices were implanted in men and women as a “bridge to decision” regarding the potential for recovery vs. evaluation for long-term ventricular assist device (VAD). Eleven patients presented in cardiogenic shock and 8 in severely decompensated HF. All implantations were performed via axillary approach. The average number of pressors was 0.9 (range 0-3 pressors). The average norepinephrine dose was 0.15 mcg (range 0.04 - 0.33 mcg) and epinephrine 0.10 mcg (range 0.06 - 0.15 mcg). After Impella implantation, patients were on pressors for an average of 1.4 days (range 0 - 4 days). The average length of Impella duration was 14 days (range 0 - 36 days). There were no major adverse complications from prolonged Impella support. No devices malfunctioned and there were no reported strokes or major bleeding events. Two (11%) patients had hemolysis requiring device removal on days 6 and 18 respectively. Thrombocytopenia requiring more than 10 units of platelets occurred in 2 patients (11%). Seven patients (37%) died and twelve (63%) survived. Of those that survived seven (37%) regained their ejection fraction (EF) and five (26%) had a VAD placed. Of the seven (37%) that died, four were not VAD candidates (for psychosocial reasons) so decided on hospice/withdrawal of care and the other three died of worsening HF and rupture of a chronic abdominal aortic aneurysm. Prolonged hemodynamic support with Impella 5.0 is a safe and viable option for patients presenting with decompensated HF and cardiogenic shock as a bridge to decision strategy. Use of Impella support for more than 10 days was safe and did not result in major adverse events. This type of strategy allows for thorough evaluation for viable VAD candidates and offers potential for cardiac recovery in a sub-group of patients.

Introduction: Transfemoral access (TFA) is widely used for coronary angiography and percutaneous coronary intervention (PCI). The influence of operator age, gender, experience, and procedural volume on performance of femoral arterial access has not been studied. Methods: A survey instrument was developed and distributed via e-mail from professional societies to interventional cardiologists worldwide from March to December 2016. Results: A total of 988 physicians from 88 countries responded to the survey. TFA is the preferred approach for patients with cardiogenic shock, left main or bifurcation PCI, and procedures with mechanical circulatory support. Older (<50 years: 56.4%; >= 50 years: 66.8%, p < 0.0039) and high PCI volume operators (<100 PCI: 57.3%; 100-299 PCI: 58.7%; >= 300 PCI: 64.3%, p < 0.134) preferred palpation only without imaging (fluoroscopy or ultrasound (US)) for TFA. Most respondents preferred not to use micropuncture needle to puncture the femoral artery. Older (>= 50 years: 64.4%; <50 years: 71.5%, p < 0.04) and high PCI volume operators (>= 300 PCI: 64.1%; 100-299 PCI: 72.6%; <100 PCI: 67.9%, p < 0.072) tended not to perform femoral angiography (FA). Of those performing FA, the majority opted to do it at the end of the procedure. Conclusion: Despite best practice guideline recommendations, older and high PCI volume interventional cardiologists prefer not to use imaging for femoral access or perform femoral angiography during TF procedures. These data highlight opportunities to further reduce TFA complications. (C) 2017 Elsevier Inc. All rights reserved.

OBJECTIVES:The aim of this study was to examine the current practice and use of transfemoral approach (TFA) for coronary angiography and intervention. BACKGROUND:Wide variability exists in TFA techniques for coronary procedures. METHODS:The authors developed a survey instrument that was distributed via e-mail lists from professional societies to interventional cardiologists from 88 countries between March and December 2016. RESULTS:Of 987 operators, 18% were femoralists, 38% radialists, 42% both, and 2% neither. Access using femoral pulse palpation alone was preferred by 60% of operators, fluoroscopy guidance by 11%, and a combination of palpation, fluoroscopy, or ultrasound by 27%. Only 11% used micropuncture in >90% of their cases. Performing femoral angiography immediately after access was preferred by 23% and at the end of the procedure by 47%, and not done at all by 31% of operators. Hemostasis by manual compression was preferred by 50%, collagen plug vascular closure device by 31%, and suture-based vascular closure device by 11% of operators. Judkins left and right catheters were preferred for diagnostic angiography of the left (99%) and right (94%) coronary arteries. Extra backup curves (XB or EBU) were most commonly preferred for percutaneous coronary intervention of the left anterior descending (80%) and left circumflex (80%), whereas the Judkins right catheter was preferred for percutaneous coronary intervention of the right coronary artery (86%). CONCLUSIONS:There is significant variability in preferences for femoral access technique. Even though recommended best practices advocate for fluoroscopic and ultrasound guidance, most operators use palpation alone. Femoral angiography is also not consistently used despite guideline recommendations. The lack of adoption of imaging guidance for vascular access deserves further investigation.

The aim of this study was to examine the current practice and use of transfemoral approach (TFA) for coronary angiography and intervention.Wide variability exists in TFA techniques for coronary procedures.The authors developed a survey instrument that was distributed via e-mail lists from professional societies to interventional cardiologists from 88 countries between March and December 2016.Of 987 operators, 18% were femoralists, 38% radialists, 42% both, and 2% neither. Access using femoral pulse palpation alone was preferred by 60% of operators, fluoroscopy guidance by 11%, and a combination of palpation, fluoroscopy, or ultrasound by 27%. Only 11% used micropuncture in >90% of their cases. Performing femoral angiography immediately after access was preferred by 23% and at the end of the procedure by 47%, and not done at all by 31% of operators. Hemostasis by manual compression was preferred by 50%, collagen plug vascular closure device by 31%, and suture-based vascular closure device by 11% of operators. Judkins left and right catheters were preferred for diagnostic angiography of the left (99%) and right (94%) coronary arteries. Extra backup curves (XB or EBU) were most commonly preferred for percutaneous coronary intervention of the left anterior descending (80%) and left circumflex (80%), whereas the Judkins right catheter was preferred for percutaneous coronary intervention of the right coronary artery (86%).There is significant variability in preferences for femoral access technique. Even though recommended best practices advocate for fluoroscopic and ultrasound guidance, most operators use palpation alone. Femoral angiography is also not consistently used despite guideline recommendations. The lack of adoption of imaging guidance for vascular access deserves further investigation.