Podcasts about catheter ablation

Commentary by Dr.  Jian'an Wang

William H. Sauer, MD, FHRS, CCDS, Brigham and Women's Hospital is joined by Isabella Alviz, MD, Brigham, and Women's Hospital, and Usha B. Tedrow, MD, MS, FHRS, Brigham and Women's Hospital to discuss how patients with ventricular tachycardia and ischemic cardiomyopathy are at high risk for adverse outcomes. Catheter ablation is commonly used when antiarrhythmic drugs do not suppress ventricular tachycardia. Whether catheter ablation is more effective than antiarrhythmic drugs as a first-line therapy in patients with ventricular tachycardia is uncertain. https://www.hrsonline.org/education/TheLead https://www.nejm.org/doi/full/10.1056/NEJMoa2409501 Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific, Research: Medtronic   Contributor Disclosure(s): I.  Alviz: Nothing to disclose. U. Tedrow: Honoraria/Speaking/Consulting/Teaching: Medtronic, Biosense Webster, Inc., St. Jude Medical, Thermedical, Boston Scientific, Baylis Medical Company This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365 https://www.heartrhythm365.org/URL/TheLeadEpisode90

OPTION - Randomized Comparison of Left Atrial Appendage Closure with Oral Anticoagulation after Catheter Ablation for Atrial Fibrillation (OPTION)

Another negative AF ablation trial, predicting AF after stroke, the value of RCTs, troponin testing in the ED and surgical aortic valve choice are the topics John Mandrola, MD, discusses this week. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I AF ablation Coronary Sinus Isolation for High-Burden Atrial Fibrillation: A Randomized Clinical Trial https://doi.org/10.1016/j.jacep.2024.09.017 Approaches to Catheter Ablation for Persistent Atrial Fibrillation (STAR AFII) https://www.nejm.org/doi/full/10.1056/NEJMoa1408288 Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation: The VENUS Randomized Clinical Trial https://doi.org/10.1001/jama.2020.16195 Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation: Results of CONVERGE Clinical Trial https://www.ahajournals.org/doi/10.1161/CIRCEP.120.009288 II Post-Stroke AF monitoring Prediction of atrial fibrillation after a stroke event: a systematic review with meta-analysisMeta-analysis 10.1016/j.hrthm.2025.01.026 Dabigatran for Prevention of Stroke after Embolic Stroke of Undetermined Source https://www.nejm.org/doi/full/10.1056/NEJMoa1813959 Rivaroxaban for Stroke Prevention after Embolic Stroke of Undetermined Source (Navigate ESUS https://www.nejm.org/doi/full/10.1056/NEJMoa1802686 Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy (ARCADIA) https://jamanetwork.com/journals/jama/fullarticle/2814933 III RCTs Large simple randomized controlled trials—from drugs to medical devices: lessons from recent experience https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-025-08724-x Outcomes 1 Year after Thrombus Aspiration for Myocardial Infarction (TASTE) https://www.nejm.org/doi/full/10.1056/NEJMoa1405707 IV Troponin Testing in the ED Cardiac Biomarker Testing in US Emergency Departments https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2829344 Updating Our Thinking on Troponin Use and Interpretation https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2777967 V Choice of AVR Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40-75 Years https://doi.org/10.1016/j.jacc.2025.01.013 You may also like: The Bob Harrington Show with the Stephen and Suzanne Weiss Dean of Weill Cornell Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Send us a textThis week, Dr. Mike Fralick and special guest, Dr. Laiya Carayannopoulos from the Intern at Work Podcast and our Medicine Pods collaboration, discuss two recent papers exploring oxygenation in acute respiratory failure and the use of ablation versus anti-arrhythmic medication for ventricular tachycardia. Two papers, here we go!High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients with Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial (0:00 – 14:45).Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia (14:45 – 22:55).And for the Good Stuff:Medicine Pods! (22:55 – 23:51).Sign-up to our mailing list to receive link to attend the Royal College Epidemiology Crash Course hosted by Dr. Mike FralickSupport the show

Welcome back Rounds Table Listeners!We are back today with our Classic Rapid Fire Podcast!This week, Dr. Mike Fralick and special guest, Dr. Laiya Carayannopoulos from the Intern at Work Podcast and our Medicine Pods collaboration, discuss two recent papers exploring oxygenation in acute respiratory failure and the use of ablation versus anti-arrhythmic medication for ventricular tachycardia. Two papers, here we go!High-Flow Nasal Oxygen vs Noninvasive Ventilation in Patients with Acute Respiratory Failure: The RENOVATE Randomized Clinical Trial (0:00 – 14:45).Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia (14:45 – 22:55).And for the Good Stuff:Medicine Pods! (22:55 – 23:51).Sign-up to our mailing list to receive link to attend the Royal College Epidemiology Crash Course hosted by Dr. Mike FralickQuestions? Comments? Feedback? We'd love to hear from you! @roundstable @InternAtWork @MedicinePods

William H. Sauer, MD, FHRS, CCDS, Brigham and Women's Hospital is joined by Jorge Romero, MD, FHRS, Brigham and Women's Hospital-Harvard Medical School, and Joshua Cooper, MD, FHRS, Temple University Health System to discuss how the posterior wall isolation (PWI) is commonly incorporated into catheter ablation (CA) strategies for persistent atrial fibrillation (AF) in an attempt to improve outcomes. In the CAPLA randomized study, adjunctive PWI did not improve freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation (PVI) alone. Whether additional PWI reduces arrhythmia recurrence over the longer term remains unknown.  https://www.hrsonline.org/education/TheLead https://doi.org/10.1093/eurheartj/ehae580 Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific, Research: Medtronic   Contributor Disclosure(s): J.  Romero: Honoraria/Speaking/Teaching/Consulting: AtriCure, Inc., Boston Scientific, Biosense Webster, Inc. J. Cooper: Honoraria/Speaking/Teaching/Consulting: Abbott, Medtronic, Inc., Boston Scientific, Zoll Medical Corporation, Biosense Webster, Inc. This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365 https://www.heartrhythm365.org/URL/TheLeadEpisode86

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances discusses a recently published original research paper on the impact of frailty on patients with atrial fibrillation and HFrEF undergoing catheter ablation.

Commentary by Dr.  Jian'an Wang.

Did you miss AHA 2024? Listen here to brief discussions of the latest research. Eric Rubin is the Editor-in-Chief of the Journal. Jane Leopold is a Deputy Editor of the Journal. Stephen Morrissey, the interviewer, is the Executive Managing Editor of the Journal. E.J. Rubin, J. Leopold, and S. Morrissey. NEJM at AHA — Catheter Ablation or Antiarrhythmic Drugs for Ventricular Tachycardia. N Engl J Med. DOI: 10.1056/NEJMe2414471.

This episode is a discussion of the paper entitled, "Catheter Ablation versus Advanced Therapy for Patients with Severe Heart Failure and Ventricular Electrical Storm." https://www.hrsonline.org/education/TheLead https://doi.org/10.1016/j.hrthm.2024.09.045 Host Disclosure(s): W.Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific, Research: Medtronic   Contributor Disclosure(s): R. Kerley: Nothing to disclose. A. Desai: Research: Novartis, Bayer Healthcare Pharmaceuticals, Abbott Medical, AstraZeneca, Honoraria/Speaking/Consulting: Novartis, Abbott, AstraZeneca, Regerneron, Alnylam Pharmaceuticals, Bayer Healthcare Pharmaceutricals, Cytokinetics, AxonTherapies, Avidity Biosciences, Medpace, Merck, New Amsterdam Pharma, Parexel, Roche Diagnostics, GlacoSmithKline, NovoNordisk, Veristat, Verily/Google, Zydus, River2Renal, Membership on Advisory Committees: BioFourmis

Darshan H. Brahmbhatt, Podcast Editor of JACC: Advances discusses a recently published original research paper on incremental efficacy for repeat ablation procedures for catheter ablation of AF.

Commentary by Dr. Candice Silversides

Commentary by Dr. Emile Daoud

This week's stories include an endoscopic ablation technique targeting ghrelin production showing results for significant weight loss, research that prior immunity to SARS-CoV-2 does not inhibit response to updated COVID-19 vaccines, and a study from the 2024 Heart Rhythm Society Meeting suggesting oral anticoagulant discontinuation after atrial fibrillation catheter ablation may be feasible and safe.

Welcome back Rounds Table Listeners! In this throwback episode, Drs. Mike and John Fralick discuss two papers exploring ablation in end-stage heart failure with atrial fibrillation and anticoagulation in frail older adults with atrial fibrillation. Check it out below! Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation (0:00 – 8:48). Switching VKA to NOAC in ...The post TBT – Atrial Fibrillation appeared first on Healthy Debate.

Welcome back Rounds Table Listeners! In this throwback episode, Drs. Mike and John Fralick discuss two papers exploring ablation in end-stage heart failure with atrial fibrillation and anticoagulation in frail older adults with atrial fibrillation. Check it out below! Catheter Ablation in End-Stage Heart Failure with Atrial Fibrillation (0:00 – 8:48). Switching VKA to NOAC in ... The post TBT – Atrial Fibrillation appeared first on Healthy Debate.

Electrophysiologist Dr. Richard Jones, of the MedStar Heart and Vascular Institute, talks about symptoms and treatment for the full spectrum of the most common form of cardiac arrythmia: atrial fibrillation.  Are you feeling a flutter in your chest, or maybe your smartwatch is signaling an irregular heartbeat? It's time to tune in to your heart's health because atrial fibrillation (AFib) is not just a condition for the textbooks—it's a growing concern for millions. In the latest episode of 'MedStarHealth Doc Talk,' we sit down with Dr. Richard Jones, an electrophysiologist from the MedStar Heart and Vascular Institute, to delve into the intricacies of AFib. With a projected 30% increase in cases every two decades, understanding AFib has never been more critical. AFib is the most common type of serious heart rhythm abnormality in adults. When the heart's upper chambers quiver chaotically, they fail to pump blood effectively, leading to symptoms like palpitations, fatigue, and potentially life-threatening strokes. But what's more alarming is that some individuals with AFib might not feel any symptoms at all, making them ticking time bombs for stroke risks. Dr. Jones explains how new guidelines by the American College of Cardiology and the American Heart Association are categorizing AFib and recommending best practices for treatment. These guidelines emphasize the importance of early intervention and the role of lifestyle changes in managing AFib. The episode also highlights the latest advancements in treatment, such as catheter ablation—a procedure that targets the heart's electrical misfires to prevent AFib episodes. Dr. Jones shares that while this isn't a cure, it's a significant step forward in managing the condition and improving quality of life.For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Commentary by Dr Takanori Yamaguchi

Welcome back Rounds Table Listeners! We are back today with our Classic Rapid Fire Podcast! This week, Drs. Mike and John Fralick discuss two recent papers exploring ablation in end-stage heart failure with atrial fibrillation and anticoagulation in frail older adults with atrial fibrillation. Two papers, here we go! Catheter Ablation in End-Stage Heart Failure ... The post Episode 70 – Atrial Fibrillation first appeared on Healthy Debate. The post Episode 70 – Atrial Fibrillation appeared first on Healthy Debate.

Welcome back Rounds Table Listeners! We are back today with our Classic Rapid Fire Podcast! This week, Drs. Mike and John Fralick discuss two recent papers exploring ablation in end-stage heart failure with atrial fibrillation and anticoagulation in frail older adults with atrial fibrillation. Two papers, here we go! Catheter Ablation in End-Stage Heart Failure ...The post Episode 70 – Atrial Fibrillation appeared first on Healthy Debate.

Michael S. Lloyd, MD, FHRS of Emory University discusses Catheter Ablation of Atrial Fibrillation in Adult Congenital Heart Disease: Procedural Characteristics and Outcomes with Natasja M. S. De Groot, MD, PhD, of Erasmus University Medical Center, and Jeremy P. Moore, MD, MS, FHRS, CCDS, CEPS-P, of UCLA Medical Center.   https://www.hrsonline.org/education/TheLead   Host Disclosure(s): M. Lloyd: Honoraria/Speaking/Consulting Fee: Medtronic, Baylis Medical Company, Boston Scientific   Contributor Disclosure(s): N. De Groot: Honoraria/Speaking/Consulting Fee: Biosense Webster J. Moore: No relevant financial relationships with ineligible companies to disclose.

Prashanthan Sanders, MBBS, PhD, FHRS, of University of Adelaide is joined by guests Dhiraj Gupta, MBBS, MD, of Liverpool Heart and Chest Hospital, and Tina Baykaner, MD, MPH, of Stanford University, to discuss same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) has been widely adopted. Nevertheless, planned SDD has been performed by using subjective criteria rather than standardized protocols. The goal of this study was to determine the efficacy and safety of the previously described SDD protocol in a prospective multicenter study. In this large, multicenter prospective registry, the use of a standardized protocol showed the safety of SDD after catheter ablation of paroxysmal and persistent AF. (Real-world Experience of Catheter Ablation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation [REAL-AF]; NCT04088071)   https://www.hrsonline.org/education/TheLead   Host Disclosure(s): P. Sanders: Research (Contracted Grants for PIs Named Investigators Only): Boston Scientific, Abbott, Medtronic, PaceMate, Becton Dickinson, CathRx; Advisory Committee Membership: Medtronic, Boston Scientific, PaceMate, CathRx   Contributor Disclosure(s): D. Gupta: Honoraria/Speaking/Consulting Fee: Abbott, Abbott Medical; Research (Contracted Grants for PIs Named Investigators Only): Biosense Webster, Inc., Medtronic Bakken Research Center T. Baykaner: Research (Contracted Grants for PIs Named Investigators Only): NIH

William H. Sauer, MD, FHRS, CCDS, of Brigham and Women's Hospital is joined by guests Bruce A. Koplan, MD, MPH, FHRS, and Victor Nauffal, MD, of Brigham and Women's Hospital, to discuss Procedure-Related Complications of Catheter Ablation for Atrial Fibrillation. In this study, online publication databases were searched for randomized trials that included patients undergoing a first ablation procedure of atrial fibrillation using either radiofrequency or cryoballoon. A total of 1,468 references were retrieved, of which 89 studies met the inclusion criteria, yielding a total of 15,701 patients included in the analysis. The reported overall and severe procedure-related complication rates were 4.51% and 2.44%, respectively. Vascular complications were the most frequent type of complication (1.31%). The next most common complications were pericardial effusion/tamponade (0.78%) and stroke/transient ischemic attack (0.17%). The procedure-related complication rate during the most recent 5-year period of publication was significantly lower than during the earlier 5-year period (3.77% vs 5.31%). The pooled mortality rate was stable over the 2 time periods (0.06% vs 0.05%). There was no significant difference in complication rate according to pattern of AF, ablation modality, or ablation strategies beyond pulmonary vein isolation. The authors conclude that procedure-related complications and mortality rates associated with catheter ablation of AF are low and have declined in the past decade.   https://www.hrsonline.org/education/TheLead   Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting Fee: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific; Research (Contracted Grants for PIs Named Investigators Only): Medtronic   Contributor Disclosure(s): B. Koplan: Honoraria/Speaking/Consulting Fee: GE Healthcare V. Nauffal: No relevant financial relationships with ineligible companies to disclose. 

A new research paper was published in Aging (Aging-US) Volume 15, Issue 15, entitled, “Cardiovascular events and death after catheter ablation in very old patients with nonvalvular atrial fibrillation.” Catheter ablation of atrial fibrillation (AF) is recommended for selected older patients. However, the preventive effects of AF ablation on cardiovascular events and death remain unclear, especially in older patients. In this new study, researchers Keisuke Okawa, Satoshi Taya, Takeshi Morimoto, Ryu Tsushima, Yuya Sudo, Ai Sakamoto, Eisuke Saito, Masahiro Sogo, Masatomo Ozaki, and Masahiko Takahashi from Kagawa Prefectural Central Hospital and Hyogo Medical University aimed to investigate the impact of AF ablation on the incidence of cardiovascular events and death in very old nonvalvular AF (NVAF) patients. “We conducted a prospective cohort study of consecutive patients with NVAF aged ≥80 years and using direct oral anticoagulants (DOACs).” The researchers defined cardiovascular events as acute heart failure (AHF), strokes and systemic embolisms (SSEs), acute coronary syndrome (ACS), and sudden cardiac death (SCD) and cardiovascular death as AHF/SSE/ACS-related death and SCD. They compared the 3-year incidence of cardiovascular events and death between the patients who underwent AF ablation (Ablation group) and those who received medical therapy only (Medication group). Among the 782 NVAF patients using DOACs, propensity score matching provided 208 patients in each group. The Ablation group had a significantly lower 3-year incidence of cardiovascular events and death than the Medication group: cardiovascular events, 24 (13.2%) vs. 43 (23.3%), log-rank P = 0.009 and hazard ratio (HR) 0.52 (95% confidence interval (CI) 0.32–0.86) and cardiovascular deaths, 5 (3.0%) vs. 15 (7.8%), log-rank P = 0.019 and HR 0.32 (95% CI 0.16–0.88). “In very old NVAF patients using DOACs, those who underwent AF ablation had a lower incidence of both cardiovascular events and death than those who received medical therapy only.” DOI - https://doi.org/10.18632/aging.204952 Corresponding author - Keisuke Okawa - k-ookawa@chp-kagawa.jp Sign up for free Altmetric alerts about this article - https://aging.altmetric.com/details/email_updates?id=10.18632%2Faging.204952 Subscribe for free publication alerts from Aging - https://www.aging-us.com/subscribe-to-toc-alerts Keywords - aging, atrial fibrillation, catheter ablation, cardiovascular event, cardiovascular death, very old patient About Aging-US Launched in 2009, Aging-US publishes papers of general interest and biological significance in all fields of aging research and age-related diseases, including cancer—and now, with a special focus on COVID-19 vulnerability as an age-dependent syndrome. Topics in Aging-US go beyond traditional gerontology, including, but not limited to, cellular and molecular biology, human age-related diseases, pathology in model organisms, signal transduction pathways (e.g., p53, sirtuins, and PI-3K/AKT/mTOR, among others), and approaches to modulating these signaling pathways. Please visit our website at https://www.Aging-US.com​​ and connect with us: SoundCloud - https://soundcloud.com/Aging-Us Facebook - https://www.facebook.com/AgingUS/ Twitter - https://twitter.com/AgingJrnl Instagram - https://www.instagram.com/agingjrnl/ YouTube - https://www.youtube.com/@AgingJournal LinkedIn - https://www.linkedin.com/company/aging/ Pinterest - https://www.pinterest.com/AgingUS/ Media Contact 18009220957 MEDIA@IMPACTJOURNALS.COM

Commentary by Dr. Emile Daoud

ESC TV Today brings you concise analysis from the world's leading experts, so you can stay on top of what's happening in your field quickly. This episode covers: Cardiology This Week: A concise summary of recent studies Healthy nutrition in a nutshell Indications for catheter ablation of atrial fibrillation Snapshots Host: Susanna Price Guests: Isabel Deisenhofer and Dariush Mozaffarian Want to watch that episode? Go to: https://esc365.escardio.org/event/1096   Disclaimer This programme is supported by Siemens Healthineers in the form of an educational grant. The scientific content and opinions expressed in the programme have not been influenced in any way by its sponsor. This programme is intended for health care professionals only and is to be used for educational purposes. The European Society of Cardiology (ESC) does not aim to promote medicinal products nor devices. Any views or opinions expressed are the presenters' own and do not reflect the views of the ESC.   Declarations of interests Stephan Achenbach, Isabel Deisenhofer, Nicolle Kraenkel, Susanna Price have declared to have no potential conflicts of interest to report. Carlos Aguiar has declared to have potential conflicts of interest to report: personal fees for consultancy and/or speaker fees from Abbott, Alnylam, Amgen, AstraZeneca, Bayer, Boehringer-Ingelheim, Daiichi-Sankyo, Ferrer, Gilead, Lilly, Novartis, Pfizer, Sanofi, Servier, Tecnimede. Davide Capodanno has declared to have potential conflicts of interest to report: Sanofi, Daiichi Sankyo, Terumo, Medtronic, Chiesi. Dariush Mozaffarian has declared to have potential conflicts of interest to report: research funding from the National Institutes of Health, the Gates Foundation, The Rockefeller Foundation, Vail Innovative Global Research, and the Kaiser Permanente Fund; personal fees from Acasti Pharma and Barilla; scientific advisory board, Beren Therapeutics, Brightseed, Calibrate, Elysium Health, Filtricine, HumanCo, Instacart Health, January Inc., and Perfect Day (ended: Day Two, Season Health, and Tiny Organics); stock ownership in Calibrate and HumanCo; and chapter royalties from UpToDate. Emma Svennberg has declared to have potential conflicts of interest to report: institutional research grants from Bayer, Bristol-Myers, Squibb-Pfizer, Boehringer- Ingelheim, Johnson & Johnson, Merck Sharp & Dohme.

Commentary by Dr. Valentin Fuster

Diets, coronary artery calcium, statins, basic CAD knowledge, and AF ablation are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Diet Some Diets Better Than Others for Heart Protection https://www.medscape.com/viewarticle/990305 - Comparison of seven popular structured dietary programmes and risk of mortality and major cardiovascular events in patients at increased cardiovascular risk: systematic review and network meta-analysis https://doi.org/10.1136/bmj-2022-072003 Plant-Based Diets Not Always Healthy; Quality Is Key https://www.medscape.com/viewarticle/990178 - Association of Healthful Plant-based Diet Adherence With Risk of Mortality and Major Chronic Diseases Among Adults in the UK https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2802814 II. CAC and Statins - Using the Coronary Artery Calcium Score to Guide Statin Therapy https://www.ahajournals.org/doi/full/10.1161/CIRCOUTCOMES.113.000799 III. Subclinical Atherosclerosis Subclinical CAD by CT Predicts MI Risk, With or Without Stenoses https://www.medscape.com/viewarticle/990254 - Subclinical Coronary Atherosclerosis and Risk for Myocardial Infarction in a Danish Cohort A Prospective Observational Cohort Study 0799 https://www.acpjournals.org/doi/10.7326/M22-3027 - A Prospective Natural-History Study of Coronary Atherosclerosis https://www.nejm.org/doi/10.1056/NEJMoa1002358?url_ver=Z39.88-2003 IV. AF ablation - Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation RecurrenceThe AWARE Randomized Clinical Trial https://jamanetwork.com/journals/jamacardiology/fullarticle/2802860 - Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial FibrillationThe CAPLA Randomized Clinical Trial https://jamanetwork.com/journals/jama/article-abstract/2800186 - Approaches to Catheter Ablation for Persistent Atrial Fibrillation https://www.nejm.org/doi/full/10.1056/NEJMoa1408288 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine. https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Commentary by Dr. Emile Daoud

Commentary by Dr. Valentin Fuster

FOURIER authors' response, a possible practice-changing paper in electrophysiology, and the ATLAS and CAPLA trials are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. FOURIER Authors Respond Recount of FOURIER Data Finds Higher Mortality With Evolocumab; Trialists Push Back https://www.medscape.com/viewarticle/986634 Restoring mortality data in the FOURIER cardiovascular outcomes trial of evolocumab in patients with cardiovascular disease: a reanalysis based on regulatory data https://bmjopen.bmj.com/content/12/12/e060172 Letter to the Editor RE: "Restoring mortality data in the FOURIER cardiovascular outcomes trial of evolocumab in patients with cardiovascular disease: a reanalysis based on regulatory data". BMJ Open https://bmjopen.bmj.com/content/12/12/e060172.responses#letter-to-the-editor-re-restoring-mortality-data-in-the-fourier-cardiovascular-outcomes-trial-of-evolocumab-in-patients-with-cardiovascular-disease-a-reanalysis-based-on-regulatory-data-bmj-open-2022123060172 Risk of selection bias assessment in the NINDS rt-PA stroke study https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202115/ Methodological survey of missing outcome data in an alteplase for ischemic stroke meta-analysis https://doi.org/10.1111/ane.13656 II. A Potential Practice-Changing Paper in Cardiac Pacing Novel 'Cure' May Avert Lead Extraction in CIED Pocket Infections https://www.medscape.com/viewarticle/986762 Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections https://doi.org/10.1016/j.jacc.2022.10.022 Treatment of Localized Implantable Cardiac Device Pocket Infections https://doi.org/10.1016/j.jacc.2022.11.018 III. ATLAS Trial Perioperative Safety and Early Patient and Device Outcomes Among Subcutaneous Versus Transvenous Implantable Cardioverter Defibrillator Implantations https://doi.org/10.7326/M22-1566 Subcutaneous or Transvenous Defibrillator Therapy https://www.nejm.org/doi/full/10.1056/NEJMoa1915932 Subcutaneous or Transvenous Defibrillator Therapy https://www.nejm.org/doi/10.1056/NEJMc2034917 IV. CAPLA Published CAPLA Shows Limits of Further Ablation Post PVI in Persistent AF https://www.medscape.com/viewarticle/986901 Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation https://jamanetwork.com/journals/jama/fullarticle/2800186 Catheter Ablation for Persistent Atrial Fibrillation https://jamanetwork.com/journals/jama/fullarticle/2800200 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

On this week's podcast, Drs.Feigenbaum and Baraki review sudden cardiac death in sport. Sponsors: https://generalleathercraft.com/ References: 2017 AHA/ACC/HRS Guideline for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death https://www.sciencedirect.com/science/article/pii/S0735109717413052?via%3Dihub AHA Exercise-Related Acute Cardiovascular Events and Potential Deleterious Adaptations Following Long-Term Exercise Training https://pubmed.ncbi.nlm.nih.gov/32100573/ Incidence of sudden cardiac death in athletes: a state-of-the-art review https://bjsm.bmj.com/content/48/15/1185 Sudden Cardiac Arrest during Participation in Competitive Sports https://pubmed.ncbi.nlm.nih.gov/29141175/ Myocarditis Cases Reported After mRNA-Based COVID-19 Vaccination in the US From December 2020 to August 2021. https://pubmed.ncbi.nlm.nih.gov/35076665/ Cardiac Complications After SARS-CoV-2 Infection and mRNA COVID-19 Vaccination - PCORnet, United States, January 2021-January 2022. https://pubmed.ncbi.nlm.nih.gov/35389977/ Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis) https://www.sciencedirect.com/science/article/pii/S0735109702026694?via%3Dihub Sudden death in young adults: a 25-year review of autopsies in military recruits https://pubmed.ncbi.nlm.nih.gov/15583223/ Performance enhancing drugs (doping agents) and sudden death--a case report and review of the literature https://pubmed.ncbi.nlm.nih.gov/9728754/ Upper and lower limits of vulnerability to sudden arrhythmic death with chest-wall impact (commotio cordis) https://www.sciencedirect.com/science/article/pii/S0735109702026694?via%3Dihub 2019 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias https://www.hrsonline.org/guidance/clinical-resources/2019-hrsehraaphrslahrs-expert-consensus-statement-catheter-ablation-ventricular-arrhythmias AHA Screening 2020 https://www.ahajournals.org/doi/10.1161/JAHA.120.016332 Policies to Prevent Sudden Cardiac Death in Young Athletes: Challenging, But More Testing Is Not the Answer https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7428526/ Seminars https://www.barbellmedicine.com/seminars/ For more of our stuff: App: https://tinyurl.com/muus5pfn Podcasts: goo.gl/X4H4z8 Website: www.barbellmedicine.com Instagram: @austin_barbellmedicine @jordan_barbellmedicine @leah_barbellmedicine @vanessa_barbellmedicine @untamedstrength @derek_barbellmedicine @hassan_barbellmedicine @charlie_barbellmedicine @alex_barbellmedicine @tomcampitelli @joe_barbellmedicine @rheece_barbellmedicine @cam_barbellmedicine @claire_barbellmedicine @ben_barbellmedicine @cassi.niemann @caleb_barbellmedicine Email: info@barbellmedicine.com Supplements/Templates/Seminars: www.barbellmedicine.com/shop/ Forum: forum.barbellmedicine.com/

Editor's Summary by Kirsten Bibbins-Domingo, PhD, MD, MAS, Editor in Chief of JAMA, the Journal of the American Medical Association, for the January 10, 2023, issue. Related Content: Audio Highlights

Optimize and update your approach to atrial fibrillation (afib) as we discuss early rhythm control, antiarrhythmic drugs, TTE/cardioversion, afib ablation, new onset afib in the hospitalized patient, and left atrial appendage closure. Plus, we try to answer, Does afib burden matter? Our guest is cardiologist-electrophysiologist, Hugh Calkins MD, @hughcalkinsMD, Professor of Cardiology at Johns Hopkins, @hopkinsheart.  Sorry, but we won't be offering CME for this episode. You can claim CME for past episodes at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | askcurbsiders@gmail.com | Free CME! Show Segments Intro, disclaimer, guest bio Guest one-liner Case from Kashlak; Definitions An approach to new-onset afib in the office Rhythm control Lifestyle modification is a pillar of afib treatment Indications for hospitalization in afib More on rhythm control and when to pursue afib ablation Rhythm control in heart failure New onset afib in the hospitalized patient Does afib burden matter? Left atrial appendage closure  Watto and Paul recap what we've learned Outro Credits Written and Produced by: Matthew Watto MD, FACP Show Notes: Matthew Watto MD, FACP Cover art and Infographic by: Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP    Reviewer: Emi Okamoto MD Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP    Technical Production: PodPaste Guest: Hugh Calkins MD Sponsor: Grammarly Go to grammarly.com/curb to sign up for a free account. And when you're ready to upgrade to Grammarly Premium, get 20% off.  Full transcript HERE

The ERASE AF ablation trial, left bundle pacing, finerenone, and perceptions of cardiology are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. AF Ablation - Low-Voltage Myocardium-Guided Ablation Trial of Persistent Atrial Fibrillation https://evidence.nejm.org/doi/10.1056/EVIDoa2200141 - Approaches to Catheter Ablation for Persistent Atrial Fibrillation https://www.nejm.org/doi/full/10.1056/NEJMoa1408288 - Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation https://jamanetwork.com/journals/jama/fullarticle/2793452 - Circumferential Pulmonary Vein Isolation Plus Low-Voltage Area Modification in Persistent Atrial Fibrillation: The STABLE-SR-II Trial https://www.jacc.org/doi/full/10.1016/j.jacep.2022.03.012 - Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation https://jamanetwork.com/journals/jama/fullarticle/2772281 - Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation https://www.ahajournals.org/doi/full/10.1161/CIRCEP.120.009288 II. Left Bundle Branch Area Pacing - FDA OKs Medtronic Lead for Left Bundle Branch Pacing https://www.medscape.com/viewarticle/982577 - Left bundle branch area pacing outcomes: the multicentre European MELOS study https://academic.oup.com/eurheartj/article/43/40/4161/6671019 - Randomized Trial of Left Bundle Branch vs Biventricular Pacing for Cardiac Resynchronization Therapy https://www.jacc.org/doi/full/10.1016/j.jacc.2022.07.019 - Early sudden distal conductor fracture of a stylet-driven lead implanted for left bundle branch area pacing https://doi.org/10.1016/j.hrcr.2022.10.004 - Repositioning and extraction of stylet-driven pacing leads with extendable helix used for left bundle branch area pacing https://pubmed.ncbi.nlm.nih.gov/33825263/ - Safety and Procedural Success of Left Atrial Appendage Exclusion With the Lariat Device https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2289126 III. Finerenone - Finerenone Benefits T2D Across Spectrum of Renal Function https://www.medscape.com/viewarticle/982626 - Cardiovascular Events with Finerenone in Kidney Disease and Type 2 Diabetes https://www.nejm.org/doi/10.1056/NEJMoa2110956 - Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis https://academic.oup.com/eurheartj/article/43/6/474/6433104 - Finerenone and Heart Failure Outcomes by Kidney Function/Albuminuria in Chronic Kidney Disease and Diabetes https://www.jacc.org/doi/10.1016/j.jchf.2022.07.013 IV. Perceptions of Cardiology - IM Residents Rate Cardiology Low on Work-Life Balance https://www.medscape.com/viewarticle/982578 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Commentary by Dr. Edward Gerstenfeld

This week, please join author Ratika Parkash and Editorialist Sean D. Pokorney as they discuss the article "Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial" and the editorial "The Evidence Builds for Catheter Ablation for Atrial Fibrillation and Heart Failure." Dr. Carolyn Lam: Welcome to Circulation on the Run, your weekly podcast summary and backstage pass to the Journal and its editors. We're your co-hosts. I'm Dr. Carolyn Lam, Associate Editor, from the National Heart Centre and Duke National University of Singapore. Dr. Greg Hundley: And I'm Dr. Greg Hundley, Associate Editor, Director of the Pauley Heart Center at VCU Health in Richmond, Virginia. Well, Carolyn, this week's feature discussion, oh, so exciting. We enter the month of June, and it pertains to heart failure and atrial fibrillation. And we are going to learn a little bit more from the RAFT-AF trial, involving randomizing patients to ablation and rhythm control, as opposed to just settling for rate control for patients with AFib. But before we do that, how about we grab a cup of coffee and start with some of the other articles in the issue? Would you like to go first? Dr. Carolyn Lam: I absolutely would. And I will start by asking everyone a question. Could a single high-sensitivity cardiac troponin T level, below the limit of detection of six nanograms per liter, exclude an acute myocardial infarction? Well, you are going to find out because, remember that data for excluding AMI with a single high-sensitivity cardiac troponin level relies largely on the limit of detection, which is really a threshold of five nanograms per liter, which cannot be reported in the United States, per the FDA, because there, only the lowest reportable concentration is allowed, which is the limit of quantitation of six nanograms per liter. Dr. Carolyn Lam: So, today's authors Dr. Sandoval from Mayo Clinic and colleagues, very cleverly sought to determine whether a single high-sensitivity cardiac troponin T level below the limit of quantitation of six nanograms per liter could indeed identify patients at low risk for AMI. Dr. Greg Hundley: Very interesting, Carolyn. So we have the limit of quantitation and then the limit of detection. This is really intriguing. And of course, cardiac troponin T, as cardiologists, we receive a lot of requests for consults on this. So, what did this study find, Carolyn? Dr. Carolyn Lam: A total of over 85,000 patients were first evaluated in the CV data marked biomarker cohort, amongst which 29% had a baseline high-sensitivity cardiac troponin T level below this limit of quantitation of six nanograms per liter. Among 11,962 patients with this baseline high-sensitivity cardiac troponin below six nanogram per liter and serial measurements, only 1.2% developed acute myocardial injury, resulting in a negative predictive value of 98.8% and a sensitivity of 99.6%. Dr. Carolyn Lam: In an adjudicated cohort, among those with a non-ischemic electrocardiogram, only 0.2% had myocardial infarction or death at 30 days. So in summary, Greg, this is the largest study evaluating a single high-sensitivity cardiac troponin T level below this limit of quantitation of six nanograms per liter to identify patients at low risk for AMI. Dr. Carolyn Lam: And indeed, the present study demonstrates that a single high-sensitivity cardiac troponin level below six nanogram per litter is a safe and rapid method to identify a substantial number of patients at very low risk for acute myocardial injury and infarction. Dr. Greg Hundley: Oh wow, Carolyn, really informative study. Well, Carolyn, my next study comes from the world of preclinical science. And Carolyn, vascular smooth muscle cell phenotypic switching contributes to cardiovascular diseases. And epigenetic regulation is emerging as a key regulatory mechanism with the methylcytosine dioxygenase Tet2, acting as a master regulator of the smooth muscle cell phenotype. Dr. Greg Hundley: The histone acetyltransferases, HATs p300, and CBP are highly homologous and often considered to be interchangeable. And their roles in smooth muscle cell phenotypic regulation are not known. So Carolyn, these authors led by Dr. Kathleen Martin from Yale University School of Medicine assessed the roles of p300 and CBP in human vascular smooth muscle cells with knockdown in inducible, smooth muscle specific knockout mice, and in samples of human intimal hyperplasia. Dr. Carolyn Lam: Cool, Greg. So what did they find? Dr. Greg Hundley: Right, Carolyn. So, they found that p300 and CBP serve non-redundant and opposing function in vascular smooth muscle cell phenotypic switching and coordinately regulate chromatin modifications through distinct functional interactions with Tet2 or HDACs. And Carolyn, targeting specific histone acetyltransferases therefore may hold therapeutic promise for future cardiovascular disease interventions. Dr. Carolyn Lam: Oh, that's great, Greg. Well, to round it all up, there are some other papers in today's issue. There's a Research Letter from Professor Zhang, entitled “Single Nucleus Transcriptomics: Apical Resection in Newborn Pigs Extends the Time-Window of Cardiomyocyte Proliferation and Myocardial Regeneration.” There's also a Research Letter from Dr. Vaduganathan, entitled “Estimating the Benefits of Combination Medical Therapy in Heart Failure with Mildly Reduced and Preserved Ejection Fraction.” Ah, that's such a cool issue. Now, let's go on to our feature discussion. Shall we, Greg? Dr. Greg Hundley: You bet, and learn a little bit more about rhythm versus rate control in patients with heart failure and atrial fibrillation. Dr. Carolyn Lam: Our feature discussion today is about the long-awaited results of the RAFT-AF trial, and that is the randomized ablation-based rhythm control versus rate control trial in patients with heart failure and atrial fibrillation. Thank you so much, Dr. Ratika Parkash for joining us today as the first and corresponding author from Queen Elizabeth II Health Sciences Center in Canada, as well as Dr. Sean Pokorney, the editorialist from Duke University. Dr. Carolyn Lam: I am so, so excited to be discussing this paper. I really meant it. You know, as a heart failure cardiologist, we've been waiting for these results and trying to understand everything in context. So maybe, Ratika, could you please start off by telling us about the RAFT-AF trial and what you found? Dr. Ratika Parkash: Thank you, Carolyn. I'm happy to be able to talk about this study on behalf of the RAFT-AF investigators and my co-PI, Dr. Anthony Tang. So the trial... First of all, the rationale for the study, I think many of us, as heart failure or heart rhythm specialists, understand that in the past, we've done many trials looking at rate versus rhythm control, the AFFIRM trial being the largest, and then of course, specifically in heart failure patients, the AF-CHF trial, both of which were negative in reducing cardiovascular events and mortality in patients with or without heart failure, in terms of a rate to rhythm control. Dr. Ratika Parkash: One of the issues with those trials is that the form of rhythm control was antiarrhythmic drugs. So we have learned that catheter ablation is superior to antiarrhythmic drugs in maintaining sinus rhythm. And based on that premise, we decided to go forward with the RAFT-AF study. Dr. Carolyn Lam: That's great, Ratika, so thanks. And what were the results? Dr. Ratika Parkash: The main finding, so the primary outcome of the study was mortality and heart failure events. Heart failure events was defined as a heart failure hospitalization or any escalation of heart failure therapy that was done in the outpatient settings, including the use of intravenous Lasix in an emergency department setting. Dr. Ratika Parkash: So the main findings were that ablation-based rhythm control was not statistically significant in reducing mortality and heart failure events over rate control in patients with atrial fibrillation and heart failure. The study included patients both with preserved ejection fraction, as well as reduced eject fraction. And we did stratify based on ejection fraction at the entry point into the trial. The hazard ratio was 0.71 and the 95% confidence interval just crossed unity, ranging from 0.49 to 1.03 with a P value of 0.066. Dr. Carolyn Lam: Oh, ouch. So, thank you. And again, truly, congratulations on a very, very important trial. Sean, I said it before, I'll say it again, really, really loved your editorial. Could you put these findings in the context of... Maybe, start with even the most recent guidelines, the 2022 ACC/AHA/HFSA heart failure guidelines, which I believe gives catheter ablation a class 2A recommendation. Maybe, start from there, and how does this fall in place? Dr. Sean Pokorney: Yeah, no, absolutely. I think, first of all, it's a really important trial and it's great to have this additional data. I do think, as you said, that it's important to understand the context. We now have several recent guidelines that have commented on the role of catheter ablation in patients with heart failure. Dr. Sean Pokorney: You mentioned the most recent heart failure guidelines. We also have additional AFib guidelines and we have the 2019 AHA/ACC/HRS guidelines for atrial fibrillation that give catheter ablation a 2B recommendation in patients who have heart failure, to potentially lower mortality and reduce hospitalization. And it has a 2A indication in the 2020 ESC guidelines. And we're currently undergoing some revisions of the guidelines for atrial fibrillation, and there'll be new guidelines around atrial fibrillation coming out from AHA/ACC/HRS in the coming years. And so that will also be helpful, I think, to incorporate some of this additional data. Sean Pokorney: When you really look at the guidelines and see what's driving the guidelines, there are several trials now that are really driving the guidelines. And so I think, looking back on the data, we have the AATAC trial, which was a trial of 203 patients that looked at ablation versus amiodarone. And we have the CASTLE-AF trial, which had 363 patients in it and was looking at atrial fibrillation in patients with heart failure with reduced ejection fraction and defibrillators. Dr. Sean Pokorney: And when you put that data into context, the AATAC trial did find lower rates of death and hospitalization as a secondary outcome, and CASTLE-AF did identify a reduction in heart failure hospitalizations and death. At the three year follow-up, there was a statistically significant reduction, although the event number was lower than the previously sort of calculated target sample size. Dr. Sean Pokorney: And so in aggregate, these trials do show a modest evidence of benefit for clinical outcomes in this population. And that's where adding more data is really critical. Dr. Carolyn Lam: That's so true. And actually, Ratika, is there any plan for some meta-analysis or sort of adding the data? And if you could, also speak to, the trial was interrupted at some point, so how that may have impacted things as well. Dr. Ratika Parkash: Those are important questions. So, first of all, there is a planned longer term follow-up for the study, to look at whether or not following these patients out beyond our meeting follow-up of 37 months, it will actually produce a different result than what we observed in the current findings. Dr. Ratika Parkash: I think a meta-analysis is obviously going to show benefit for ablation-based rhythm control, based on the data that Sean had just described. One of the things that we'd need to keep in mind is that this trial, the RAFT-AF study really enrolled patients who were suitable for either ablation-based rhythm control or rate control. So it wasn't a study that looked at rhythm control only. Dr. Ratika Parkash: So, the CASTLE-AF trial had essentially two rhythm control arms. The medical therapy arm was, was amiodarone in that trial, versus catheter ablation. So patients could get rhythm control in both. And so, the types of patients that would've gotten into CASTLE-AF were different than the patients in our trial, even when you look at the reduced ejection fraction patients. Dr. Ratika Parkash: Having said that, our curves, when you look at the reduced ejection fraction group in our study does mirror what was observed in CASTLE-AF. So, even if a patient is not deteriorating initially with rate control, it appears that over time they begin to deteriorate. And that's what all of these trials have shown, is that patients do better with ablation-based rhythm control, the best form of sinus rhythm maintenance that we have. Dr. Ratika Parkash: And it takes time for them to deteriorate and it takes time to accrue those events. And this is evident in all trials of atrial fibrillation. You either need a very large sample size, like 15,000 patients, to look at heart failure in a short period of time, or you follow them longer, so that you can accrue those events. Dr. Ratika Parkash: In terms of the stopping of the trial, certainly, had we reached the sample size of 600, which was the intended sample size after recalculation during the study from 1000 down to 600, I believe we would have reached a positive outcome. But again, we hope that our longer term follow-up might shed some light on that. The interruption of the study was based on the DSMC decision and certainly could have affected the power of the study. Dr. Ratika Parkash: We have to remember that the other possibilities are that ablation-based rhythm control is not superior to rate control. And as someone who is pro-ablation, it's difficult to say that, but we see hints of benefit and we have to recognize that. Dr. Ratika Parkash: The other issue is that the secondary endpoints in our trial were all significant, as overall, it doesn't matter which group you looked at, NT-proBNP, six-minute walk test, quality of life, both for heart failure and atrial fibrillation, as well as ejection fraction, were all improved. And for many of the studies that have been done previously, those were the primary endpoints of those studies. Dr. Ratika Parkash: The idea of whether ablation-based rhythm control reduces heart failure per se, is from our study, purely from our study, we can't be a hundred percent certain. There's definitely a hint of clinical benefit there. From all the secondary endpoints, which are the current guidelines, is what they indicate ablation should be done for, is to improve quality of life. Our study was certainly supportive of that. Dr. Carolyn Lam: You know, Sean, I especially appreciated your discussion of these issues, the early stopping of the trial, the secondary endpoints. Could you know, share some of those thoughts? Dr. Sean Pokorney: I think it's really an important topic. I think that, again, as Ratika said, part of why this trial is so important is that many of the previous trials that have been published and many of the data sets have really looked at rhythm control versus rhythm control in this population, even including the analysis from CABANA, which included almost 780 patients from CABANA that had heart failure. And in that population, they did show a reduction in the composite primary endpoint of death, disabling stroke, serious bleeding, or cardiac arrest. And again, CABANA was, as well, a study of rhythm control with ablation versus medical therapy, most patients getting rhythm control in that medical therapy arm. Dr. Sean Pokorney: And so this data really is additive. I think that one of the challenges is always, how do we make sure to get the most information out of a clinical trial once we commit patients to that scientific process? And I think here, at least in retrospect, it's obviously unfortunate that the trial was stopped early. I think that more data would certainly be helpful. Dr. Sean Pokorney: I appreciate the fact that longer term data may help solve that gap and close that gap a little bit. I think that, I guess, it'd be interesting to hear from Ratika a little bit more about the process that was involved with interaction with the DSMC and stopping the trial. Dr. Ratika Parkash: Yeah. Thanks, Sean. That also is a very good question. The DSMC really evaluated the data, evaluated the progress of the trial, back in 2017. It had been six years since we'd started the study. The data they had, in fact, did not show any benefit to ablation-based rhythm control over rate control at the time. So the follow-up period at the time was around two years. Dr. Ratika Parkash: And again, if you look at our Kaplan-Meier curves, you can understand why they would have made that decision at the time, based on 363 patients for the data that was available to them. They had a futility index that they looked at. it was calculated. The cutoff for stopping of the study was 0.8, and it was 0.81. So, there was a 19% chance that the study was going to show any benefit. And based on that, plus the progress of the trial, they made a decision to stop the study. Dr. Sean Pokorney: Yeah. I think it's really important when we look at these decisions, that there was example when we talk about this in the editorial as well with the ISIS-2 trial, where early on in the data, ISIS-2 was a trial looking at aspirin versus placebo. And basically in that trial, when you looked early on at the events that were accumulating, there was really roughly no difference between aspirin and placebo. And ultimately, that trial became positive and was a really critical trial. And if it had been stopped at that point for futility, we wouldn't have had some really critical data. Dr. Sean Pokorney: So, it's always a challenging decision. And obviously, the decisions are trying to be made in the best interest of the patients. Here, it just shows how important this additional follow-up data is for this trial, for RAFT in particular. And ultimately, it'll be interesting to see, as you mentioned, as we add additional long-term follow-up, how that will affect the results. Dr. Ratika Parkash: Absolutely. So, we hope that our additional follow-up is of benefit to clarifying our results. The unfortunate issue, I agree, was the stopping of the study, but we do trust our DSMCs. We have them for a reason and they perform an important function. So, we have to pay attention of course, to how they see things and evaluate the... at the time. Dr. Ratika Parkash: The other thing we should keep in context is that ablation for those, that time period, is not the same as it is today. Our safety has improved. You may have noticed that there were some adverse events in the study with ablation, and we would expect it to actually be lower, but in this day and age, but at the time, contact force wasn't available. Dr. Ratika Parkash: There were some tools and techniques that we now have at our disposal, improved mapping systems and so on, that allow us to do a safer and more efficacious job. But even in the context of that, our sinus rhythm maintenance was almost 80 to 90% for patients that you wouldn't normally expect to have that much sinus rhythm. Dr. Sean Pokorney: Yeah. I think that's a really critical point. You made a lot of really important points there, actually. Obviously, the vision of the field of electrophysiology is shifting, as you mentioned. And with data from EAST-AFNET 4, we're really shifting towards earlier rhythm control, as well as additional ablation trials attest, stop AFib or stop AF. Dr. Sean Pokorney: So again, there have been several studies that have shown the benefits of earlier rhythm control, EAST-AFNET 4, I think, being obviously one of the most relevant, looking at addressing atrial fibrillation of population of patients who've been diagnosed within the last year, and showing that there was a benefit to rhythm control, although the majority of rhythm control in that study was antiarrhythmic medications. Dr. Sean Pokorney: I think in the heart failure population, the challenge with rhythm control is that we're a lot more limited in terms of the medical therapies that are available for these patients. And I think that's where ablation really plays in a more important role, because not only have you shown that it seems to be efficacious in this patient population, with a really high rate of rhythm control, but in a lot of these patients, it's often a safer alternative than antiarrhythmic therapy. Dr. Ratika Parkash: Absolutely. And we've already shown that amiodarone is ineffective in this population, in AF-CHF. So, using that drug does not seem to be, in a population that could go for an ablation, the appropriate approach. Dr. Sean Pokorney: Yeah. And as well, I think that's important. And when you look back at data from SCD-HeFT as well, there were some concerns with safety signals of amiodarone in patients with heart failure as well, from that study, again, likely related to the side effects of the medication itself. Dr. Sean Pokorney: So again, it is a complex patient population in terms of decision-making and management. And I do think, again, we talked a lot about the trial being stopped earlier than we would've ideally liked. I still think that the data that you guys produced is really important and critical and additive. Again, we're consistently seeing these modest treatment effects across multiple studies. And the fact that all the studies are pointing in the same direction is very reassuring. Dr. Ratika Parkash: Yeah. I was just going to comment on some of the points that Sean had raised, with respect to early rhythm control and the concept of atrial substrate, and how advanced atrial substrate with a negative remodeling effect in patients with heart failure or prolonged atrial fibrillation may not necessarily be in our patient's benefits to then try to intervene, and trying to get these patients early would be useful. Dr. Ratika Parkash: So in RAFT-AF, patients did not have to fail an antiarrhythmic drug in order to get into the study. So that, again, critical, very much along the lines of EAST-AFNET and EARLY-AF, which was also published, demonstrating benefit for early intervention. Dr. Carolyn Lam: Wow. Just, thank you so much, both of you. That was such a rich discussion, really, really unpacking very, very important elements of the trial, not just the trial results, but also the implications of what happens with trial conduct and execution and so on. Dr. Carolyn Lam: Again, thank you so much Ratika, for publishing this very important paper in circulation, Sean, for your beautiful editorial that put it all in context, the audience for listening today. From Greg and I, you've been listening to circulation on the run. Thank you for joining us today, and don't forget to tune in again next week. Dr. Greg Hundley: This program is copyright of the American Heart Association, 2022. The opinions expressed by speakers in this podcast are their own, and not necessarily those of the editors or of the American Heart Association. For more, please visit AHAJournals.org.  

AF ablation vs rate control in HF, TAVI vs SAVR, atherosclerosis, and surrogate endpoints in observational studies are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I – AF ablation vs Rate Control RAFT-AF, Despite Itself, Hints at Advantage for Ablation Rhythm Control in Heart Failure With AF https://www.medscape.com/viewarticle/951326 • Randomized Ablation-Based Rhythm-Control Versus Rate-Control Trial in Patients with Heart Failure and Atrial Fibrillation: Results from the RAFT-AF trial https://www.ahajournals.org/doi/suppl/10.1161/CIRCULATIONAHA.121.057095 • Catheter Ablation for Atrial Fibrillation with Heart Failure https://www.nejm.org/doi/full/10.1056/nejmoa1707855 • Lenient versus Strict Rate Control in Patients with Atrial Fibrillation https://www.nejm.org/doi/full/10.1056/nejmoa1001337 II – TAVI vs SAVR Surgery Groups Push Back on VARC-3 Valve Trial Definitions https://www.medscape.com/viewarticle/970753 • Joint Surgical Associations (EACTS, LACES, ASCVTS, AATS, and STS) Position Statement Regarding the VARC-3 Definitions for Aortic Valve Clinical Research https://doi.org/10.1093/ejcts/ezac110 III – Atherosclerosis Medical Management Best for Atherosclerotic Stroke: New AAN Guidance https://www.medscape.com/viewarticle/970886 • Stroke Prevention in Symptomatic Large Artery Intracranial Atherosclerosis Practice Advisory https://n.neurology.org/content/98/12/486 IV – ECHO parameters with Rhythm Control Global Gains in Heart Function From Early AF Rhythm Control https://www.medscape.com/viewarticle/970329 • Restoring Sinus Rhythm Reverses Cardiac Remodeling and Reduces Valvular Regurgitation in Patients With Atrial Fibrillation https://doi.org/10.1016/j.jacc.2021.12.029 • Effects of Atrial Fibrillation and Sinus Rhythm on Cardiac Remodeling and Valvular Regurgitation https://doi.org/10.1016/j.jacc.2021.12.028 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

2/23/22- Korey Strozier, School Board Director for Tacoma Public Schools, joins the show to talk about his recent heart procedure, Catheter ablation. (8:00)- the start of his heart troubles (11:47)- first time having cardioversion (17:00)- your heart popping out of rhythm (20:50)- the big fix (25:50)- the potential negatives (27:10)- setting the date & preparing for the day (31:45)- the day of surgery (37:15)- the breathing tube (39:15)- arterial catheter (42:00)- the long ride down the hallway (44:37)- surgery time (53:37)- waking up (56:45)- the recovery The Jeremy Mills Podcast Episode #342 Everything You Need: https://linktr.ee/jeremyjoemills Website: www.jeremymillspodcast.com; Twitter & Instagram @jeremyjoemills; Email: jeremymillspodcast@gmail.com. Theme Song: Jeremy Mills Podcast - Don Dishes & M3_Beats

In this episode, Thomas Slater discusses key points from a recent case report published in EHJ – Case Reports.

Mortality risk after AF ablation

Commentary by Dr. Usha Tedrow

Commentary by Drs. Maully Shah

What is the association between the Johnson and Johnson COVID-19 vaccine and Guillain Barré syndrome? Find out about this and more in today's PV Roundup podcast.

COVID-19, COVID-19 vaccines, hybrid AF ablation TAVR and who gets to be called a doctor are the topics by John Mandrola, MD, in this week’s podcast. https://www.medscape.com/twic COVID-19 UK Regulators to Offer Under-30s Alternative to AZ COVID Vaccine https://www.medscape.com/viewarticle/948934 - News - Communicating the potential benefits and harms of the Astra-Zeneca COVID-19 vaccine https://wintoncentre.maths.cam.ac.uk/news/communicating-potential-benefits-and-harms-astra-zeneca-covid-19-vaccine/ Hybrid Ablation for Persistent AF - Hybrid Convergent Procedure for the Treatment of Persistent and Long-Standing Persistent Atrial Fibrillation https://www.ahajournals.org/doi/10.1161/CIRCEP.120.009288 - Converge trial Rationale Paper https://doi.org/10.1016/j.ahj.2020.02.016 - Approaches to Catheter Ablation for Persistent Atrial Fibrillation https://www.nejm.org/doi/full/10.1056/NEJMoa1408288 - Toward evidence-based medical statistics. 2: The Bayes factor https://pubmed.ncbi.nlm.nih.gov/10383350/ TAVR - TAVR Feasible, Comparable to Surgery in Rheumatic Heart Disease https://www.medscape.com/viewarticle/948832 - Transcatheter Versus Surgical Aortic Valve Replacement in Patients With Rheumatic Aortic Stenosis https://doi.org/10.1016/j.jacc.2021.02.032 - Upsides, Downsides for TAVR, Minimally Invasive AVR https://www.medscape.com/viewarticle/946104 - Minimally invasive surgery versus transcatheter aortic valve replacement: a systematic review and meta-analysis https://openheart.bmj.com/content/8/1/e001535#ref-9 Who Should Get to Be Called 'Doctor'? https://www.medscape.com/viewarticle/948887 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact news@medscape.net

Commentary by Dr. Emile Daoud

With Thomas Luescher, Senior Editor EHJ and Brian Halliday, National Heart and Lung Institute, London - UK Link to EHJ paper

2020年11月2日 星期一 第1期FDA 淀粉样变心肌病的新药上市LANCET 肾去神经支配术治疗高血压的新研究Science Advance 四维心脏补片治疗缺血性心肌病他法米迪（tafamidis）2019年5月，他法米迪（tafamidis）被FDA批准用于治疗家族性或野生型甲状腺素运载蛋白介导（ATTR型）的淀粉样变心肌病。淀粉样变心肌病是一种淀粉样原纤维在心脏细胞外区沉积导致的疾病，其中约95%是由甲状腺素运载蛋白介导的（ATTR型）、或由免疫球蛋白轻链介导的（AL型）。淀粉样变性可累及多个脏器，其中心脏受累可导致心力衰竭、心律失常和死亡。他法米迪在甲状腺素结合位点与甲状腺素运载蛋白结合，稳定化合物、防止四聚体分离和淀粉样物质生成。《ATTR-ACT研究：他法米迪治疗ATTR型淀粉样变心肌病》New England Journal of Medicine，2018年9月 (1)这个多中心、国际、双盲、安慰剂对照、3期试验中，纳入441名患者ATTR型淀粉样心肌病患者，分别接受他法米迪80mg、他法米迪20mg或安慰剂治疗30个月。接受他法米迪治疗的患者的全因死亡率和心血管相关的住院率显著低于安慰剂组（P

2020年11月2日 星期一 第1期FDA 淀粉样变心肌病的新药上市LANCET 肾去神经支配术治疗高血压的新研究Science Advance 四维心脏补片治疗缺血性心肌病他法米迪（tafamidis）2019年5月，他法米迪（tafamidis）被FDA批准用于治疗家族性或野生型甲状腺素运载蛋白介导（ATTR型）的淀粉样变心肌病。淀粉样变心肌病是一种淀粉样原纤维在心脏细胞外区沉积导致的疾病，其中约95%是由甲状腺素运载蛋白介导的（ATTR型）、或由免疫球蛋白轻链介导的（AL型）。淀粉样变性可累及多个脏器，其中心脏受累可导致心力衰竭、心律失常和死亡。他法米迪在甲状腺素结合位点与甲状腺素运载蛋白结合，稳定化合物、防止四聚体分离和淀粉样物质生成。《ATTR-ACT研究：他法米迪治疗ATTR型淀粉样变心肌病》New England Journal of Medicine，2018年9月 (1)这个多中心、国际、双盲、安慰剂对照、3期试验中，纳入441名患者ATTR型淀粉样心肌病患者，分别接受他法米迪80mg、他法米迪20mg或安慰剂治疗30个月。接受他法米迪治疗的患者的全因死亡率和心血管相关的住院率显著低于安慰剂组（P

With Lucas Boersma and Vincent van Dijk, St. Antonius Hospital Nieuwegein - Netherlands Link to EHJ paper  

Commentary by Dr. Valentin Fuster

Editor's Summary by Howard Bauchner, MD, Editor in Chief of JAMA, the Journal of the American Medical Association, for the January 21, 2020 issue

Commentary by Dr. Valentin Fuster

With Christopher B Granger and Sean D Pokorney, Duke University Medical Center Link to paper Link to editorial

In this interview, Spencer King and David Wilbur discuss atrial fibrillation, catheter ablation, and the results of the CABANA trial (Catheter Ablation vs Antiarrhythmic Drug Therapy in Atrial Fibrillation).

Oussama Wazni, MD, Section Head, Cardiac Electrophysiology and Pacing and Bruce Lindsay MD, past Section Head and past president of Heart Rhythm Society discusses the challenges and findings from the CABANA trial and its implications on future clinical practice, when to offer ablation vs. medical management.

Dr. Brian Olshansky discusses a paper in the February 2018 New England Journal of Medicine regarding a trial of catheter ablation for atrial fibrillation with heart failure. Dr. Nancy Sokol hosts. Dr. Olshansky is Professor Emeritus of Internal Medicine at the University of Iowa, Adjunct Professor of Medicine at Des Moines University, and Section Editor for UpToDate cardiology topics. Reference: Marrouche NF, Brachmann J, Andresen D, et al. Catheter Ablation for Atrial Fibrillation with Heart Failure. N Engl J Med 2018; 378:417. Contributor Disclosure: Speaker’s Bureau: Lundbeck [Orthostatic hypotension (Droxidopa)]; CryoLife [Heart Valve Replacement (On-X Aortic Valves)]. Consultant/Advisory Boards: Lundbeck [Orthostatic hypotension (Droxidopa)]; CryoLife [Heart Valve Replacement (On-X Aortic Valves)]. Other Financial Interest: Amarin [Hypertriglyceridemia (EPA; Chair, Data and Safety Monitoring Board)]; Boerhringer Ingelheim [Atrial fibrillation (GLORIA AF trial)].

Management of patients with atrial fibrillation has long centered on the relative merits of rate control versus rhythm control. The CASTLE-AF trial evaluated catheter ablation as a treatment for patients with both heart failure with reduced ejection fraction and atrial fibrillation. Listen to this week's podcast episode to learn about the results of this new trial and how the catheter ablation impacted clinical outcomes.  Guest: Alan Ehrlich MD

This week on The Rounds Table Kieran Quinn and Paxton Bach are covering two important articles: catheter ablation for atrial fibrillation with heart failure and the association between myocardial infarction (MI) and influenza. It is common for atrial fibrillation and CHF to co-exist in patients. Yet, optimal management of these co-existing conditions has yet to ...The post King of the CASTLE: Catheter Ablation for Afib with Heart Failure and Myocardial Infarction in Influenza appeared first on Healthy Debate.

This week on The Rounds Table Kieran Quinn and Paxton Bach are covering two important articles: catheter ablation for atrial fibrillation with heart failure and the association between myocardial infarction (MI) and influenza. It is common for atrial fibrillation and CHF to co-exist in patients. Yet, optimal management of these co-existing conditions has yet to ... The post King of the CASTLE: Catheter Ablation for Afib with Heart Failure and Myocardial Infarction in Influenza appeared first on Healthy Debate.

A new study reveals that patients receiving radiofrequency catheter ablation compared to traditional drug therapies for atrial fibrillation (AF) have significantly lower hospitalization and mortality rates. The findings are published in the New England Journal of Medicine. The study's lead author, cardiologist Nassir F. Marrouche, MD, discusses the research and what it means for patients.

  Paul Wang:         Welcome to the monthly podcast On the Beat for Circulation, Arrhythmia, and Electrophysiology. I'm Dr. Paul Wang, Editor in Chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field.                                 In our first study, Boris Schmidt and associates studied 134 patients with persistent atrial fibrillation, randomized to laser balloon or wide area circumferential pulmonary vein isolation using irrigated radiofrequency current ablation and 3D mapping.                                 They found that 71% of patients in the laser balloon group had freedom from atrial fibrillation between 90 and 365 days after a single ablation, similar to 69% of patients in the radiofrequency group, p=0.40. In the laser balloon group, one patient developed stroke, one had false aneurysm and one had phrenic nerve palsy. In the radiofrequency group, two patients developed a false aneurysm and one patient needed surgical repair. Procedure and fluoroscopy times were similar between the two groups. The authors concluded that the two methods were associated with similar efficacy in patients with persistent atrial fibrillation.                                 In the next study, Kairav Vakil and associates examined the success of VT ablation in elderly patients who were part of the International VT Center Collaborative Study Group Registry. Of the 2,049 patients in the registry, 33% or 681 were greater than or equal to 70 years of age with a mean age of 75 years.                                 Compared to patients less than 70 years, patients 70 years or greater had higher in-hospital, 4.4% versus 2.3%, p=0.1 mortality, and also a higher one year mortality, 15% versus 11%, p=0.002. But they had a similar instance of VT recurrence, 26% versus 25% and a similar time to recurrence, 280 versus 289 days.                                 The authors concluded that VT ablation in elderly is feasible with reasonable safety and modestly higher in-hospital and one year mortality with similar rates of VT recurrence at a one year compared to younger patients.                                 In the next study, Angel Ferrero-de Loma-Osorio and associates studied the optimal dosage of cryotherapy using cryoballoon ablation of pulmonary veins. The study the prospective, randomized, multicenter, non-inferiority study including 140 patients with paroxysmal atrial fibrillation which was refractory to antirrhythmic drugs.                                 Patients were randomly assigned to a conventional strategy group of 180 seconds cryoablation applications per vein with a bonus freeze 70 patients or a shorter time application protocol with one application that lasted the time required for a electrical time to effect plus 60 seconds and a 120 second freeze bonus, 70 patients.                                 At one year followup there was no difference in freedom from atrial fibrillation 79.4% of the control group versus 78.3% in the study group, p=0.87. The time to effect was detected in 72% of the veins. The study and control group had similar mean number of applications per patient, 9.6 versus 9.9. compared to controls the study group had a significantly shorter cryotherapy time, 28.3 versus 19.4 minutes, p80 or >90, especially when one refers to the appropriate use criteria where appropriateness was reclassified based on what the age range was and what the indication was from a primary prevention defibrillator. Further study is need to understand whether we really should apply an age cutoff to the benefit of ICDs but it is an important thing to consider when counseling patients, especially in light of evolving evidence in this area.                                 Still staying in the realm of heart failure but now going to more basic electrophysiology, we review a paper published in Circulation this past month by Cho et al., entitled Delayed Repolarization Underlies Ventricular Arrhythmias in Rats With Heart Failure and Preserved Ejection Fraction.                                 Increasingly, heart failure with preserved ejection fraction is being diagnosed to the point where it is now approximately half of all diagnosed heart failure with incidences that continue to increase nevertheless. One of the leading causes of mortality in heart failure with preserved ejection fraction is sudden death but the underlying mechanisms for this is less clear.                                 Thus in a rat model, Cho et al., sought to evaluate why heart failure with preserved ejection fraction might result in an increase risk of sudden death. They exposed salt sensitive rats to a high salt diet and evaluated the effect on systolic and diastolic function. After verifying, some rats that suffered from HFpEF at this point versus control rats, they underwent programmed electrical stimulation and they measured corrected QT interval from surface ECG as well. Furthermore they did optical mapping, whole-cell patch clamping and quantitative polymerase chain reaction and Western blotting to evaluate ion channel expression.                                 They noted that 31 of 38 rats exposed to a high salt diet demonstrated diastolic dysfunction and preserved ejection fraction along with signs of heart failure. There was an increased susceptibility to ventricular arrhythmias amongst these particular rats when compared to controls. They also noted that the corrected QT interval was significantly longer. Interestingly optical mapping showed that these rats had prolonged action potentials and multiple reentry circuits during induced ventricular arrhythmias. Furthermore there was confirmed a delay of repolarization based on patch clamping with a downregulation of transient outward potassium currents or ITO. Finally they noted that there was a downregulation of IK1 as well as IKR.                                 Thus they felt that the susceptibility to ventricular arrhythmias was indeed markedly increased, at least in a rat model of HFpEF. These could be caused by QT prolongation, which is associated with delayed repolarization from downregulation of potassium currents and also associated multiple reentry circuits which can mediate ventricular arrhythmia. These findings are significant in that they highlight both potential targets for sudden death risk in the setting of HFpEF as well as potential targets for treatments that might prevent ventricular arrhythmias in the long term.                                 Staying within the realm of ventricular arrhythmias, we next review an article by Do et al., published in the Journal of the American Heart Association this past month, entitled Thoracic Epidural Anesthesia Can Be Effective for the Short‐Term Management of Ventricular Tachycardia Storm.                                 Similar to the earlier discussed article, of optogenetic stimulation of left stellate ganglion, even short term management options for VT storm are important. Some inject lidocaine or bupivacaine into the left stellate ganglion or into both stellate ganglia in order to get control. However, depending on comfort level, the utility of this may be variable at different institutions.                                 Thus, novel therapies aimed at modulating the autonomic nervous system that might be available at other institutions such as thoracic epidural anesthesia are important to consider. The group sought to evaluate via multicenter experience what the effect on VT storm was with thoracic epidural anesthesia.                                 They noted amongst 11 patients reviewed between July 2005 and March 2016 that the majority who underwent thoracic epidural anesthesia had incessant VT with a minority of them being polymorphic VT. Furthermore almost half of them had nonischemic cardiomyopathies. Almost half of the patients had a complete response to thoracic epidural anesthesia where the VT became quiescent. And one patient had a partial response.                                 Thus, they suggested that thoracic epidural anesthesia may be effective and should be considered as a therapeutic option in patients with VT storm, especially those with incessant VT, who are refractory to initial management. They also noted clinically that improvement in VT burden associated with deep sedation may suggest a higher likelihood of responding to thoracic epidural anesthesia. For a clinical electrophysiologist especially in community hospitals where rapid utilization of ablation may not be possible or other advanced methods of autonomic modulation might not be feasible, options such as thoracic epidural anesthesia are important to be considered. They exist in an armament that includes intravenous drugs, left stellate ganglion injections, general anesthesia and use of IV beta blockers. These findings are highly suggestive and the fact that certain clinical characteristics might suggest those that are more likely to benefit might just to clinicians exposed to a patient of VT storm what the next step should be.                                 Changing gears a little bit we will now review an article by Rafaat in the Journal of the American Heart Association entitled Swine Atrioventricular Node Ablation Using Stereotactic Radiosurgery: Methods and In Vivo Feasibility Investigation for Catheter‐Free Ablation of Cardiac Arrhythmias.                                 The group sought to demonstrate using a linear accelerator based stereotactic radiosurgery system whether or not atrioventricular node ablation could be safely performed with minimal damage to surrounding structures. They used the linear accelerator to apply energy in a pig model after implantation of a pacemaker using a CT scan to guide therapy. They also performed pathologic evaluation of the region of the AV node and the surrounding tissues. They found that all animals included had disturbances of AV conduction with progressive transition into complete heart block. There was no damage to the surrounding myocardium and all pigs had preserved systolic function echocardiography.                                 Thus they suggested that catheter free radioablation using this approach might be feasible in an intact swine. These findings are important because they build on other studies done by groups at other centers suggesting that noninvasive linear accelerator based therapies either using stereotactic radiosurgery with existing technologies, proton beams, carbon beams or other approaches, might offer feasible methodologies for noninvasive treatment for cardiac arrhythmias. Further study is indeed needed to validate what the effect on surrounding tissues actually is.                                 Next we will review an article published by Williamson et al., in JACC Clinical Electrophysiology this past month entitled Real-World Evaluation of Magnetic Resonance Imaging in Patients With a Magnetic Resonance Imaging Conditional Pacemaker System.                                 Results of four year prospective followup in over 2,600 patients, while MRI conditional pacemakers are more increasingly used, long term longevity as well as effects of multiple MRI scans in terms of MRI functioning the devices is unclear. Thus, the study was sought to be a large scale, real world evaluation of MRI in patients with MRI conditional pacemakers. They included over 2,600 patients in multiple centers and all these patients had a SureScan pacing system. They noted that there were no MRI related complications occurring during or after the MRI, meeting the primary objective. In fact, almost a third of the patients underwent two or more scans and even then there was no cumulative increase in problems in these patients. The pacing capture thresholds stayed stable throughout all patients.                                 Thus this report constituted the largest longitudinal MRI experience in patients implanted with an MRI conditional device. The importance of this is to be able to highlight to patients that in fact even multiple MRIs despite having a device in place is safe. There is an increasing body of data that suggests that however, MRIs might be safe in a controlled setting, even in patients with legacy pacemakers. Whether MR conditional pacemakers actually offer incremental safety over legacy pacemakers however, is less clear and will likely require randomized trials of a large scale given the low number of events to really come to a conclusion. However, in most centers where it's not possible to do MRIs in legacy pacemakers, this offers some level of certainty that patients will likely be safe even undergoing multiple MRIs in a setting of having chronic pacemakers that are MRI conditionally safe.                                 Staying within the realm of looking at large multicenter experiences, we review an article by Hosseini et al., entitled Catheter Ablation for Cardiac Arrhythmias, Utilization and In-Hospital Complications, 2000 to 2013, published in JACC Clinical Electrophysiology this past month.                                 In this study, Hosseini et al., sought to investigate the overall utilization and in-hospital complications associated with catheter ablation in of all types in the United States between 2000 and 2013 using the National Inpatient Sample and Nationwide Inpatient Samples. They included all patients 18 years of age and older who underwent inpatient catheter ablation over this time period.                                 They estimated total a total of almost 520,000 inpatient ablations performed in this time period with a median age of 62 years amongst patients. Interestingly the annual volume of ablations and the number of hospitals performing ablations increased year over year but the rate of complications and length of stay also increased. A large number, almost more than a quarter of inpatient ablation procedures were actually performed in low volume hospitals and in turn were associated with an increased risk for complications with an odds ratio 1.26. Independent predictors of in-hospital complications and in-hospital mortality included complex ablations for atrial fibrillation and ventricular tachycardia, older age and a greater number of comorbidities. In addition to this, lower hospital volumes was an independent predictor of complications.                                 Thus the authors note that there has been a steady progressive in the number of in-hospital catheter ablation procedures. However, despite the increasing number, the number of periprocedural complications is increasing which may be partly mediated by taking in sicker patients from a complex procedures but also to performing these at lower volume centers. These findings are critical when considering the future of ablation strategies and ablation performance when we consider multicenter experiences or when we consider where certain procedures might be performed based on the experience of the operator or the institution. Why exactly it is that lower volume centers of higher complication rates still needs to be evaluated. However, it should be understood that ablations are  complex procedures and thus require a certain amount of experience in order to allow for procedural efficacy and safety similar to any cardiac surgery or other procedure. It remains to be understood what the number of procedures to be able to be felt to be competent and safe should be. But, these findings should be considered by all providers based on their own personal experience and based their own personal numbers.                                 Staying with the realm of catheter ablation, we will next review an article by Haldar et al., published regarding Catheter ablation vs electrophysiologically guided thoracoscopic surgical ablation in longstanding persistent atrial fibrillation: The CASA-AF Study in last month's edition of Heart Rhythm.                                 In this article, they sought to evaluate catheter ablation outcomes for longstanding persistent atrial fibrillation as compared with those of thoracoscopic surgical ablation. There's a limited amount of data comparing these two methodologies for ablation. They included 51 patients with de novo symptomatic atrial fibrillation. 26 underwent thoracoscopic surgical ablation and the remainder underwent stepwise left atrial ablation with a primary end point being single-procedure freedom from atrial fibrillation and atrial tachycardia lasting >30 seconds without antiarrhythmic drugs at 12 months. They noted that single- and multi procedure freedom from atrial fibrillation was higher in the surgical ablation group than in the catheter ablation group. Namely the overall success rate from the surgical ablation group was 73% versus 32% in the catheter ablation group. It should be noted that there was testing of the surgical ablation lesion set by electrophysiologists that was felt increased success rate in achieving acute conduction block by 19%. It also should be noted that the complication rate in the surgical ablation group, was significantly higher than the catheter ablation group, namely 27% versus 8%. This did not reach statistical significance however, possibly due to the low numbers considered.                                 The conclusion from the authors was that meticulous electrophysiologically guided thoracoscopic surgical ablation as a first line strategy in long standing persistent atrial fibrillation, may provide excellent single procedure success rates as compared with traditional catheter ablation. However again, there is an increased upfront risk of nonfatal complications. These considerations are important when thinking about what strategy to use in specific patients. Whether at a large level, thoracoscopic surgical ablation should be routinely used is still unclear and larger studies are likely needed to compare different modalities of ablation to better evaluate which is the right one for which patients.                                 Again staying in Heart Rhythm in 2017, we next review an article by Sheldon et al., published regarding Catheter ablation in patients with pleomorphic, idiopathic, premature ventricular complexes.                                 When a patient presents with idiopathic PVCs that are a single monomorphic focus, it is often considered reasonable to ablate them. However when patients have pleomorphic PVCs or polymorphic PVCs, the role of ablation is less clear and often considered more complex. Thus in this study, Sheldon et al., sought to evaluate patients who underwent ablation with pleomorphic PVCs. They reviewed about 100 consecutive patients 31% of whom had pleomorphic versus 69% who had monomorphic PVCs, however all of who were considered idiopathic. They noted the overall success rate was lower in patients with pleomorphic PVCs, namely 71% versus 90%. In fact, the presence of pleomorphic PVCs was independently associated with unsuccessful ablation. Also, pleomorphic PVCs more often had an epicardial origin than did monomorphic PVCs. And repeat ablation procedures were required in almost 20% of the cohort. Interestingly, three of the patients who came back for another procedure, had an increase of a nonpredominant PVC and one patient had a newly emerged PVC focus.                                 The conclusion by Sheldon et al. Was the presence of pleomorphic PVCs can affect ablation outcomes but it's still possible to achieve successful elimination of the predominant PVC even if not all PVCs are targeted. Furthermore, they suggested that most recurrences are due to reemergence of the originally targeted predominant PVC morphology though sometimes other PVC morphologies may arise. Larger scale evaluation is still necessary to understand when a patient should be taken to ablation and when not. We recognize that sometimes the presumption of idiopathic might be due to a lack of consideration of other ideologies such as subclinical inflammation that can be related to myocarditis or sarcoidosis or other finding. Thus it should always be considered what the actual underlying substrate is with rigorous imaging such as MRI or PET scanning. However, the findings by Sheldon et al. suggest that just because there are multiple PVC morphologies present, does not necessarily mean that they cannot be ablated.                                 Switching gears away from PVCs, we next review an article by Romero et al. published in Heart Rhythm this past month entitled Emergence of atrioventricular nodal reentry tachycardia after surgical or catheter ablation for atrial fibrillation: Are we creating the arrhythmia substrate?                                 They reviewed patients who had AVNRT ablation performed and sought to evaluate how many of them had prior surgical or catheter ablation for atrial fibrillation. They reviewed cases of ablation for specifically persistent atrial fibrillation who eventually required a repeat ablation procedure and had a diagnosis of AVNRT at that time. A total of nine patients were identified meeting these characteristics. All of these patients were noted to have evidence of atrial fibrosis in the septum or proximal CS, and in fact six had undergone ablation either at the septum or the coronary sinus ostium or body and the other three had inferior mitral lines at a surgical MAZE approach. All had typical AVNRT inducible that was abolished with slow pathway ablation, though five required ablation in the roof of the coronary sinus or on the mitral valve annulus.                                 Thus Romero et al. concluded that ablation involving the septum or proximal CS may create a substrate that can induce AVNRT. These findings are important when we consider ablation. Oftentimes when we do ablation, we think of a targeting substrate without thinking about the substrate we might create. Thus, rigorous evaluation for other mechanisms of tachycardia that one might not think of because of the absence of it during the index ablation should always be considered such as the creation of substrate for AVNRT. While most of us will consider atrial flutters or focal atrial tachycardias or macro reentry atrial tachycardias as the principle mechanisms of tachycardia in patients returning after prior atrial fibrillation ablation should also be considered that we might be creating substrate for other types of arrhythmias such as AVNRT.                                 The next article we will review is published in the American Journal of Physiology, Heart and Circulatory Physiology by Yang et al., entitled Effect of ovariectomy on intracellular calcium regulation in guinea pig cardiomyocytes.                                 It is believed that long-term deficiency of ovarian hormones after ovariectomy can alter cellular calcium handling mechanisms in the heart that can in turn result in the formation of a proarrhythmic substrates. This is important when considering possible arrhythmogenic mechanisms in women who might be undergoing ovariectomy or who might be in a post menopausal state. Thus in a series of animals, they evaluated the effective of ovariectomy as well as estrogen supplementation to ovariectomized animals on calcium handling at the level of the heart. They demonstrated that the ovariectomized guinea pig cardiac myocytes had higher frequencies of calcium waves and isoprenaline challenged cells displayed more early after depolarizations after ovariectomy. In addition to this, they noted the observations of calcium regulation alternations were not observed in myocytes from ovariectomized guinea pigs who were supplemented with 17β-Estradiol suggesting that in fact, these changes in the arrhythmogenic substrate were due to ovarian hormone deficiency resulting in dysregulation of cardiac calcium.                                 While this was all performed at the level of guinea pigs, it is an important consideration again, as a potential mechanisms of cardiac arrhythmogenesis in women who might be undergoing ovariectomy or who might be post menopausal. In some cases ovarian hormones might be beneficial in regulating the arrhythmogenic substrate.                                 The next article we review is published in Heart this past month by Stewart et al., entitled Nitric oxide synthase inhibition restores orthostatic tolerance in young vasovagal syncope patients.                                 Syncope is probably one of the most difficult things that we treat in electrophysiology. In particular, vasovagal syncope. People have looked at different pacing maneuvers and specialized pacemakers for treatments. However, there's improving body of knowledge regarding other mechanisms, specific physiologic mechanisms that might underlie vasovagal syncope. This group in question had previously demonstrated that impaired post synaptic adrenergic responsiveness in those who have vasovagal syncope may be reversed by blocking nitric oxide synthase. Thus, they sought to evaluate volunteers who either had vasovagal syncope or were otherwise healthy, what the effect of a nitric oxide synthase inhibitor would be.                                 They demonstrated that arterial vasoconstriction is impaired in young vasovagal syncope patients but inhibiting nitric oxide synthase could correct this problem. Namely, that this might provide a potential mechanism of avoiding the changes in blood pressure associated with orthostatic intolerance resulting in vasovagal syncope. Whether or not this proves to be an ambulatory therapy still remains to be seen but at least in the acute study state within which these patients were evaluated, it suggests to be a potential promising target.                                 The next paper we review is also published in Heart this past month by Lazzerini et al., entitled Systemic inflammation as a novel QT-prolonging risk factor in patients with torsades de pointes.                                 There is increasing evidence of the role systemic inflammation can play in arrhythmogenesis and particularly in acquired long QT syndrome in patients with sarcoid or myocarditis and other disease states is well recognized that ventricular arrhythmias that are potentially life threatening can happen. What the role of correcting this inflammatory state is, is less clear. However, this group decided to evaluate whether systemic inflammation may represent a currently overlooked risk factor contributing to torsades de pointes in the general population. They looked at 40 consecutive patients who experienced torsades and enrolled them to evaluate circulating levels of different inflammatory biomarkers and compared them with patients with active rheumatoid arthritis, comorbidity or healthy controls. They demonstrated that in the torsades group, 80% of patients showed an elevated inflammatory markers and in fact a definite inflammatory disease was identifiable in 18 of the 40 patients with 12 having acute infections, five having immune mediated diseases and one described as other.                                 Thus they proposed that systemic inflammation via elevated IL-6 levels could represent a novel QT-prolonging risk factor that can contribute to torsades. In their group they showed that CRP reduction was associated with IL-6 level decrease and resulted in QTC shortening. It remains to be seen whether this increased inflammatory pathway might be due to the torsades event itself or the cause. However, it does bring up the interesting question of whether or not systemic inflammation may in fact be causing untoward effects on normal arrhythmic profiles resulting in a greater risk of ventricular arrhythmias.                                 The next article we review is published by Kottkamp et al., entitled Global multielectrode contact mapping plus ablation with a single catheter: Preclinical and preliminary experience in humans with atrial fibrillation in this past month's issue of the Journal of Cardiovascular Electrophysiology.                                 Within the realm of catheter ablation for atrial fibrillation, There's a constant search for new approaches to achieve either more durable or quicker or safer pulmonary vein isolation. It is well recognized that pulmonary vein isolation is the cornerstone of atrial fibrillation ablation. In this particular paper, they sought to evaluate the utility of a catheter, namely a basket catheter that could allow for both diagnostic mapping as well as targeted ablation. This novel catheter has a distal multielectrode array with 16 ribs with 122 gold-plated electrodes. With each electrode being able to ablate, pace and able to measure tissue contact, temperature, current, and intracardiac electrograms. They noted in three patients that complete pulmonary vein isolation was achieved in all 12 and in most veins, PVI was achieved with a single placement in front of that respective vein though in one case there was a single gap requiring reapplication.                                 This suggests a new technique for quote unquote, single shot pulmonary vein isolation. Furthermore, the fact that multiple electrodes could be used to map at the same time as performing ablation, suggest that there might be opportunities for mapping more than just the veins themselves. What the safety and utility of this approach would be over other quote unquote, single shot approaches, such as laser and cryo based balloon systems, is unclear. Furthermore, whether or not they actually reflect a paradigm that offer additional utility due to the ability for more mapping, also remains to be seen. However, the critical portion of understanding these different tools is being able to differentiate them in practice and understanding what their relative values and opportunities are will be critical as one makes selections of which technologies to use.                                 The next article we review is published in Europace this past month by Hellenthal et al., entitled Molecular autopsy of sudden unexplained deaths reveals genetic predispositions for cardiac diseases among young forensic cases.                                 While we recognize that coronary artery disease causes the majority of sudden cardiac deaths in the older population. When we have a young patient who experiences sudden cardiac death, we always have to be concerned about the role of a genetic component. This is not just important for the patient themselves but also for family members who might still be alive. In this study they sought to determine the portion of underlying genetic heart disease among unexplained putative sudden cardiac death cases from a large German forensic departments.                                 The number included were only 10 patients who had sudden unexplained death aged 19 to 40 years. DNA was analyzed for 174 candidate genes and also genetic testing was offered to affected families. Amongst 172 forensic cases again, 10 cases of sudden unexplained death were identified and a genetic disposition was found in eight of 10 cases, with pathogenic mutations in three and variants of uncertain significance in five. Furthermore, subsequent selective screening of the family members revealed two additional mutation carriers in family members who had not suffered from a sudden death event yet.                                 The role of molecular autopsy in patients is evolving. However, the amount of molecular autopsies that are sent are still too low. All patients who are young and die unexpectedly, might benefit from molecular autopsy beyond just traditional forensic pathology to understand whether or not there's a genetic predisposition that led to their event. This might help the family members of that affected individual, especially in understanding whether or not they may also be at risk.                                 The next article we review is by Constantino et al., entitled Neural networks as a tool to predict syncope risk in the Emergency Department in Europace this past month.                                 Many patients when they pass out immediately come into the emergency department. However, it can be very difficult to understand what the risk of that syncope patient is and thus many are automatically admitted to the hospital despite the fact that history might provide a lot of data. In this study, Constantino et al., sought to evaluate the utility for artificial neural networks in stratifying risk in patients presenting with syncope to the hospital. They analyzed individual level data from three prior prospective studies and included a a cumulative sample of 1,844 patients. They included ten variables from patient history, ECG, and the circumstances of syncope to train and test the neural network. They actually had two different approaches used for training and validating neural network given the exploratory nature of the study. They found that they could identify adverse events after syncope with a sensitivity if 95% if they used one approach versus 100% if they used an approach that considers more factors.                                 Thus the study suggested that artificial neural networks could effectively predict the short-term risk of patients with syncope after presenting to the emergency departments. They did not seek to address what the predictive capability of the artificial neural network would be when compared with traditional clinical judgment and existing rule sets that might exist in various emergency departments. The reason this study's important is that as artificial neural networks become more robust we might find that their role in complementing physician decision making might become more and more important. This is especially true on the front lines amongst emergency department physicians or in other groups and consideration of employment of novel technologies or rule sets or methodologies to augment decision making on risk of patients who are being evaluated might need to be considered. It also might help individual stratify patients into those that require sooner evaluation.                                 The final article we review is published in the Journal of Interventional Cardiac Electrophysiology this past month by Schmier et al., entitled Effect of battery longevity on costs and health outcomes associated with cardiac implantable electronic devices: a Markov model-based Monte Carlo simulation.                                 Economic effects of increasing utilization of cardiac implantable electronic devices is of increasing concern. We also note that a lot of focus goes on what the battery life of a device is. However, how that battery longevity might affect overall cost and health outcomes is less clear. Thus in this study, Schmier et al., sought to develop a Monte Carlo Markov model simulation model to evaluate what happens to patients based on the battery longevity. They sought evaluations such as infection and non-infectious complication rates as well as overall costs over the lifetime of that individual patient. These outcomes were largely derived from Medicare data. They noted that an increase in battery longevity was an associated reduction in the number of revisions needed by 23%, the number of battery changes needed by 44%, the number of infections by 23%, the number of non-infectious complications by 10% and total costs per patient by 9%.                                 Thus, they demonstrated that using batteries that have longer longevity could be associated with fewer adverse outcomes and reduced healthcare costs. The understanding of the magnitude of the cost benefits of extended battery life is critical and how to optimize the battery life is also critical. It might be that as we move forward, when encountering a situation or a patient in which the battery life is far less than expected, consideration of the reasons why that battery life was limited will be critical in order to optimize the ongoing chronic care of that patient. Both to reduce the burden on the healthcare system and to improve that individual patient's long term outcomes in terms of infectious risk or other issues.                                 This is primarily simulation model and was not necessarily tested in a prospective fashion though this would be quite difficult given the long duration over which would be required to see a lot of these beneficial costs and complication rate effects. However, it is provocative in the fact that it allows us to understand that there might be benefits from taking further care in selecting not just the right device based on indication but the right device based on patient age, the number of general changes one expects a patient to have and what the longevity of that patient is expected to be.                                 I appreciate everyone's attention in these key and hard hitting articles that we have just focused on from this past months of cardiac electrophysiology across the literature. Thanks for listening. Now back to Paul. Paul Wang:         Thanks Suraj. You did a terrific job surveying all journals for the latest articles on topics of interest in our field. There's not an easier way to stay in touch with the latest advances. These summaries and a list of all major articles in our field each month can be downloaded from the Circulation, Arrhythmia and Electrophysiology website. We hope you'll find the journal to be the go to place for everyone interested in the field. See you next month.    

Commentary by Dr. Valentin Fuster

Commentary by Dr. Valentin Fuster

Commentary by Dr. Valentin Fuster

Dr. Wang:            Welcome to the monthly podcast On The Beat for Circulation, Arrhythmia and Electrophysiology. I'm Dr. Paul Wang, editor-in-chief, with some of the key highlights from this month's issue. We'll also hear from Dr. Suraj Kapa, reporting on new research from the latest journal articles in the field.                                 This month's issue of Circulation: Arrhythmia and Electrophysiology has a number of fascinating and important articles. Let's start with the first article by Philip Halbfass and Associates, which describes the use of esophageal endoscopy in patients undergoing atrial fibrillation ablation. Of 1,802 patients undergoing afib ablation, 832 underwent post-procedural esophageal endoscopy. All patients were ablated using a single tip re-circular ablation catheter. Category one lesions described as erythema erosion were seen in 98 out of these 295 patients, while in 52 out of the 295 patients, ulceration was seen. In three of the 832 patients, esophageal perforation occurred, and in two of the 832 patients, atrial-esophageal fistula occurred.                                 Esophageal perforation only occurred in patients with category two lesions with an absolute risk of 9.6%. The authors concluded that post-ablation esophageal endoscopy is able to identify patients with high-risk lesions. One out of 10 patients with post-ablation esophageal ulcers progressed to perforation, while no patients without esophageal ulcers showed evidence of perforating complications.                                 In the next article by Christian Sohns and Associates describes the relationship between atrial fibrosis identified with magnetic resonance imaging and atrial rotor activity identified by noninvasive electrophysiological mapping. Ten patients underwent pulmonary vein isolation for persistent atrial fibrillation. Late gadolinium enhancement using magnetic resonance imaging, which projected onto the anatomy used for noninvasive electrophysiologic mapping.                                 The noninvasive electrophysiologic mapping identified 410 rotors evenly distributed between the left atrium and the right atrium. This study found that there was no statistically significant association between the presence of late gadolinium enhancement and the presence of rotors.                                 In the next article written by Jereon Venlet examines the endocardial unipolar voltage that best identifies abnormal epicardial electrograms. Thirty-three patients underwent endocardial epicardial right ventricular electro-anatomical mapping in ablation of right ventricular scar-related ventricular tachycardia. Eighty-six percent of abnormal epicardial electrograms had corresponding endocardial sites with bipolar electrogram less than 1.5 millivolts.                                 The remaining abnormal epicardial electrograms could be identified by endocardial unipolar voltages of less than 3.7 millivolts. The authors concluded that this use of endocardial unipolar voltage cut off at normal bipolar voltage sites improves the identification of all abnormal epicardial electrograms where there is less than 1 millimeter of fat.                                 The next article by Alan Bulava and Associates examines the outcomes of hybrid epicardial and endocardial radial frequency ablation, a persistent atrial fibrillation. Seventy patients underwent the epicardial thoracoscopic procedure followed by endocardial mapping ablation two to three months later. At the time of catheter ablation, 76% of patients were in sinus rhythm. All four pulmonary veins were found to be isolated in 69% of the patients and the left atrial posterior wall was isolated in 23% of the patients.                                 In the 12 months after the catheter ablation, 77% were arrhythmia-free, off antirrhythmic drugs. The majority of arrhythmia occurrences occur during the first 12 months following catheter ablation. Using previously ineffective antiarrythmics drugs and re-ablation procedures, arrhythmia-free survival increased to 97% during a mean followup of 936 days. Left atrial volume greater than 165 milliliters, the absence of sinus rhythm before catheter ablation and induce-ability of any sustained tachyarrhythmia at the end of catheter ablation predicted atrial fibrillation recurrence.                                 The authors concluded that the majority of patients after epicardial ablation required endocardial catheter ablation to complete the linear ablation or pulmonary vein isolation lesion sets. In the next article, Jason Roberts and Associates studied the clinical phenotype of Type 6 Long QT Syndrome, stemming from mutations in the KCNE2 encoded voltage gated channel beta subunit.                                 The authors examined individuals reported pathogenic KCNE2 mutations collected from inherited arrhythmia clinics in the Rochester LQTS registry as well as previously reported LQT6 cases identified through a med-line database search. Of 44 probands studied, 16 probands had resting QTC intervals and only developed QT prolongation and malignant arrhythmias following exposure to QT prolonging stressors. Ten had other Long QT pathogenic mutations and 10 did not have a Long QT phenotype, with the remaining eight subjects having a Long QT phenotype, but with evidence suggesting that the KCNE2 variant was not the underlying culprit.                                 The authors noted that the collective frequency of KCNE2 variance implicated in Long QT6 syndrome in the exome aggregation consortium database was 1.4%, in comparison with the 0.0005% estimated clinical prevalence of LQT6 syndrome. Thus, the authors concluded that based on clinical phenotype, the high allelic frequencies of LQT6 mutations in the exome consortium database, in absence of prior documentation of genotype phenotype segregation, many KCNE2 variants, and perhaps all have been erroneously designated as long QT syndrome causative mutations.                                 Instead, KCNE2 variants may confer pro-arrhythmic susceptibility when provoked by additional environmental acquired or genetic factors. In the next article, Alexander Quinn and Associates examine how mechanically-induced ectopy may cause ventricular fibrillation, the mechanism of commotio cordis. It is known that the block of stretched sensitive ATP inactivated potassium channels limits ventricular fibrillation occurrence in a porcine model of commotio cordis.                                 In isolated rabbit heart preparations using optical voltage mapping combined with pharmacological block of potassium ATP or stretch activated cation nonselective channels, the authors showed that the mechanical stimulation reliably triggers premature ventricular excitation at the contact site with induce-ability predicted by local tissue indentation. Mechanically-induced premature ventricular excitation induction is decreased by stretch activated cation nonselective channel block.                                 The authors also found that mechanically-induced premature ventricular excitation resulted in ventricular fibrillation only if the mechanical stimulation site overlaps the re-polarization wave edge in hearts where T-waves involve a well-defined re-polarization edge traversing the epicardium. This defines a narrow subject-specific vulnerable window for commotio cordis-induced ventricular fibrillation in both time and space.                                 In the next article Matthias Seidl and Associates examine the gene expression required for development of atrial fibrillation in a transgenic mouse model. Recent studies showed that atrial fibrillation susceptibility is associated with down regularization of target genes of the CREB/CREM family of transcription factors. CREB/CREM refers to cyclic and P-response element binding protein modulator.                                 Short CREM repressor isoforms like CREM-IbΔC-X bind to cyclical A&P responsive elements preventing transcriptional activation. Messenger RNA for CREM-IbΔC-X is up-regulated in atrial biopsies from patients with paroxysmal or chronic atrial fibrillation. The authors examined transgenic mice expressing CREM-IbΔC-X, which spontaneously developed atrial fibrillation proceeding to permanent fibrillation with age.                                 The authors found that the most prominent alterations of the gene program linked to CREM-induced atria modeling were identified in expression of genes related to structure, metabolism, contractility and electrical activity regulation. In the next article by Takumi Yamada and Associates electrophysiologic characteristics of the idiopathic ventricular arrhythmias originating from the parietal band, one of the muscle bands of the right ventricle, were examined.                                  Of 294 consecutive patients with right ventricular origins, 14 patients had ventricular arrhythmia origins in the parietal band. All patients have left bundle block pattern with 12 inferior and two superior axis. All patients had the notch in the middle of the curess in all cases. Seven patients had precordial transition before lead V3 and four patients had a slow curess onset.                                 Far field ventricular electrogram with an early activation was always recorded in His bundle region regardless of the location of the ventricular arrhythmia origin. During the catheter ablation, a mean number of 10.4 radio frequency of applications with a mean duration of 1,099 seconds were delivered. Catheter ablation was successful in 10 patients and ventricular arrhythmias recurred in four with a mean followup of 41 months.                                 In the Advances in Arrhythmia and Electrophysiology section, the Buza and Associates have reviewed cancer treatment-induced arrhythmias. The authors describe ECD advances in arrhythmias associated with individual cancer chemotherapeutic agents. Now here with a review of the highlights from the articles from journals throughout the world in the past month, is Dr. Suraj Kapa. Dr. Kapa:              Hello. Today we're going to be going over several hard hitting articles we have identified that seem to stand out in the electrophysiological literature from the month of July 2017. The first area we will be delving into is that of atrial fibrillation. Specifically related to cardiac mapping and ablation. The first article in this area that we've chosen was published by Samuel et al. in the Journal of Cardiovascular Electrophysiology entitled Catheter Ablation for the Treatment of Atrial Fibrillation Is Associated with a Reduction in Healthcare Resource Utilization.                                 Samuel et al. reviewed data from a large population base cohort in Quebec, Canada including over 1,500 patients undergoing cardiac ablation for atrial fibrillation. They demonstrated that healthcare resource utilization including hospitalizations, emergency room visits and cardioversions were significantly reduced both 12 months as well as 24 months after the next ablation. These findings seem to suggest that catheter ablation has a sustained overall impact on resource utilization amongst patients with atrial fibrillation.                                 While the study was not randomized and was a retrospective evaluation of outcomes, these findings are provocative. Certainly as we wait for the results of the Cabana trial in about one year we hope to see whether or not cardiac ablation carries the weight of potential beneficial impacts both in terms of long-term care as well as long-term outcomes. Of course being a retrospective evaluation, one question that lies with regards to these findings is whether or not the reduction in resource utilization might be a byproduct of improved ambulatory care of these patients or whether it's a byproduct of patients understanding their disease process better, and thus perhaps not seeking emergency room care or hospitalization as frequently.                                 The next publication we'll focus on was published by Anselmino et al. in The International Journal of Cardiology entitled Conduction Recovery Following Catheter Ablation in Patients with Recurrent Atrial Fibrillation and Heart Failure. This publication synergizes with several other publications that have come out in the month of July. Focusing on the publication by Anselmino et al., they reviewed retrospectively patients undergoing redo atrial fibrillation ablation in the setting of underlying heart failure.                                 What they demonstrated was that nearly a third of patients had no pulmonary vein reconnection, but tended to have more persistent forms of atrial fibrillation suggesting more extensive atrial substraights. This study is complimentary to a publication by [inaudible 00:15:23] et al., published in JACC EP. this past month where they evaluated the longterm outcomes of patients who, when presenting for redo atrial fibrillation ablation had persistent pulmonary vein isolation.                                 In that article, they found that nearly 17% of patients presenting for redo ablation had persistent pulmonary vein isolation. Moreover, these patients tended to perform significantly worse in terms of longterm outcomes than those who presented with PV reconnection, with about a 56% freedom from affiliate swipe after we do ablation in the setting of persistent pulmonary vein isolation as opposed to 76% when there was PV reconnection seen.                                 So the question becomes if we see this greater atrial substraight, should we automatically be doing more ablation? Of course as we all know, there have been many studies performed trying to tease out whether additional ablation in patients who might have more significant atrial substraight carries benefits. In this regard, Fink et al. in last month's edition of Circulation, Arrhythmia and Electrophysiology demonstrated that in fact as an index procedure of performing a stepwise concomitant café plus linear ablation on top of pulmonary vein isolation in persistent and long standing persistent atrial fibrillation patients did not necessarily confer an increased likelihood of longterm success over pulmonary vein isolation alone.                                 Thus, the jury continues to still be out as far as what the right strategy is in many of these patients. However, these studies highlight the importance of continued evaluation and understanding of how we can use information about atrial substraight to guide our ablation procedures more successfully. Changing gears, we'll move on the pathophysiology mechanisms of disease within atrial fibrillation.                                 The article we will choose to focus on here was published by Die et al. in The Journal of Cardiovascular Electrophysiology entitled The Effects of Extrinsic Cardiac Nerve Stimulation on Atrial Fibrillation Induce-ability: The Regulatory Role of the Spinal Cord. Over the course of the last several years many investigators have sought to show that modulation of the autonomic nervous system can successfully alter cardiac electrophysiology and provide antiarrythmic benefits.                                 However, when subject to prospective trials such as the recently published Defeat HF Trial, they have not necessarily found clear benefit. Thus, a critical question becomes how we translate our animal models into human treatment. The interesting results from Die et al. lie in the fact that they looked at the effects of spinal cord stimulation and spinal cord block in addition to concomitant stimulation of other centers such as the venous nerve, the stellate ganglion and ganglionated plexi.                                 They demonstrated that spinal cord stimulation enhanced the effects of venial nerve stimulation while attenuating the effects of stimulating the left stellate ganglion or ganglionated plexus. In turn, the combinations of these different levels of stimulation had different effects on affiliate swipe induce-ability, whether significantly increasing or decreasing the potential.                                 The reason this article is important is it highlights the extensive cross linking and synergy that exists within the autonomic nervous system and that attention paid to only a single center of autonomic innovation may not be sufficient for certain paradigms of care. This past month there were also two reviews summarizing the role of the autonomic nervous system and modulation of that nervous system and the treatment of arrhythmias.                                 The first was by Witt et al. and Europace. The other by Schwartz et al. in the International Journal of Cardiology. These articles help the reader understand the extensive crosslinking and cross communication that might occur, that might sometimes defeat our efforts to use a single element of the autonomic nervous system to modulate cardiac arrhythmias. Changing gears yet again, we'll move on to risk stratification and management for atrial fibrillation.                                 Perino et al. in last month's edition of The Journal of the American College of Cardiology published an article entitled Treating Specialty in Outcomes in Newly Diagnosed Atrial Fibrillation from the Treat AF Study. They present data based on a very large cohort of over 180,000 veterans regarding the effect of treating specialty on atrial fibrillation outcome. Interestingly they demonstrated that when a cardiologist was involved in the care of the patient, there was an overall decrease in stroke and mortality.                                 Albeit with a concomitant increase in hospitalization for AF. The stroke reduction seen was also seen to be secondary to better anticoagulation prescription within 90 days of diagnosis when those patients were seen by a cardiologist as compared with a general internist. This earlier prescription anticoagulation however did not mediate the mortality reduction. These data presented by a Perino et al. are provocative in this era of rising healthcare costs.                                 The question is, as atrial fibrillation rates rise, as the general population ages, how quickly and how aggressively we should engage specialty care early on in patient evaluation. The data by Perino et al. suggests that maybe this engagement should occur earlier. Part of the reasons for this might be improved understanding of current evidence regarding treatment of such patients or better systems of care that allow for providers to identify patients who might need alterations and care faster.                                 However, if anything this is hypothesis-generating. Why anticoagulation prescriptions are delayed when patients are not seen by a specialist or why there would be a difference in mortality are important factors to review further. In this past month Hernandez et al. in Stroke published an article discussing the large degree of geographic variation that exists with regards to appropriate anticoagulation prescription in patients with atrial fibrillation.                                 They demonstrated that there's extensive inhomogeneity across the United States in terms of how and in whom anticoagulation gets prescribed. Thus, how much of these outcomes are specialist-driven, geographically-driven or based on elements of access to care or other issues are going to be important features that have to be evaluated.                                 The next article in risk stratification was published by Mostofsky et al. in Heart, entitle Chocolate Intake and Risk of Clinically Apparent Atrial Fibrillation: The Danish Diet, Cancer and Heart Study. In this study they demonstrated in a population of over 55,000 patients that when accounting for as many variables as they could, higher chocolate intake, more than once per month, was associated with a decreased atrial fibrillation risk when compared with those consuming less chocolate than once per month.                                 Of course, they note that despite these attempts to account for multiple confounding variables, residuary confounders cannot be accounted for. The relevance of this article lies in the question of lifestyle choices patients are asked to make when thinking about how to either prevent themselves from having atrial fibrillation or trying to even treat their atrial fibrillation risk.                                 Chocolate has been shown to have multiple potential beneficial effects in multiple areas of cardiology, however, how to counsel patients with data like these becomes very difficult. The questions lies in how chocolate might mediate arrhythmia risk and how it might also modulate other potential risks such as weight gain or other factors.                                 Thus while important to consider this in light of patients often asking what they can and cannot have, it is important to further consider that we don't understand the full story. The other key element to understand is that really when they say that chocolate intake reduces risk of clinically apparent atrial fibrillation they are speaking about moderate chocolate intake and not necessarily having it for three meals a day.                                 Changing gears away from atrial fibrillation, we will next focus on the area of ICDs pacemakers and CRT. Aberi et al. in Nature's Scientific Reports published regarding inductively power wireless pacing via miniature pacemaker and remote stimulation control system. Their approach provides potential novel opportunities beyond currently available both lead-based and leadless pacemakers and improving battery and allowing for further miniaturization of such devices.                                 They noted by creating a very novel inductive power supply they're able to miniaturize the pacing components and also significantly reduce the power requirements. In fact, they suggested that they could create a leadless device that could be as small as being delivered out of the anterior ventricular vein. This is the first report of such an inductively powered miniaturized pacing system with low enough power consumption that may prove viable for ambulatory human use.                                 The desire to create improved pacing and fibrillation systems is further highlighted by an article published by [Kalu 00:25:41] et al. in JACC Clinical Electrophysiology this past month where they demonstrated initial results of percutaneous epicardially delivered partially insulated defibrillator lead. Work like these holds the potential to improve options for patients and in traditional vascular access is not desired, or an identifying new ways of delivering pacing therapy that exists outside the traditional lead base or even somewhat miniaturized leadless approaches.                                 We'll next focus on the area of sudden death and cardiac arrest. The first article we'll focus on was published by Stecker et al. in The Journal of The American Heart Association entitled Health Insurance Expansion and Incidence of Out of Hospital Cardiac Arrest: A Pilot Study in the US Metropolitan Community. This article looked at the results of The Affordable Care Act, mainly health insurance expansion, on the rate of out of hospital cardiac arrest in a large US metropolitan community of over 600,000 people.                                 They separately studied a middle aged population that might have been affected by healthcare expansion versus an older population, above 65, who would have had relatively stable insurance plans having been covered by Medicare both prior to and after this change in healthcare plans. They demonstrated that there was a significant decrease in overall out of hospital cardiac arrests amongst middle age people without any significant change amongst the more elderly Medicare population in the same time period.                                 The time period studied was relatively short, nearly less than a decade. Of course, whether there were other events that might have occurred to alter this risk such as improvements in care beyond the combination of availability and mandates plus carrying health insurance, it remains to be seen. However, the data is very suggestive. Further evaluation at the national level in varying communities however would be useful, as well as consideration of population level cost benefit analysis.                                 The next article published by Shen et al. in the New England Journal of Medicine entitled Declining Risk of Sudden Death in Heart Failure. They presented data across 40,000 patients from multiple clinical trials over two decades regarding the changing rates of sudden death amongst heart failure patients. Interestingly they noted there was an overall 44% reduction in sudden death rates across these trials over time dating from the 1990s to 2014.                                 In the earliest trials considered, the mortality rate within 90 days after randomization was as high as 2.4% while the most recent trials suggest that that rate is more like 1.0%. This profound decline was attributed to improved usage and prescription of medications early on in the heart failure course, which may modulate outcomes.                                 The relevance of these findings lies in trials that have been published recently and met analysis that we've discussed regarding utility of defibrillators in nonischemic cardiomyopathy or even ischemic cardiomyopathy. The recently published Danish study suggested that ICDs might not confer an equivalent mortality risk as what would have been expected years ago. However, this publication by Shen et al. is particularly provocative because it calls into question whether the same mortality benefit we anticipated from earlier heart failure trials should still be the rubric by which current defibrillator trials are powered.                                 Namely, if we consider that Danish saw the 25% difference in mortality, with a 44% overall reduction in sudden death seen in trials over time for heart failure, seeking a 25% reduction might be excessive. Thus, this highlights the need to potentially power trials for ICDs and the benefit of such ICDs better. This importance of better stratifying better heart failure patients for sudden death risk has been raised in multiple articles this month, including in a review by Holiday et al. in Circulation and in the series of reviews published in Volume 237 of The International Journal of Cardiology.                                 The last article we choose to focus on in the role of sudden death and cardiac arrest was published by Vehmeijer in Circulation: Arrhythmia and Electrophysiology entitled Prevention of Sudden Cardiac Death in Adults with Congenital Heart Disease: Do the Guidelines Fall Short? They reviewed outcomes amongst 26,000 adults with congenital heart disease in light of existing guidelines for risk prediction and prevention of sudden death.                                 They demonstrated that less than half of the patients with sudden cardiac death actually had a guideline basis recommendation for an ICD on the basis of either the 2014 consensus statement on arrhythmias or the 2015 European Society of Cardiology Guidelines. These findings are very provocative in suggesting that we don't really understand who requires treatment amongst adults with congenital heart disease.                                 With improved care paradigms, both with improvements in surgical outcomes as well as ambulatory care of these patients and recognition of need for interventions, arrhythmias are becoming a greater and greater problem amongst patients with adult congenital heart disease. However, large scale studies are limited in stratifying overall risk of arrhythmias. The risk is certainly present as many of these patients have ventricular scar often attributable to cardiac surgeries or have hemodynamic insults that may result in progressive fibrosis of the ventricles.                                 In addition, the basal abnormalities of cardiac formation itself may lend itself to a sudden increased risk of arrhythmias. Thus, the question remains as how to best risk stratify these patients in order to reduce these overall sudden death rates. Changing gears yet again, we'll focus on two articles within the realm of cellular electrophysiology. The first article was published by Cerrone et al. in Nature Communications entitled Plakophilin-2 is Required for Transcription of Genes that Control Calcium Cycling and Cardiac Rhythm.                                 They demonstrated that plakophilin-2, or PKP2, which is known to mediate arrhythmogenic right ventricular cardiomyopathy due to abnormalities in the desmosomes actually has other direct electrical effects independent of substraight effects that are seen. Specifically PKP2 plays a significant role in maintaining gene transcription for several genes that mediate normal electrophysiologic activity, such as the ryanodine receptor, calsequestrin and others.                                 They demonstrated that this reduced expression of other genes secondary to PKP2 absence or abnormality leads to increased isoproterenol or adrenaline-induced arrhythmias that in turn can be suppressed with Flecainide. These findings are provocative in the fact that they suggest that it is possible for patients to have abnormalities of genes such as PKP2 that result in electrical abnormalities independent of the structural abnormalities.                                 Furthermore, it suggests that manifestation of the disease such as catecholaminergic polymorphic ventricular tachycardia may be immediate upstream of typical channels associated with the disease. For example, if PKP2 reduces expression of the ryanodine receptor, this might result in manifestations similar to CPTB in some patients. Along the same lines, Hewitt et al. published in Science Advances regarding deregulated calcium cycling underlies the development of arrhythmia and heart disease due to mutant obscurin.                                 Obscurins are a relatively growing area of interest as these are cytoskeletal proteins that have be associated with both hypertrophic and dilated cardiomyopathy. Similar to the story we just told about PKP2 however, they demonstrated that obscurins, likely through circa 2 and pentameric phospholamban can cause abnormal calcium handling. In fact, they demonstrated that the principle phenotype associated with obscurin abnormalities is one of an electrical abnormality, namely frequent PVCs.                                 In turn, mechanical phenotypes such as cardiomyopathy result in the setting of chronic pathologic stress such as increased afterload, thus these findings demonstrate that genes such as obscurin or PKP2, which are commonly associated with structural or mechanical myopathic processes might have direct independent electrical effects. The story with obscurin raises further question into how this may apply to conditions of PVC-related cardiomyopathy or other such conditions.                                 The other key point about these two areas of interest lie in the fact that it is possible as these genetic abnormalities mediate not just direct substraight elements, but arrhythmogenesis via abnormal channel expression, whether in all patients presenting with such specific genetic abnormalities substraight-based ablation alone will result in reduction of arrhythmia tendency. Of course this remains to be seen and is primarily hypothesis-generating.                                 Next we'll focus on three articles within the area of genetic channelopathies. The first paper was published by Rohatgi et al. in The Journal of the American College of Cardiology entitled Contemporary Outcomes in Patients With Long QT Syndrome. In a large single center practice, they reviewed the results of over 600 patients predominantly affected by LQT1 or LQT2 and demonstrated that after initial evaluation along with treatment based on the individual, done at a highly skilled center, 92% of patients did not experience any breakthrough cardiac events over longterm followup.                                 It was noted however, that the incidence of breakthrough cardiovascular events over longterm followup were far more common in patients who were symptomatic prior to their first evaluation than asymptomatic. In other words, if you were symptomatic prior to your first evaluation, the likelihood of a breakthrough cardiovascular event over longterm followup was as high as 25%, but if you were asymptomatic it was as low as 2%.                                 These data suggest that our overall care of the Long QT patient is improving. However, it also supports that further improvements in care are needed as breakthrough cardiovascular events can continue to occur. It also highlights the importance of close followup of that symptomatic patient in the modern era.                                 The second article was published by Kannenkeril et al. in JAMA Cardiology entitled the Efficacy of Flecainide in the Treatment of Catecholaminergic Polymorphic Ventricular Tachycardia. Flecainide currently carries a class 2A indication according to both the 2015 ENC guidelines and 2013 HRS AHRA APHRS consensus statement for treatment of patients with CPVT who fail max dose beta blockers. A lot of this evaluation however, has been based on retrospective evaluations.                                 Kannenkeril reviewed in a prospective single blind placebo controlled crossover trial the effect of Flecainide on exercise associated arrhythmias in CPTV patients who were already on max tolerated beta blockers and had an ICD. Amongst the 14 patients included of whom 13 completed the study, they showed there was a significant reduction in median ventricular arrhythmia score during exercise and in fact there was complete suppression with Flecainide compared to the placebo of 85%.                                 These findings thus add to the existing literature in terms the potential incremental value of Flecainide in achieving adequate arrhythmia suppression when used in conjunction with maximal tolerated beta blockers. The last article within the realm of genetic channelopathies we'll focus on was published by Yang et al. in The Journal of Physiology entitled A Multi-Scale Computational Modeling Approach Predicts Mechanisms of Female Sex Risk in the Setting of Arousal-Induced Arrhythmias.                                 It is recognized that female gender can increase the risk of Torsades in the setting of both inherited and acquired prolonged QT syndromes. In a combination of experimental and computational approaches, Yang et al. demonstrated that hormone concentrations can partly mediate this risk, specifically as it relates to her-related mutations. They demonstrated testosterone and high progesterone levels provide a protective effect against Torsades. However, estrogen can enhance Torsadogenic potential, particularly in the setting sympathetic stress.                                 They also demonstrated the mechanism by which this likely occurs is due to interaction of estrogen with pore loop or intracavity binding site of the her channel. In fact, on top of this they demonstrated that combined treatment with both estrogen and Dofetilide can simultaneously blockade the pore channel of her. These findings are provocative and hypothesis-generating. In terms of potential future research to further clarify risk for patients, particularly as it may apply to menstruating females who might have varying levels of estrogen, especially when being treated with concomitant QT prolonging agents such as Defetilide.                                 Next we will focus on three articles within the realm of ventricular arrhythmias. The first article was published by Sapp et al. in JACC Clinical Electrophysiology entitled Real Time Localization of Ventricular Tachycardia Origin from the Twelve Lead Electrocardiogram. They presented a methodology for rapidly determining in real time the approximate origin of a ventricular tachycardia using the 12 lead during cardiac ablation.                                 In 38 patients they used a variety of methods that involved multiple linear regression learning methods and demonstrated that a patient-specific regression method using at least 10 training set pacing sites in the individual patient can provide a localization accuracy of the exit site for VT of as much as five millimeters. Furthermore, with additional pacing sites that accuracy could improve further.                                 These findings support the continued utility of the standard 12 lead ECG in localizing the exit site of ventricular tachycardia. Furthermore, it points out the importance of considering that the electrocardiogram can be patient-specific. By using multiple pacing sites, this helps an algorithm learn how a patient-specific heart exists in terms of its electrical propagation potential. Further informing based on a 12 lead of a specific VT approximately where it should be exiting from.                                 The next article we will focus on was published by Muser et al. in again, JACC Clinical Electrophysiology entitled Longterm Outcomes of Catheter Ablation of Electrical Storm in Nonischemic Dilated Cardiomyopathy COMpared with Ischemic Cardiomyopathy. The summary point to this article is in a single center, large volume group of patients including about 267 total, the longterm outcomes of VT recurrence or mortality was no different between nonischemic and ischemic patients.                                 This is important to note as most prospective studies and in fact retrospective studies of the role of ventricular tachycardia ablation have focused on ischemic patients where the substraight is relatively predicable. These findings highlight that ablation may provide a reasonably effective therapy irrespective of the cause of the myopathy. Finally, changing gears within the realm of ventricular arrhythmias, we'll focus on a translational article by Motloch et al. in JACC Basic to Translational Science entitled Increased Afterload Following Myocardial Infarction Promotes Conduction-Dependent Arrhythmias That Are Unmasked by Hypokalemia.                                 They studied the role of increased afterload after myocardial infarction in a listing arrhythmias in a porcine infarct model. They demonstrated that in the setting of increased afterload there was increased widespread interstitial fibrosis. Interestingly, pacing -induced arrhythmias induced by a rapid burst pacing were mediated by hypokalemia associated conduction abnormalities rather than repolarization abnormalities.                                 The reason these findings are potentially important lie in the fact that arrhythmias in the early stages after myocardial infarction, especially in a setting of increased afterload, might be considered to be secondary to either repolarization abnormalities or depolarization abnormalities. These findings suggest that in the setting of concomitant hypertension the primary problem really lies in hypokalemia associated conduction abnormalities.                                 Thus, treatments that impair cardiac excitability, for example, even sodium channel blockade, may similarly confer an increased risk of ventricular arrhythmias when in the presence of increased afterload and myocardial infarction. It also calls into question whether interventions such as antitachycardia pacing in patients with hypertension, in other words increased afterload, might be more prone to acceleration of the ventricular arrhythmias than patients who are relatively better managed as far as afterload.                                 Changing gears yet again, we will focus on EP relevant myopathies. [inaudible 00:44:19] et al. published in JACC Clinical Electrophysiology regarding use of the 12 lead electrocardiogram to localize regions of abnormal electron atomic substraight in arrhythmogenic ventricular cardiomyopathy. There were really two major articles in this regard that have been published both in the same month.                                 The other article was published by Andrews et al. in Circulation, Arrhythmia and Electrophysiology entitled Electrical and Structural Substraight of Arrhythmogenic Right Ventricular Cardiomyopathy Determined Using Noninvasive Electrocardiographic Imaging and Late Gadolinium Magnetic Resonance Imaging.                                 The relevance of both of these articles lies in their statements about the potential utility of noninvasive approaches essentially using electrocardiograms to determine the distribution of substraight in arrhythmogenic right ventricular cardiomyopathy. The article by [inaudible 00:45:16] et al. specifically focused on fractionation of the QRS. They showed that patients with evidence of fractionation in the QRS on a 12 lead ECG had more extensive substraight.                                 Furthermore, distribution of fractionation to specific leads such as inferior, anterior or basal superior leads, was 100% specific, but veritably sensitive for identifying substraight as it localizes to specific cardiac regions. In turn, the publication by Andrews et al. in Circulation, Arrhythmia and Electrophysiology reviewed how the addition of multiple leads by a noninvasive electrocardiographic imaging could be used to even more specifically hone in on the relevant substraights.                                 Their further benefit was in the suggestion that repolarization abnormalities in fact co-localized with origination sites for ventricular ectopy in these patients. In combination, these sites highlight the utility of simple, noninvasive methods of electrocardiographic imaging in identifying and defining the arrhythmogenic substraight in the NRVC.                                 The next article we will review was by Sommariva et al. in Nature's Scientific Reports published just this past month entitled MIR 320A as a Potential Novel Circulating Biomarker of Arrhythmogenic Cardiomyopathy. They did micro RNA analysis on 53 healthy controls, 21 idiopathic VT patients and 36 arrhythmogenic cardiomyopathy patients and demonstrated that the circulating micro RNA 320A was significantly higher in arrhythmogenic cardiomyopathy than in either other cohorts.                                 It is recognized that some patients with idiopathic VT, especially right ventricular [inaudible 00:47:09] VT might reflect a cohort that might have what we call "concealed ARVC." The question thus becomes how to define why a patient has a specific manifestation of disease because longterm outcomes, if there is some underlying ARVC might be worse if the ARVC is not recognized and if cure is assumed based on treatment of the initial presenting rhythm.                                 Thus identifying novel ways of defining the presence of a disease even in the absence of obvious structural abnormalities carries benefit in terms of suggestions on longterm followup. Complimentary to the previously discussed article on the role of PKP2 mutations on mediating electrical instability in the heart, the study by [inaudible 00:48:01] et al. does in fact suggest that there might be methods of distinguishing arrhythmogenic cardiomyopathy from whether it be controls or truly idiopathic ventricular tachycardia using a very specific circulating biomarker.                                 On a completely different route, we'll finish our podcast today with a discussion of Bruner et al. published in European Heart Journal entitled Alcohol Consumption, Sinus Tachycardia and Cardiac Arrhythmias at the Munich Oktoberfest: Results from the Munich Beer-Related Electrocardiogram Workup Study or Munich Brew.                                 Bruner et al. studied over 3,000 voluntary participants with a combination of breath alcohol concentration measurements and electrocardiographic recordings via smartphone throughout the Munich Oktoberfest. In addition, they sought to evaluate chronic alcohol consumption effects on arrhythmias in a separate cord of over 4,000 patients from the Cora S4 study. In the study regarding acute alcohol effects, they demonstrated that in line with increasing BAC, there was a greater occurrence of arrhythmias in particular sinus tachycardia in almost a third of patients.                                 What was even further interesting was that respiratory sinus arrhythmia over the course of higher BAC is from baseline was reduced in the setting of alcohol use. Similarly, with chronic alcohol consumption there was an apparent significant association with the occurrence of sinus tachycardia. The reason these findings are important is in their suggestive element that the effects of alcohol intake in terms of whether it be acute or chronic arrhythmogenesis might somewhat lie in their effects on the basal autonomic states. As demonstrated by the reduction in overall sinus arrhythmia.                                 These findings serve to further elucidate mechanisms by which alcohol may mediate arrhythmias in a large real world patient sample. Thank you for joining us on this edition of On The Beat. Tune in next month again for more articles that might be of interest to the general electrophysiologic community all summarized in a single location.

The Christ Hospital Health Network offers patients the most experienced cardiac rhythm program in Greater Cincinnati. Our physicians are deeply involved in research and have performed many of the world's "first" cardiac rhythm procedures. Patients benefit from access to the latest treatment and approaches to successfully treat rhythm disorders, or arrhythmias.In this segment, Dr. Dan Beyerbach, Clinical Cardiac Electrophysiologist with The Christ Hospital Health Network, comes on the show with an update on advanced cardiac catheter ablation techniques.

Commentary by Dr. Valentin Fuster

Dr. Stefan Hohnloser and Dr. Serge Korjian Discuss

Catheter ablation for atrial fibrillation is a nonsurgical procedure in which the areas of the atrium responsible for the generation of arrhythmia are mapped and then destroyed using either radiofrequency energy (heat) or cryoenergy (freezing).Tune into SMG radio to hear Jonathan Steinberg, MD explain how Catheter ablation is used to help treat atrial fibrillation.

Catheter ablation for atrial fibrillation is a nonsurgical procedure in which the areas of the atrium responsible for the generation of arrhythmia are mapped and then destroyed using either radiofrequency energy (heat) or cryoenergy (freezing).Tune into SMG radio to hear Jonathan Steinberg, MD explain how Catheter ablation is used to help treat atrial fibrillation.

Commentary by Dr. Valentin Fuster

Commentary by Dr. David Wilber

Editor-in-chief Shawn Kennedy and Clinical Editor Betsy Todd present the highlights of the October issue of the American Journal of Nursing. This month's cover celebrates AJN's 115th anniversary with a collage showcasing archival photographs and past covers. Our first CE, “Integrative Care: The Evolving Landscape in American Hospitals,” provides an overview of some of the integrative care initiatives being introduced in hospitals throughout the U.S. and reports on findings from a survey of nursing leaders at hospitals that have implemented integrative care programs. Our second CE, “Catheter Ablation of Atrial Fibrillation,” gives an overview of the procedure, its possible complications, and best practices for nursing care. In “Intergenerational Lessons and ‘Fabulous Stories',” Robert Wood Johnson Foundation senior adviser for nursing Susan B. Hassmiller, along with two nurse historians, shares five lessons learned from interviewing her mother, Jacqueline J. Wouwenberg, a 1947 graduate of the Bellevue Hospital School of Nursing, and being interviewed herself. “The NP: Celebrating 50 Years”—which includes an illustrated timeline from the Barbara Bates Center for the Study of the History of Nursing—highlights important events in the history of the NP and shows how the NP role has changed and expanded through the decades. Finally, “Pathfinding on the Frontier” describes the success of a patient care coordination program in a primary care practice in rural Kansas. In addition, there's News, Reflections, Drug Watch, Art of Nursing, and more.

Editor-in-chief Shawn Kennedy and Clinical Editor Betsy Todd present the highlights of the October issue of the American Journal of Nursing. This month’s cover celebrates AJN’s 115th anniversary with a collage showcasing archival photographs and past covers. Our first CE, “Integrative Care: The Evolving Landscape in American Hospitals,” provides an overview of some of the integrative care initiatives being introduced in hospitals throughout the U.S. and reports on findings from a survey of nursing leaders at hospitals that have implemented integrative care programs. Our second CE, “Catheter Ablation of Atrial Fibrillation,” gives an overview of the procedure, its possible complications, and best practices for nursing care. In “Intergenerational Lessons and ‘Fabulous Stories’,” Robert Wood Johnson Foundation senior adviser for nursing Susan B. Hassmiller, along with two nurse historians, shares five lessons learned from interviewing her mother, Jacqueline J. Wouwenberg, a 1947 graduate of the Bellevue Hospital School of Nursing, and being interviewed herself. “The NP: Celebrating 50 Years”—which includes an illustrated timeline from the Barbara Bates Center for the Study of the History of Nursing—highlights important events in the history of the NP and shows how the NP role has changed and expanded through the decades. Finally, “Pathfinding on the Frontier” describes the success of a patient care coordination program in a primary care practice in rural Kansas. In addition, there’s News, Reflections, Drug Watch, Art of Nursing, and more.

Dr. Michael Hoskins. Catheter Ablation of Ventricular Tachycardia. Recorded 2012-03-05. Recorded 2012-09-24.

Host: Janet Wright, MD Guest: David Wilber, MD Although medications are generally first-line therapy for patients with atrial fibrillation, or a-fib, adverse events or inadequate efficacy often make drug therapy suboptimal. How effective is catheter ablation, and should it be considered first-line therapy for some patients? Host Dr. Janet Wright talks with Dr. David Wilber, director of the Cardiovascular Institute and the George M. Eisenberg professor of cardiovascular sciences at Loyola University Chicago Stritch School of Medicine, about recent findings on the efficacy of catheter ablation for a-fib. What are the most significant risks to be aware of when considering catheter ablation therapy? Produced in Cooperation with

Host: Janet Wright, MD Guest: David Wilber, MD Although medications are generally first-line therapy for patients with atrial fibrillation, or a-fib, adverse events or inadequate efficacy often make drug therapy suboptimal. How effective is catheter ablation, and should it be considered first-line therapy for some patients? Host Dr. Janet Wright talks with Dr. David Wilber, director of the Cardiovascular Institute and the George M. Eisenberg professor of cardiovascular sciences at Loyola University Chicago Stritch School of Medicine, about recent findings on the efficacy of catheter ablation for a-fib. What are the most significant risks to be aware of when considering catheter ablation therapy? Produced in Cooperation with