Atrial fibrillation (AF) is a very common arrhythmia that mainly affects older individuals. The mechanism of atrial fibrillation is complex and is related to the pathogenesis of trigger activation and the perpetuation of arrhythmia. The pulmonary veins in the left atrium arei confirm that onfirm the most common triggers due to their distinct anatomical and electrophysiological properties. As a result, their electrical isolation by ablation is the cornerstone of invasive AF treatment. Multiple factors and comorbidities affect the atrial tissue and lead to myocardial stretch. Several neurohormonal and structural changes occur, leading to inflammation and oxidative stress and, consequently, a fibrotic substrate created by myofibroblasts, which encourages AF perpetuation. Several mechanisms are implemented into daily clinical practice in both interventions in and the medical treatment of atrial fibrillation.

Cardiac resynchronization therapy (CRT) using biventricular (BiV) pacing is the standard treatment for heart failure (HF) patients with reduced left ventricular ejection fraction (LVEF) and electrical dyssynchrony. However, one in three patients remains a non-responder. Left bundle branch area pacing (LBBAP) could represent a more physiological alternative, but its effectiveness is limited in cases of atypical left bundle branch block (LBBB) or intraventricular conduction delay (IVCD). Left Bundle Branch Pacing Optimized cardiac resynchronization therapy (LOT-CRT) integrates LBBAP with coronary sinus (CS) lead pacing to improve electrical synchrony and clinical outcomes. This review evaluates the feasibility, advantages, disadvantages, and clinical outcomes of LOT-CRT. Additionally, we describe our center’s experience and propose an evidence-based implantation algorithm. A review of published studies investigating LOT-CRT was conducted, comparing its effectiveness with BiV-CRT and LBBAP alone using QRS narrowing, LVEF improvement, left ventricular remodeling, New York Heart Association (NYHA) class changes and NT-proBNP levels. It was found that LOT-CRT outperforms BiV-CRT or LBBAP alone in selected populations, at the cost of higher clinical skills, longer procedural times, and specific device setups. Randomized trials are underway to further define its role in clinical practice.

Patients with kidney failure on maintenance dialysis have a high stroke and bleeding risk. Multivariable prediction models can be used to estimate the risk of ischemic stroke and bleeding. A systematic review and meta-analysis was performed to determine the performance of the existing models in patients on dialysis. MEDLINE and Embase databases were searched, from inception through January 12, 2024, for studies of prediction models for stroke or bleeding, derived or validated in dialysis cohorts. Discrimination measures for models with c-statistic data from ≥ 3 cohorts were pooled by random effects meta-analysis and a 95% prediction interval (PI) was calculated. Risk of bias was assessed using PROBAST. The review was conducted according to the PRISMA statement and the CHARMS checklist. Eight studies were included in this systematic review. All the included studies validated pre-existing models that were derived in cohorts from the general population. None of the identified studies reported the development of a new dialysis specific prediction model for stroke, while dialysis specific risk scores for bleeding were proposed by two studies. In meta-analysis of c-statistics, the CHA₂DS₂-VASc, CHADS₂, ATRIA, HEMORR(2)HAGES and HAS-BLED scores showed very poor discriminative ability in the dialysis population. Six of the eight included studies were at low or unclear risk of bias and certainty of evidence was moderate. The existing prediction models for stroke and bleeding have very poor performance in the dialysis population. New dialysis-specific risk scores should be developed to guide clinical decision making in these patients.

Key Points: Treatment with sodium-glucose cotransporter-2 inhibitor (SGLT-2i) provides kidney and cardiovascular protection in patients with advanced CKD. The glycosuric action of SGLT-2i is attenuated in advanced CKD resulting in no change in glycated hemoglobin and fewer volume depletion events. The use of SGLT-2i did not increase the incidence of AKI, urine infections, fractures, or treatment discontinuation due to adverse events. Background: The efficacy and safety of sodium-glucose cotransporter-2 inhibitor (SGLT-2i) in patients with advanced CKD, defined as an eGFR <30 ml/min per 1.73 m², has not been adequately studied. Methods: We conducted a systematic review and meta-analysis of phase 3 randomized controlled trials of SGLT-2i in adults. We searched the medical literature analysis and retrieval system online and excerpta medica database databases from inception to April 2024. The primary outcomes were composite kidney (worsening kidney function, kidney failure, and kidney or cardiovascular [CV] death) and CV (CV death or hospitalization for heart failure) outcomes. Secondary outcomes included other reported CV and kidney outcomes, eGFR slopes, mechanistic, and safety outcomes. The risk ratios (RR) were estimated using a random effects model. Interaction effects were estimated for treatment effect modification by baseline eGFR (<30 and ≥30 ml/min per 1.73 m²). Results: A total of ten randomized controlled trials were included (total of 4800 patients with eGFR <30 ml/min per 1.73 m²). Participants were randomized to receive either placebo or an SGLT-2i. The use of SGLT-2i was associated with a lower incidence of the primary composite kidney outcome in patients with eGFR <30 ml/min per 1.73 m² (RR, 0.79; 95% confidence interval [CI], 0.70 to 0.89) and ≥30 ml/min per 1.73 m² (RR, 0.71; 95% CI, 0.64 to 0.79). The incidence of the primary CV outcome was numerically lower in the SGLT-2i arm in patients with eGFR <30 ml/min per 1.73 m² (RR, 0.88; 95% CI, 0.71 to 1.10). In patients with eGFR ≥30 ml/min per 1.73 m², SGLT-2i use was associated with a lower incidence of the composite CV outcome (RR, 0.77; 95% CI, 0.71 to 0.83). However, there was no interaction between advanced CKD status and the effect of SGLT-2i on any of the primary or secondary outcomes. The incidence of adverse events was similar in both arms. Conclusions: SGLT-2i retain their kidney and CV protective effect in patients with advanced CKD, with no added safety concerns.

Left bundle branch area pacing (LBBAP) is an emerging pacing method, which may prevent the deleterious effects of right ventricular pacing. The aim of this study is to compare the effects of LBBAP with right ventricular septal pacing (RVSP) in patients with advanced atrioventricular conduction abnormalities and preserved left ventricular ejection fraction. The effect of pacing was evaluated by echocardiographic indices of dyssynchrony, including global myocardial work efficiency (GWE) and peak systolic dispersion (PSD). The primary endpoint was GWE postprocedural, at 3, 6 and 12 months after the procedure. Twenty patients received LBBAP and 18 RVSP. Complete follow-up was accomplished in 37 patients (97.4%), due to the death of a patient (RVSP arm), from non-related cause. GWE was significantly increased in the group of LBBAP compared to RVSP at all timepoints (90.8% in LBBAP vs 85.8% in RVSP group at 12 months, p=0.01). PSD was numerically lower in the LBBAP arm at all timepoints, yet not statistically significant (56.4 msec in LBBP vs 65.1 msec in RVSP arm at 12 months, p=0.178). The implantation time was increased (median 93 min in LBBAP vs 45 min in RVSP group, p<0.01), along with fluoroscopy time and dose area product (DAP), in the arm of LBBAP. There were no severe perioperative acute complications in either group. LBBAP is an emerging and safe technique for patients with a pacing indication. Despite the longer procedural and fluoroscopy time, as well as higher DAP, LBBAP seems to offer better left ventricular synchrony compared to RVSP, according to GWE measurements.

(1) Background: Ultrasound-guided axillary (USAX) vein puncture is a relatively new method to obtain venous access for the implantation of cardiac implantable electronic devices (CIED). However, its use is limited as most of the operators are not familiar with this technique. Our aim was to investigate the safety and efficacy of the USAX compared with the traditional cephalic vein dissection for venous access in CIED implantation. (2) Methods: This was a single-center, randomized, controlled, superiority trial. A total of 114 patients were randomized (1:1 ratio) to either USAX (u/s axillary group; 59 patients) or cephalic vein access (cephalic group; 55 patients). The primary study endpoint was defined as successful placement of all leads via the chosen access. Secondary study endpoints included time from local anesthetic injection to lead advancement in the SVC, total procedure time (skin to skin), procedure-related complications and pain perception. (3) Results: USAX was superior to cephalic access in terms of primary endpoint (OR: 4.3, 95% CI: 1.3, 14.0; p = 0.012). Total procedure duration was higher in the cephalic group (55.15 ± 16.62 vs. 48.35 ± 12.81 min, p = 0.017) but there was neither a significant difference in fluoroscopy time (p = 0.872) nor in total radiation dose (p = 0.815). The level of pain was higher in the cephalic group (p = 0.016), while the rates of complications were similar in both groups (p > 0.05). (4) Conclusion: USAX was superior to cephalic access regarding success rate, total procedure duration and level of pain, while having no difference in complication rates.