Background: Delayed pericardial effusion or pericardial tamponade (PE/PT) is a relatively rare complication of left atrial appendage closure (LAAC) but has serious consequences for affected patients. There are limited data related to delayed PE/PT. The aim of this study was to analyze the incidence and potential risks of delayed PE/PT following LAAC. Methods: Patients with nonvalvular atrial fibrillation who were successfully implanted with LAAC devices from October 2014 to July 2023 were screened retrospectively. Patients were divided into two groups according to whether delayed PE/PT occurred. Univariate and multivariate analyses were used to evaluate the potential risks of delayed PE/PT. Results: A total of 1866 patients with successfully implanted LAAC devices were included. Fifty-two patients were excluded because of missing transesophageal echocardiogram or cardiac CT angiogram data 45 days after the procedure, and 106 patients were excluded because of loss to follow-up. Thirty-seven patients were excluded because of acute PE/PT during perioperative period. Among the remaining 1671 patients, 11 developed delayed PE/PT during the follow-up period (2 Watchman2.5, 2 ACP and 7 LAmbre). Ten of these patients recovered after pericardiocentesis, and one patient required cardiac surgery. Patients with delayed PE/PT had a larger left atrial appendage (LAA) orifice diameter, a higher rate of nitinol plug device use and a lower incidence of systolic heart failure. Univariate and multivariate analyses revealed that the use of a nitinol plug device was associated with delayed PE/PT (OR=1.819 95% CI: 0.757-4.343, P=0.018). A larger maximal LAA orifice diameter was also associated with the occurrence of delayed PE/PT (OR=1.473 95% CI: 1.163-1.866, P=0.001). Conclusion: Delayed PE/PT is a rare complication of LAAC device implantation and is related to the use of a nitinol plug device rather than a nitinol cage device. Patients with larger LAA orifice diameters are at greater risk of delayed PE/PT after LAAC.

Background: High-frequency low-tidal-volume (HFLTV) ventilation is a safe and cost-effective strategy that improves catheter stability, first-pass pulmonary vein isolation, and freedom from all-atrial arrhythmias during radiofrequency catheter ablation (RFCA) of paroxysmal and persistent atrial fibrillation (AF). However, the incremental value of adding rapid-atrial pacing (RAP) to HFLTV-ventilation has not yet been determined. Objective: To evaluate the effect of HFLTV-ventilation plus RAP during RFCA of paroxysmal AF on procedural and long-term clinical outcomes compared to HFLTV-ventilation alone. Methods: Patients from the REAL-AF prospective multicenter registry, who underwent RFCA of paroxysmal AF using either HFLTV+RAP (500-600 msec) or HFLTV ventilation alone from April 2020 to February 2023 were included. The primary outcome was freedom from all-atrial arrhythmias at 12-month follow-up. Secondary outcomes included procedural characteristics, long-term clinical outcomes, and procedure-related complications. Results: A total of 545 patients were included in the analysis (HFLTV+RAP=327 vs. HFLTV=218). There were no significant differences in baseline characteristics between the groups. No differences were observed in procedural (HFLTV+RAP 74 [57-98] vs. HFLTV 66 [53-85.75] min, p=0.617) and RF (HFLTV+RAP 15.15 [11.22-21.22] vs. HFLTV 13.99 [11.04-17.13] min, p=0.620) times. Both groups showed a similar freedom from all-atrial arrhythmias at 12-month follow-up (HFLTV+RAP 82.68% vs. HFLTV 86.52%, HR=1.43, 95% CI [0.94-2.16], p=0.093). There were no significant differences in freedom from AF-related symptoms (HFLTV+RAP 91.4% vs. HFLTV 93.1%, p=0.476) or AF-related hospitalizations (HFLTV+RAP 98.5% vs. HFLTV 97.2%, p=0.320). Procedure-related complications were low in both groups (HFLTV+RAP 0.6% vs. HFLTV 0%, p=0.247). Conclusion: In patients undergoing RFCA for paroxysmal AF, adding RAP to HFLTV-ventilation was not associated with improved procedural and long-term clinical outcomes.

Background SCN5A is the most common susceptibility gene in patients with Brugada syndrome (BrS); however, the interpretation and management of benign or variants of unknown clinical significance (VUS) in SCN5A remains a challenge despite the availability of genetic testing. Objective This study aimed to investigate the relationship between the SCN5A variants and clinical symptoms of BrS patients. Methods We resequenced the SCN5A gene in 239 patients diagnosed with BrS at Hiroshima University Hospital and analyzed the association between the SCN5A variants and clinical features, 12-lead electrocardiography (ECG) parameters, or signal-averaged ECG. Results Overall, 84 SCN5A variants were identified: 55 benign, 7 pathogenic, and 22 VUS . No significant difference in the incidence of previous cardiac events was observed between patients with and without SCA5A benign variants. The female proportion was higher in BrS patients with SCN5A VUS or pathogenic variants. Moreover, the symptomatic proportion was higher in BrS patients with SCN5A VUS or pathogenic variants. Multivariate analyses revealed that the presence of SCN5A VUS or pathogenic variants, longer r-J interval in lead V1, and the presence of fragmented QRS were independently associated with the cardiac events in BrS patients and that positive late potentials, longer LAS40, and lower RMS40 were significantly associated with symptomatic BrS in patients carrying SCN5A VUS. Conclusions The SCN5A VUS or pathogenic variants were found to be independent risk factors for the cardiac events in the BrS patients. In BrS patients with SCN5A VUS, the signal-averaged ECG was the key to risk stratification for cardiac events.

Background Patients with chronic obstructive pulmonary disease (COPD) are at high risk for developing arrhythmias due to hypoxemia, right heart failure, and the use of beta-agonist inhalers. Symptoms related to arrhythmias can often be masked or confounded by symptoms related to COPD exacerbation and remain undiagnosed. With this study, we identify the incidence of actionable arrhythmias in patients with no prior cardiology follow-up and moderate-severe COPD with continuous monitoring. Methods An automatic referral for electrophysiology (EP) consult was generated in patients with moderate-severe COPD if they endorsed one of the following: palpitations, dizziness, abnormal ECG, or near syncope. Eligible patients underwent ILR implantation after evaluation with an EP specialist and were followed via remote monitoring for 12 months. A control group of patients without COPD matched for age, sex, and implant indication were randomly selected in a 3:1 ratio. Actionable arrhythmias, defined as arrhythmias that correlated with symptoms triggered by the patient, necessitating EP intervention, were recorded for both groups. Results In this prospective cohort study, 21 patients with COPD were enrolled and compared to 63 controls. COPD patients experienced a significantly higher rate of actionable arrhythmias compared to the controls (48% vs 11%, p<0.001). EP interventions in response to actionable arrhythmias included eight patients initiated on anticoagulation, three catheter ablations, one implantable cardiac defibrillator, and one permanent pacemaker implanted. In multivariate analysis, COPD was an independent predictor of actionable arrhythmias (aOR 4.3, 95% CI 1.2-15.2, p=0.02) when adjusting for chronic kidney disease and all-cause readmissions. Conclusion: Continuous monitoring was highly effective in diagnosing significant arrhythmic events in patients with moderate-severe COPD. Awareness should be raised about the high arrhythmic risk in this population and the role of continuous monitoring should be evaluated in larger studies.

; Introduction: A 22-year-old male with no prior cardiovascular history presented with frequent symptomatic ventricular premature contractions (VPCs) with multiple QRS morphologies despite bisoprolol treatment. Results: The coupling intervals progressively increased from VPC1 to VPC3, and VPC2 was the most frequent (VPC1: 9.3%, VPC2: 30.2%, VPC3: 0.5%). The earliest activation site was identified at the left-right coronary cusp junction. Single ventricular extrastimuli with variable coupling intervals from this site successfully reproduced QRS morphologies identical to VPC 1-3. Conclusion: The findings revealed the utility of unique pace-mapping technique in cases of VPCs with multiple morphologies.

Background Currently, there is no reliable endpoint for the conclusion of atrial fibrillation (AF) ablation. Atrial burst pacing and/or isoproterenol challenge are poor diagnostic tools. A newly proposed Vagal AF Induction Test(VAFIT) uses effective atrial refractory period measurement, simultaneously with extra-cardiac vagal stimulation(ECVS) to study AF inducibility pre and post-ablation. Objective Prospective study in patients submitted to radiofrequency catheter pulmonary vein isolation(PVI) plus cardioneuroablation(CNA) evaluating the VAFIT result before and at the end of the procedure with AF recurrence. Methods Prospective study of 142 patients, 57.5[48.9-70.2] years-old, 71% males, with symptomatic AF (79.6% paroxysmal/20.4% persistent), left atrium diameter of 38.0[35.0-41.2] mm, and left ventricular ejection fraction of 63.0 [62.0-68.2]. VAFIT was considered positive or negative depending on whether AF induction occurred. It was performed at baseline and after PVI+CNA, with a single atrial extra stimulus during ECVS (5s/50Hz/1V/kg up to 70V/Pulse Width=50 µs). Patients were followed for a median of 15.0[7.0-20.0] months. The association of VAFIT-positive status at the end of the procedure with AF recurrence was investigated by univariate and multivariate Cox regression analysis. Results Pre-ablation VAFIT was positive in all cases and became negative in 62.9% of patients. AF recurrence: 18.7% in VAFIT-positive and 5.6% in VAFIT-negative patients(p=0.012). VAFIT-positivity was associated with AF recurrence (HR: 4.56(1.37-15.23,p=0.014). Conclusion A VAFIT-positive status following PVI+CNA was strongly and independently associated with AF recurrence. It remains to be investigated in randomized studies whether achieving VAFIT-negativity at the end of the procedure, as demonstrated in this study, would lead to better clinical outcomes.

Introduction: Substernal extravascular defibrillators (EV ICDs) have been shown to be effective and safe for patients at risk of sudden cardiac death, however, there is little evidence around the safety of extracting chronic devices. Methods and Results: We present a 50-year-old patient in whom a Medtronic EV ICD system was successfully removed without specialist extraction tools, 186 weeks after implantation, by an operator experienced in transvenous lead extraction but without formal training in EVICD implantation. Conclusion: The successful extraction of an EV ICD system is possible without specialised tools at least 3.6 years post-implant.

Background Data are scarce regarding WPW syndrome and asymptomatic pre-excitation in Africa. Objectives This study aimed to understand how accessory pathways related arrhythmias are managed in Africa. Methods This prospective study was conducted in 20 centers from 17 African countries. All the included participants had ventricular pre-excitation patterns. The data collected included symptoms, locations of accessory pathways (AP) and tachyarrhythmia, risk stratification, as well as acute and long-term management. In addition, we assessed the clinical effectiveness and the impact of socio-economic and health metrics on this treatment approach. Results Of 541 participants, 93% were diagnosed with WPW syndrome, and orthodromic atrioventricular reciprocating tachycardia (AVRT) was the most prevalent arrhythmia, affecting 55% of the cases. Approximately 30% of patients, excluding the southern region, received Intravenous Amiodarone as the first-choice drug for orthodromic AVRT while Adenosine was the drug of choice in Southern region. Electrical cardioversion was the first-line treatment for pre-excited atrial fibrillation and antidromic AVRT across all of Africa. Radiofrequency ablation was the first long-term therapy option for 88 % of patients in all African regions, except in western and central Africa, where it was implemented for less than 30% of patients (P<0.001). The rates of success, long-term recurrence, and complication were 93%, 4.1%, and 3.8%, respectively. Conclusion Significant differences and challenges in the diagnosis and management strategies among countries are reported across Africa. While several countries fell short of ideal or expected health expenditures, ablation techniques are rising with success rates comparable to those in the developed world.

Background Atrial fibrillation (AF) is the most common cause of arrhythmia-induced cardiomyopathy. Effective management strategies include medical therapy for rate and rhythm control, catheter ablation (CA), and goal directed medical therapy. Sodium-glucose co-transporter 2 inhibitors (SGLT2i), a novel class of anti-diabetic drugs, have shown a promising impact in reducing cardiovascular events in diabetic and non-diabetic heart failure (HF) patients. It is unclear what impact SGLT2i use may have on AF recurrence following catheter ablation. Aim To evaluate the effects of SGLT2i on preventing AF recurrence following CA and impact on other cardiovascular outcomes. Methods and results We performed a comprehensive literature search through multiple search engines (Pubmed, Scopus, Web of Science, and Cochrane) to include eligible studies using the appropriate keywords until 10th April 2024. Our search yielded nine eligible studies with 16,857 patients. Our analysis reveals a significant reduction in AF recurrence after catheter ablation among patients receiving SGLT2i compared to non-SGLT2i medications (RR = 0.72, 95% CI [0.67, 0.78], P < 0.00001). Additionally, SGLT2i therapy was associated with decreased all-cause hospitalizations and reduced risk of ischemic stroke. However, no significant difference in all-cause mortality was observed between SGLT2i and non-SGLT2i groups. Conclusion Our study found that SGLT2 inhibitors significantly reduced AF recurrence post-CA in diabetic patients. Moreover, SGLT2i use was associated with lowered hospitalization and ischemic stroke risk. Though no significant difference in mortality was noted, the decrease in hospitalization suggests a possible favorable effect on cardiovascular events.

Background: Left bundle branch area pacing (LBBAP) offers physiological pacing with potential advantages over right ventricular (RV) pacing, particularly in children. However, data on LBBAP in pediatric populations are scarce. Objective: This study aimed to assess the feasibility and safety of LBBAP in children by reporting 6 cases done successfully. Methods: Six children (four males, two females), aged 2 to 16 years, underwent LBBAP between December 2022 and January 2024 at the American Univeristy of Beirut Medical Center (AUBMC). The implantation procedure followed established techniques. Baseline characteristics, echocardiographic measurements, and pacing parameters were recorded. Results: All six cases fulfilled the criteria for LBBAP. Successful LBBAP was achieved in all cases. Median weight is 20.5 kg, with three patients under 5 years old. Baseline left ventricular ejection fraction (LVEF) was normal in 4 cases, with two exhibiting 52%. The interventricular septal thickness averaged 4.5 mm. No major complications were encountered during follow-up. Conclusion: Left bundle branch area pacing might be a promising alternative to conventional RV pacing, offering potential advantages over traditional pacing methods. Further research is needed to fully elucidate its efficacy and long-term benefits in pediatric populations.

Background: Radiofrequency(RF) ablation of premature ventricular complexes(PVCs) is a well-established treatment for patients high PVCs burden, even when arising from epicardial/intramural localization. Consistent data about safety of using high power RF is lacking in literature in these regions. Aim: The aim of this study is to investigate safety of different RF power settings, efficacy and outcome of non-endocardial PVCs ablation. Methods: Consecutive patients who underwent PVC ablation were included (2017-2023). We defined “Non-Endocardial Radiofrequency Ablation”(NERA) a procedure in which at least one ablation site has been identified into the cardiac venous system, aortic cusps, inter-leaflet region or pulmonary cusps. Results: Total number of NERA sites was 64 in 53 procedures. In 63% of the procedures, high power (≥40W) and in 60% long duration (≥60 seconds) RF was delivered in at least one site (mean power:37±9W(15-50), mean duration of single RF 88±65 seconds (30-304)). In 21% of the procedures, a combination of both high power and long duration RF applications was performed. Procedural success was achieved in 47 procedures(84%). Only one severe complication (pericardial bleeding) was observed. In 22(39%) procedures, multisite ablation was performed which was associated with procedural failure (OR 7,47;p=0,01). During follow-up, mean and median PVC burden reduction were 69±41% and 96% respectively. Multisite ablation and coronary venous system RF were predictors of recurrence (HR 3.6;p=0.026 and HR 3.85;p=0.014). Conclusion: Ablation from non-endocardial sites is a safe and effective procedure, even using high power and/or long duration RF with clear benefit in terms of PVC burden reduction.

Introduction The docking button of the Aveir leadless pacemaker (LP) is often difficult to access due to its inappropriate position in the right ventricle (RV). Methods and Results We report a case where the Aveir LP was successfully retrieved by releasing the wedged docking button in the inferior wall of the RV using a loop wire technique. Conclusion The loop wire technique may be useful to change the position of the Aveir LP. This may be helpful to retrieve the Aveir LP even in the case where the docking button is wedged in the inferior wall of the RV.

Introduction Implantable loop recorders (ILR) are recommended to detect atrial fibrillation (AF) in cases of cryptogenic stroke (CS). However, the utility of loop recorder for detection of other actionable arrhythmias in these patients is limited. Objective: To evaluate the utility of ILR to detect arrythmias other than AF in patients with cryptogenic stroke. Methods: We enrolled consecutive CS patients referred for an ILR. A retrospective chart review was conducted from 2018 to 2021. All patients were monitored for a minimum of one year. Results: The cohort included 260 consecutive patients with cryptogenic stroke with a mean age of 68. 2 +/- 13.27 years patients of this cohort had at least one actionable arrhythmic event. AF was found in 47 (18%) patients and 44 (17%) patients were found to have other arrhythmias. Out of these 44 patients, 23 patients (9%) were found to have supraventricular tachycardias (SVT), 4 patients (2%) had ventricular tachycardias, 9 patients (3%) had pauses, 8 patients (3%) had significant bradycardia events. Anticoagulation was initiated in all 47 patients with AF. A total of 15 patients (6%) underwent procedures which included 7 pacemakers, 1 implantable cardioverter-defibrillator, 1 SVT ablation, 6 electrophysiology studies because of ILR findings. Conclusion: ILRs can successfully identify AF in patients with cryptogenic stroke. However, there is a high incidence of other arrythmias that can be detected by implanting ILRs that would otherwise would not be identified or have delayed detection. The study demonstrates the advantage of long-term remote monitoring of patients with CS beyond AF detection.

In recent years, the number of patients with implanted leadless pacemaker has increased significantly. Due to the small size of the device, low risk of infection, indications for removal are rare. The dwell time is correlated with extraction difficulty. Although the MICRA TPS contains retrieval feature at the proximal part of the device, the manufacturer (Medtronic) does not offer tools dedicated to this procedure. Complete encapsulation of the device may also make removal difficult or even impossible. We present the case of a patient in whom MICRA TPS was successfully removed 70 months after implantation with non-dedicated commercially available tools.

A 56-year-old man with non-ischemic cardiomyopathy with three prior ablations targeting two different MMVTs presented with recurrent VT. Therefore, he underwent epicardial mapping with adjuvant CT imaging which demonstrated midmyocardial scar. Fractionated potentials noted during mapping in this region, and entrainment suggested inner loop. Interestingly, pacing showed two different QRS morphologies identical to his previously ablated VTs with a long stim-QRS at this region. Epicardial ablation carried on during the VT successfully terminated it, but the VT remained inducible and required endocardial ablation to make it noninducible. The patient has been VT-free for 12 months following this ablation off antiarrhythmic drugs.

Introduction Implantable permanent pacemaker function is supported by their energy sources by a mean period of 8,8 to 12,4 years. We previously published this case of a patient with a normally functioning VVI pacemaker, 31 years after implantation. Methods and Results In this report, we state that the device is still functioning normally 40 years after implantation. The most recent device interrogation revealed pacing threshold of 0.9 V/0.5 ms. Holter monitoring for 24 hours recorded a total of 98.707 beats with 97,78% paced beats, without any indication of pacemaker malfunction and with stable heart rate at 70-71 bpm. Conclusion Most patients with implantable devices have the appropriate follow-up and settings of low energy consumption. Manufacturing companies are mainly considered responsible for achieving prolonged device longevity, focusing on the goal of high energy capacity of future devices.

A 70-year-old man presented with regular wide QRS complex tachycardia (WCT) at a rate of 185 beats/min, characterized by left bundle branch block morphology. WCT termination was achieved through electrical cardioversion. A subsequent 12-lead electrocardiogram revealed sinus rhythm with complete right bundle branch block (CRBBB) morphology. Echocardiography showed normal left ventricular function without structural heart disease. An electrophysiological study was then conducted, followed by catheter ablation. At baseline, the atrio-His and His-ventricular intervals were normal. Fractionated ventricular potentials were observed in the para-Hisian region during sinus rhythm. Neither dual atrioventricular (AV) nodal physiology nor ventriculoatrial conduction was observed during programmed pacing. Clinical WCT was induced by ventricular extra-stimulation with concurrent AV dissociation and no visual His bundle potential, confirming the diagnosis of ventricular tachycardia (VT). Figure 1 illustrates 12-lead electrocardiograms recorded during overdrive pacing from the right ventricular apex (RVA) and right atrial septum during VT. The electroanatomical activation map revealed a distinctive focal breakout pattern with fractionated potentials originating from the para-Hisian region. In the noncoronary cusp (NCC), corresponding to the opposite side of the para-Hisian region, prolonged and fractionated ventricular potentials preceding QRS onset by 56 ms were recorded (Figure 2A). Figure 2B shows the intracardiac electrogram recorded during ventricular overdrive pacing from the NCC during VT. Based on these observations, what is the mechanisms underlying the tachycardia?

Background Previous research indicates disparities in atrial fibrillation (AF) recurrence and complications following catheter ablation in women; however, long-term outcomes based on gender remain underexplored. Objective This study evaluated the long-term rates of AF recurrence and major adverse cardiovascular and cerebrovascular events (MACCE) following catheter ablation, investigating gender-related risk factors to inform clinical practice improvement. Methods We conducted a retrospective analysis using data from a prospectively observational registry of AF ablation procedures at our institution from 2015 to 2020. Patients were followed up for MACCE and AF recurrence. The risk factors of AF recurrence and MACCE were further explored. Results The study cohort consisted of 2,293 patients, including 1,441 males and 852 females, and had an average follow-up duration of 50.36 months. After catheter ablation, females exhibited a notably higher rate of recurrence compared to males, with a hazard ratio of 1.305 and a 95% confidence interval ranging from 1.101 to 1.547, which was statistically significant (p=0.0014). Gender differences in AF recurrence persisted regardless of early versus late intervention (both p<0.05). No significant difference in MACCE rates was observed between genders. Independent risk factors for AF recurrence included female gender, diabetes, left atrial diameter ≥40 mm. Conclusions Gender differences significantly impact the long-term outcomes of AF recurrence, but not MACCE rates post-catheter ablation. The study highlights the necessity to integrate gender considerations into AF management strategies.