Background: The interpretation of recent trials on pulmonary vein ablation (PVI) for the treatment of atrial fibrillation (AF) is hampered by the lack of blinding and sham controls. The feasibility of a sham-controlled trial has been questioned. We aimed to assess the attitude of potential participants regarding a sham-controlled trial in a common AF-patient population planned for PVI. Methods: Patients in two tertiary care centres planned for PVI were asked for their current AF symptoms using the Atrial Fibrillation Effect on QualiTy of Life (AFEQT) questionnaire 1 day before catheter ablation. Subsequently, the study design of a hypothetical sham-controlled PVI-study was introduced, and patients were asked for their agreement in participation. Telephone follow-up of the AFEQT questionnaire was conducted 3 months after PVI. Results: One hundred and ninety-six patients (mean age 64 ± 11 years, 63% male) were included. Seventy-nine (40%) patients expressed their agreement to participate in the hypothetical sham-controlled trial. An additional 7% agreed to participate if a cross-over option after three months was offered. Agreement rate was similar in patients with first and Redo-PVI and minimal, moderate or severe symptoms. Mean overall AFEQT at baseline was 55 ± 19 and improved by 25 ± 20 points after 3 months (p < 0.001 versus baseline). Conclusion: With a participation rate of 40% in potential study participants, a sham-controlled trial for pulmonary vein isolation seems feasible. Patient-reported symptom relief after pulmonary vein isolation is in accordance with previous randomized open studies. The benefit of PVI should be rigorously evaluated in a sham-controlled trial. Graphic

Background Continuous monitoring using implantable cardiac monitors (ICMs) results in atrial fibrillation (AF) detection rates of up to 30% in patients with cryptogenic stroke (CS). Although higher age is an independent risk factor for AF, there are no age-specific recommendations for the implantation of ICM. Objective The aim of this study was to analyze age-related AF rates in patients with CS and continuous rhythm monitoring, to determine the rates of oral anticoagulation (OAC) and recurrent cerebrovascular events (stroke or transient ischemic attack) in patients with ICM-detected AF, and to describe the temporal relationship of AF detection and recurrent cerebrovascular events. Methods In this observational study, patients with CS provided with ICMs were systematically followed. All patients underwent 72-hour electrocardiography monitoring, transcranial Doppler ultrasound, and transthoracic echocardiography prior to ICM insertion. Follow-up included a regular outpatient presentation every 3 months with medical history, physical examination, and interrogation of the ICM. Results One-hundred eighty-six patients (mean age: 65 ± 12 years, 54% female) were included in this analysis. AF was detected in 6, 27, 56, and 65% (p < 0.001) of patients aged less than 60, 60 to 69, 70 to 79, and more than or equal to 80 years, respectively. All patients with AF under 60 years had an impaired left ventricular systolic function. OAC was initiated in 85% of the patients with AF. Recurrent cerebrovascular events occurred in 34 patients of whom 14 had a diagnosis of AF. In nine patients, AF was diagnosed before the occurrence of a recurrent cerebrovascular event. Conclusion AF prevalence increased with age and was absent in CS patients younger than 60 years and with preserved left ventricular ejection fraction. The temporal relationship of AF and recurrent cerebrovascular events was weak.

The contribution of left atrial disease and excessive supraventricular ectopic activity (ESVEA) to the risk for incident atrial fibrillation (AF) is incompletely understood. To analyse the ten-year risk to develop AF in patients with cardiovascular risk factors and to define the impact of parameters of left atrial disease and ESVEA on AF risk. 148 patients from the Diast-CHF trial with at least one cardiovascular risk factor and free of AF at baseline were followed for 10 years. Left atrial disease was defined as left atrial volume index (LAVI) >35 ml/m², P-terminal force in lead V₁ (PTFV₁) >4000 ms*μV or elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) >250 pg/ml. We analyzed the association of these parameters and ESVEA (either >720 premature atrial contractions (PAC) or one atrial run >20 beats per day) on AF-free survival. After ten years, AF was newly detected in twelve patients (13.4%) with signs of left atrial disease and two patients (3.4%) without signs of left atrial disease (p = 0.04). LAVI (p = 0.005), ESVEA (p = 0.016) and NT-proBNP (p = 0.010) were significantly associated with AF-free survival in univariate analysis. A combined Cox model of left atrial disease parameters showed associations for NT-proBNP (HR 3.56; 95%CI 1.33–5.31; p = 0.04) and PAC (HR 2.66; 95%CI 1.25–10.15; p = 0.01) but not for LAVI or PTFV₁ with AF-free survival. The risk for AF is higher in patients with cardiovascular risk factors and signs of left atrial disease. NT-proBNP and premature atrial contractions independently predict AF-free survival. The role of excessive supraventricular ectopic activity for the assessment of AF risk may be underestimated and requires further study.

Geometric Deep Learning is a modern approach to deep learning that focuses on the assessment of the structure and inherent symmetry of the data. How to best represent Electrocardiogram (ECG) data is unclear. The single-lead ECG can be interpreted as a shift-invariant one-dimensional grid as common for time series. However, the leads' spatial relationships in multi-lead ECGs are non- Euclidean due to the spread of electrical activation along the heart tissue. In the domain of Electroencephalogram (EEG), Graph Neural Networks are being adopted to represent channel interactions. This method is transferred to ECGs as well, calling for a systematic literature review to compare approaches and identify leading directions and research gaps. Consequently, we conducted this review about Geometric Deep Learning-based approaches to ECG data. However, since all but two approaches used Graph Neural Networks, we focus more heavily on them. Our results suggest missing diversity in applications for 12-lead ECG. It is mainly used for the recognition of arrhythmias, where single- or two-lead approaches already showed superb performance. It is unclear whether multilead spatial modeling would significantly improve classification for this use case. While a variety of approaches from EEG analysis have swept over to ECG, there is no consensus on topology, feature set or network architecture. In consequence, we propose two directions of future work. A more application-driven branch to compare existing approaches and expand on their explainability, and a more fundamental branch to focus on theoretical insights and experiment with simulation data to integrate physiological and anatomical information.

Introduction: Patients hospitalized with acute decompensated heart failure (ADHF) often experience impaired physical function, reduced quality of life (QoL), and loss of independence. While current guidelines recommend rehabilitation, structured programmes are lacking in Germany. Thus, this trial focuses on the feasibility of a structured, home-based rehabilitation programme in pre-frail and frail patients recently hospitalized for ADHF. Methods: The Pilot-CRHF (trial registry number: NCT06269263) study is a monocentric, single-arm prospective interventional study including multidimensional home-based exercises targeting endurance, strength, and balance. Adherence rate, physical function (6-minute walk test [6MWT], timed-up-and-go [TUG], Berg-Balance-Scale [BBS]) and QoL (Kansas City Cardiomyopathy Questionnaire [KCCQ]) were assessed at baseline and after 12 weeks of intervention. Results: 30 patients (mean age 79 ± 8; 40% female; 87% NYHA III or IV) were enrolled between March, 2024 and January, 2025. Among those, 43% had heart failure with preserved ejection fraction and 57% left ventricular ejection fraction (LVEF) <50%. 24 patients (80%) completed the programme. After 12 weeks, 6MWT distance improved significantly (220 ± 134 m vs 308 ± 147 m; P < .001). TUG improved only in patients with LVEF <50% (12.1 ± 5.0 s vs 9.7 ± 4.9 s; P = .04). BBS remained unchanged. QoL improved significantly (KCCQ: 56 ± 16 vs 75 ± 19; P < .001). Conclusion: Home-based rehabilitation is feasible leading to clinically meaningful improvements in physical function and QoL in pre-frail and frail heart failure patients, particularly those with LVEF. The results support further evaluation in a larger randomized trial.