Catheter mapping and ablation of premature ventricular contractions (PVCs) requires accurate annotation of earliest local activation time (LAT), but displacement in catheter position between sinus rhythm (SR) and the PVC complicates three-dimensional mapping localization. An automated algorithm to annotate LAT sites at the corresponding sinus rhythm sites would provide an alternative to manual annotation and improve procedural efficiency. A retrospective single center study assessed 64 patients undergoing catheter ablation of PVCs. We divided the study patients into two groups: the patients underwent RF ablation using the CARTO 3 version 7 with LAT-hybrid™ module (hybrid group) and the other patients using the CARTO 3 version 6 without LAT-hybrid™ module (conventional group). The primary results of this study demonstrate that the mean hybrid distance is 4.03 ± 2.33 mm, and this automated algorithm can correct for the positional shift with accuracy comparable to manual correction. Moreover, this algorithm showed significantly shorter RF time and the shorter PVC offset compared to the conventional method. PVC mapping with the LAT-hybrid™ module demonstrated that an automated algorithm can map in more detail with no compromise in accuracy. The LAT-hybrid™ module showed significantly shorter RF time and PVC offset from the earliest LAT in LVOT cases. Spatial displacement of earliest site of activation for premature ventricular contractions (PVCs) relative to sinus rhythm beats in high-risk para-His bundle region. Automated spatial correction (LAT-Hybrid) provides a more focal area of interest 1.4mm posterior to the His region adjacent to the tricuspid annulus. The LAT-Hybrid automated algorithm directed ablation to the successful site with single burn elimination.

Localization of premature ventricular contractions (PVCs) from the outflow tract regions based upon ECG localization criteria may prove challenging based upon cardiac rotation and surface lead placement. Multiple studies describe ECG parameters based upon axis and precordial R wave transition for distinction of left (LVOT) vs right ventricular outflow tract (RVOT) site of origin. No previous studies describe intracardiac fiducial points to assist in site discrimination for PVC origin between LVOT, RVOT, and intramyocardial sites.

BACKGROUND The PAINESD (Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA functional class, Ejection fraction, Storm, Diabetes mellitus) risk score has been validated as a predictor of periprocedural acute hemodynamic decompensation (AHD) in patients undergoing ventricular tachycardia (VT) ablation. Whether the addition of total scar volume (TSV) determined by preprocedure computed tomography imaging provides additional risk stratification has not been previously investigated.OBJECTIVES The purpose of this study was to evaluate the impact of TSV on the risk of AHD and its adjunctive benefit to the PAINESD score newly modified as Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA class, Ejection fraction, Storm, Scar volume, Diabetes mellitus (PAINES2D) based on the addition of scar volumes. METHODS This was a retrospective analysis of all index VT ablations at a quaternary care center from 2017 to 2022. Associations between TSV and AHD were evaluated among patients with structural heart disease.RESULTS Among 61 patients with TSV data, 13 (21%) had periprocedural AHD. TSV and PAINESD were independently associated with AHD risk. Both TSV and PAINESD were associated with AHD (P = 0.016 vs P = 0.053, respectively). The highest TSV tertile ($37.30 mL) showed significant association with AHD (P = 0.018; OR: 4.80) compared to the other tertiles. The PAINESD and PAINES2D scores had significant impact on AHD (P = 0.046 and P = 0.010, respectively). The PAINES2D score had a greater impact on AHD compared to PAINESD (area under the curve: 0.73; P = 0.011; 95% CI: 0.56-0.91 and area under the curve: 0.67; P = 0.058; 95% CI: 0.49-0.85, respectively).CONCLUSIONS Addition of TSV to a modified PAINESD score, PAINES2D, enhances risk prediction of AHD. Further prospective study is needed to assess benefit in various cardiomyopathy populations undergoing VT ablation. (J Am Coll Cardiol EP 2023;9:1684-1693)& COPY; 2023 by the American College of Cardiology Foundation.

Background Ventricular tachycardia (VT) ablation of mid- or epicardial substrate is difficult and requires a creative approach in patients with a history of coronary bypass that precludes percutaneous epicardial catheter manipulation. The coronary venous system (CVS) provides limited access to the epicardial surface of the heart. The objective of this study is to assess the feasibility, safety, and efficacy of epicardial mapping and ablation of VT substrates from the CVS in patients with history of coronary bypass. Methods Patients undergoing VT ablation at our institution were retrospectively reviewed. Those who had basal to mid ventricular substrate based on computed tomography imaging and history of coronary bypass were included. Endocardial and CVS mapping and ablation was performed in standard fashion using 3D electroanatomic mapping. The primary endpoint was defined as VT circuit elimination, termination, non-inducibility, or perturbation of the circuit. Results Of 192 consecutive VT ablations from 2017 to 2020, 35 (18%) had a history of coronary bypass and basal to the mid-ventricular substrate by imaging. There were no significant characteristic differences between the endocardial only ( n = 19) vs endocardial + CVS ( n = 16) groups. In 14 (88%) of patients undergoing CVS mapping, the VT circuit was identified to be within access from the epicardial surface. Ablation was attempted in 8 (57%) of these patients, and the primary endpoint was reached in 88% of those undergoing CVS ablation. There were no complications related to CVS ablation. Conclusion Mapping and ablation of mid- or epicardial VT circuits from the CVS branches are feasible and safe and may be helpful in the treatment of VT in patients who are otherwise not candidates for percutaneous epicardial ablation.

The PAINESD (Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA functional class, Ejection fraction, Storm, Diabetes mellitus) risk score has been validated as a predictor of periprocedural acute hemodynamic decompensation (AHD) in patients undergoing ventricular tachycardia (VT) ablation. Whether the addition of total scar volume (TSV) determined by preprocedure computed tomography imaging provides additional risk stratification has not been previously investigated. The purpose of this study was to evaluate the impact of TSV on the risk of AHD and its adjunctive benefit to the PAINESD score newly modified as Pulmonary disease, Age, Ischemic cardiomyopathy, NYHA class, Ejection fraction, Storm, Scar volume, Diabetes mellitus (PAINES2D) based on the addition of scar volumes. This was a retrospective analysis of all index VT ablations at a quaternary care center from 2017 to 2022. Associations between TSV and AHD were evaluated among patients with structural heart disease. Among 61 patients with TSV data, 13 (21%) had periprocedural AHD. TSV and PAINESD were independently associated with AHD risk. Both TSV and PAINESD were associated with AHD (P = 0.016 vs P = 0.053, respectively). The highest TSV tertile (≥37.30 mL) showed significant association with AHD (P = 0.018; OR: 4.80) compared to the other tertiles. The PAINESD and PAINES2D scores had significant impact on AHD (P = 0.046 and P = 0.010, respectively). The PAINES2D score had a greater impact on AHD compared to PAINESD (area under the curve: 0.73; P = 0.011; 95% CI: 0.56-0.91 and area under the curve: 0.67; P = 0.058; 95% CI: 0.49-0.85, respectively). Addition of TSV to a modified PAINESD score, PAINES2D, enhances risk prediction of AHD. Further prospective study is needed to assess benefit in various cardiomyopathy populations undergoing VT ablation.

Importance Newborn screening for Angelman syndrome (AS), Prader-Willi syndrome (PWS), and chromosome 15 duplication syndrome (Dup15q) may lead to benefit from early diagnosis and treatment. Objective To examine the feasibility of newborn screening for these chromosome 15 imprinting disorders at population scale. Design, Setting, and Participants In this diagnostic study, the validation data set for the first-tierSNRPNtest, called methylation-specific quantitative melt analysis (MS-QMA), included 109 PWS, 48 AS, 9 Dup15q, and 1190 population control newborn blood spots (NBS) and peripheral tissue samples from participants recruited from January 2000 to December 2016. The test data set included NBS samples from 16 579 infants born in 2011. Infants with an NBS identified as positive for PWS, AS, or Dup15q by the first-tier test were referred for droplet digital polymerase chain reaction, real-time polymerase chain reaction, and low-coverage whole-genome sequencing for confirmatory testing. Data analyses were conducted between February 12, 2015, and August 15, 2020. Results In the validation data set, the median age for the 77 patients with PWS was 3.00 years (IQR, 0.01-44.50 years); for the 46 patients with AS, 2.76 years (IQR, 0.028 to 49.00 years); and for the 9 patients with Dup15q, 4.00 years (IQR, 1.00 to 28.00 years). Thirty-eight patients (51.4%) in the PWS group, 20 patients (45.5%) in the AS group, and 6 patients (66.7%) in the Dup15q group who had sex reported were male. The validation data set showed MS-QMA sensitivity of 99.0% for PWS, 93.8% for AS, and 77.8% for Dup15q; specificity of 100% for PWS, AS, and Dup15q; positive predictive and negative predictive values of 100% for PWS and AS; and a positive predictive value of 87.5% and negative predictive value of 100% for Dup15q. In the test data set of NBS samples from 16 579 infants, 92 had a positive test result using a methylation ratio cut-off of 3 standard deviations from the mean. Of these patients, 2 were confirmed to have PWS; 2, AS; and 1, maternal Dup15q. With the use of more conservative PWS- and AS-specific thresholds for positive calls from the validation data set, 9 positive NBS results were identified by MS-QMA in this cohort. The 2 PWS and 2 AS calls were confirmed by second-tier testing, but the 1 Dup15q case was not confirmed. Together, these results provided prevalence estimates of 1 in 8290 for both AS and PWS and 1 in 16 579 for maternal Dup15q, with positive predictive values for first-tier testing at 67.0% for AS, 33.0% for PWS, and 44.0% for combined detection of chromosome 15 imprinting disorders for the validation data set. Conclusions and Relevance The findings of this diagnostic study suggest that it is feasible to screen for all chromosome 15 imprinting disorders usingSNRPNmethylation analysis, with 5 individuals identified with these disorders out of 16 579 infants screened.

Introduction/Hypothesis: To develop and validate a deep learning model to automatically segment and measure left atrial (LA) volumes from routine noncontrast chest CTs and evaluate for outcomes prognosis. Methods: A prototype AI algorithm, with a conditional variational auto-encoder architecture, was initially developed and trained using training data from 1313 patients (paired CTA and non-contrasted exams; “training group”). Left atrium contours from contrasted cases were used to train the model on corresponding non-contrasted dataset. We then retrospectively evaluated 274 patients (mean age 67.9 years, 54.6% male, 57.2% caucasian) who underwent a routine non ECG-gated, noncontrast chest CT for coronary artery calcium or lung cancer screening for validation of the AI model (“validation group”). Outcomes included heart failure (HF) hospitalization and new-onset atrial fibrillation within 5 years. Simple logistic regressions with appropriate univariate statistics were used for modelling outcomes. Results: In the validation group, there was excellent correlation between AI and expert results with a LA volume index (LAVi) intraclass correlation coefficient of 0.950 (0.936-0.960). Bland-Altman plot demonstrated that the AI underestimated LAVi by a mean 5.86 mL/m2. AI-LAVi independently predicted new-onset atrial fibrillation (AUC = 0.855, OR = 1.12, 95% CI 1.08 - 1.18; p<0.0001). AI-LAVi was independently associated with HF hospitalization (AUC = 0.903, OR = 1.08, 95% CI 1.04 - 1.13, p = 0.0009). Conclusion: In this large validation cohort, AI for automated measurement of LA volume on routine noncontrast chest CTs had excellent agreement with manual quantification. AI-LAVi is independently predictive for new-onset atrial fibrillation and HF hospitalization within 5 years.

Background: The accuracy of noninvasive arrhythmia source localization using a forward-solution computational mapping system has not yet been evaluated in blinded, multicenter analysis. This study tested the hypothesis that a computational mapping system incorporating a comprehensive arrhythmia simulation library would provide accurate localization of the site-of-origin for atrial and ventricular arrhythmias and pacing using 12-lead ECG data when compared with the gold standard of invasive electrophysiology study and ablation. Methods: The VMAP study (Vectorcardiographic Mapping of Arrhythmogenic Probability) was a blinded, multicenter evaluation with final data analysis performed by an independent core laboratory. Eligible episodes included atrial and ventricular: tachycardia, fibrillation, pacing, premature atrial and ventricular complexes, and orthodromic atrioventricular reentrant tachycardia. Mapping system results were compared with the gold standard site of successful ablation or pacing during electrophysiology study and ablation. Mapping time was assessed from time-stamped logs. Prespecified performance goals were used for statistical comparisons. Results: A total of 255 episodes from 225 patients were enrolled from 4 centers. Regional accuracy for ventricular tachycardia and premature ventricular complexes in patients without significant structural heart disease (n=75, primary end point) was 98.7% (95% CI, 96.0%–100%; P <0.001 to reject predefined H 0 <0.80). Regional accuracy for all episodes (secondary end point 1) was 96.9% (95% CI, 94.7%–99.0%; P <0.001 to reject predefined H 0 <0.75). Accuracy for the exact or neighboring segment for all episodes (secondary end point 2) was 97.3% (95% CI, 95.2%–99.3%; P <0.001 to reject predefined H 0 <0.70). Median spatial accuracy was 15 mm (n=255, interquartile range, 7–25 mm). The mapping process was completed in a median of 0.8 minutes (interquartile range, 0.4–1.4 minutes). Conclusions: Computational ECG mapping using a forward-solution approach exceeded prespecified accuracy goals for arrhythmia and pacing localization. Spatial accuracy analysis demonstrated clinically actionable results. This rapid, noninvasive mapping technology may facilitate catheter-based and noninvasive targeted arrhythmia therapies. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04559061.

Background: Despite the increasing number of clinical trials involving children with neurodevelopmental disorders, appropriate and objective outcome measures for behavioral symptoms are still required.Aim: This study assessed the agreement between parents' and clinical researchers' ratings of behavioral problem severity in children with fragile X syndrome (FXS) and chromosome 15 imprinting disorders.Methods and Procedures: The cohort comprised 123 children (64% males), aged 3-17 years, with FXS (n = 79), Prader-Willi (PWS; n = 19), Angelman (AS; n = 15), and Chromosome 15q duplication (n = 10) syndromes. Specific items from the Autism Diagnostic Observation ScheduleSecond Edition and Aberrant Behavior Checklist-Community Edition mapping to corresponding behavioral domains were selected ad-hoc, to assess behavioral problems. Outcomes and Results: Inter-rater agreement for the cohort was slight for self-injury (Intraclass Correlation Coefficient (ICC) = 0.12), fair for tantrums/aggression (0.24) and mannerisms/stereotypies (0.25), and moderate for hyperactivity (0.48). When stratified by diagnosis, ICC ranged from poor (0; self-injury, AS and PWS) to substantial (0.48; hyperactivity, females with FXS).Conclusions and Implications: The high level of inter-rater disagreement across most domains suggests that parents' and researchers' assessments led to discrepant appraisal of behavioral problem severity. These findings have implications for treatment targets and outcome measure selection in clinical trials, supporting a multi-informant approach.

To evaluate the effectiveness of a novel artificial intelligence (AI) algorithm for fully automated measurement of left atrial (LA) volumes and function using cardiac CT in patients with atrial fibrillation. We included 79 patients (mean age 63 ± 12 years; 35 with atrial fibrillation (AF) and 44 controls) between 2017 and 2020 in this retrospective study. Images were analyzed by a trained AI algorithm and an expert radiologist. Left atrial volumes were obtained at cardiac end-systole, end-diastole, and pre-atrial contraction, which were then used to obtain LA function indices. Intraclass correlation coefficient (ICC) analysis of the LA volumes and function parameters was performed and receiver operating characteristic (ROC) curve analysis was used to compare the ability to detect AF patients. The AI was significantly faster than manual measurement of LA volumes (4 s vs 10.8 min, respectively). Agreement between the manual and automated methods was good to excellent overall, and there was stronger agreement in AF patients (all ICCs ≥ 0.877; p < 0.001) than controls (all ICCs ≥ 0.799; p < 0.001). The AI comparably estimated LA volumes in AF patients (all within 1.3 mL of the manual measurement), but overestimated volumes by clinically negligible amounts in controls (all by ≤ 4.2 mL). The AI’s ability to distinguish AF patients from controls using the LA volume index was similar to the expert’s (AUC 0.81 vs 0.82, respectively; p = 0.62). The novel AI algorithm efficiently performed fully automated multiphasic CT-based quantification of left atrial volume and function with similar accuracy as compared to manual quantification. Novel CT-based AI algorithm efficiently quantifies left atrial volumes and function with similar accuracy as manual quantification in controls and atrial fibrillation patients. • There was good-to-excellent agreement between manual and automated methods for left atrial volume quantification. • The AI comparably estimated LA volumes in AF patients, but overestimated volumes by clinically negligible amounts in controls. • The AI’s ability to distinguish AF patients from controls was similar to the manual methods.

Traditionally, left ventricular (LV) lead position was guided by anatomic criteria of pacing from the lateral wall of the LV. However, large trials showed little effect of LV lead position on outcomes, other than noting worse outcomes with apical positions. Given the poor correlation of cardiac resynchronization therapy (CRT) outcomes with anatomically guided LV lead placement, focus shifted toward more physiologic predictors such as targeting the areas of delayed mechanical and electrical activation. Measures of left ventricular delay and interventricular delay are strong predictors of CRT response.

BACKGROUND:As same-day discharge (SDD) after catheter ablation (CA) for atrial fibrillation (AF) is increasingly utilized, it is important to further investigate this approach. OBJECTIVE:To investigate the safety and efficacy of SDD after CA for AF in a large nationwide administrative sample. METHODS:The IBM MarketScan Commercial Claims and Encounters database was used to identify adult patients under 65 years undergoing CA for AF (2016-2020). Eligible patients were indexed to date of first CA and classified into SDD or overnight stay (ONS) groups based on length of service. A 1:3 propensity score matching was used to create comparable SDD:ONS samples. Study outcomes were CA-related complications within 30 days after index procedure and AF recurrence within 1 year. Cox proportional hazards models were estimated for outcome comparison. RESULTS:In the postmatch 30-day cohort, there were 1610 SDD and 4637 ONS patients with mean age 56.1 (± 7.6) years. There was no significant difference in composite 30-day postprocedural complication rate between SDD and ONS groups (2.7% vs 2.8%, respectively; P = .884). The most common complications were cerebrovascular events (0.7% vs 0.7%; P = .948), vascular access events (0.6% vs 0.6%; P = .935), and pericardial complications (0.6% vs 0.5%; P = .921). Further, no significant difference in composite AF recurrence rate at 1 year was observed among SDD and ONS groups (10.2% vs 8.8%; hazard ratio = 1.167; 95% confidence interval 0.935-1.455; P = .172). CONCLUSION:In a large, propensity-matched, real-world sample, SDD appears to be safe and have similar outcomes compared with overnight observation following CA for AF.

BACKGROUND:Chronic Kidney Disease (CKD) and end-stage renal disease (ESRD) are associated with poor outcomes in patients with cardiovascular disease. There is a paucity of contemporary data on in-hospital outcomes and care patterns of atrial fibrillation (AF) associated hospitalizations CKD and ESRD. METHODS:Outcomes and care patterns were evaluated in GWTG-AFIB database (Jan 2013-Dec 2018), including in-hospital mortality, use of a rhythm control strategy, and oral anticoagulation (OAC) prescription at discharge among eligible patients. Generalized logistic regression models with generalized estimating equations were used to ascertain differences in outcomes. Hospital-level variation in OAC prescription and rhythm control was also evaluated. RESULTS:Among 50,154 patients from 105 hospitals the median age was 70 years (interquartile range 61-79) and 47.3% were women. The prevalence of CKD was 36.0% while that of ESRD was 1.6%. Among eligible patients, discharge OAC prescription rates were 93.6% for CKD and 89.1% for ESRD. After adjustment, CKD and ESRD were associated with higher in-hospital mortality (odds ratio [OR] 3.08, 95% confidence interval [CI] 1.57-6.03 for ESRD and OR 2.02, 95% CI 1.52-2.67 for CKD), lower odds of OAC prescription at discharge (OR 0.59, 95% CI 0.44-0.79 for ESRD and OR 0.84, 95% CI 0.75-0.94 for CKD) compared with normal renal function. CKD was associated with lower utilization of rhythm control strategy (OR 0.92, 95% CI 0.87-0.98) with no significant difference between ESRD and normal renal function (OR 1.32, 95% CI 0.79-1.11). There was large hospital-level variation in OAC prescription at discharge (MOR 2.34, 95% CI 2.05-2.76) and utilization of a rhythm control strategy (MOR 2.69, 95% CI 2.34-3.21). CONCLUSIONS:CKD/ESRD is associated with higher in-hospital mortality, less frequent rhythm control, and less OAC prescription among patients hospitalized for AF. There is wide hospital-level variation in utilization of a rhythm control strategy and OAC prescription at discharge highlighting potential opportunities to improve care and outcomes for these patients, and better define standards of care in this patient population.

Catheter ablation (CA) of frequent premature ventricular contractions (PVC) is increasingly performed in older patients as the population ages. The aim of this study was to assess the impact of age on procedural characteristics, safety and efficacy on PVC ablations.

BACKGROUND:Pacing at sites of late intraventricular activation (QLV) or long interventricular conduction (right ventricle [RV]-left ventricular [LV]) have been associated with improved cardiac resynchronization therapy (CRT) outcomes. Quadripolar leads improve CRT outcomes by allowing for electrical repositioning to optimize pacing sites. However, little is known regarding the effect of such repositioning on electrical delay.OBJECTIVE:Determine the relationship between different electrical bipoles from a quadripolar lead and measures of electrical delay.METHODS:Forty-six patients underwent CRT with a quadripolar lead. The RV-LV and QLV intervals were measured for both the proximal and distal bipoles and the difference (Δ) between bipoles for each measure were calculated. Multivariate analyses were performed to identify predictors of electrical delays.RESULTS:This was a typical CRT population with a mean age of 65 years and ejection fraction of 27%, with left bundle branch block (LBBB) present in 70%. The regression model for ΔQLV was significant (p = .05), with both gender (p = .008) and LBBB status (p = .020) significant predictors. The overall regression model for ΔRV-LV was not significant. ΔQLV and ΔRV-LV were significant among LBBB patients. Among non-LBBB, only ΔRV-LV was significant (mean: 7.2 ms, p = .006). ΔRV-LV versus ΔQLV were strongly correlated in LBBB (R2  = .92) but not non-LBBB (R2  = .06).CONCLUSION:In LBBB, ΔRV-LV and ΔQLV are closely correlated suggesting that the proximal bipole and thus basal LV pacing sites should be selected when feasible. Greater variation in activation pattern is present in non-LBBB, so pacing sites should be individualized.

Introduction: This study was performed to evaluate a novel AI algorithm for fully automated measurement of LA volumes and function using cardiac CTA in patients with atrial fibrillation (AF). Methods: A prototype AI algorithm (AI-LAV), with a conditional variational auto-encoder architecture, was developed and trained using 555 manually annotated ECG-gated, contrast-enhanced cardiac CTs. A total of 79 patients (mean age 63 ± 12 years; 35 with AF and 44 controls) evaluated between 2017 and 2020 were included in this retrospective study to validate the AI model. Images were analyzed by the trained AI algorithm and experienced radiologists. Left atrial volumes were obtained at cardiac end-systole (LAVmax), end-diastole (LAVmin), and pre-atrial contraction (LAVpc), which were then used to obtain LA function indices (total, passive, and active emptying fractions). Statistical analysis was performed. Results: AI was significantly faster than manual measurement of LA volumes and function (4 s vs 10.8 min, respectively). Agreement between the manual and automated methods was good to excellent overall, and there was stronger agreement in AF patients (all ICCs ≥ 0.877; p<0.001) than controls (all ICCs ≥ 0.799; p<0.001). The AI comparably estimated LA volumes and function in AF patients (all within 1.3 mL and 1.7% of the manual measurement), but overestimated volumes and function by clinically negligible amounts in controls (all by ≤ 4.2 ml and ≤ 3.5%). The AI’s ability to distinguish AF patients from controls using the LA volume index was similar to the experts’ (AUC 0.81 vs 0.82, respectively; p = 0.62). Conclusion: In a validation cohort, the novel AI algorithm efficiently performed fully automated multiphasic CTA-based quantification of left atrial volume and function with similar accuracy to expert manual quantification. Figure. Scatter and Bland-Altman plots for LAVmax and LAVmin. Segmentation comparison between expert (manual) and AI on cardiac CTA.

Atrial fibrillation/flutter (AF) remains the most common rhythm disturbance in adult patients presenting to emergency departments (EDs). Although pharmacologic cardioversion has been established as safe and effective in recent-onset AF, its use in U.S. EDs is uncommon. The purpose of this study was to assess the safety and efficacy of intravenous (IV) procainamide for pharmacologic cardioversion in patients presenting to the ED with AF of <48-hr duration. Patients presenting to the ED with recent-onset AF (<48 hr) undergoing a cardioversion strategy with IV procainamide from 2017 to 2019 were reviewed. Clinical outcomes assessed included rates of cardioversion, hospital admission, stroke, and return ED visits for arrhythmia or serious adverse events. A total of 64 patients received procainamide therapy—60.9% achieved cardioversion and 35.9% were admitted to the hospital. The mean dose was 1062.4 mg (12.1 mg/kg). No patients returned to the ED secondary to stroke and 9.4% experienced complications attributed to procainamide, the most common being hypotension. Within 30 days of therapy, 20.3% of patients returned to the ED secondary to arrhythmia recurrence. Patients experiencing cardioversion with procainamide were less likely to be admitted to the hospital (25.6% vs. 52.0%; p = 0.04) or receive a rate control agent (17.9% vs. 64.0%; p = 0.001). There was no significant difference in the rate of 30-day return between those who experienced pharmacologic cardioversion and those who did not ( p = 0.220). The implementation of a procainamide-based acute cardioversion strategy for patients presenting to the ED with recent-onset AF resulted in a 60% cardioversion rate, which was associated with a significantly higher rate of discharge from the ED. Transient hypotension was the most common adverse event. Further investigation into ED-based protocols for management of recent-onset AF is necessary to better understand their safety and efficacy.

BACKGROUND:Catheter ablation (CA) is a common treatment for atrial fibrillation (AF). This study evaluated outcomes of same day discharge (SDD) versus overnight stay (ONS) among AF patients undergoing outpatient CA.METHODS:The Optum SES Clinformatics Extended Data Mart database was used to identify patients ≥18 years of age undergoing outpatient CA for AF (2016-2020). Eligible patients were indexed to the date of first CA and classified into SDD and ONS groups based on the length of service. A 1:3 propensity score matching was used to create comparable SDD:ONS samples. The primary safety outcome was CA-related complications within 30 days of index procedure. The primary efficacy outcome was AF recurrence within 1 year. Cox proportional hazards models were estimated for outcome comparison.RESULTS:In the postmatch 30-day cohort for safety evaluation, there were 6600 patients (1660 [25.2%] SDD; 4940 [74.8%] ONS), with a mean age of 66.6 years. There was no significant difference in the 30-day composite rate of postablation complications (4.7% [78/1660] vs. 3.8% [187/4940]; p = 0.100) and 1-year composite rate of AF recurrence (14.3% [142/996] vs. 14.5% [430/2972]; p = 0.705) between the SDD and ONS groups.CONCLUSION:This study demonstrated that SDD following CA to treat patients with AF is safe, with low rates of postablation complications and AF recurrence, which were comparable to rates in patients with an ONS after CA.