A patient underwent the LARIAT left atrial appendage (LAA) ligation procedurewith persistent atrial fibrillation history. The procedure was done successfully. A transthoracic echocardiography did not show pericardial effusion. The patient was examined under fluoroscopy where the tip of the drain was not in the pericardial space and contrast injection pericardial drain confirmed its location in the inferior vena cava.

Previous research showed a significant difference in the presence of subclinical coronary artery disease (CAD) on cardiac CT angiography (CTA) between patients with idiopathic paroxysmal atrial fibrillation (iAF) versus a matched sinus rhythm population (iSR). Here we present 5-year follow-up data and the consequences of subclinical CAD on baseline CTA on the development of cardiovascular disease in iAF. In 99 iAF patients (who underwent CTA as part of work-up for pulmonary vein isolation) and 221 matched iSR controls (who underwent CTA for CAD assessment), the incidence of hypertension, diabetes and major cardiovascular events (MACCE) during follow-up was obtained. Multivariable Cox regression analysis was used to reveal predictors of incident cardiovascular disease in the iAF group. During a follow-up of 68±11 months, over one third of patients developed cardiovascular disease, with no difference between iAF and iSR (log-rank p=0.56), and comparable low rates of MACCE (4.0% vs 5.0%,p=0.71). Within the iAF group, age (HR1.12(1.03-1.20);p=0.006), left atrial diameter (HR1.16(1.03-1.31);p=0.01), Segment Involvement Score (total number of coronary segments with atherosclerotic plaque; HR1.43(1.09-1.89);p=0.01) and the number of calcified plaques on CTA (HR0.53(0.30-0.92);p=0.01) were independent predictors of incident cardiovascular disease. Subclinical coronary disease on CTA may be useful to identify the subset of patients with iAF that harbour concealed cardiovascular risk factors and need intensive clinical follow-up to ensure timely initiation of appropriate therapy once CV disease develops, including anticoagulation and vascular prophylactic therapy.

The effect of intensive versus standard blood pressure (BP) lowering on the risk of atrial fibrillation (AF) is uncertain. Intensive BP lowering is associated with a lower risk of AF among patients with hypertension. We searched PubMed, EMBASE, and CENTRAL (inception to June 5, 2020) for randomized controlled trials evaluating the effect of intensive versus standard (target systolic BP < 140 mmHg) BP lowering on incident AF. We assessed heterogeneity using the I2 statistic then used fixed-effects meta-analysis models to report pooled treatment effects and 95% confidence intervals. We also tested for publication bias by three funnel plot-based methods. The quality of each study was assessed with the Cochrane Risk of Bias tool. We assessed 16 candidate studies for eligibility from 2,312 published articles, but only three randomized clinical trials were eligible for inclusion and included a combined 12,219 participants with hypertension: Cardio-Sis (Studio Italiano Sugli Effetti Cardiovascolari del Controllo della Pressione Arteriosa Sistolica), ACCORD-BP (Action to Control Cardiovascular Risk in Diabetes Blood Pressure trial), and SPRINT (Systolic Blood Pressure Intervention Trial). The target systolic BP in the intensive BP arm was <120 mmHg for participants in SPRINT and ACCORD-BP, but <130 mmHg for participants in Cardio-Sis. Participants randomized to intensive BP lowering had significantly lower risk of incident AF compared with those randomized to standard BP lowering (AF incidence 2.2% vs. 3.0%, respectively; pooled hazard ratio (95% confidence interval): 0.74 (0.59 - 0.93)). Intensive BP lowering is associated with a significantly lower risk of incident AF in patients with hypertension. These findings add to the current evidence supporting the benefits of intensive BP control.

It remains unclear whether atrial fibrillation (AF) alone determines systemic changes in hemocoagulation. Our aim was to examine the prothrombin fragment F1+2 and fibrinopeptide A (FPA) as early markers of coagulation activity still in the first twenty-four hours of paroxysmal AF (PAF) and to correlate them with the arrhythmia onset. 51 non-anticoagulated patients (26 men, 25 women, aged 59.84±1.6 years) and 52 controls (26 men, 26 women, aged 59.50±1.46 years) were sequentially selected. F1+2 and FPA plasma levels were measured by enzyme-linked immunoassays. F1+2 was significantly higher in patients (292.61pmol/L±14.03pmol/L vs 183.40pmol/L±8.38pmol/L; p<0.001). FPA was also substantially higher (4.47ng/mL±0.25 ng/mL vs 3.09ng/mL±0.15ng/mL, p<0.001). Among the potential predictors for these deviations: age, gender, BMI, PAF duration and CHA2DS2-VASc score, it was established that higher F1+2 and FPA plasma levels were independently associated only with PAF duration (p<0.05). Moreover, longer episodes were associated with higher values of F1+2 (Adjusted R2 = 0.68) and FPA (Adjusted R2 = 0.70). Increased coagulation activity was present still in the first twenty-four hours of PAF clinical presentation. The disease itself was associated with increasing hypercoagulability over time, suggesting its importance as an independent risk factor for thromboembolic events.

High power ultra-short duration (HPUSD) ablation has been advocated to prevent esophageal injuries during atrial fibrillation (AF) ablation procedures. Prior research using the standard circular mapping catheter (CMC) has shown that ultra-short ablations may compromise lesion durability resulting in an increased need for redo procedures. The purpose of this study was to determine if HD mapping of concealed pulmonary vein (PV) connections could improve freedom from atrial fibrillation and redo procedures compared to CMC guided AF ablation. A total of 472 consecutive first time AF ablation procedure patients with at least one year of follow up were included with an average follow-up of 18 months. HPUSD AF ablation consisted of 50 W for 2-3 seconds on the posterior wall and 5-15 seconds on the anterior wall of the left atrium. Acute pulmonary vein isolation (PVI) was defined as no concealed 1) PV signals, 2) activation into PVs, or 3) voltage into PVs with no intra-procedural waiting period utilizing the HD Grid catheter versus entrance/exit block with a 30-minute wait with the circular mapping catheter. Freedom from atrial fibrillation and all atrial arrhythmias following a 90-day blanking period were assessed. Acute pulmonary vein isolation was achieved in all 472 patients. HPUSD ablation using the HD Grid was associated with shorter procedure (70.2 vs 104.3 minutes, p<0.001) and fluoroscopy times (4.2 vs 15.0 minutes, p<0.001) when compared to CMC. The recurrence of any atrial arrhythmias at 1 year was 13% with HD Grid and 25% with CMC (p<0.001) with the need for redo procedures of 6% for HD Grid and 20% for CMC (p<0.001). No esophageal ulcerations/perforations were seen. No deaths, strokes, or TIAs were observed in either group. HPUSD AF Ablation, as guided by HD Grid mapping, may prevent esophageal injuries while at the same time improve freedom from any atrial arrhythmias and the need for redo procedures. Procedure and fluoroscopy times were also significantly decreased when compared to traditional CMC mapping.

Unmappable regular atrial tachycarrhythmias (ATs) occasionally develop during atrial fibrillation (AF) ablation, and are difficult to treat by conventional ablation. Recently, low-voltage areas (LVAs) have been reported to represent AT substrate. The purpose of this study was to elucidate the efficacy of LVA ablation for unmappable AT. This observational study included 32 consecutive patients who developed unmappable ATs during and after AF ablation. Unmappable AT was defined as AT lasting for >5 s, but that terminated or changed the activation sequence over too short a time to create a sufficient activation map. We used conventional ablation to target undetermined AT circuits estimated from activation timings of electrograms recorded on the placed electrode catheter, the response to entrainment mappings, and/or diastolic potentials during AT. Subsequently, in cases without successful elimination of unmappable ATs by conventional ablation, LVA (≤ 0.5 mV) ablation was performed at the discretion of the operators. Conventional ablation failed to eliminate at least one unmappable AT in 29 patients. Among them, LVA ablation was performed in 16 patients. LVA ablation eliminated all the unmappable ATs in 8 of 16 patients. The LVA size did not differ between patients with and without the acute elimination of unmappable ATs (17±11 vs. 21±12 cm2, p = 0.39), and AT/AF recurrence rates were comparable between the two groups (38% vs. 63%, p = 0.62) during a mean follow-up period of 14±8 months. LVA ablation was efficacious to some extent for the elimination of unmappable ATs refractory to conventional ablation.

The novel Polarx™ cryoablation system is currently being studied for atrial fibrillation (AF) ablation. To the best of our knowledge, no study comparing the novel cryoablation system with the standard Arctic Front™ cryoballoon is available in today's literature. This study aims to compare Polarx™ and Arctic Front™ cryoballoon in terms of safety and efficacy. From a total cohort of 202 patients who underwent pulmonary vein (PV) isolation for paroxysmal AF through cryoablation, a population of 30 patients who used Polarx™ were compared with 30 propensity-score matched patients who used Arctic Front™. Pulmonary vein occlusion and electrical isolation were achieved in all (100%) veins with a mean number of 1.09 ± 0.3 occlusion per vein using Polarx™ and 1.19 ± 0.5 occlusion per vein using Arctic Front™ (p = 0.6). Shorter procedure and fluoroscopy time were observed with Polarx™ group (60.5 ± 14.23 vs 73.43 ± 13.26 mins, p = 0.001; 12.83 ± 6.03 vs 17.23 ± 7.17 mins, p = 0.01, respectively). Lower cumulative freeze duration per vein was also observed with Polarx™ (203.38 ± 72.03 vs 224.9 ± 79.35 mins, p = 0.02). There was no significant difference in isolation time between the two groups (34.47 ± 21.23 vs 34.18 ± 26.79 secs, p = 0.9). The novel Polarx™ cryoablation system showed similar efficacy in vein occlusion and isolation and safety profile when compared to Arctic Front™ cryoablation system. Procedure time, fluoroscopy time, and cumulative freeze duration were significantly lower with Polarx™ cryoablation system.

Right free wall (RFW) accessory pathways (AP) typically present anatomical challenges to ablation leading to high rates of procedural failure and recovery of AP conduction. Patients with a diagnosis of Wolff-Parkinson-White Syndrome (WPW) and a manifest RFW AP undergoing an electrophysiology study (EPS) or an ablation at our center between 01/01/2008 and 08/01/2019 were identified from our databases using diagnosis codes and manual chart review. Twenty-one patients with manifest RFW AP underwent EPS, all of which were targeted for ablation. Single procedure success rate was 19 / 21 (90.5%). Of the 19 successful cases, 4 (17.4%) patients were found to have recurrent right free wall pathway conduction at follow-up and each underwent a successful 2nd procedure (9.5%). Fluoroscopic and 3D electroanatomic mapping software was used in all cases to guide ablation. A 4 mm or 8 mm non-irrigated radiofrequency (RF) ablation catheter was used in 76% of cases while an 8 mm cryo-catheter was used in one case. More than one type of ablation catheter was used in four cases (16%). A steerable sheath was used in 68% of cases. In a tertiary center, RFW AP ablation has high acute success (>90%) but approximately 21% of patients with initially successful ablation required a 2nd procedure for recurrence of pathway conduction. A combination of a large tip ablation catheter and a steerable sheath were used in most cases.

With the expanding integration of complementary and alternative medicine (CAM) practices in conjunction with modern medicine, yoga has quickly risen to being one of the most common CAM practices across the world. Despite widespread use of yoga, limited studies are available, particularly in the setting of dysrhythmia. Preliminary studies demonstrate promising results from integration of yoga as an adjunct to medical therapy for management of dysrhythmias. In this review, we discuss the role of autonomic nervous system in cardiac arrhythmia,interaction of yoga with autonomic tone and its subsequent impact on these disease states. The role of yoga in specific disease states, and potential future direction for studies assessing the role of yoga in dysrhythmia.

Manufacturer/federal drug administration (FDA) recommends inpatient initiation of dofetilide with the manufacturer providing an initiation algorithm. The outcomes of algorithm deviation have not been reported outside of clinical trials. We sought to perform a chart review of all the patients admitted for inpatient initiation of dofetilide to report on the incidence of protocol deviations and their implications. We performed a retrospective review of all patients over a 15-month periodwho were initiated on dofetilide for the very first time or reinitiated on dofetilide after a break of three months or more at our institution. We assessed data about patients who were given dofetilide without adherence to the protocol (i.e. protocol deviation). A total of 189 patients were included in the study with a median age of 66 ± 9 years. Mean baseline QTc interval was 436 ± 32 msec, and 61% (116/189) were in atrial fibrillation (AF) at the time of dofetilide initiation. In 9% (17/189) of patients, the drug was discontinued due to intolerance or inefficacy. Therapy in 49% (93/189) of patients was noted to deviate from manufacturer recommended protocol with deviations more than once in some patients during the same hospitalization. Baseline QTc exceeding 440 msec(>500msec in conduction abnormalities) was the most frequent deviation (25%; 47/189).Ventricular tachyarrhythmia occurred in 4% (7/189) of patients, did not differ between patients, and occurred with and without protocol deviations (5% vs 2%; p = 0.27). In our retrospective study, there were frequent deviations from the manufacturer-recommended algorithm guidelines for dofetilideinitation, primarily due to prolonged baseline QTc interval. The impact of these protocol deviations on drug discontinuation was uncertain; however, significant adverse events were higher in the deviation group compared to the group that fully adhered to the protocol. Further multicenter studies are warranted to clarify our findings.