Aims: We aimed to investigate the association of clinically overt and silent brain lesions with cognitive function in atrial fibrillation (AF) patients. Methods and results: We enrolled 1227 AF patients in a prospective, multicentre cohort study (Swiss-AF). Patients underwent standardized brain magnetic resonance imaging (MRI) at baseline and after 2 years. We quantified new small non-cortical infarcts (SNCIs) and large non-cortical or cortical infarcts (LNCCIs), white matter lesions (WML), and microbleeds (Mb). Clinically, silent infarcts were defined as new SNCI/LNCCI on follow-up MRI in patients without a clinical stroke or transient ischaemic attack (TIA) during follow-up. Cognition was assessed using validated tests. The mean age was 71 years, 26.1% were females, and 89.9% were anticoagulated. Twenty-eight patients (2.3%) experienced a stroke/TIA during 2 years of follow-up. Of the 68 (5.5%) patients with ≥1 SNCI/LNCCI, 60 (88.2%) were anticoagulated at baseline and 58 (85.3%) had a silent infarct. Patients with brain infarcts had a larger decline in cognition [median (interquartile range)] changes in Cognitive Construct score [−0.12 (−0.22; −0.07)] than patients without new brain infarcts [0.07 (−0.09; 0.25)]. New WML or Mb were not associated with cognitive decline. Conclusion: In a contemporary cohort of AF patients, 5.5% had a new brain infarct on MRI after 2 years. The majority of these infarcts was clinically silent and occurred in anticoagulated patients. Clinically, overt and silent brain infarcts had a similar impact on cognitive decline. Clinical Trial Registration: ClinicalTrials.gov Identifier: NCT02105844, https://clinicaltrials.gov/ct2/show/NCT02105844

Background: Vein of Marshall (VOM) ethanol infusion is a relatively new therapeutic option for atrial tachyarrhythmias. We aimed to evaluate the feasibility, pitfalls, and complications associated with this procedure in a large cohort of patients. Methods: Successful ethanol infusion, VOM-related lesion extent, and serious complications were evaluated in 713 consecutive patients treated with VOM ethanol infusion. Results: While feasible in 88.9% of cases, VOM ethanol infusion failure mainly resulted from nonidentification (6.2%), noncannulation (1.5%), or ethanol infusion in the wrong vein (1.7%). The Vieussens valve was a helpful landmark and was visible in 63.2% of cases. Multivariable analysis identified previous coronary sinus ablation as the only predictor for nonidentification. The mean area of VOM-related endocardial scarring was 10.2±5.3 cm ² . VOM dissection (10.7%), iodine leakage (3.0%), and VOM morphology without visible branches (3.0%) were associated with smaller VOM-related scarring (5.0±3.9, 6.6±3.5, and 4.7±2.3 cm ² , with a P <0.0001, P <0.044, and P <0.0001, respectively). Ethanol infusion in a wrong vein was associated with less mitral line block (72.7% versus 95.8%, P =0.012). A total of 14 serious complications (2.0%) occurred: 7 tamponades, of which were 6 delayed and treated with pericardiocentesis (2 of these patients had per-procedural VOM perforation), 4 strokes, 1 anaphylactic shock, 1 atrioventricular block, and 1 left appendage isolation. Only 4 of these complications occurred during the procedure. Conclusions: Although limited by previous coronary sinus ablation, VOM ethanol infusion is a highly feasible treatment for atrial tachyarrhythmia, with a low rate of serious complications.

Pulsed-field ablation (PFA) has emerged as a novel treatment technology for patients with atrial fibrillation (AF). Cryoballoon (CB) is the most frequently used single shot technology. A direct comparison to a novel CB system is lacking. We aimed to compare pulmonary vein isolation (PVI) using PFA vs. a novel CB system regarding efficiency, safety, myocardial injury, and outcomes. One hundred and eighty-one consecutive patients underwent PVI and were included (age 64 ± 9.7 years, ejection fraction 0.58 ± 0.09, left atrial size 40 ± 6.4 mm, paroxysmal AF 64%). 106 patients (59%) underwent PFA (FARAPULSE, Boston Scientific) and 75 patients (41%) underwent CB ablation (PolarX, Boston Scientific). The median procedure time, left atrial dwell time and fluoroscopic time were similar between the PFA and the CB group with 55 [interquartile range (IQR) 43–64] min vs. 58 (IQR 48–69) min (P < 0.087), 38 (30–49) min vs. 37 (31–48) min, (P = 0.871), and 11 (IQR 9.3–14) min vs. 11 (IQR 8.7–16) min, (P < 0.81), respectively. Three procedural complications were observed in the PFA group (two tamponades, one temporary ST elevation) and three complications in the CB group (3× reversible phrenic nerve palsies). During the median follow-up of 404 days (IQR 208–560), AF recurrence was similar in the PFA group and the CB group with 24 vs. 30%, P = 0.406. Procedural characteristics were very similar between PFA and CB in regard to procedure duration fluoroscopy time and complications. Atrial fibrillation free survival did not differ between the PFA and CB groups. Comparison between pulsed field ablation and cryoballoon PolarX. AF, atrial fibrillation.

Background: Impaired heart rate variability (HRV) is associated with increased mortality in sinus rhythm. However, HRV has not been systematically assessed in patients with atrial fibrillation (AF). We hypothesized that parameters of HRV may be predictive of cardiovascular death in patients with AF. Methods and Results: From the multicenter prospective Swiss‐AF (Swiss Atrial Fibrillation) Cohort Study, we enrolled 1922 patients who were in sinus rhythm or AF. Resting ECG recordings of 5‐minute duration were obtained at baseline. Standard parameters of HRV (HRV triangular index, SD of the normal‐to‐normal intervals, square root of the mean squared differences of successive normal‐to‐normal intervals and mean heart rate) were calculated. During follow‐up, an end point committee adjudicated each cause of death. During a mean follow‐up time of 2.6±1.0 years, 143 (7.4%) patients died; 92 deaths were attributable to cardiovascular reasons. In a Cox regression model including multiple covariates (age, sex, body mass index, smoking status, history of diabetes mellitus, history of hypertension, history of stroke/transient ischemic attack, history of myocardial infarction, antiarrhythmic drugs including β blockers, oral anticoagulation), a decreased HRV index ≤ median (14.29), but not other HRV parameters, was associated with an increase in the risk of cardiovascular death (hazard ratio, 1.7; 95% CI, 1.1–2.6; P =0.01) and all‐cause death (hazard ratio, 1.42; 95% CI, 1.02–1.98; P =0.04). Conclusions: The HRV index measured in a single 5‐minute ECG recording in a cohort of patients with AF is an independent predictor of cardiovascular mortality. HRV analysis in patients with AF might be a valuable tool for further risk stratification to guide patient management. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02105844.

Management of patients with atrial fibrillation (AF) and concomitant heart failure (HF) remains complex. The Antwerp score, based on four parameters [QRS >120 ms (2 points), known aetiology (2 points), paroxysmal AF (1 point), severe atrial dilation (1 point)] adequately estimated the probability of left ventricular ejection fraction (LVEF) recovery after AF ablation in a single-centre cohort. The present study aims to externally validate this prediction model in a large European multi-centre cohort. A total of 605 patients (61.1 ± 9.4 years, 23.8% females, 79.8% with persistent AF) with HF and impaired LVEF (<50%) undergoing AF ablation in 8 European centres were retrospectively identified. According to the LVEF changes at 12-month echocardiography, 427 (70%) patients fulfilled the ‘2021 Universal Definition of HF’ criteria for LVEF recovery and were defined as ‘responders’. External validation of the score yielded good discrimination and calibration {area under the curve 0.86 [95% confidence interval (CI) 0.82–0.89], P < .001; Hosmer–Lemeshow P = .29}. Patients with a score < 2 had a 93% probability of LVEF recovery as opposed to only 24% in patients with a score > 3. Responders experienced more often positive ventricular remodelling [odds ratio (OR) 8.91, 95% CI 4.45–17.84, P < .001], fewer HF hospitalizations (OR 0.09, 95% CI 0.05–0.18, P < .001) and lower mortality (OR 0.11, 95% CI 0.04–0.31, P < .001). In this multi-centre study, a simple four-parameter score predicted LVEF recovery after AF ablation in patients with HF and discriminated clinical outcomes. These findings support the use of the Antwerp score to standardize shared decision-making regarding AF ablation referral in future clinical studies. On the upper side, the four variables included in the score and their respective weight is shown. The score was evaluated in 605 heart failure (HF) patients with impaired (<50%) left ventricular ejection fraction (LVEF) undergoing atrial fibrillation (AF) catheter ablation (CA), recruited from 8 European centres. Based on the 2021 universal definition of HF, 12-month post-procedural LVEF improvement was observed in 427 (70%) patients (Responders). Responders were identified if: (i) in case of baseline LVEF between 40% and 50%: LVEF improvement to more than ≥50%; (ii) in case of baseline LVEF 40%. In this external evaluation study, the score accurately predicted the response rate [area under the curve (AUC) 0.859, P < .001] with a good calibration (P = .296), as shown on the lower right side. In the lower left side, the specific response rate stratified according to the score value is represented.

Background and Aims: Left bundle branch area pacing (LBBAP) promotes physiological synchronous activation of the left ventricle and may be particularly beneficial in patients with atrioventricular block (AVB), but its mortality benefit remains unclear. This study aims to compare long-term survival in AVB patients receiving either LBBAP or right ventricular pacing (RVP) and to analyse predictors of mortality during LBBAP. Methods: MELOS RELOADED, a multicentre European collaboration, was a registry-based study of pacemaker patients with AVB, left ventricular ejection fraction (LVEF) >40% and ventricular pacing >20%. The primary outcome was all-cause mortality based on national registries. A 1:1 propensity score matching was performed between the RVP and LBBAP groups. Kaplan–Meier curves and multivariable Cox proportional hazards models were used to estimate survival. Results: In total, 3382 patients receiving LBBAP or RVP were matched. At 4-year follow-up, the Kaplan–Meier curve showed an absolute difference in survival of 11.8% in favour of LBBAP (P < .001). LBBAP was a robust predictor of reduced mortality with a hazard ratio (HR) of 0.53 (95% confidence interval 0.42–0.65, P < .001). Within the LBBAP group, the following independent predictors of increased mortality were identified: lack of confirmed left bundle branch capture (HR 1.85, P < .001), lower percentage of ventricular pacing (HR 1.12), and age. Conclusions: This is the first large study demonstrating the long-term survival benefit of LBBAP. This strengthens the use of LBBAP in AVB patients with preserved/mildly reduced LVEF while awaiting the results of randomized trials. Confirmation of left bundle branch capture seems advisable to achieve optimal results with LBBAP.