BACKGROUND:The risk of ventricular arrhythmias (VAs) after cardiac resynchronization therapy (CRT) has been associated with ischemic disease/scar, sex, and possibly left ventricular mass (LVM). OBJECTIVE:The purpose of this study was to evaluate sex differences and baseline/postimplant change in LVM on VA risk after CRT implantation in patients with nonischemic cardiomyopathy and left bundle branch block. METHODS:In patients meeting the criteria, baseline and follow-up echocardiographic images were obtained for LVM assessment. VA events were reported from device diagnostics and therapies. VA risk was stratified by receiver operating characteristic (Youden index cutoff point) for baseline LVM and baseline/postimplant change in LVM. Multivariate Cox regression model was also used for VA risk stratification. RESULTS:One hundred eighteen patients (71 female patients [60.2%]; mean age 60.5 ± 11.3 years; left ventricular ejection fraction 19.2% ± 7.0%; QRS duration 165.6 ± 20 ms; LVM 313.9 ± 108.8 g) were enrolled and followed up for a median of 90 months (interquartile range 44-158 months). Thirty-five patients (29.6%) received appropriate shocks or antitachycardia pacing at a median of 73.5 months (interquartile range 25-130 months) postimplantation. Males had a higher VA incidence (male patients 18 of 47 [38.3%] vs female patients 17 of 71 [23.9%]; P = .02). Baseline LVM > 308.9 g separated patients with higher VA risk (P = .001). Less than a 20% decrease in LVM increased VA risk (P < .001). Baseline LVM was the only baseline characteristic predicting VA events in the Cox regression model (hazard ratio 1.01; 95% confidence interval 1.001-1.009; log-rank, P = .003). Sex differences in VA risk were eliminated by the baseline LVM parameters. CONCLUSION:VA risk after CRT implantation in nonischemic cardiomyopathy was associated with baseline LV > 308.9 g and a decrease in LVM ≤ 20%, without sex differences.

BackgroundData are lacking on patient-reported outcomes (PRO) following cryoballoon ablation (CBA) versus radiofrequency ablation (RFA). We sought to evaluate QoL and clinical outcomes of cryoballoon pulmonary vein isolation only (CRYO-PVI-ONLY) versus RFA with PVI and posterior wall isolation (RF-PVI+PWI) in a large prospective PRO registry.MethodsPatients who underwent AF ablation (2013-2016) at our institution were enrolled in an automated, prospectively maintained PRO registry. CRYO-PVI-ONLY patients were matched (1:1) with RF-PVI+PWI patients based on age, gender, and type of AF (paroxysmal vs. persistent). QoL and clinical outcomes were assessed using PRO surveys at baseline and at 1-year. The atrial fibrillation symptom severity scale (AFSSS) was the measure for QoL. Additionally, we assessed patient-reported clinical improvement, arrhythmia recurrence, and AF burden (as indicated by AF frequency and duration scores).ResultsA total of 296 patients were included (148 in each group, 72% paroxysmal). By PRO, a significant improvement in QoL was observed in the overall study population and was comparable between CRYO-PVI-ONLY and RF-PVI+PWI (baseline median AFSSS of 11.5 and 11; reduced to 2 and 4 at 1 year, respectively; p = 0.44). Similarly, the proportion of patients who reported improvement in their overall QoL and AF related symptoms was high and similar between the study groups [92% (CRYO-PVI-ONLY) vs. 92.8% (RF-PVI+PWI); p = 0.88]. Arrhythmia recurrence was significantly more common in the CRYO-PVI-ONLY group (39.7%) compared to RF-PVI+PWI (27.7 %); p = 0.03. Comparable results were observed in paroxysmal and persistent AF.ConclusionCRYO-PVI-ONLY and RF-PVI+PWI resulted in comparable improvements in patient reported outcomes including QoL and AF burden; with RF-PVI+PWI being more effective at reducing recurrences.

BACKGROUND:Left bundle branch area pacing (LBBAP) is a newer technique to deliver more synchronous left ventricular activation. Several criteria have been proposed, but not fully validated, to confirm LBBAP during implantation of the pacing lead. Spectral analysis has been used to characterize the frequency components of the clinical QRS utilizing the Fourier transform algorithm. We hypothesized that higher frequency content of the paced QRS complex may show predictive value of successful LBBAP. METHODS:We evaluated 84 patients with ejection fraction > 50%, who underwent LBB lead placement (n = 42) using ≥ 1 current criteria and right ventricular midseptal (RVsp) lead placement (n = 42) from 2000 to 2022. Time frequency analysis (Matlab) was used to determine the frequency content of the paced QRS complex. The centroid frequency (CF), which is the weighted average QRS frequency, was calculated. RESULTS:Patients in RVsp group had a longer paced QRS duration (155.6 ± 28.0 vs 127.1 ± 17.2, p < 0.002) compared to the LBBAP group. Of all standard ECG leads, the paced QRS in V2 gave the greatest difference of the CF of the LBBAP group at 8.8 ± 1.6 Hz versus 5.7 ± 0.7 Hz of the RVsp group. This difference was significant by both univariate (p < 0.003) and multivariate (p < 0.010) analysis. Predictive value of the CF for successful LBB pacing in lead V2 was highest with an AUC of 0.98. The sensitivity and specificity were 88.1% and 97.6%, respectively. CONCLUSION:Spectral analysis predicts successful LBBAP with higher frequency content when compared to RVsp pacing. Given the limitations to the current criteria to confirm LBBAP, intraprocedural use of frequency content analysis of the paced QRS complex in patients may prove useful at verifying LBB capture if verified by prospective clinical trials.

Historically, slow pathway (SP) ablations were considered an anatomically focused procedure. Presently, novel mapping techniques have been used to identify targets for Atrioventricular Nodal Tachycardia (AVNRT). There have been various anatomical descriptors along the perinodal region. Described in literature, preferential myocardial bundles are arranged from the sinoatrial node (SAN) with inputs into atrioventricular node (AVN). Two of these bundles, the right inferior extension and penetrating bundle, have colloquially been named the slow and fast pathway, respectively.

In patients (pts) with ventricular arrhythmias (VAs) undergoing catheter ablation (CA), the need for multiple vascular access points with large bore sheaths predisposes to vascular complications. Whether arterial/venous vascular closure devices prevent vascular complications is unknown.

Junctional tachycardia (JT) is typically considered to have an automatic mechanism originating from the distal atrioventricular node. When there is 1:1 retrograde conduction via the fast pathway, JT would resemble the typical form of atrioventricular nodal re-entrant tachycardia (AVNRT). Atrial pacing maneuvers have been proposed to exclude AVNRT and suggest a diagnosis of JT. However, after excluding AVNRT, one should consider the possibility of an infra-atrial narrow QRS re-entrant tachycardia, which can exhibit features that resemble AVNRT as well as JT. Pacing maneuvers and mapping techniques should be performed to assess for infra-atrial re-entrant tachycardia before concluding that JT is the mechanism of a narrow QRS tachycardia. Distinguishing JT from typical AVNRT or infra-atrial re-entrant tachycardia has notable implications regarding the approach to ablation of the tachycardia. Ultimately, a contemporary review of the evidence on JT raises some questions as to the mechanism and source of what has traditionally been considered JT.

Background:Confirming the presence and participation of concealed nodo-ventricular (cNV) or concealed His-ventricular (cHV) pathways in tachyarrhythmias is challenging. We describe novel observations to aid in diagnosing cNV or cHV pathways. Methods:We present 7 cases of cNV and cHV pathway-mediated arrhythmias and focus on several laboratory observations: (1) differential ventricular overdrive pacing (VOD) from the base versus apex, (2) response to His refractory premature ventricular complexes, (3) paradoxical atriohisian response (shorter atriohisian interval during tachycardia than that during sinus rhythm) in long RP tachycardia, and (4) the role of adenosine to aid in the diagnosis. Results:Three cases underwent differential VOD during tachycardia. All demonstrated a shorter postpacing interval minus tachycardia cycle length during basal pacing than apical pacing with one case exhibiting apical VOD results compatible with atrioventricular nodal reentrant tachycardia. Basal VOD was useful for localizing the ventricular connection in a case with cHV pathway. In 3 cases, His refractory premature ventricular complexes reset the tachycardia without conduction to the atrium, which excluded the involvement of an atrioventricular pathway or atrial tachycardia, or atrioventricular nodal reentrant tachycardia alone. One case had His refractory premature ventricular complexes followed by subsequent constant AA interval and then tachycardia termination, suggesting a bystander cNV pathway involvement. Two cNV pathway cases presented with long RP tachycardia had paradoxical atriohisian shortening of >15 ms, suggesting parallel activation of the atrium and the atrioventricular node. Adenosine terminated the tachycardia with retrograde block in 2 cases with cNV pathways but had no response on a cHV pathway. Conclusions:cNV and cHV pathways mediated tachyarrhythmias can present with variable clinical presentations. We emphasize the important role of differential VOD sites, His refractory premature ventricular complexes that reset or terminate the tachycardia without conduction to the atrium, paradoxical atriohisian response in long RP tachycardia, and the use of adenosine for diagnosing cNV and cHV pathways.

Randomized clinical trials have proposed that catheter ablation can improve outcomes in atrial fibrillation (AF) patients with heart failure and reduced ejection fraction (HFrEF). Nevertheless, the impact of catheter ablation in patients with heart failure with mildly reduced ejection fraction (HFmrEF) or preserved ejection fraction (HFpEF) remains scarce.

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Background: Ablation is used for both rhythm control and improved quality of life (QoL) in atrial fibrillation (AF). It has been suggested that young adults may experience high recurrence rates after ablation and data remain lacking regarding QoL benefits. We aimed to investigate AF ablation outcomes and QoL benefits in young adults undergoing AF ablation using a large prospectively maintained registry and automated patient-reported outcomes (PRO). Methods: All patients undergoing AF ablation (2013–2016) at our center were prospectively enrolled. Patients aged 50 years or younger were included. For PROs, QoL measures and symptoms were assessed at baseline, 3 months after ablation, and every 6 months thereafter. The AF severity score served as the main assessment of QoL. Results: A total of 241 young adults (age, 16–50 years) were included (17% female, 40.3% persistent AF). In all, 77.2% of patients remained arrhythmia-free during the first year of follow-up (80% in nonstructural AF and 66% in structural AF). Using PROs, 90% of patients reported improvement in QoL throughout all survey time points up to 5 years postablation ( P <0.0001). The baseline median AF severity score was 14 and improved to between 2 and 4 on all follow-up after ablation ( P <0.0001). Patients also reported fewer and shorter AF episodes, fewer emergency room visits secondary to AF, and fewer hospitalizations ( P <0.0001). Conclusions: Ablation remains an effective rhythm-control strategy in young adults with AF. Young adults also experience significant improvement in QoL with reduction of the frequency and duration of AF episodes and AF-related healthcare utilization.

Background: Atrial fibrillation (AF) is associated with mortality, morbidity, and medical costs.Despite the increasing public health importance of AF, race-specific disease distributions and associations between clinical risk factors and AF have received limited attention.Objective: This study aimed to compare established associations between risk factors and AF in white Europeans from the UK Biobank and Asian subjects from the Korean NHIS-HEALS (National Health Insurance Service-Health Screening) study.Methods: This study included 402,229 and 484,406 patients without a diagnosis of nonvalvular AF from the Korean NHIS-HEALS cohort and UK Biobank, respectively.The incidence of AF, its associations with mortality, common risk factors, biomarkers, prevalent cardiovascular disease, and their attributable risk by race were examined.The median follow-up time was 11.8 years (interquartile range [IQR] 11.1-12.6) in the UK Biobank and 7.6 years (IQR 7.0-8.2) in the Korean NHIS-HEALS.Results: Fewer AF cases were observed in Korean NHIS-HEALS (N59182; 2.3%) than in the UK Biobank (N525312; 5.2%).Cardiovascular risk factors, comorbidities, and glucose levels were associated with an increased risk of new-onset AF in both cohorts, with significant interactions by country for associations with body mass index (BMI), economic status, smoking history, history of heart failure, and cholesterol level.BMI was more strongly related to new-onset AF in UK Biobank [hazard ratio (HR), 1.31; 95% confidence interval (CI), 1.29-1.33]compared to Korean NHIS-HEALS (HR, 1.11; 95% CI, 1.09-1.14),with a relative risk ratio of 1.18 (95% CI, 1.15-1.21).Total cholesterol was inversely associated with incident AF in both cohorts (HR, 0.86; 95% CI, 0.85-0.87versus 0.91; 95% CI, 0.89-0.93 in Korean NHIS-HEALS), relative risk ratio 0.95 (95% CI, 0.92-0.97).Attributable risk proportion of most classical risk factors were similar in both the studies.Conclusion: In this first large-scale comparison of Caucasian and Asian populations, the cumulative risk of developing AF was higher in the UK than in Korea over most of their lifespan.Higher BMI, smoking, history of heart failure, and lower total cholesterol levels were associated with a higher risk of AF in the UK than in Asians.Cumulative incidence curves and 95% confidence intervals for atrial fibrillation in race with death as a competing risk

Data on the feasibility of left bundle branch area pacing (LBBAP) and atrioventricular node (AVN) ablation in patients with pulmonary hypertension (PH) are limited. This study investigated the characteristics and outcomes of LBBAP and AVN ablation in patients with PH. This is a retrospective study of patients with PH and AF who underwent LBBAP and AVN ablation at the Cleveland Clinic between January 1, 2019 and August 1, 2022. Pre-procedural, post-procedural, and follow-up patient data were obtained. A total of 11 patients (mean age 74±10 years old, 100% female) with PH and AF who underwent concomitant LBBAP and AVN ablation were included. The etiology of PH was Group III PH in all patients (55% had COPD and 91% had restrictive lung disease), with the average pulmonary arterial systolic pressure (PASP) of 42 mmHg by echocardiogram, FEV1 of 61.9±17.4% predicted, and FVC of 59.9±7.8% predicted. Baseline ejection fraction was 57±10%, QRS duration was 96±20 ms. Concomitant LBBAP and AVN ablation was successful in all patients. Final implant characteristics included: QRS duration was 124±8 ms, left ventricular activation time was 73.7±5.4 ms; threshold 0.6±0.2 mV @ 0.4 ms and was 0.7±0.2 mV @ 0.4 ms on follow-up; impedance was 618±119 ohms and was 545±145 ohms on follow-up. Prior to the LBBAP and AVN ablation procedure, the average number of AF or heart failure (HF) hospitalizations 24 months prior to the procedure was 4.9±5.3, 64% of patients were on antiarrhythmic drugs, and 100% were on either beta-blockers or calcium channel blockers. During a mean follow-up of 21.9±15.3 months after the LBBAP and AVN ablation procedure, the average AF or HF hospitalization was 0.4±0.9, and all patients were no longer on any antiarrhythmic drugs, beta-blockers, or calcium channel blockers. There were no cases of lead dislodgement. In patients with elevated PA systolic pressure, successful LBBAP and AVN ablation with good two-year outcomes are achievable.Tabled 1Pre LBBAP and AVN ablation*Post LBBAP and AVN ablation**P-valueAF or HF hospitalizations4.9 ± 5.30.4 ± 0.9P<0.01On antiarrhythmic drugs7 (63.6%)0 (0%)P<0.01On rate control drugs11 (100%)0 (0%)NALead dislodgement-0 (0%)NALead capture threshold, mV-0.7 ± 0.2NAValues are mean ± SD or n (%) *24 months prior to LBBAP and AVN ablation **Average follow-up of 22±15 months after LBBAP and AVN ablation Open table in a new tab

Ablation can be used for both sustained rhythm control and improved quality of life (QoL) in symptomatic atrial fibrillation (AF). Limited studies have suggested young adults may have shortened arrhythmia-free survival near 40-60% depending on follow-up duration and data are lacking regarding QoL benefits.

Cryoballoon ablation (CBA) for atrial fibrillation (AF) has become an effective strategy to maintain sinus rhythm and improve symptoms and quality of life (QoL). Data are lacking on QoL and patient-reported outcomes (PRO) following CBA in comparison to radiofrequency ablation (RFA).

Introduction: Increasingly, catheter ablation for atrial fibrillation (AF) has been utilized for rhythm control and to improve quality of life (QoL). Data are limited on patient-centered ablation outcomes in individuals with chronic kidney disease (CKD). Objective: To examine clinical outcomes and QoL following AF ablation in CKD patients from a large patient-reported outcomes (PRO) database. Methods: All patients undergoing AF ablation (2013-2016) at our center were enrolled and assessed for outcomes using automated PRO surveys (baseline, 3 and 6 months after ablation, every 6 months thereafter). This analysis captured data at 1- and 3-year follow-up. CKD was defined as estimated glomerular filtration rate (eGFR) <60 ml/min using the 2021 CKD-EPI equation. The atrial fibrillation symptom severity scale (AFSSS) was used as the main measure for QoL assessment. In addition, data were collected on clinical improvement by patient report, AF burden, and healthcare utilization. Results: A total of 488 patients were identified (66% male, mean age 68.5, 56.2% persistent AF). QoL was significantly improved from baseline median (IQR) AFSSS of 14 (6-19.5) to 3 (0-9) at 1-year and 4 (0-9.5) at 3-year; P≤0.0001 for both. About 90% of patients reported improvement in their overall AF-related symptoms both at 1- and 3-year follow up. The proportion of patients in AF at the time of completion of the baseline survey was 51.2%, and this decreased to 6.2% at 1-year and 9.7% at 3-year follow up (P<0.0001 for both). AF burden was significantly reduced at 1-year and 3-year including frequency and duration of episodes (P<0.05 for both), with associated decrease in ER visits and hospitalizations; P<0.0001 for all comparisons. The proportion of patients on antiarrhythmics decreased from 61.8% at baseline to 35.6% and 22.7% at 1-year and 3-year, respectively (P<0.0001 for both). Conclusions: In a large AF-specific PRO system, catheter ablation for AF was associated with a significant improvement of QoL in most patients with CKD; with a decrease in AF burden and healthcare utilization.

Introduction: The surface EKG of typical atrioventricular nodal reentrant tachycardia (AVNRT) shows simultaneous ventricular-atrial (RP) activation with pseudo R’ in V1 and typical heart rates ranging from 150-220/min. Slower rates are suspicious for junctional tachycardia (JT). However, occasionally we encounter typical AVNRT with slow ventricular rates. We describe a series of typical AVNRT cases with heart rates under 110/min. Methods: A total of 1972 patients with AVNRT who underwent slow pathway ablation were analyzed. Typical AVNRT was diagnosed when; 1) evidence of dual atrioventricular nodal conduction, 2) tachycardia initiation by atrial drive train with A-H-A response, 3) septal ventriculoatrial (VA) time < 70 ms, and 4) ventricular-atrial-ventricular (V-A-V) response to ventricular overdrive (VOD) pacing with post pacing interval-tachycardia cycle length (PPI-TCL) > 115ms. JT was excluded by either termination or advancement of tachycardia by atrial extrastimuli (AES) or atrial overdrive (AOD) pacing. Results: We found 11 patients (Age 20-78 years old, 6 female) who met the above-mentioned criteria. The TCL ranged from 560ms to 782ms. Except for one patient showing tachycardia termination, all patients demonstrated a V-A-V response and PPI-TCL over 115ms with VOD. AES or AOD pacing successfully excluded JT by either advancing the tachycardia in 10 patients or by tachycardia termination in one patient. Slow pathway was successfully ablated, and tachycardia was not inducible in all patients. Conclusions: This case series describes patients with typical AVNRT with slow ventricular rate (less than 110/min) who may mimic JT. We emphasize the importance of using pacing maneuvers to exclude JT.

The color codes in Figures 3 and 4 are incorrect. Green is meant to signify High DFT and Blue should represent Acceptable DFT in Figure 3. Green is meant to signify System Modification and Blue should represent No System Modification in Figure 4. Corrected versions of Figures of 3 and 4 appear below. The content of the text remains unchanged. The authors regret this error. The published article can be found here Central illustration is added for online version of the paper