Frailty is highly prevalent in patients with atrial fibrillation (AF) and is associated with adverse outcomes compared with non-frail individuals. This study aimed to explore whether the effects of ablation versus drug therapy on clinical outcomes and quality of life (QoL) differ according to frailty status in patients with AF. This is a post hoc analysis of the Catheter Ablation versus Antiarrhythmic Drug Therapy for Atrial Fibrillation (CABANA) trial. The frailty index (FI) was calculated using 30 items, with an FI ≥ 0.21 defined as frailty. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. The secondary outcomes included all-cause death and heart failure (HF) hospitalization. QoL was assessed periodically over 60 months using the Mayo AF-Specific Symptom Inventory (MAFSI). In this study, a total of 2189 and 2070 patients were included in the intention-to-treat (ITT) and per-protocol (PP) populations, respectively. Over a median follow-up of 1440 (IQR, 900–2880) days, 184 patients experienced the primary endpoint, 122 died, and 174 experienced HF hospitalizations. Compared with drug therapy, catheter ablation did not significantly reduce the risk of clinical outcomes, with no significant difference observed across frailty strata. Regarding QoL, patients with AF and frailty in the ablation group experienced significant improvement compared with those in the drug group: a mean difference among all follow-ups of − 1.58 (− 2.11 to − 1.06; P < 0.001) in the MAFSI frequency score and − 1.26 (− 1.69 to − 0.84, P < 0.001) in the MAFSI severity score. However, patients with AF and without frailty in the ablation group showed no significant QoL improvement compared with those in the drug group. There is no significant difference in the effectiveness of reducing clinical outcomes of catheter ablation according to frailty status in patients with AF compared with drug therapy, while patients with AF and frailty could derive a higher QoL improvements from catheter ablation therapy. These findings highlight the potential role of catheter ablation in improving QoL for patients with AF and frailty.

Background: Atrial fibrillation (AF) is the most noted cardiac arrhythmia in the intensive care unit (ICU). Inflammation is crucial in its onset and advancement. Our study sheds light on the association of the albumin (ALB)/neutrophil-to-lymphocyte ratio (NLR) score (ANS) with all-cause mortality (ACM) risk among critically ill AF patients. Methods: Our retrospective study leveraged Medical Information Mart for Intensive Care IV (MIMIC-IV) data. AF patients were identified, and ANS was stratified into quartiles. Outcomes across quartiles were compared through Kaplan-Meier (KM) survival curves. The linear and nonlinear relationship between ANS and ACM was unveiled through Multivariate Cox proportional hazards models and restricted cubic spline (RCS) analyses. The prediction performance of ANS was assessed via receiver operating characteristic (ROC) curve analysis. The robustness of our results was rated in subgroup and interaction analyses. Results: 5,056 participants were encompassed, with 19.2% aged under 60 years and 58.7% being male. KM analysis demonstrated that higher ANS levels were significantly associated with reduced ACM at 30, 90, 180, and 360 days (log-rank P<0.001). Furthermore, Cox regression analyses confirmed a significant inverse relationship between ANS and ACM. RCS analysis revealed a J-shaped relationship between ANS and ACM, with inflection points for 30-, 90-, 180-, and 360-day ACM observed at ANS values of 1.312, 1.527, 1.684, and 1.723. The area under the ROC curves (AUCs) for ANS in predicting 30-, 90-, 180-, and 360-day ACM were 0.7575, 0.7438, 0.7162, and 0.6997, respectively, demonstrating a modestly superior discriminative performance compared with NLR, whereas the difference relative to ALB was not statistically significant. Subgroup analyses further supported the consistency of these associations. Conclusions: In critically ill AF patients, elevated ANS levels are significantly associated with reduced ACM risks at 30, 90, 180, and 360 days. ANS may serve as a valuable prognostic biomarker, but prospective studies are needed to validate our findings and assess its clinical utility.

The triglyceride-glucose (TyG) index has been recognized as a surrogate marker for insulin resistance (IR) and an independent risk factor for cardiovascular disease (CVD). However, the combined effect of the TyG index and visceral obesity on CVD incidence remains unclear. We aimed to investigate the interaction, joint association, and potential mediators between the TyG index and comprehensive anthropometric indices with CVD risk in middle-aged and older adults. We analyzed 7046 participants aged ≥ 45 years without baseline CVD from the China Health and Retirement Longitudinal Study (CHARLS) over a 9-year follow-up period. Retrospective collection included sociodemographic details, health status, physical examination results, and blood biomarkers. Adjusted Cox proportional hazards models were used to examine the interaction between TyG levels and anthropometric indices and their joint associations with CVD incidence. Subgroup analyses were conducted to evaluate the associations across different populations, and mediation analysis was performed to identify potential mediating pathways. The predictive value was determined using the area under the curve (AUC) of receiver operating characteristic curves. In addition, we validated the findings in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. In the CHARLS study, 1768 (25.1

Background: Ethanol infusion into the vein of Marshall (EI-VOM) is widely used to facilitate atrial fibrillation ablation and block of the mitral isthmus. However, it cannot be completed in some anatomically challenging cases. This study aimed to introduce and evaluate a novel reversed U curve method of EI-VOM. Methods: This case-series study enrolled consecutive patients with atrial fibrillation or atrial flutter who were scheduled for EI-VOM. When VOM venography was successfully performed, the conventional EI-VOM method was attempted first. If this approach failed or took ≥20 min, the novel method was applied. The success rate, complications, and applicable anatomical conditions of the new method were summarized. Results: Of the 205 patients enrolled in this study, the novel method was applied to 45 patients, and technical success was achieved in 42 patients (93.3%). Among the patients who underwent the novel method, twenty-four (53.3%) had a long cavotricuspid isthmus, nineteen (42.2%) had a VOM ostium close to the coronary sinus ostium, and sixteen (35.6%) had a prominent Eustachian ridge. The total mean procedure time of EI-VOM using the novel method was 30.00 ± 4.5 min. Acute bidirectional mitral isthmus block was achieved in 40 cases (88.9%), and the mean ethanol volume injected was 8.21 ± 1.5 mL. No serious in-hospital complications were documented in patients treated with the novel method. Conclusions: In this single-center case series, the reversed U curve method appeared feasible as a femoral bailout strategy for EI-VOM in selected anatomically challenging cases. Further prospective, multicenter studies involving multiple operators are required to confirm its reproducibility, efficacy, and safety over conventional approaches.

Background:A subset of patients with atrial fibrillation (AF) first present with ischemic stroke. After neurological recovery, catheter ablation (CA) may be considered in arrhythmia clinic. However, outcomes of CA in patients with atrial fibrillation detected after stroke (AFDAS) remain insufficiently characterized compared with people with previously known AF (KAF). Methods:We conducted a retrospective analysis of consecutive patients who underwent catheter ablation between January 2023 and October 2024 in a special arrhythmia ward. Propensity score matching was performed to balance baseline characteristics. Outcome analyses were restricted to the matched cohort. The primary endpoint was freedom from atrial arrhythmia. The key secondary endpoint was a composite of all-cause death, stroke, or cardiovascular rehospitalization. Results:Among 3,417 eligible patients, 232 were included in the matched analysis (48 AFDAS, 184 KAF). AFDAS patients had numerically lower 2-year atrial arrhythmia recurrence rates [14.6% vs. 22.1%; HR 0.70, (95% CI 0.31-1.57); log-rank P = .39], although the difference was not statistically significant. The incidence of the key secondary endpoint was also similar between groups [9.2% vs. 14.1%; HR 0.73, (95% CI 0.28-1.90); log-rank P = .52]. Conclusion:In this propensity score-matched cohort, CA was associated with comparable efficacy and safety outcomes in AFDAS and KAF patients. Larger prospective studies are needed to further clarify long-term outcomes in this population.

Mitral isthmus (MI) gap conduction is common despite ethanol infusion into the vein of Marshall (EI-VOM) and endocardial ablation of the MI. This study aimed to investigate the characteristics of electrograms of the distal coronary sinus (CSd) to guide the identification of the gap location in the MI. A total of 187 patients who underwent EI-VOM and MI ablation were included in the study. After routine completion of EI-VOM and endocardial MI ablation, the characteristics of the electrogram in the CSd during left atrial appendage pacing were analyzed in unblocked MI conduction. Among the 187 patients, 43.3% (81/187) had unblocked MI following EI-VOM and linear lesion creation in the endocardium. In patients with unblocked MI, 84.0% (68/81) showed double potentials in the CSd during left atrial appendage pacing, among whom 80.9% (55/68) presented with an earlier high-frequency near-field potential followed by a low-frequency far-field potential, suggesting an epicardial gap, whereas 19.1% (13/68) presented with a far-field potential followed by a near-field potential, suggesting an endocardial gap. In patients with single potentials in the CSd (16.0%, n=13), simple activation mapping of the endocardium and CSd revealed the gap location. Intracoronary sinus ablation was necessary in 77.8% (63/81) of the patients, with a mean of 1.3±1.7 sites and 1.1±0.4 minutes of ablation. Eventually, 95.7% (179/187) of the patients achieved MI block. These findings were confirmed in an external validation cohort, which demonstrated the effectiveness and efficiency of CSd potential-guided gap identification. The characteristics of the electrograms in the CSd could aid in the prompt identification of the gap location(s) in the MI in patients with unblocked MI conduction.

Background Assessing individuals’ risk of developing incident atrial fibrillation (AF) is important for making preventive and screening strategies. Objectives The performance of the mC2HEST score for predicting incident AF has scarcely been evaluated, especially in a multi-ethnic population. Methods Participants from the MESA (Multi-Ethnic Study of Atherosclerosis were enrolled in the present study, which involved population of different ethnicities (Caucasian, African-American, Chinese-American, and Hispanic) aged between 45 and 84 from 6 communities in the United States. The discriminative and calibration performance of the mC2HEST score was compared with other risk models. Results A total of 4,524 subjects (mean age 60.2 ± 9.5 years; 53.0% female) were included; 565 (mean age 67.0 ± 7.9 years; 46.5% female) developed AF during 13.6 ± 2.5 years of follow-up, with an incidence of 0.93%/year. The mC2HEST score had good prediction at 10 years (C-index, 0.72; 95% CI: 0.701 to 0.753), and 15 years (0.773, 95% CI: 0.749 to 0.798). The risk of incident AF increased with higher mC2HEST score points and risk groups (log-rank P < 0.001). The mC2HEST score showed positive net reclassification indexes (0.057, 0.090, 0.128, and 0.143) and integrated discriminative improvement (3.2%, 3.9%, 5.7%, and 4.9%) compared with C2HEST, HAVOC, HATCH, and CHA2DS2-VASc scores, respectively. Optimal calibration was seen in the mC2HEST score (P = 0.41). Conclusions The mC2HEST score is a practical model for predicting individuals’ risk of incident AF that may be used for guiding AF surveillance, resource allocation, and screening strategies.

The associations between left atrial (LA) size, echocardiographic diastolic parameter (E/A ratio), and incident atrial fibrillation (AF) in older inpatients remain underexplored. This study aimed to evaluate the relationship between LA size, E/A ratio, and AF risk in older hospitalized patients. Between January 2015 and May 2023, a total of 2,615 older inpatients (aged ≥ 65 years) were enrolled in this retrospective longitudinal study. Left atrial diameter (LAD) and E/A ratio were measured using transthoracic echocardiography. Over a median follow-up of 844 days (IQR: 331–1355 days), 209 patients (8.0

Ischemic cardiomyopathy (ICM) is characterised by the insufficient capacity of the heart to effectively pump blood, which ultimately contributes to heart failure (HF). In this study, the down regulation of SENP1 is identified in the cardiomyocyte of ICM mouse models and in patients. The depletion of SENP1 exacerbates hypoxia-induced apoptosis of cardiomyocytes in vitro and deteriorated cardiomyocyte injury of ICM mice in vivo. Mechanistically, SENP1 deSUMOylates the SUMO2-mediated modification of MEF2C at lysine 401 for stabilising protein stability. Moreover, the interaction with SENP1 controls the nuclear condensation of MEF2C to promote the expression of genes critical for cardiomyocyte function. When rescuing SENP1 expression using adeno-associated virus serotype 9, the attenuation of cardiomyocyte injury is discerned in the mouse model of ICM. Therefore, these finding elicits a previously unrecognised role and mechanism of SENP1 in safeguarding cardiomyocyte in ICM progression while establishing a basis for the development of SENP1 as a potential marker for ICM diagnosis and treatment. KEY POINTS: SNEP1 is downregulated in the cardiomyocyte of ICM mouse models and in patients. SENP1 deSUMOylates the SUMO2-mediated modification of MEF2C at lysine 401 for protein stability. The interaction with SENP1 controls the nuclear condensation of MEF2C to promote cardiomyocyte function. Cardiac rescue of SENP1 alleviates ischemic heart injury in ICM mouse models by AAV9.

BACKGROUND:The risk of incident atrial fibrillation (AF) increases with accumulating risk factors. Baseline-only risk assessment may not reflect the real risk of incident AF. We aimed to evaluate the performance of the dynamic change of the C2HEST score (C2: coronary artery disease/chronic obstructive pulmonary disease (1 point each); H: hypertension (1 point); E: elderly (age ≥75 years, 2 points); S: systolic/diastolic heart failure (2 points); and T: thyroid disease (hyperthyroidism, 1 point) C2HEST) score to assess the risk of incident AF during follow-up. METHODS:The present study data were retrieved from the Information Management and Big Data Center of Peking University Hospital Group. Patients without AF at baseline were enrolled. New-onset comorbidities were recorded during follow-up. The change in the C2HEST score was analyzed. The baseline and the change in C2HEST scores were compared for the prediction of incident AF. RESULTS:A total of 120 133 patients were included in the final analysis. During 346 400 patient-years of follow-up, 2304 developed incident AF (0.67 per 100 patient-years). The mean C2HEST score increased significantly from 1.62 to 2.96 (P<0.05). A significant proportion of patients had newly diagnosed comorbidities (61.9% with ∆C2HEST ≥1 in AF and 14.6% with C2HEST ≥1 in non-AF). The change in C2HEST scores showed better performance compared with the baseline score, as assessed by area under curve analyses (∆C2HEST 0.821 [0.811-0.830], baseline 0.758 [0.747-0.769]), decision curve analysis, and positive net reclassification index. CONCLUSIONS:The risk for incident AF is not static and increases with the accumulation of new comorbidities. The change in C2HEST score had better prediction in assessing individual risk of incident AF compared with the baseline score.

BACKGROUND:Mitral regurgitation (MR) is the most common valvular heart disease and the most common comorbidities of atrial fibrillation (AF), which is prevalent with age. Nonetheless, the prognosis of MR in elderly patients with AF has not been fully elucidated. AIM:This study is a post hoc analysis of the CABANA (Catheter Ablation vs Antiarrhythmic Drug Therapy for Atrial Fibrillation) trial. METHODS:Patients were classified into two groups: those with moderate or severe MR (msMR) and those with no or mild MR (nmMR). The primary endpoint was a composite of death, disabling stroke, serious bleeding or cardiac arrest. The secondary endpoints included all-cause mortality and the composite of all-cause mortality and heart failure hospitalisation. Quality of life was assessed at baseline, 3 and 12 months, and annually up to 60 months. RESULTS:Overall, 1368 participants were included in the final analysis (mean age: 65.6±8.2; female 61.3%), including 135 patients with msMR and 1233 with nmMR. The primary endpoint occurred in 7.2% of patients with nmMR versus 14.1% with msMR (HR 1.97, 95% CI 1.20 to 3.25; p=0.008). The secondary endpoint rates for nmMR versus msMR, respectively, were 4.7% vs 8.8% for all-cause mortality (HR 1.73, 95% CI 0.92 to 3.25; p=0.089) and 10.8% vs 15.5% for the composite of death and heart failure hospitalisation (HR 1.25, 95% CI 0.78 to 1.99; p=0.357). CONCLUSIONS:Among elderly patients with AF, msMR is associated with an increased risk of the primary composite endpoint of death, disabling stroke, serious bleeding or cardiac arrest. TRIAL REGISTRATION NUMBER:NCT00911508.

BACKGROUND:We aimed to use cluster analysis to improve phenotyping of patients with AF, assess the long-term clinical outcomes of the identified clusters, and examine the impact of these clusters on the effectiveness of ablation versus drug therapy. METHODS:Using data from the CABANA trial, we performed cluster analysis on 2205 patients using 12 clinical variables. The primary endpoint was a composite of death, disabling stroke, serious bleeding, or cardiac arrest. We compared the differences in the primary endpoint and all-cause mortality across clusters. Additionally, we analyzed the differences in treatment outcomes within each cluster. RESULTS:Among the 2205 patients, we identified three distinct AF phenotypes using K-prototype cluster analysis. Cluster 1 predominantly included females (69.0 %) and had the highest proportion of paroxysmal AF (61.7 %). Cluster 2 consisted of the youngest male-dominated phenotype (89.4 %). Cluster 3 represented the oldest AF phenotype with multiple comorbidities. Compared to Cluster 1, Cluster 2 had a similar risk of the primary endpoint (HR 0.83, 95 %CI 0.55-1.25; P = 0.369) and all-cause mortality (HR 0.92, 95 % CI 0.57-1.48; P = 0.727). In contrast, Cluster 3 exhibited a higher risk of the primary endpoint (HR 2.38, 95 % CI 1.69-3.35; P < 0.001) and all-cause mortality (HR 2.06, 95 % CI 1.35-3.41; P = 0.0001). CONCLUSIONS:Through cluster analysis, we stratified CABANA trial participants into three distinct AF phenotypes with varying clinical characteristics, prognoses, and responses to treatment. These findings underscore the heterogeneity of AF and suggest the need for personalized treatment strategies tailored to individual patient characteristics. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00911508.

患者男性,50岁,因间断黑矇1个月入院,心电图及动态心电图均提示间断高度-三度房室传导阻滞,超声心动图、心脏CT及心脏M RI均提示矫正型大动脉转位.入院后成功行无导线起搏器植入术,将无导线起搏器植入解剖学左室内,术后各项参数稳定.

BACKGROUND:Ventricular premature depolarizations (VPDs) originating from the mid interventricular septum (IVS) adjacent to the atrioventricular annulus between the His bundle and the coronary sinus ostium (mid IVS VPDs) have not been characterized.OBJECTIVE:The aim of this study was to investigate the electrophysiological characteristics of mid IVS VPDs.METHODS:Thirty-eight patients with mid IVS VPDs were enrolled. VPDs were divided into different types according to precordial transition of the electrocardiogram (ECG) and QRS morphology in lead V1.RESULTS:Four types of VPDs were divided. The precordial transition zone appeared earlier and earlier from types 1 to 4. The notch in lead V1 moved gradually backward, and its amplitude gradually became higher, resulting in the transition from left to right bundle branch block morphology in lead V1 from types 1 to 4. Based on activation and pace mapping, ablation response, and 3830 electrode pacing morphology in the mid IVS, the 4 types of ECG morphology corresponded to an origin in the right endocardial side, right/mid intramural region, left intramural region, and left endocardial side of the mid IVS, respectively. An intramural origin was identified for 50% of VPDs. Eighty-nine percent of mid IVS VPDs could be eliminated. Bilateral ablation (waiting for delayed efficacy) or bipolar ablation was sometimes needed for intramural VPDs.CONCLUSION:Mid IVS VPDs were found to have unique electrophysiological characteristics. The ECG characteristics of mid IVS VPDs were important in terms of prediction of its exact origin, the choice of ablation method, and the likelihood of treatment being successful.

To study the safety and electrical characteristics of various implanting sites of the Micra pacemaker. A total of 15 patients from Beijing Anzhen Hospital, Capital Medical University, were included, who were implanted with Micra leadless pacemakers and allocated to either the high ventricular septum group (eight patients) or the low ventricular septum group (seven patients) based on their individual patient factors and clinical conditions. The baseline of the patients, the implanting area, the electrocardiogram change after implantation, the implantation data, the threshold, R wave, impedance, and the date of the 1-month follow-up were then analyzed. With all of the data, the characteristics of different implantation sites of the Micra pacemaker were determined. Overall, the thresholds were low at implantation and remained stable over the 1-, 3-, 6-month, 1-, 2-, 3-, and 4-year follow-ups. On comparing the two groups, there was no difference in QRS duration at pacing (140.00 [40.00] ms vs. 179.00 [50.00] ms), threshold at implantation (0.38 [0.22] mV vs. 0.63 [1.00] mV), R wave at implantation ([10.85 ± 4.71] V vs. [7.26 ± 2.98] V), or impedance at implantation ([906.25 ± 162.39] Ω vs. [750.00 ± 173.40] Ω). While the difference in QRS duration between the two groups was not significant, the QRS duration of the high ventricular septum group exhibited a reduced tendency compared with that of the low ventricular group. The corrected QT interval during pacing exhibited a significant difference (440.00 [80.00] ms vs. 520.00 [100.00] ms; p < .05). For the 1-, 3-, 6-month, 1-, 2-, 3-, and 4-year follow-ups, there was no difference between the threshold of the high ventricular septum group and that of the low ventricular septum group ( p > .05). High ventricular septum pacing appears to be a safe site for implantation of the Micra pacemaker. It could entail a shorter QRS duration at pacing and could be more physiological than low ventricular septum pacing.

BACKGROUND:Congenitally corrected transposition of the great arteries (ccTGA) is a rare cardiac anomaly and can lead to abnormal electrical activity of the heart. The implant of a pacemaker in such patients is more complicated than conventional operations. This case report of an adult with ccTGA who had a leadless pacemaker implant will provide a reference for diagnosing and treating such patients.CASE PRESENTATION:A 50-year-old male patient was admitted to hospital having experienced intermittent vision loss for a month. An electrocardiogram and Holter monitoring showed intermittent third-degree atrioventricular block, and echocardiography, cardiac computed tomography and cardiac magnetic resonance imaging confirmed a diagnosis of ccTGA. A leadless pacemaker was successfully implanted into the patient's anatomical left ventricle, and the postoperative parameters were stable.CONCLUSION:Implanting a leadless pacemaker into a patient with a rare anatomical and electrophysiological abnormality, such as ccTGA, is feasible and efficacious, but preoperative imaging evaluation is of considerable importance.

目的 探讨通用钢丝支撑的导线(Solia S60)在三维引导鞘支撑下行左束支区域起搏(LBBaP)的可行性、安全性.方法 15例患者入选,在三维引导鞘支撑下应用Solia S60电极行LBBaP,记录术中电极导线的参数,QRS波形态及时限,LBBaP时V5导联左室达峰时间、透视时间及术中并发症等,比较术后随访中起搏参数、QRS时限等变化.结果 15例中12例(80％)成功应用Solia S60完成LBBaP,手术时间(87.73±24)min;术后QRS波时限与术前相比无差异[(120.17±9.3)ms和(119.25±26.5)ms,P>0.05],术后随访电极阻抗相对稳定[单极(418.4±92.0)Ω,双极(642.3±103.9)Ω].失败3例,1例为巨大右房,1例为复杂解剖异常,此2例改为普通起搏;另1例为术中出现停搏之后心室颤动,改为间隔起搏.结论 钢丝支撑的导线在特殊鞘支撑下行LBBaP是可行且安全的.

To explore short-term changes after left bundle branch pacing (LBBP) using echocardiography and computed tomography (CT), especially for postoperative ventricular septal perforation. Between January and September 2019, 33 patients with atrioventricular block underwent LBBP at Beijing Anzhen Hospital. All the patients were evaluated using electrocardiography, pacing, parameters and echocardiographic measurements, including for major complications, during the 1, 3, 6, 12 and 24-month follow-up. Interval perforations were examined during a 1-month follow-up echocardiogram and CT. Left bundle branch pacing was successfully performed in 100% (33/33) of patients. The mean seizure threshold was stable and unchanged postoperatively at the 1, 3, 6, 12 and 24-month follow-up. The paced QRS duration of the LBBP was 119.72 ± 2.53 ms and <130 ms in all patients. Unipolar impedance during the procedure was higher than 500 Ω (662.00 ± 181.50 Ω). No ventricular septal perforation occurred at the end of the procedure. At the 1-month follow-up, two patients reported transthoracic echocardiography, with CT revealing septal lead perforation. Through CT, two other patients were found to have septal lead perforation, and echocardiography indicated that the pacing lead had penetrated the interventricular septum and entered the left subendocardium. At the 1, 3, 6, 12 and 24-month follow-up, these four patients exhibited no significant increase in pacing threshold or impedance ( p > .05). No ventricular thrombus or stroke was detected. Permanent LBBP is safe and feasible in patients with bradycardia. Echocardiography and/or CT can more accurately evaluate changes in cardiac structure and function after LBBP.