Background Left atrial posterior wall isolation (LAPWI) is increasingly used as an adjunct to pulmonary vein isolation in patients with persistent atrial fibrillation (PerAF) despite the absence of strong evidence, but the optimal ablation modality remains uncertain. Objective Our study focuses on procedural differences between pulsed-field ablation (PFA) and radiofrequency (RF) ablation when LAPWI is performed, rather than on the efficacy of LAPWI itself. PFA may offer advantages over RF ablation owing to its nonthermal mechanism and improved tissue selectivity. Methods In this single-center study, 92 patients with PerAF and posterior low-voltage substrate identified using high-density mapping were treated with either PFA (n = 46) or RF ablation (n = 46) for pulmonary vein isolation plus LAPWI. Remapping was performed to confirm complete electrical isolation. Groups were 1:1 propensity score matched for analysis. Results The primary end point was freedom from any sustained atrial arrhythmia (>30 seconds) at 12-month follow-up, assessed using structured Holter electrocardiogram monitoring at 3, 6, and 12 months. Complete LAPWI was achieved in 100% of PFA and 95.7% of RF ablation patients. Procedure time was significantly shorter with PFA (68.2 minutes [44-91] vs 86.8 minutes [58-118]; P < .05). Arrhythmia-free survival at 12 months was similar between groups (58.7% vs 52.2%; P = .57; relative risk 1.13; 95% confidence interval 0.78-1.63). Multivariable Cox regression identified LA diameter, body mass index of >30 kg/m(2), and hypertension as independent predictors of arrhythmia recurrence. Complication rates were low and comparable. Conclusion In patients with PerAF and posterior low-voltage substrate, PFA and RF ablation yielded similar arrhythmia-free survival at 1 year. PFA was associated with shorter procedure times and high rates of posterior wall isolation.

Pulsed field ablation (PFA) has emerged to an innovative approach to achieve pulmonary vein isolation (PVI) in atrial fibrillation (AF) treatment. Despite its fast adoption and promising safety profile, insights into immediate ablation effects and lesion characteristics and their influence on follow-up arrhythmia recurrence using ultra-high-density mapping (UHDM) are sparse. This study aims to evaluate acute lesion dynamics and formation and their clinical impact using UHDM. This study enrolled 204 patients undergoing PVI with a pentaspline PFA system. UHDM was used for pre- and post-ablation assessment of the pulmonary veins (PV) and left atrium (LA). Clinical and mapping data were analyzed to define immediate lesion formation. Machine learning (ML) techniques, including SMOTE for data augmentation, were utilized to predict the recurrence of atrial tachycardia during follow-up and understand their underlying mechanisms. UHDM of immediate outcomes showed typical isolation patterns around the PV ostia. UHDM revealed a significantly narrowed electrically intact bridge on the LA roof. Furthermore, UHDM detected 14 non-isolated PV gaps in 13 patients, matching the typical lesion distribution. Gaps were undetected by the pentaspline PFA catheter. During follow-up, LA roof-dependent tachycardia was the most common recurrent arrhythmia (n = 11, 5.4

Pulmonary vein isolation aims to reduce the burden of atrial fibrillation leading to symptom alleviation and improvement in quality of life. The newer pulsed-field ablation offers a non-thermal alternative to radiofrequency- and cryoballoon- ablation. We present one of the first clinical, pilot prospective comparisons of these three procedures with respect to freedom from recurrence up to one year, procedure safety, and assessment of quality of life. Localization of the pulmonary veins during pulsed-field ablation and radiofrequency ablation was supported by electroanatomical mapping, whereas only fluoroscopy was used for cryoballoon ablation. The ablation techniques also differed in terms of energy delivery. Pulsed-field ablation and cryoballoon ablation used a single-shot technique, while radiofrequency ablation used high-power, short-duration energies (50 W/10 Seconds) with point-by-point lesions. The study included 36 patients, 15 of whom were treated with pulsed-field ablation, 10 with high-power, short-duration radiofrequency ablation and 11 with cryoballoon ablation. Cryoballoon ablation showed the shortest ablation and catheter-dwell times. The fluoroscopy time and the dose area product were lowest for radiofrequency ablation. No recurrences of atrial fibrillation were recorded in the cryoballoon ablation group during the follow-up period, whereas 26.7

Background The optimal management of concomitant coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) remains controversial. Whether routine percutaneous coronary intervention (PCI) before TAVR provides clinical benefit compared to a strategy of deferral is unclear. Methods We performed a meta-analysis of randomized controlled trials (RCT) comparing routine PCI before TAVR with a strategy of PCI deferral. The primary end points were a composite of major adverse cardiovascular and cerebrovascular events (MACCE) and all-cause mortality. Secondary end points included myocardial infarction, stroke, revascularization, and major bleeding. We applied a random-effects model to calculate hazard ratios (HR) and 95% CI. We also performed a pooled time-to-event analysis using reconstructed individual patient data. Results We included 3 RCT (ACTIVATION, NOTION-3, and PRO-TAVI) comprising a total of 1156 patients. The pooled cohort had a median age exceeding 81 years and exhibited low anatomic coronary complexity (median SYNTAX score ≤10). Routine PCI did not significantly reduce the risk of MACCE (HR, 0.84; 95% CI, 0.62-1.13; P = .25) or all-cause mortality (HR, 0.88; 95% CI, 0.67-1.17; P = .38). Pooled Kaplan-Meier analysis confirmed no difference in all-cause mortality over 48 months (HR, 0.89; 95% CI, 0.68-1.17; P = .41). Although routine PCI was associated with a significant reduction in any revascularization (HR, 0.24; 95% CI, 0.06-0.89; P = .03) and urgent revascularization (HR, 0.33; 95% CI, 0.12-0.87; P = .02), it was associated with increased bleeding events (HR, 1.96; 95% CI, 1.28-3.00; P < .01). No significant differences were observed regarding myocardial infarction or stroke. Conclusions Routine PCI before TAVR did not reduce mortality or MACCE compared to a deferral strategy. Although routine PCI lowered the risk of subsequent urgent revascularization, it significantly increased the risk of major bleeding.

Pulsed field ablation (PFA) has emerged as a novel nonthermal modality for pulmonary vein isolation (PVI) in atrial fibrillation (AF). While it offers distinct advantages over traditional radiofrequency ablation (RFA), including a favorable safety profile, its impact on myocardial injury, as reflected by biomarker plasma concentrations, remains underexplored. This study aimed to compare postprocedural high-sensitivity troponin-T (hs-TnT) and creatine kinase (CK) levels in patients undergoing PVI with PFA versus RFA and to identify independent predictors of myocardial injury. We analyzed 94 patients (48 PFA, 46 RFA) undergoing PVI for paroxysmal or persistent AF. Biomarkers (hs-TnT and CK) were measured preprocedure and 24 h postprocedure. Baseline clinical and procedural characteristics were evaluated for comparability. Statistical analyses included linear regression with permutation feature importance to identify predictors of postprocedural troponin levels. Patients undergoing PFA exhibited significantly higher median hs-TnT levels at 24 h postprocedure compared to those treated with RFA (1071.0 ng/L [IQR: 861.0–1316.5] vs. 602.5 ng/L [IQR: 504.0–795.5]; p < 0.001). Similarly, CK levels were markedly higher in the PFA group (286.0 U/L [IQR: 215.0–356.5] vs. 122.5 U/L [IQR: 90.5–190.5]; p < 0.001). Baseline levels of both biomarkers were comparable between groups. Linear regression identified PFA as the most significant determinant of troponin plasma concentration, followed by preprocedural GFR, with reduced GFR correlating with greater troponin elevation. PFA is associated with higher myocardial biomarker plasma concentration compared to RFA, suggesting greater myocardial injury. Reduced GFR amplifies this effect, underscoring the importance of careful patient selection and procedural planning, particularly in patients with renal impairment. While PFA shows promise as a safe and effective ablation strategy, further research is needed to assess its long-term clinical implications.

Early integration of palliative care (EIPC) has been proposed to improve quality of life in heart failure (HF), but evidence is mixed and potential differences by HF subtype remain unclear. This exploratory secondary analysis of the EPCHF trial examined whether patient-reported outcomes differed between patients with and without reduced EF. A total of 205 patients with symptomatic HF were randomized 1:1 to EIPC or standard care in the EPCHF trial. For this exploratory analysis, patients were stratified by left ventricular ejection fraction (≤ 40

Background Thermal-based ablation techniques, such as cryoballoon ablation (CBA), are widely used for pulmonary vein isolation (PVI) but show notable recurrence rates, particularly in obese patients. One possible reason is the reduced efficacy of thermal energy in tissues with significant epicardial fat, which can impede effective lesion formation and insulation of targeted areas. Objective Pulsed-field ablation (PFA) has shown promising results for atrial fibrillation (AF) treatment, providing effective isolation with a favorable safety profile. This study investigates the clinical and safety outcomes of PFA compared with CBA in obese patients with AF. Methods This retrospective propensity-matched study included symptomatic patients with paroxysmal and persistent AF and a body mass index (BMI) >30 who underwent PFA or CBA at a single institution. Matching criteria included age, left atrial diameter, left ventricular ejection fraction, and AF type (paroxysmal vs persistent), as well as preexisting conditions such as diabetes, coronary artery disease, and hyperlipoproteinemia. Procedural workflows were standardized, focusing on PV isolation. Outcomes assessed were procedural efficiency, recurrence rates, and complications. Results Postmatching revealed lower recurrence rates in the PFA group (25%) compared with the CBA group (42.9%; P = .02). PFA was associated with significantly shorter left atrial (LA) time (33.8 min vs 49.7 min; P < .01) and procedural time (46.8 min vs 69.3 min, P < .01) than CBA, although fluoroscopy time showed no significant difference. Safety outcomes were similar across both groups. Conclusion PFA offers an alternative to CBA in obese patients, with superior recurrence outcomes and shorter procedural durations postmatching in this single-center cohort. PFA may be a preferred approach for AF management in this high-risk population. Future randomized trials are warranted to validate these findings and optimize treatment protocols for obese patients with AF.

Introduction:Cardiac amyloidosis (CA) impacts about 20 % of elderly heart failure patients, leading to myocardial dysfunction and life-threatening risks. However, it often remains undetected due to the significant risks associated with invasive biopsies. This highlights the critical need for safer and accurate non-invasive diagnostic techniques. Aim:To compare the diagnostic value of Cardiac Magnetic Resonance (CMR) imaging and Cardiac Scintigraphy Imaging in the diagnosis of CA. Methods:A comprehensive literature search across PubMed, Scopus, Web of Science, and Cochrane databases yielded studies that utilized CMR or cardiac scintigraphy for diagnosing CA. QUADAS-2 was employed for quality assessment. Results:From 7117 records, 35 studies involving 4866 patients were analyzed. Cardiac scintigraphy demonstrated higher sensitivity and specificity across different radiotracers, with 99mTc-HMDP showing the highest specificity (1.00, 95 % CI: 0.93-1.00) and 99mTc-DPD the highest sensitivity (0.93, 95 % CI: 0.89-0.95). CMR imaging showed variable diagnostic accuracy with a sensitivity of 0.83 (95 % CI: 0.81-0.85) and a lower specificity of only 0.53 (95 % CI: 0.50-0.56). Conclusion:Cardiac scintigraphy, particularly with 99mTc-HMDP, offers superior diagnostic accuracy for CA compared to CMR imaging. Controlled, randomized, prospective studies directly comparing these non-invasive techniques are essential to validate these findings.

Importance Healthcare concepts for chronic diseases based on tele-monitoring have become increasingly important during COVID-19 pandemic. Objective To study the effectiveness of a novel integrated care concept (NICC) that combines tele-monitoring with the support of a call centre in addition to guideline therapy for patients with atrial fibrillation, heart failure, or treatment-resistant hypertension. Design A prospective, parallel-group, open-label, randomized, controlled trial. Setting Between December 2017 and August 2019 at the Rostock University Medical Center (Germany). Participants Including 960 patients with either atrial fibrillation, heart failure, or treatment-resistant hypertension. Interventions Patients were randomized to either NICC ( n = 478) or standard-of-care (SoC) ( n = 482) in a 1:1 ratio. Patients in the NICC group received a combination of tele-monitoring and intensive follow-up and care through a call centre. Main outcomes and measures Three primary endpoints were formulated: (1) composite of all-cause mortality, stroke, and myocardial infarction; (2) number of inpatient days; (3) the first plus cardiac decompensation, all measured at 12-months follow-up. Superiority was evaluated using a hierarchical multiple testing strategy for the 3 primary endpoints, where the first step is to test the second primary endpoint (hospitalization) at two-sided 5%-significance level. In case of a non-significant difference between the groups for the rate of hospitalization, the superiority of NICC over SoC is not shown. Results The first primary endpoint occurred in 1.5% of NICC and 5.2% of SoC patients (OR: 3.3 [95%CI 1.4–8.3], p = 0.009). The number of inpatient treatment days did not differ significantly between both groups ( p = 0.122). The third primary endpoint occurred in 3.6% of NICC and 8.1% of SoC patients (OR: 2.2 [95%CI 1.2–4.2], p = 0.016). Four patients died of all-cause death in the NICC and 23 in the SoC groups (OR: 4.4 [95%CI 1.6–12.6], p = 0.006). Based on the prespecified hierarchical statistical analysis protocol for multiple testing, the trial did not meet its primary outcome measure. Conclusions and relevance Among patients with atrial fibrillation, heart failure, or treatment-resistant hypertension, the NICC approach was not superior over SoC, despite a significant reduction in all-cause mortality, stroke, myocardial infarction and cardiac decompensation. Trial registration ClinicalTrials.gov Identifier: NCT03317951.

Background Heart disease and atrial fibrillation are the leading causes of death worldwide. Patient morbidity and mortality associated with cardiovascular disease can be reduced by more accurate and continuous diagnostic and therapeutic tools provided by cardiovascular implantable electronic devices (CIEDs). Objectives Long-term operation of CIEDs continues to be a challenge due to limited battery life and the associated risk of device failure. To overcome this issue, new approaches for autonomous battery supply are being investigated. Results Here, the state of the art in CIED power supply is presented and an overview of current strategies for autonomous power supply in the cardiovascular field is given, using the body as a sustainable energy source. Finally, future challenges and potentials as well as advanced features for CIEDs are discussed. Conclusion CIEDs need to fulfil more requirements for diagnostic and telemetric functions, which leads to higher energy requirements. Ongoing miniaturization and improved sensor technologies will help in the development of new devices.

Background Patients with atrial fibrillation are at a significantly increased risk of thromboembolic events, especially ischemic strokes. Oral anticoagulation reduces this risk, but cannot be used in some patients for various reasons and is associated with a relevantly increased risk of bleeding. As an alternative for prophylaxis of thromboembolic events in patients with atrial fibrillation, there are different options of left atrial appendage closure. Aim This article explains the possibilities of interventional atrial occlusion as well as the suitable patient clientele using an overview of the currently available systems for atrial occlusion, a guideline for patient selection and a summary of the current scientific data. Conclusion and available scientific data In carefully selected patients suffering from atrial fibrillation with relative or absolute contraindications for oral anticoagulation, interventional closure of the atrial appendage is a safe alternative for prophylaxis against thromboembolic events. The currently available scientific evidence from randomized controlled trials is sparse. Nevertheless, extensive amounts of registry study data suggest a benefit, while the results of several large randomized controlled trials are expected in the coming years.

BACKGROUND:Heart failure (HF) management guided by the measurement of intracardiac and pulmonary pressure values obtained through innovative permanent intracardiac microsensors has been recently proposed as a valid strategy to individualize treatment and anticipate hemodynamic destabilization. These sensors have potential to reduce patient hospitalization rates and optimize quality of life.OBJECTIVE:The aim of this study was to evaluate the usability and patients' attitudes toward a new permanent intracardiac device implanted to remotely monitor left intra-atrial pressures (V-LAP, Vectorious Medical Technologies, Tel Aviv, Israel) in patients with chronic HF.METHODS:The V-LAP system is a miniaturized sensor implanted percutaneously across the interatrial septum. The system communicates wirelessly with a "companion device" (a wearable belt) that is placed on the patient's chest at the time of acquisition/transmission of left heart pressure measurements. At first follow-up after implantation, the patients and health care providers were asked to fill out a questionnaire on the usability of the system, ease in performing the various required tasks (data acquisition and transmission), and overall satisfaction. Replies to the questions were mainly given using a 5-point Likert scale (1: very poor, 2: poor, 3: average, 4: good, 5: excellent). Further patient follow-ups were performed at 3, 6, and 12 months.RESULTS:Use and acceptance of the first 14 patients receiving the V-LAP technology worldwide and related health care providers have been analyzed to date. No periprocedural morbidity/mortality was observed. Before discharge, a tailored educational session was performed after device implantation with the patients and their health care providers. At the first follow-up, the mean score for overall comfort in technology use was 3.7 (SD 1.2) with 93% (13/14) of patients succeeding in applying and operating the system independently. For health care providers, the mean score for overall ease and comfort in use of the technology was 4.2 (SD 0.8). No significant differences were found between the patients' and health care providers' replies to the questionnaires. There was a general trend for higher scores in patients' usability reports at later follow-ups, in which the score related to overall comfort with using the technology increased from 3.0 (SD 1.4) to 4.0 (SD 0.7) (P=.40) and comfort with wearing and adjusting the measuring thoracic belt increased from 2.8 (SD 1.0) to 4.2 (SD 0.4) (P=.02).CONCLUSIONS:Despite the gravity of their HF pathology and the complexity of their comorbid profile, patients are comfortable in using the V-LAP technology and, in the majority of cases, they can correctly and consistently acquire and transmit hemodynamic data. Although the overall patient/care provider satisfaction with the V-LAP system seems to be acceptable, improvements can be achieved after ameliorating the design of the measuring tools.TRIAL REGISTRATION:ClincalTrials.gov NCT03775161; https://clinicaltrials.gov/ct2/show/NCT03775161.

Patienten mit Vorhofflimmern sind einem signifikant erhöhten Risiko für thromboembolische Ereignisse, insbesondere für ischämische Schlaganfälle, ausgesetzt. Eine orale Antikoagulation reduziert dieses Risiko zuverlässig, ist jedoch aus unterschiedlichen Gründen nicht bei jedem Patienten einsetzbar und geht mit einer relevanten Erhöhung des Blutungsrisikos einher. Alternativ bestehen zur Prophylaxe thromboembolischer Ereignisse bei Patienten mit Vorhofflimmern unterschiedliche Möglichkeiten eines Vorhofohrverschlusses. Anhand einer Übersicht der aktuell verfügbaren Systeme zum Vorhofohrverschluss, eines Leitfadens zur Patientenauswahl und einer Zusammenfassung der aktuellen wissenschaftlichen Datenlage sollen die Möglichkeiten des interventionellen Vorhofohrverschlusses erläutert sowie die geeignete Patientenklientel charakterisiert werden. Für Patienten mit Vorhofflimmern und relativer oder absoluter Kontraindikation einer oralen Antikoagulation stellt der interventionelle Verschluss des Vorhofohrs nach sorgfältiger Patientenselektion eine sichere Alternative zum Schutz vor thromboembolischen Ereignissen dar. Die aktuell verfügbare wissenschaftliche Evidenz aus randomisierten, kontrollierten Studien ist gering. Umfangreiche Registerstudiendaten lassen dennoch einen eindeutigen Nutzen vermuten, während die Ergebnisse mehrerer großer randomisierter, kontrollierter Studien in den kommenden Jahren erwartet werden.

Background Detection of atrial fibrillation (AF) after cryptogenic stroke (CS) has therapeutic implications, but the most effective type and optimal duration of monitoring have still to be defined. This study that involved patients with CS or transient ischemic attack (TIA), all of whom carried an implantable cardiac monitor (ICM), sought to assess the incidence of AF and other arrhythmia detected using tele-monitoring or interval-based follow-up by an internal cardiologist at the university medical center of Rostock (UMR) or an external cardiologist. Methods The ICM implantation was performed during the inpatient stay in the neurology department, with inclusion and exclusion criteria jointly determined by the neurology and cardiology departments. Cardiologists programmed individual threshold values during ICM implantation, which were designed to instantly trigger an episode being recording and an alarm message being sent out. Outpatient care consisted of tele-monitoring of implants or interval-based follow-up care. Results The indication for ICM implantation was made for 102 patients, 88 of whom underwent ICM implantation, with full documentation available for these 88 study patients. Within a median observation period of 21.5 months, AF occurred in 19 patients, with a median observation time to the event of 7 months. In all cases, AF detection was followed by immediate medical intervention. Comparing patients with and without AF revealed that the median age of the AF group exceeded by 10 years that of the other patients. Stroke recurrence was recorded in five patients, with a median observation time to the event of 9 months. Comparing patients with and without stroke recurrence revealed that the median age in the stroke recurrence group tended to be higher by 14 years. No statistically significant between-group differences were found with regard to integration into tele-monitoring, nor were there any differences identified between outpatient care at the UMR or in the outpatient sector. Conclusions This study confirmed the feasibility of using an interdisciplinary and intersectoral therapeutic approach for monitoring CS patients with implanted ICMs. Further randomized studies are warranted to confirm these encouraging data. An open discussion concerning optimal care forms and opportunities for introducing digitizing care pathways appears warranted.

Subvenous epicardial fat tissue (SEAT), which acts as an electrical insulation, and the venous diameter (VD) both constitute histomorphological challenges for optimal application and lead design in cardiac synchronization therapy (CRT). In this study, we characterized the morphology of human coronary veins to improve the technical design of future CRT systems and to optimize the application of CRT leads. We retrospectively analyzed data from cardiac computed tomography (CT) of 53 patients and did studies of 14 human hearts using the postmortem freeze section technique and micro CT. Morphometric parameters (tributary distances, offspring angles, luminal VD, and SEAT thickness) were assessed. The left posterior ventricular vein (VVSP) had a mean proximal VD of 4.0 ± 1.4 mm, the left marginal vein (VMS) of 3.2 ± 1.5 mm and the anterior interventricular vein (VIA) of 3.9 ± 1.3 mm. More distally (5 cm), VDs decreased to 2.4 ± 0.6 mm, 2.3 ± 0.7 mm, and 2.4 ± 0.6 mm, respectively. In their proximal portions (15 mm), veins possessed mean SEAT thicknesses of 3.2 ± 2.4 (VVSP), 3.4 ± 2.4 mm (VMS), and 4.2 ± 2.8 mm (VIA), respectively. More distally (20–70 mm), mean SEAT thicknesses decreased to alternating low levels of 1.3 ± 1.1 mm (VVSP), 1.7 ± 1.1 mm (VMS), and 4.3 ± 2.6 mm (VIA), respectively. In contrast to the VD, SEAT thicknesses alternated along the further distal vein course and did not display a continuous decrease. Besides the CRT responsiveness of different areas of the LV myocardium, SEAT is a relevant electrophysiological factor in CRT, potentially interfering with sensing and pacing. A sufficient VD is crucial for successful CRT lead placement. Measurements revealed a trend toward greater SEAT thickness for the VIA compared to VVSP and VMS, suggesting a superior signal-to-noise-ratio in VVSP and VMS.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia. The most feared complication of AF is thromboembolism. Oral anticoagulation (OAC) is the standard treatment to reduce thromboembolism occurrence in patients with AF. The rate of relevant bleeding, medical interactions and incompliance under OAC remains consistent. In this context, patients with AF at high risk for thromboembolism and with a contraindication to OAC may be considered as candidates for percutaneous left atrial appendage closure. In this review, we discuss the rationale, indications, technical aspects and clinical results of left atrial appendage closure by means of the WATCHMAN® (Boston Scientific, MA, USA) device.

Data concerning the effect of chronic right ventricular pacing in patients with normal left ventricular ejection fraction (LVEF%) are contradictory. The aim of this study is to evaluate the prevalence of pacing-induced cardiomyopathy (PICM) at midterm follow-up after permanent pacemaker implantation (PPM). A series of 170 patients were submitted to PPM within our facility. Inclusion criteria were the absence of structural heart disease and a preserved LVEF% (> 45%) at the time of PPM. A midterm clinical and echocardiographic follow-up was performed, and data were collected and analyzed retrospectively. PICM was defined as follow-up LVEF ≤ 45%, dyskinesia during RV pacing, and the absence of other known causes of cardiomyopathy. At a median echocardiographic follow-up of 24.5 months (IQR 10.0–43.0 months), the overall mean LVEF% decreased from a preimplantation value of 66.7% (± 8.6%) to 63.2% (± 10.6%) (p < 0.0001). PICM occurred in 11 patients (6.5%). Patients developing PICM had a significantly lower preimplantation LVEF% (58.4 ± 8.0% vs. 67.3 ± 8.4%; p = 0.005), a trend for higher right ventricular pacing time rate (0.7 ± 0.3 vs. 0.5 ± 0.4; p = 0.1), a significantly lower rate of PPM indication for sick sinus syndrome (SSS) (18.2% vs. 61.0%; p = 0.009), and significantly higher rate of second-grade cardiac conduction block (36.4% vs. 11.3%; p = 0.03). At multivariate logistic regression, only preimplantation LVEF% (OR = 0.88; CI 0.80–0.96; p = 0.006) and the presence of SSS (OR = 0.1; CI 0.03–0.9; p = 0.04) were independently related (inverse relationship) to follow-up PICM. In this selected PPM patient cohort with preserved LVEF%, the rate of PICM at midterm follow-up is relatively low, but its occurrence seems to be related to baseline LVEF% and PPM indication category.

Purpose. In atrial fibrillation (AF) patients, the effect of catheter ablation or drug therapy on cognition is currently not well investigated. Therefore, we prospectively evaluated AF patients who were either treated 'with drug therapy or underwent catheter ablation for the prevalence and progression of cognitive impairment (CI). Methods. Randomized participants of the CABANA trial (catheter ablation versus antiarrhythmic drug therapy for atrial fibrillation) and the CASTLE-AF (catheter ablation versus standard conventional treatment in patients with left ventricular dysfunction and atrial fibrillation) study were assessed twice within 6 months by Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in our institution. Results. Forty-five patients from both trials were investigated, and twenty-eight patients received catheter ablation, whereas seventeen patients received drug therapy for rhythm or rate control. The mean age of the twenty-one CABANA trial patients (AF group) was 68.8 ± 7.0 years and of the twenty-four CASTLE-AF study patients (AF/HF group) was 66.8 ± 8.1 years, respectively. Mean time from ablation/randomization to the first interview was 16.8 ± 11 months in the AF group and 28.3 ± 18.4 months in the AF/HF group, respectively. All patients investigated were classified as cognitively impaired with mean cutoff scores <24 by MoCA. Overall, we could not detect significant differences in medically treated versus catheter ablation patients within both groups in mean MMSE or MoCA scores between the first and the second interview (p>0.09). Moreover, patients who received catheter ablation did not show statistically significant differences in the prevalence or progression of cognitive impairment compared to patients who were treated medically, neither within the two groups nor between AF and AF/HF patients (p>0.05). Conclusions. Prevalence of cognitive impairment in AF patients with comorbidities is substantial. However, in this preliminary prospective study, no apparent impact of AF pretreatment on the prevalence and course of cognitive impairment could be observed.

Current guidelines recommend considering deactivation of cardiac implantable electronic devices (CIEDs) in patients nearing death. We evaluated the implementation of this recommendation in unselected deceased individuals with CIEDs. Over a 7-month period in 2016, all deceased persons taken to the Rostock crematorium were prospectively screened for CIEDs and these were interrogated in situ. Pacing rate, pacing mode, and lead output were documented as well as patient data including location and time of death. In implantable cardioverter-defibrillators (ICDs), tachycardia therapy adjustment and occurrence of shocks 24 h prior to death were also recorded. We examined 2297 subjects, of whom 154 (6.7%) had CIEDs. Of these subjects, 125 (100%) pacemakers (PMs) and 27 (96.4%) ICDs were eligible for analysis. Death in persons with ICDs occurred most frequently in hospital (55.6%), while this was less frequently the case for individuals with PMs (43.2%). Furthermore, 33.3% of subjects with ICDs and 18.5% with PMs died in palliative care units (PCU). Shock therapies were switched off in three (60%) individuals with ICDs who died in the PCU, whereas antibradycardia therapy was not withdrawn in any PM patient in the PCU. Therapy withdrawal occurred in two patients with PMs (1.3%) who died in hospital. Patients with PMs had high ventricular pacing rates at the last interrogation (69 ± 36.0%) and often suffered atrioventricular block (39.2%). Six (25%) of the 24 active ICDs presented shocks near the time of death. Many CIED patients died in hospital; nonetheless, in practice, CIED deactivation near death is rarely performed and might be less feasible in subjects with PMs. However, there is still a need to consider deactivation, especially in individuals with ICDs, as one fourth of them received at least one shock within 24 h prior to death.