(1)Introduction: Catheter ablation has become a cornerstone for the management of patients with atrial fibrillation (AF). Nevertheless, recurrence rates remain high. Epicardial adipose tissue (EAT) has been associated with AF pathogenesis and maintenance. However, the literature has provided equivocal results regarding the relationship between EAT and post-ablation recurrence.(2) Purpose: to investigate the relationship between total and peri-left atrium (peri-LA) EAT with post-ablation AF recurrence. (3) Methods: major electronic databases were searched for articles assessing the relationship between EAT, quantified using computed tomography, and the recurrence of AF following catheter ablation procedures. (4) Results: Twelve studies (2179 patients) assessed total EAT and another twelve (2879 patients) peri-LA EAT. Almost 60% of the included patients had paroxysmal AF and recurrence was documented in 34%. Those who maintained sinus rhythm had a significantly lower volume of peri-LA EAT (SMD: −0.37, 95%; CI: −0.58–0.16, I2: 68%). On the contrary, no significant difference was documented for total EAT (SMD: −0.32, 95%; CI: −0.65–0.01; I2: 92%). No differences were revealed between radiofrequency and cryoenergy pulmonary venous isolation. No publication bias was identified. (5) Conclusions: Only peri-LA EAT seems to be predictive of post-ablation AF recurrence. These findings may reflect different pathophysiological roles of EAT depending on its location. Whether peri-LA EAT can be used as a predictor and target to prevent recurrence is a matter of further research.

Alcohol consumption is a known, modifiable risk factor for incident atrial fibrillation (AF). However, it remains unclear whether the protective effect of moderate alcohol consumption-that has been reported for various cardiovascular diseases also applies to the risk for new-onset AF. The purpose of this meta-analysis was to evaluate the role of different drinking patterns (low: <14 grams/week; moderate: 168 grams/week) on the risk for incident AF. Major electronic databases were searched for observational cohorts examining the role of different drinking behaviors on the risk for incident AF. We analyzed 16 studies (13,044,007 patients). Incident AF rate was 2.3%. Moderate alcohol consumption significantly reduced the risk for new-onset AF when compared to both abstainers (logOR: −0.20; 95%CI: −0.28–−0.12; I2: 96.71%) and heavy drinkers (logOR: −0.28; 95%CI: −0.37–−0.18; I2: 95.18%). Heavy-drinking pattern compared to low also increased the risk for incident AF (logOR: 0.14; 95%CI: 0.01–0.2; I2: 98.13%). Substantial heterogeneity was noted, with more homogeneous results documented in cohorts with follow-up shorter than five years. Our findings suggest a J-shaped relationship between alcohol consumption and incident AF. Up to 14 drinks per week seem to decrease the risk for developing AF. Because of the substantial heterogeneity observed, no robust conclusion can be drawn. In any case, our results suggest that the association between alcohol consumption and incident AF is far from being a straightforward dose-response effect.

Pulmonary vein isolation (PVI) is the cornerstone in atrial fibrillation (AF) ablation; yet, the role of arrhythmogenic superior vena cava (SVC) is increasingly recognized and different ablation strategies have been employed in this context. SVC can act as a trigger or perpetuator of AF, and its significance might be more pronounced in patients undergoing repeated ablation. Several cohorts have examined efficacy, safety and feasibility of SVC isolation (SVCI) among AF patients. The majority of these studies explored as-needed SVCI during index PVI, and only a minority of them included repeated ablation subjects and non-radiofrequency energy sources. Studies of heterogeneous design and intent have explored both empiric and as-needed SVCI on top of PVI and reported inconclusive results. These studies have largely failed to demonstrate any clinical benefit in terms of arrhythmia recurrence, although safety and feasibility are undisputable. Mixed population demographics, small number of enrollees and short follow-up are the main limitations. Procedural and safety data are comparable between empiric SVCI and as-needed SVCI, and some studies suggested that empiric SVCI might be associated with reduced AF recurrences in paroxysmal AF patients. Currently, no study has compared different ablation energy sources in the setting of SVCI, and no randomized study has addressed as-needed SVCI on top of PVI. Furthermore, data regarding cryoablation are still in their infancy, and regarding SVCI in patients with cardiac devices more safety and feasibility data are needed. PVI non-responders, patients undergoing repeated ablation and patients with long SVC sleeves could be potential candidates for SVCI, especially via an empiric approach. Although many technical aspects remain unsettled, the major question to answer is which clinical phenotype of AF patients might benefit from SVCI?

Background: Atrial fibrillation (AF) is the most common supraventricular arrhythmia and is associated with an impaired prognosis. Studies using implantable cardiac monitors suggest that this association is closely linked to AF burden, defined as the percentage of time spent in AF. Consequently, there is a growing need for affordable and comfortable alternative devices, such as wearables, capable of reliably monitoring AF burden in patients with AF. Methods: Major electronic databases were searched for studies comparing AF burden quantification using wearables and reference ECG monitoring methods. A Bayesian approach was adopted for the final analysis. Results: Six studies, including a total of 448 patients and 36,978 h of valid simultaneous recordings, were analyzed. Bayesian analysis revealed no statistically significant differences between wearables and reference methods in AF burden quantification. The mean error was 1% (95% CrIs: −4% to 7%). Similar findings were observed in the subgroup analysis of studies assessing only smartwatches. Between-study heterogeneity was low, and no evidence of publication bias was detected. Conclusion: Our analysis suggests that AF burden quantification using wearables is comparable to reference ECG monitoring methods. These findings support the potential role of wearables in clinical practice, particularly for research and prognostic purposes. However, more studies are needed to determine whether the observed statistical equivalence translates to clinical significance, thereby supporting the widespread use of wearables in the assessment of rhythm control therapeutic strategies.

Background: Ultrasound (US)-guided axillary vein puncture (AVP) is an established technique for cardiac implantable electronic device (CIED) implantation. Yet real-world data concerning shifting from conventional venous access into US-guided AVP are not widely available. Methods: This is a single-center prospective registry reporting safety (complications) and efficacy (success rate: i.e., accomplishment of the vein access utilizing only the initially employed approach) of self-taught US-guided AVP integration into the standard workflow of CIED procedures. Results: A total of 539 patients (mean age 71.5 ± 12.4 years old, 78.7% males) were treated in our institution over a three-year period. Regarding CIED type and lead number, 58.3% used an implantable cardioverter defibrillator, 32% used permanent pacemakers, and two leads were involved in 65.8% of the cases and three leads in 8.9%. Before integration of US-guided AVP, the venous access success rate was 93.5%. The US-guided AVP success rate was 377/400 procedures (94.2%). After the first semester of US-guided AVP utilization, a pattern of increased success rate was observed (p = 0.002) and remained stable over the following semesters. No major complication (periprocedural or 30-day mortality, hemothorax, pneumothorax and tamponade) occurred after US AVP integration in our workflow. Conclusions: The integration of US-guided AVP in a self-taught manner is feasible among electrophysiologists with experience in US-guided vascular access. A high success rate can be reached quickly and safely.

Sacubitril/valsartan through reverse structural remodeling and neurohormonal inhibition could play an antiarrhythmic role. This systematic review and meta-analysis was performed to explore the arrhythmiologic effects of switching patients with heart failure with reduced ejection fraction (HFrEF) from angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) to sacubitril/valsartan. We searched major databases for studies comparing device-detected, incident atrial and ventricular arrhythmias in patients with HFrEF while on ACEi/ARBs versus while on sacubitril/valsartan. For pooling the primary outcome of interest, we calculated the risk difference (RD) with the corresponding 95% confidence interval (CI) in the probability of experiencing each arrhythmic event while on ACEi/ARBs and while on sacubitril/valsartan. A random effects (DerSimonian-Laird) model was adopted. We analyzed 4 eligible studies, resulting in 497 patients with a pooled mean age of 67.8±10.36. 64% had ischemic cardiomyopathy while 98% had either an implantable cardioverter defribrillator or a cardiac resynchronization therapy device. Main comorbidities were hypertension (68.7%) and dyslipidemia (59.6%). Almost all (96.3%) patients were treated with b-blockers and 23.7% were also receiving anti-arrhythmic drugs, mainly amiodarone. After switching to sacubitril/valsartan there was a trend towards reduced risk for sustained ventricular tachycardia/fibrillation and non-sustained ventricular tachycardias (RD: −0.04, 95% CI: −0.09–0.02, I²: 65.7% and −0.06, 95% CI: −0.19–0.07, I²: 85%; respectively). Meta-regression analysis showed that patients with ischemic cardiomyopathy experience greater benefit. Incident paroxysmal atrial fibrillation/tachycardia was significantly reduced (RD: −0.09 95% CI: −0.14 to −0.03, I²: 0%), while favorable effects were noticed for the risk of appropriate shock delivery and inadequate biventricular pacing (RD: −0.06, 95% CI: −0.09 to −0.03, I²: 0% and −0.06, 95% CI: −0.11 to 0.00, I²: 35.55%, respectively). All results seem to suffer from publication bias. Limited data support that switching to sacubitril/valsartan seems to be associated with reduced risk for both ventricular and atrial arrhythmias. More studies are needed to clarify the potential anti-arrhythmic role of this drug. Whether patients with frequent arrhythmias or at high arrhythmic risk may benefit from early switch is a matter of further investigation. Figure 1 Figure 1 Figure 2 Figure 2