Aims: Atrioventricular node ablation (AVNA) with permanent pacemaker implantation is an established rate-control treatment approach for patients with AF with uncontrolled ventricular rates. Conduction system pacing (CSP) utilizing His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) has advanced as a treatment alternative to standard right ventricular pacing in addition to biventricular pacing (BVP). This systematic review and meta-analysis aim to provide a comprehensive summary and evaluation of clinical outcomes in the literature for CSP in comparison to BVP in conjunction with AVNA. Methods and results: This study protocol was registered in the PROSPERO registry (CRD42024510974), and the review was conducted as per the PRISMA guidelines. Databases were searched for relevant studies from inception till 11 January 2024. Results were synthesized using a random effects meta-analysis. From a total of 259 references identified, 122 full texts were assessed, and 25 studies were included in the systematic review. Of these included studies, five were used for comparative meta-analysis. A total of 1652 (HBP 1069 and LBBAP 644) and 369 patients received CSP and BVP implantation with AVNA, respectively. Conduction system pacing resulted in a narrower QRS duration (QRSd) with a change of −35.8 ms (95% CI −61.8 to −9.72; P < 0.05; I2 = 96.3%) vs. BVP. Conduction system pacing also resulted in better symptomatic improvement in from of NYHA reduction (MD −0.53, 95% CI −1.01 to −0.04, I2 = 62.1; P = 0.03). For left ventricular ejection fraction, a non-significant weighted mean increases of 3.36% (95% CI −0.75–7.47%; P = 0.11, I2 = 68.5%) was observed following CSP implantation in comparison to BVP. Conduction system pacing showed no significant differences in procedural and fluoroscopy times and had comparable periprocedural complications. His bundle pacing demonstrated a non-significant reduction in the events of acute threshold elevation in comparison to BVP (Log odds ratio −0.69, 95% CI −2.05–0.66, I2 = 0.00; P = 0.32). Conclusion: Conduction system pacing with AVNA is a safe and feasible treatment option for symptomatic (AF) patients undergoing a pace and ablate strategy, offering an alternative to BVP. Overall, CSP results in a narrower QRS duration while providing comparable clinical and echocardiographic outcomes.

Background: pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (PAF) improves health-related quality of life (QoL). This study compares QoL improvement after radiofrequency ablation (RF) and cryoballoon ablation (cryo) and assesses additional ablations’ role in QoL improvement. Methods: we evaluated the QoL of consecutive patients with first-time RF and cryo for PAF between January 2017 and June 2019. A combined EQ-VAS, AFEQT, and EQ-5D-3L paper questionnaire was sent to patients at baseline, 12, and 30 months after the procedure. Procedure and patient details were collected from medical notes. Results: the analysis included 207 patients, of which 127 (61%) had RF and 144 (70%) were males. RF patients had more additional ablations (52 [41%] versus 22 [28%], p = 0.01). There was a significant improvement from baseline to 12 months post-RF in AFEQT (43 ± 9 to 83 ± 7.8, p < 0.001), EQ-5D-3L (−0.01 ± 0.01 to 1.1 ± 0.02, p < 0.001), and EQ-VAS (51 ± 8 to 77 ± 13, p = 0.01). Similarly, an improvement at 12 months was observed after cryo in AFEQT (55 ± 11 to 77 ± 9, p < 0.001), EQ-5D-3L (−0.04 ± 0.03 to 1.3 ± 0.03, p < 0.001), and EQ-VAS (56 ± 7 to 85 ± 9, p = 0.01). QoL improvement was similar between RF and cryo. Additional ablations provided no additional QoL improvement compared to patients with PVI alone. Conclusions: Patients undergoing first-time PVI for PAF, RF, and cryo showed similar QoL improvement at 12 months, which was sustained at 30 months. Additional ablations did not provide further QoL benefits.

Background: Pulmonary vein isolation (PVI) is an effective management method for paroxysmal atrial fibrillation (PAF). The P wave in the 12-lead electrocardiogram (ECG) represents atrial depolarisation. This study aims to utilise the P wave to predict PVI outcomes for PAF. Methods: This single-centre retrospective study aimed to predict PVI outcomes using P wave parameters. It included 211 consecutive patients with first PVI for PAF between 2018 and 2019 and targeted the pulmonary veins (PVs). Procedure success was defined by freedom of ECG-documented AF at 12 months. Digital 12-lead ECGs with 1–50 hertz bandpass filters were monitored before the procedure. Corrected P wave duration (PWDc), P wave amplitude (PWV), P wave dispersion (PWDisp), intra-atrial block (IAB), P wave area (PWA), and P wave terminal force in V1 (PTFV1) were measured before ablation and correlated with the outcomes. Results: Successful PVI occurred in 154 patients (73%). Demographics were similar between both arms. P wave parameters correlated with PVI failure included increased PWDc in all leads except for lead III, aVR, and V3, decreased PWV in lead I (hazard ratio [HR]: 0.7, 95% confidence interval [CI]: 0.53–0.95), lead II (HR: 0.45, 95% CI: 0.22–0.65), aVL (HR: 0.58, 95% CI: 0.22–0.98), and aVF (HR: 0.67, 95% CI: 0.58–0.87), decreased PWA in lead I (HR: 0.55, 95% CI: 0.21–0.76), lead II (HR: 0.48, 95% CI: 0.34–0.87), aVL (HR: 0.65, 95% CI: 0.45–0.96), and aVF (HR: 0.61, 95% CI: 0.32–0.89), and the presence of IAB (HR: 2, 95% CI: 1.4–4.2, p = 0.02). PWDisp and PTFV1 were not correlated with PVI outcome. Conclusions: PWDc, PWA, PWV, and IAB are valuable predictors for PVI outcome for PAF at 12 months.

Background: Ebstein’s anomaly occurs when there is an apical displacement of the tricuspid valve with septal and posterior valve leaflets tethering. This condition often occurs in association with other congenital, structural, or conduction system diseases, including intracardiac shunts, valvular lesions, arrhythmias, accessory conduction pathways, and first-degree atrioventricular (AV) block. We present for the first time a case of a patient with Ebstein’s anomaly who presented with second-degree Mobitz II AV block and was successfully treated with conduction system pacing (CSP) due to her young age and the likelihood of a long-term high percentage of pacing. Case summary: We present a case of a 42-year-old lady with a background of complex congenital heart disease, including severe pulmonary stenosis, Ebstein anomaly, and atrial septal defect (ASD). She required complex surgical intervention, including tricuspid valve (TV) repair and subsequently replacement, ASD closure, and pulmonary balloon valvuloplasty. She presented to our hospital with symptomatic second-degree Mobitz II AV block (dizziness, shortness of breath, and exercise intolerance) and right bundle branch block (RBBB) on her baseline ECG. Her echocardiogram showed dilated right ventricle (RV) and left ventricle (LV) with low normal LV systolic function. Due to her young age and the likelihood of a long-term high percentage of RV pacing, we opted for CSP after a detailed discussion and patient consent. The distal HIS position is the preferred pacing strategy at our centre. We could not cross the TV with the standard Medtronic C315 HIS catheter, so we had to use the deflectable C304 HIS catheter. Mapping and pacing of the distal HIS bundle were achieved by Medtronic Selectsecure 3830, 69 cm lead. HIS bundle pacing led to the correction of both second-degree Mobitz II AV block and pre-existing RBBB. The implantation was uneventful, and the patient was discharged home the next day without any acute complications. Discussion: Distal HIS pacing is feasible in patients with surgically treated complex Ebstein anomaly and heart block. This approach can normalize the QRS complex with a high probability of preserving or improving LV function.

Background: Atrial fibrillation (AF) incurs significant healthcare costs, mainly from acute hospitalisations. Digitally-enabled models could provide hospital-level care at home for selected patients, but evidence in acute care remains inconsistent. Methods: In a propensity score-matched, non-randomised comparative study using real-world data (January–December 2022). Adults with acute AF admitted to the AF virtual ward (AFVW) were matched 1:1 to standard-of-care (SOC) inpatients meeting AFVW eligibility criteria. The primary outcome was a composite of emergency readmissions, urgent care attendance, or death within 90 days. A separate cost analysis was undertaken from the National Health Service (NHS) secondary care perspective. Results: Ninety-one AFVW patients were matched to 91 SOC patients. The primary outcome did not differ at 90 days (HR 0.61, 95% CI 0.34-1.10). Emergency bed-day use following readmission was higher in AFVW cohort (0.42 vs 0.07 per spell; ratio 6.04; 95% CI 2.70-15.90), although the readmission rate itself was similar (7.7% versus 7.0%). Thirty-day emergency attendances, outpatient appointments, and mortality were similar. In a separate, clinically screened but non-propensity-matched population (75 AFVW, 315 SOC patients), mean direct secondary-care cost per patient was £948 versus £1,631, an adjusted saving of £642. Friends and Family Test respondents rated the AFVW positively. Conclusion: We found no significant difference in adverse outcomes between an acute AF virtual ward and matched SOC, but the study was not powered for non-inferiority, and downstream emergency bed-day use was higher in the virtual ward arm. AFVW costs were lower in an exploratory analysis. These findings require confirmation in future studies.