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<span class="paragraphSection">This is a correction to: Leonardo Calò <span style="font-style:italic;">et al.</span>, Multipoint pacing is associated with improved prognosis and cardiac resynchronization therapy response: MORE-CRT MPP randomized study secondary analyses, <span style="font-style:italic;">EP Europace</span>, Volume 26, Issue 11, November 2024, <a href="https://doi.org/10.1093/europace/euae259">https://doi.org/10.1093/europace/euae259</a></span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Atrial fibrillation (AF), the most common sustained arrhythmia in adults, is increasing in prevalence globally. Catheter ablation (CA), particularly pulmonary vein isolation (PVI), is a key treatment option. Pulmonary vein isolation can be performed using different energy sources, including cryoballoon ablation (CBA), radiofrequency ablation (RFA), or pulse field ablation. Anaesthesia modalities for these procedures include general anaesthesia (GA), deep sedation (DS), and conscious sedation (CS). However, the optimal anaesthesia modality remains unclear, as previous studies have shown mixed outcomes. This study aims to compare the safety and efficacy of different anaesthesia modalities in PVI.<div class="boxTitle">Methods and results</div>This prospective, multicentre study, based on the Israeli Catheter Ablation Registry, evaluated the impact of different anaesthesia modalities on procedural outcomes and safety in AF ablation. Data from 1002 patients who underwent PVI between January 2019 and December 2021 across 14 centres were analysed. Patients were stratified by anaesthesia modality—CS vs. GA, with the latter encompassing DS. Key outcomes, including AF recurrence, procedural complications, and success rates, were evaluated over a 24-month follow-up period. Additionally, a sensitivity analysis was performed for the subgroup of patients who underwent CBA. Of the 1002 patients, 53% received GA, 6.3% DS, and 40% CS, with CBA used in 84% of cases. Complete PVI was achieved in 91% of patients, with comparable success rates observed between CS and GA groups. No significant differences were found between CS and GA modalities in terms of AF recurrence rates at 12 months (15% vs. 16%) and 24 months (19.5% vs. 21.2%), or in 12-month rehospitalization rates (19.8% vs. 16.5%). Sensitivity analysis of the CBA subgroup yielded similar results, with no significant differences in AF recurrence, complications, or procedural duration between CS and GA modalities.<div class="boxTitle">Conclusion</div>Conscious sedation is as safe and effective as general anaesthesia in AF ablation, particularly with cryoablation. The choice of anaesthesia appears to be driven by patient characteristics and institutional factors without affecting long-term outcomes such as AF recurrence or complication rates.</span>
<span class="paragraphSection">This is a correction to: Ken Okumura, Koichi Inoue, Masahiko Goya, Hideki Origasa, Makiho Yamazaki, Akihiko Nogami, Acute and mid-term outcomes of ablation for atrial fibrillation with VISITAG SURPOINT: the Japan MIYABI registry, <span style="font-style:italic;">EP Europace</span>, Volume 25, Issue 9, September 2023, euad221, <a href="https://doi.org/10.1093/europace/euad221">https://doi.org/10.1093/europace/euad221</a></span>
<span class="paragraphSection">This is a correction to: Tolga Aksu <span style="font-style:italic;">et al.</span>, Cardioneuroablation for the treatment of reflex syncope and functional bradyarrhythmias: A Scientific Statement of the European Heart Rhythm Association (EHRA) of the ESC, the Heart Rhythm Society (HRS), the Asia Pacific Heart Rhythm Society (APHRS) and the Latin American Heart Rhythm Society (LAHRS), <span style="font-style:italic;">EP Europace</span>, Volume 26, Issue 8, August 2024, <a href="https://doi.org/10.1093/europace/euae206">https://doi.org/10.1093/europace/euae206</a></span>
<span class="paragraphSection">We read with great interest the study by Cheng <span style="font-style:italic;">et al.</span>,<sup><a href="#euaf020-B1" class="reflinks">1</a></sup> which examined the global burden of atrial fibrillation (AF) and atrial flutter (AFL) and revealed the varying patterns of AF/AFL prevalence across gender, socio-demographic index (SDI) quintiles, and regions. Additionally, the authors emphasize that higher disability-adjusted life years (DALYs) concentrated in upper SDI quintiles from 1990 to 2021. Other studies also reported similar heterogeneity of AF/AFL burden in different SDI groups from 1990 to 2019.<sup><a href="#euaf020-B2" class="reflinks">2</a>,<a href="#euaf020-B3" class="reflinks">3</a></sup> These disparities underscore the need to address cross-country inequalities in AF/AFL.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Electronic healthcare records (EHR) are at the forefront of advances in epidemiological research emerging from large-scale population biobanks and clinical studies. Hospital admissions, diagnoses, and procedures (HADP) data are often used to identify disease cases. However, this may result in incomplete ascertainment of chronic conditions such as atrial fibrillation (AF), which are principally managed in primary care (PC). We examined the relevance of EHR sources for AF ascertainment, and the implications for risk factor associations, patient management, and outcomes in UK Biobank.<div class="boxTitle">Methods and results</div>UK Biobank is a prospective study, with HADP and PC records available for 230 000 participants (to 2016). AF cases were ascertained in three groups: from PC records only (PC-only), HADP only (HADP-only), or both (PC + HADP). Conventional statistical methods were used to describe differences between groups in terms of characteristics, risk factor associations, ascertainment timing, rates of anticoagulation, and post-AF stroke and death. A total of 7136 incident AF cases were identified during 7 years median follow-up (PC-only: 22%, PC + HADP: 49%, HADP-only: 29%). There was a median lag of 1.3 years between cases ascertained in PC and subsequently in HADP. AF cases in each of the ascertainment groups had comparable baseline demographic characteristics. However, AF cases identified in hospital data alone had a higher prevalence of cardiometabolic comorbidities and lower rates of subsequent anticoagulation (PC-only: 44%, PC + HADP: 48%, HADP-only: 10%, <span style="font-style:italic;">P</span> < 0.0001) than other groups. HADP-only cases also had higher rates of death [PC-only: 9.3 (6.8, 12.7), PC + HADP: 23.4 (20.5, 26.6), HADP-only: 81.2 (73.8, 89.2) events per 1000 person-years, <span style="font-style:italic;">P</span> < 0.0001] compared to other groups.<div class="boxTitle">Conclusion</div>Integration of data from primary care with that from hospital records has a substantial impact on AF ascertainment, identifying a third more cases than hospital records alone. However, about a third of AF cases recorded in hospital were not present in the primary care records, and these cases had lower rates of anticoagulation, as well as higher mortality from both cardiovascular and non-cardiovascular causes. Initiatives aimed at enhancing information exchange of clinically confirmed AF between healthcare settings have the potential to benefit patient management and AF-related outcomes at an individual and population level. This research underscores the importance of access and integration of de-identified comprehensive EHR data for a definitive understanding of patient trajectories, and for robust epidemiological and translational research into AF.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Exercise stress test (EST) represents the gold standard for diagnosis of catecholaminergic polymorphic ventricular tachycardia (CPVT). We aimed to determine the relevance of exercise induced VT for the occurrence of LAE at follow-up.<div class="boxTitle">Methods and results</div>In <span style="font-style:italic;">RYR2</span>-related CPVT patients who underwent a baseline EST, we assessed the incidence and severity of ventricular arrhythmias (VA). Data were analysed using logistic regression models and Cox proportional hazards models. The primary outcome was the occurrence of life-threatening arrhythmic event (LAE; composite of sudden cardiac death, aborted cardiac arrest, or hemodynamically non-tolerated VT) at follow-up. In 102 RYR2-related CPVT patients (65 females; median age 16 years, IQR: 11–36 years), exercise-induced VT (bidirectional in 64% of cases) was elicited in 56% patients. VT could not be induced in pre-school children. Lower basal heart rate, early onset VA (within the first step of EST) and heart rate at the first minute of recovery were associated with exercise-induced VT. Cox analyses showed that early onset VA (HR 6.0, 95% CI: 1.3–27.9, <span style="font-style:italic;">P</span> = 0.022) and exercise-induced VT (HR 6.6, 95% CI: 1.5–29.1, <span style="font-style:italic;">P</span> = 0.012) at baseline EST were significantly associated with the occurrence of LAE at follow-up, and remained associated even after correction for symptoms.<div class="boxTitle">Conclusion</div>Early onset VA and exercise-induced VT at baseline EST was associated with LAE at follow-up, allowing to identify a sub-set of patients at higher risk already at diagnosis.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Early rhythm control therapy in atrial fibrillation (AF) results in higher freedom from atrial arrhythmia (AA) recurrence and improved cardiovascular outcomes. The optimal timing of cryoballoon ablation (CBA) is unknown.<div class="boxTitle">Methods and results</div>We evaluated AA recurrence and procedure-related complications of early vs. late CBA (≤12 vs. >12 months from diagnosis) in patients enrolled in the prospective Cryo Global Registry (121 centres in 37 countries, NCT02752737). A total of 3447 subjects were followed through 12 months and 1220 through 24 months. In summary, 1573 patients (46%) had early ablation at a median (IQR) of 0.3 (0.1–0.6) years from AF diagnosis (age 62 ± 12 years., 35.8% female, 71.4% paroxysmal), and 1874 (54%) had late ablation at a median of 3.4 (1.9–6.7) years after diagnosis (age 61 ± 11 years, 36.2% female, 75.0% paroxysmal). Early ablation patients were less hypertensive (53.5% vs. 57.9%, <span style="font-style:italic;">P</span> = 0.01) and less symptomatic (1.5 ± 1.1 vs. 1.8 ± 1.1 symptoms/patient, <span style="font-style:italic;">P</span> < 0.01) and had smaller left atrial diameters (41 ± 7 mm vs. 42 ± 7 mm, <span style="font-style:italic;">P</span> < 0.01). Freedom from AA recurrence was 81.5% (95% CI: 78.7–83.9%) in the early vs. 71.7% (95% CI: 68.9–74.3%) in the late ablation group at 24 months (<span style="font-style:italic;">P</span> < 0.01). The risk of cardioversion was 41% lower in the early ablation group [HRAdj: 0.59 (0.42–0.83), <span style="font-style:italic;">P</span> < 0.01]. Serious procedure-related adverse events occurred in 2.4 and 3.5% of patients in the early and late ablation groups (<span style="font-style:italic;">P</span> = 0.045), respectively.<div class="boxTitle">Conclusion</div>CBA within 12 months from AF diagnosis resulted in higher freedom from AA recurrence and is associated with fewer safety events in a real-world evaluation.<div class="boxTitle">Clinical trial registration</div><a href="https://clinicaltrials.gov/ct2/show/NCT02752737">https://clinicaltrials.gov/ct2/show/NCT02752737</a></span>
<span class="paragraphSection"><strong>This editorial refers to ‘Impact of atrial fibrillation diagnosis-to-ablation time on 24-month efficacy and safety outcomes in the Cryo Global Registry’ by D. Lawin <span style="font-style:italic;">et al.</span>, <a href="https://doi.org/10.1093/europace/euaf008">https://doi.org/10.1093/europace/euaf008</a>.</strong></span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>The subcutaneous implantable cardioverter defibrillator (S-ICD) is an alternative to traditional ICDs. The PRAETORIAN score, based on chest radiographs, has been validated to predict the probability of successful S-ICD defibrillation testing by assessing factors like fat thickness between the coil and sternum and generator placement. This study evaluated the correlation between the PRAETORIAN score and clinical characteristics, as well as implantation variables.<div class="boxTitle">Methods and results</div>We retrospectively analysed data from 1253 patients who had undergone implantation of an S-ICD across 33 centres. The intermuscular positioning of the pulse generator was adopted in all patients. Post-implantation posterior–anterior and lateral chest radiographs were analysed to calculate the PRAETORIAN score. A total of 95.7% of patients had a PRAETORIAN score < 90, indicative of a low risk of conversion failure. Body mass index (BMI) was the only independent predictor of a score ≥ 90, and all patients with BMI < 25 kg/m<sup>2</sup> (normal weight or underweight) had a score < 90. The intermuscular positioning technique resulted in optimal posterior placement of the device in all patients and significant sub-generator fat in only 3% of cases. A shock impedance value > 88 Ohm enabled to detect a PRAETORIAN score ≥ 90 with 98% (95% CI 97–99%) negative predictive value.<div class="boxTitle">Conclusion</div>In contemporary practice, the PRAETORIAN score can be simplified. By adopting an intermuscular approach, two of the three steps of the score—evaluating the adequate posterior positioning of the generator and measuring the sub-generator fat—become superfluous, and impedance may serve as a reliable surrogate of sub-coil fat thickness. Furthermore, our data suggest that for non-obese patients, a favourable PRAETORIAN score is assured, making the score evaluation potentially unnecessary.<div class="boxTitle">Clinical trial registration</div>URL: <a href="http://clinicaltrials.gov/">http://clinicaltrials.gov/</a> Identifier: NCT02275637.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Atrial fibrillation (AF) and atrial flutter (AFL) after cardiac surgery are common and associated with adverse outcomes. The increased risk related to AF or AFL may extend beyond discharge. This study aims to determine whether photoplethysmography (PPG)-based smartphone monitoring to detect AF or AFL after hospital discharge following cardiac surgery improves AF management.<div class="boxTitle">Methods and results</div>The intervention group performed 1 min rhythm checks three times daily using a smartphone-based PPG application during 6 weeks after hospitalization for cardiac surgery. The primary outcome involved AF management interventions by independent physicians, including initiation of oral anticoagulation (OAC), direct cardioversion, and up-titration or initiation of antiarrhythmic drugs. The study included 450 patients [mean (SD) age, 64.1 (9.2) years; 96 women (21.3%); 130 patients with AF history (28.9%); median (IQR) CHA2DS2-VASc score, 2 (1–3)], of whom 238 were randomized to PPG-based monitoring and 212 to usual care. AF/AFL was detected with PPG or electrocardiography in 44 patients (18.5%) in the monitoring group and 4 patients (1.9%) in the usual care group (OR 11.8; 95% CI, 4.2–33.3; <span style="font-style:italic;">P</span> < 0.001); these were new detections in, respectively, 22 patients (9.2%) and 1 patient (0.5%) (OR 21.3; 95% CI, 2.9–166.7; <span style="font-style:italic;">P</span> = 0.003). AF management interventions occurred in 24 patients (10.1%) in the monitoring group compared to 5 patients (2.4%) in the usual care group [odds ratio (OR), 5.1; 95% CI, 1.8–14.4; <span style="font-style:italic;">P</span> = 0.002].<div class="boxTitle">Conclusion</div>In unselected patients discharged home following cardiac surgery, PPG-based smartphone monitoring revealed significantly more AF/AFL which led to significantly more optimization of AF management.</span>
<span class="paragraphSection">We read with great interest the article by Cheng <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B1" class="reflinks">1</a></sup> in which they stated that the prevalence of atrial fibrillation (AF) increased by 1.37 times and its incidence by 1.24 times in 31 years. It is very important to establish specific units that will provide both preventive health services and follow up patients for AF, which is increasingly becoming a major public health problem. They emphasized that because AF is preventable and treatable, cost-effective techniques targeting modifiable risk factors should be urgently adopted in regions with increasing prevalence rates.<sup><a href="#euaf016-B1" class="reflinks">1</a></sup> Walli-Attaei <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B2" class="reflinks">2</a></sup> highlighted the significant burden, which AF-related symptoms and cardiovascular events (CVEs) impose on both patients and healthcare systems, particularly healthcare costs, in Europe and Central Asia. The latest published consensus article stated that patients with AF and low arrhythmia burden have a lower risk of stroke and other CVEs than those with high arrhythmia burden, and compiled what needs to be done.<sup><a href="#euaf016-B3" class="reflinks">3</a></sup> Salmela <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B4" class="reflinks">4</a></sup> emphasized that women use antiarrhythmic drugs more than men, but they undergo ablation and cardioversion procedures less than those younger than 65 years of age. Zörner <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B5" class="reflinks">5</a></sup> reported in their study that older patients, women, patients with lower levels of education were less likely to receive AF ablation. Okoye <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B6" class="reflinks">6</a></sup> noted that older adults with AF exhibited a more rapid annual decline in walking speed compared with those without AF in their 15-year follow-up study. While high body mass index (BMI) is a known risk factor for the development of AF, Vermeer <span style="font-style:italic;">et al</span>.<sup><a href="#euaf016-B7" class="reflinks">7</a></sup> emphasized that obesity is an independent risk factor for repeat ablation. The latest guideline has provided us with the most systematic approach to AF patients to date.<sup><a href="#euaf016-B8" class="reflinks">8</a></sup> The application of AF-<span style="font-style:italic;">CARE</span> (<span style="font-style:italic;">C</span>omorbidity and risk factor management, <span style="font-style:italic;">A</span>void stroke and thromboembolism, <span style="font-style:italic;">R</span>educe symptoms by rate and rhythm control, <span style="font-style:italic;">E</span>valuation and dynamic reassessment) principles to all patients is emphasized.<sup><a href="#euaf016-B8" class="reflinks">8</a></sup> Additionally, new opportunities in technology (especially innovations in artificial intelligence and genetics) may provide cardiologists with new guidance to predict AF, improve AF screening, and personalize patient management.<sup><a href="#euaf016-B9" class="reflinks">9</a></sup> Finally, colchicine has been shown by meta-analysis to prevent the development of AF in postoperative patients.<sup><a href="#euaf016-B10" class="reflinks">10</a></sup> An AF-CARE unit can be established in all cardiology clinics, starting with preventive cardiology services for each individual (e.g. maintaining a BMI of 20–25 kg/m<sup>2</sup>, 150–300 min of moderate-intensity aerobic physical exercise per week, population-based screening using a prolonged non-invasive ECG-based approach to enable earlier detection of AF<sup><a href="#euaf016-B8" class="reflinks">8</a></sup> in individuals aged ≥75 years or ≥65 years with additional risk factors), and continuing with cardiac rehabilitation programmes for all AF patients, whether or not they have had ablation.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Background</div>Ibrutinib, a widely used anti-cancer drug, is known to significantly increase the susceptibility to atrial fibrillation (AF). While it is recognized that drugs can reshape the gut microbiota, influencing both therapeutic effectiveness and adverse events, the role of gut microbiota in ibrutinib-induced AF remains largely unexplored.<div class="boxTitle">Method</div>Utilizing 16S rRNA gene sequencing, faecal microbiota transplantation, metabonomics, electrophysiological examination, and molecular biology methodologies, we sought to validate the hypothesis that gut microbiota dysbiosis promotes ibrutinib-associated AF and to elucidate the underlying mechanisms.<div class="boxTitle">Result</div>We found that ibrutinib administration pre-disposes rats to AF. Interestingly, ibrutinib-associated microbial transplantation conferred increased susceptibility to AF in rats. Notably, ibrutinib induced a significantly decrease in the abundance of <span style="font-style:italic;">Lactobacillus gasseri</span> (<span style="font-style:italic;">L. gasseri</span>), and oral supplementation of <span style="font-style:italic;">L. gasseri</span> or its metabolite, butyrate (BA), effectively prevented rats from ibrutinib-induced AF. Mechanistically, BA inhibits the generation of reactive oxygen species, thereby ameliorating atrial structural remodelling. Furthermore, we demonstrated that ibrutinib inhibited the growth of <span style="font-style:italic;">L. gasseri</span> by disrupting the intestinal barrier integrity.<div class="boxTitle">Conclusion</div>Collectively, our findings provide compelling experimental evidence supporting the potential efficacy of targeting gut microbes in preventing ibrutinib-associated AF, opening new avenues for therapeutic interventions.</span>
<span class="paragraphSection"><div class="boxTitle">Abstract</div><div class="boxTitle">Aims</div>Loss of bipolar electrograms immediately after pulsed field ablation (PFA) makes lesion durability assessment challenging.<div class="boxTitle">Objective</div>The aim of this trial (NCT 06700226) was to evaluate a novel ablation system that can optically predict lesion durability by detecting structural changes in the tissue during ablation.<div class="boxTitle">Methods and results</div>Patients with paroxysmal atrial fibrillation underwent pulmonary vein isolation (PVI) using PFA (AblaView®, MedLumics). Using polarization-sensitive optical coherence reflectometry (PS-OCR), reflective characteristics of myocardial tissue and visualization of real-time contrast between healthy tissue and ablated tissue using a drop in tissue birefringence (BiR) was assessed. Wide antral PVI was performed using single point irrigated PFA (unipolar, 1800V, 3 trains, 21 s). Remapping was performed at 3 months. Primary efficacy outcome was the ability of PS-OCR to predict lesion durability at 3-month remapping. Serious adverse events were recorded. Ten patients were included. In total, 38/40 PVs could be isolated with the system. The mean drop of BiR was 17.3 ± 11.5%. Dragging across the ablation lines showed a persistent drop in BiR. During the remap procedures (8/10 patients ablated only with PFA), 12 PVs (37.5%) were found to be electrically reconnected. The mean loss of BiR during all PFA for durable lesions was 20.9%, while only 10.1% BiR loss was observed during the index ablation for reconnected areas (<span style="font-style:italic;">P</span> < 0.001). None of the points with ≥17% loss of birefringence was found to be reconnected.<div class="boxTitle">Conclusion</div>This first-in-human study supports the use of real-time drop in tissue BiR for lesion assessment and durability during PFA delivery, and its procedural safety.</span>
<span class="paragraphSection"><strong>This editorial refers to ‘Repeat Procedures After Pulsed Field Ablation for Atrial Fibrillation: <span style="font-style:italic;">MANIFEST-REDO</span> Study’, by D. Scherr <span style="font-style:italic;">et al</span>., <a href="https://doi.org/10.1093/europace/euaf012">https://doi.org/10.1093/europace/euaf012</a>.</strong></span>
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