IntroductionOutcomes of catheter ablation for non-paroxysmal atrial fibrillation (AF) remain suboptimal. Non-invasive stratification of patients based on the presence of atrial cardiomyopathy (ACM) could allow to identify the best responders to pulmonary vein isolation (PVI).MethodsObservational multicentre retrospective study in patients undergoing cryoballoon-PVI for non-paroxysmal AF. The duration of amplified P-wave (APW) was measured from a digitally recorded 12-lead electrocardiogram during the procedure. If patients were in AF, direct-current cardioversion was performed to allow APW measurement in sinus rhythm. An APW cut-off of 150 ms was used to identify patients with significant ACM. We assessed freedom from arrhythmia recurrence at long-term follow-up in patients with APW ≥ 150 ms vs. APW < 150 ms.ResultsWe included 295 patients (mean age 62.3 ± 10.6), of whom 193 (65.4%) suffered from persistent AF and the remaining 102 (34.6%) from long-standing persistent AF. One-hundred-forty-two patients (50.2%) experienced arrhythmia recurrence during a mean follow-up of 793 ± 604 days. Patients with APW ≥ 150 ms had a significantly higher recurrence rate post ablation compared to those with APW < 150 ms (57.0% vs. 41.6%; log-rank p < 0.001). On a multivariable Cox-regression analysis, APW≥150 ms was the only independent predictor of arrhythmia recurrence post ablation (HR 2.03 CI95% 1.28–3.21; p = 0.002).ConclusionAPW duration predicts arrhythmia recurrence post cryoballoon-PVI in persistent and long-standing persistent AF. An APW cut-off of 150 ms allows to identify patients with significant ACM who have worse outcomes post PVI. Analysis of APW represents an easy, non-invasive and highly reproducible diagnostic tool which allows to identify patients who are the most likely to benefit from PVI-only approach.

A 20-year-old male presented with severe chest discomfort associated with palpitations 1-day after his second Pfizer-BioNTech COVID-19 vaccine dose. Other than obesity (body mass index of 32kg/m2) he had no other medical conditions and no preceding infective symptoms. Electrocardiogram showed global concave ST-segment elevation suggestive of pericarditis (Panel A). There was a serial rise in troponin (peak 1035ng/L, normal< 14ng/L). Viral screen, including for SARSCoV-2 was negative. There were no arrhythmias on telemetry monitoring. Transthoracic echocardiography revealed low normal left ventricular (LV) systolic function (ejection fraction 50%) but no pericardial effusion. Cardiovascular magnetic resonance (CMR) four-chamber view (supplemental video 1) demonstrated elevated lateral LV myocardial T1 (Panel B), T2 (Panel C) and corresponding subepicardial late gadolinium enhancement (LGE, Panel D). Short axis imaging confirmed inferior wall involvement (Panels E, F and G). Once symptoms had improved and troponin levels were decreasing, he was discharge on a 3-month course of colchicine. A repeat CMR in 3-months and further Holter monitoring was arranged. Cases of myocarditis after SARS-CoV-2 mRNA vaccine in the young population are rare, mild and are typically seen after the second vaccine dose. Presence of long-term consequences are yet to be determined. Differential diagnosis for such presentations such as viral myopericarditis and takotsubo cardiomyopathy should be considered. Serial troponins, echocardiography and multiparametric CMR were pivotal for diagnosis and guiding appropriate management. Overall, the evidence for benefits of reduced hospitalizations and deaths due to COVID-19 following the vaccine are far out-weighed by the potential risks.

Takotsubo cardiomyopathy following temporal lobe encephalitis—a case of ‘Harry Potter’ syndrome Santhiya Kumarakulasingam, Santhiya Kumarakulasingam Department of Cardiology, Newham University Hospital, Glen Road, Plaistow, Barts Health NHS Trust, London E13 8SL, UK https://orcid.org/0000-0003-0800-798X Search for other works by this author on: Oxford Academic PubMed Google Scholar Dhanya Salimkumar, Dhanya Salimkumar Department of Cardiology, Newham University Hospital, Glen Road, Plaistow, Barts Health NHS Trust, London E13 8SL, UK https://orcid.org/0000-0001-9127-3562 Search for other works by this author on: Oxford Academic PubMed Google Scholar Juno Sunny, Juno Sunny Department of Cardiology, Newham University Hospital, Glen Road, Plaistow, Barts Health NHS Trust, London E13 8SL, UK https://orcid.org/0000-0002-7112-5236 Search for other works by this author on: Oxford Academic PubMed Google Scholar Angela Gallagher, Angela Gallagher Department of Cardiology, Newham University Hospital, Glen Road, Plaistow, Barts Health NHS Trust, London E13 8SL, UK https://orcid.org/0000-0001-5512-7429 Search for other works by this author on: Oxford Academic PubMed Google Scholar Mohammed Y Khanji Mohammed Y Khanji Department of Cardiology, Newham University Hospital, Glen Road, Plaistow, Barts Health NHS Trust, London E13 8SL, UKDepartment of Cardiology, NIHR Barts Biomedical Research Centre, William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, EC1M6BQ, UK Corresponding author. Tel: 00442073638079; Email: m.khanji@qmul.ac.uk https://orcid.org/0000-0002-5903-4454 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 42, Issue 31, 14 August 2021, Page 3028, https://doi.org/10.1093/eurheartj/ehab016 Published: 19 January 2021

OBJECTIVES: Chronic obstructive pulmonary disease (COPD) exacerbation is one of the most common reasons for hospital admission.Patients with COPD with a long length of stay (LoS) occupy a disproportionately high fraction of hospital bed-days.The objective of this study was to identify associations of long LoS in patients admitted with COPD exacerbation. MATERIAL AND METHODS:From December 2012 until June 2013, 499 patients were admitted to Queens Hospital, Romford, UK, with COPD exacerbation.Mean LoS was 7 days, with a median of 5 days, and a 90th percentile of 14 days.In this retrospective observational cohort study, 64 patients with a short LoS were compared with 62 patients with a long LoS. RESULTS:Relative to the short LoS, patients with long LoS had significantly lower arterial blood pH, higher arterial PaCO2 and HCO3, higher white cell count, higher globulin and more frequent chest X-ray changes, lower albumin levels, and lower Barthel and Braden scores.They were less likely to have seen the hospital COPD specialist nurse, more likely to require escalation of social care on discharge, and more likely to die during admission.Nearly 66% of the long LoS patients remained in hospital beyond the time of being medically fit for discharge.Commonly cited reasons for delayed discharge were the wait for therapy and social services assessments and the wait for commencement of community social care. CONCLUSION:Meticulous targeting of features peculiar to long LoS patients has the potential to reduce future hospital bed-days for patients with COPD in our and other hospitals.

Introduction: Treating exacerbation accounts for the bulk of COPD healthcare expenditure. Published features associated with long Length of Stay (LoS) following admission include old age (1), extent of co-morbidity and socio-economic deprivation (2). Aims and Methods: We aimed to identify factors associated with a long LoS at Queens Hospital. According to coding data, 499 patients had a COPD admission from Dec 2012 to May 2013. Median LoS was 5 days and the 90th percentile was 14 days. Data was compared from 46 patients with a LoS around 5 days (short LoS) and 52 patients with a LoS above 14 days (long LoS). Results: In comparison to short LoS, long LoS was associated with: a higher PaCO2 (7.2 vs 5.6 kPa, p<0.01), higher HCO3 (29 vs 25 mM, p=0.01), higher WCC (13 vs 11 x 109/L, p=0.05), higher CRP (71 vs 41, p=0.05), lower albumin (36 vs 38 g/L, p=0.05), and lower Braden score (18 vs 20, p=0.04). In addition, Long LoS patients more frequently had carers at home prior to admission (40% vs 26%), and required new social care or care home placement on discharge (28% vs 6%). Discussion: Although differences in biochemical and physiological parameters are associated with long LoS, other very important associations are the need for social support prior to admission and for new social support on discharge. Our hospital COPD population is elderly (Mean age 78 vs 71 in the UK COPD national audit (1)), with extensive co-morbidity, and high levels of socio-economic deprivation. Complex discharge planning will increasingly be a key aspect of hospital COPD management for all as the population ages. (1) Price LC et al, Thorax 2006, 61: 837-842; (2) Agboado G et al, BMJ Open 2012, 2: e000869.