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BackgroundSecond-generation cryoballoon ablation is safe and effective in patients with persistent atrial fibrillation (AF). The aim of this study is to report the real long-term AF burden and freedom from AF post-cryoablation using continuous monitoring, and to assess whether intraoperative confirmation of pulmonary vein isolation using electrical mapping is necessary.MethodsA total of 33 patients (mean age 75.7 ± 5.6 years, 16 men) with persistent AF who underwent second-generation cryoablation without electrical mapping were reviewed. All patients had a cardiac implantable device and were followed up for a mean of 755 ± 170 days.ResultsAF burden significantly decreased from 67.51% ± 34.90% to 18.28% ± 26.65% at 1-year follow-up, and this reduction was maintained at final follow-up (18.26% ± 23.70%, p < 0.001). Continuous monitoring revealed a freedom from AF rate of 33% and 24% at 1-year and full follow-up, respectively. Patients who remained in persistent AF at final follow-up had a trend towards higher pre-ablation AF burden (81.6% ± 29.7% vs 57.3% ± 36.4%, p = 0.08).ConclusionSecond-generation cryoablation without confirming pulmonary vein isolation using electrical mapping is effective leading to significant reductions in AF burden based on continuous beat-to-beat monitoring at 1-year and long-term follow-up.

Figure 1 as originally published is incorrect. On the published Fig. 1 it reads 3 patients Medtronic Sensia and 3 patients Medtronic Advisa. This should read 1 patient Medtronic Sensia and 1 patient Medtronic Advisa. Figure 1 has been corrected below.

Catheter ablation is the treatment of choice for patients with symptomatic accessory pathways (APs) causing recurrent atrioventricular reciprocating tachycardia or in situations where APs conduct rapidly, posing a risk of sudden cardiac death. Conventional AP mapping relies on point-by-point assessment of local electrograms looking closely for pathway electrograms or early atrial or ventricular electrograms, which may be challenging and time consuming. Recently, open window mapping (OWM) using 3D navigational systems has emerged as a novel technique to help localise and ablate APs. OWM has significant advantages over conventional point-by-point mapping techniques. The purpose of this review is to summarise the currently available literature on the OWM technique and to highlight the technical aspects and mapping considerations for OWM, including specific cases demonstrating its utility.

A 59-year-old woman was admitted to our hospital with acute pulmonary oedema and cardiogenic shock 35 days after anterior ST elevation myocardial infarction. She developed a new loud pan systolic murmur. Echocardiography revealed a ventricular septal rupture with a significant left to right shunt. She was immediately transferred to the local cardiothoracic unit where she underwent a successful ventricular septal defect (VSD) repair. Ventricular septal rupture often presents within the first 24 hours of acute myocardial infarction and is rare thereafter. It carries a poor mortality (41–80%) even when recognised. Timely recognition of this life-threatening complication can help reduce the resultant morbidity and mortality. Doctors should be aware that this well-recognised complication may present unusually late as in this case.

IntroductionThe rate of pacemaker implantation over the last two decades has risen and will continue to rise as the population becomes more elderly. As such, the number of pacemaker generator changes performed in nonagenarians will also increase. There is little data regarding the risks associated with routine generator changes in this patient cohort. This is important as this cohort of patients are generally more frail and have more co-morbidities, potentially increasing the risks associated with generator change. We retrospectively analysed data on pacemaker generator changes in nonagenarians from a single high volume centre over 10 years.MethodsElectronic health record data were reviewed for all patients aged >90 undergoing pacemaker generator change between October 2010 and December 2021. 207 records were identified which met the inclusion criteria. 7 were excluded from the analysis as duplicate entries or occasions where the procedure was not begun due to patient factors such as advanced dementia or acute sickness. The primary outcome was any procedural-related complication occurring in the first year post generator change.ResultsThe mean age was 93 ± 2.34 years. 94 (47%) patients were male. 200 procedures were performed, of which 50 (25%) patients had a single-chamber pacemaker as their original device, 138 (69%) patients had a dual–chamber pacemaker, and 9 (4.5%) patients had a CRT-P device. 1 (0.5%) patient had a CRT-D device in situ, 1 (0.5%) patient had a single-chamber ICD, and 1 (0.5%) patient had a dual-chamber ICD. Twenty-two patients (11%) had a lead capped to convert dual-chamber pacemakers to single-chamber pacemakers. The average procedural time was 40 ± 16 minutes.Complications occurred in 13 patients (6.5%), of which 12 (6%) were classified as “minor”. The most common complication was poor lead performance requiring adjustment of thresholds at follow-up. This was seen in 7 patients (3.5%). The next most common complication was wound haematoma requiring conservative management, seen in 4 patients (2.0%). 1 patient had a minor wound infection, requiring further antibiotic treatment (0.5%). The only major complication seen was threatened erosion of the device, requiring re-siting, which occurred in 1 patient (0.5%). Following generator replacement, mean time to death was 895 ± 718 days. 2 patients died within 30 days of generator change.ConclusionComplication rates during and post generator replacement in nonagenarians are low, with very low rates of serious complications requiring revision. The rates seen in this study are in keeping with previous analyses of generator replacement across patients of all ages, and do not suggest a significantly increased risk of complication amongst patients greater than 90 years old.Abstract 100 Figure 1Breakdown of complications arising from generator replacement in nonagenariansConflict of InterestNone

Arterial stiffness is an independent risk factor for cardiovascular disease. There has been no previous research comparing the acute changes to arterial stiffness following aerobic exercise in different groups of athletes. The aim of this study was to compare the acute effect of aerobic exercise on arterial stiffness in resistance-trained (RT) athletes, endurance-trained (ET) athletes and sedentary controls. Central and peripheral pulse wave velocity (PWV) were measured before and at 3, 15 and 30 min intervals post-exercise in RT athletes (n = 18), ET athletes (n = 19) and sedentary controls (n = 15). PWV was measured using Doppler flow velocimeters and derived from the ‘foot-to-foot’ transit times. Blood pressure and heart rate recordings preceded all PWV measurements. Resting PWV did not differ significantly between groups. In the endurance and control group, central PWV increased at 3 min post-exercise (from 7.7 ± 2.2 to 10.6 ± 4.2 m/s; P = 0.02 and from 7.4 ± 2.2 to 9.1 ± 3.1 m/s; P = 0.01 respectively), followed by a decline to baseline within 15 min of exercise cessation. Central PWV fell at 30 min post-exercise (P = 0.08) in the resistance group, although this was a non-significant reduction. Peripheral PWV did not change significantly from respective baseline values in any group. The ET and control group exhibited differences in their central arterial response to exercise compared to the RT group, although peripheral arterial response was similar between the groups. Higher intensity and/or prolonged exercise is likely to be required for more pronounced differences.

IntroductionOrthostasis induces a rapid and large gravity-related shift of 500-1000mls of blood volume from the thorax to below the diaphragm. It has been reported that the central mechanism in patients with orthostatic intolerance is due to this gravity shift and related hypotension.The ROX Coupler is a device that allows creation of a central arteriovenous anastomosis at the iliac level resulting in an A-V shunt of 0.8L/m. We performed a prospective controlled study investigating the effects of the ROX Coupler on cardiac haemodynamics and right heart parameters during orthostasis compared to age matched controls.Methods10 patients with a ROX Coupler were compared to 10 age matched controls during an active stand at baseline, 30, 60, 90 and 120 seconds. Cardiac haemodynamics were measured using impedance cardiography and non-invasive beat-to-beat monitoring (Task Force® Monitor) along with right-sided echocardiography. An independent-group t-test was used to compare baseline variables and demographics. Differences in cardiac haemodynamics and right-sided echocardiography were compared within each group at the specific time intervals using repeated measures analysis of variance. Significance was established at P <0.05.ResultsThere was no significant difference in age (68.40 ± 7.09 vs 69.40 ± 11.09, p = 0.81) or BMI (29.1± 4.52 vs 27.72 ± 4.8, p = 0.51) between ROX Coupler patients and controls. At baseline ROX Coupler patients had a significantly higher cardiac index and lower indexed total peripheral resistance (Table 1). ROX Coupler patients also had a significantly higher right ventricular end systolic volume (RV ESV), right ventricular end diastolic volume (RVEDV) and right atrial end diastolic volume (RAEDV) than controls (Table 2).Abstract 102 Table 1Baseline comparison of cardiac haemodynamicsRox CouplerControlP Value Heart rate80.0 ± 12.574.2 ± 12.40.31Systolic BP129.1 ± 21.2127.8 ± 17.10.88Diastolic BP74.8 ± 18.681.6 ± 14.10.37Stroke Index38.6 ± 11.334.6 ± 5.00.32Cardiac Index3.2 ± 0.82.5 ± 0.50.03Total peripheral resistance2729 ± 10253855 ± 9990.02Thoracic fluid content27.6 ± 4.130.1 ± 5.30.24Abbreviations: BP Blood pressure. Values given as mean ± Standard deviationAbstract 102 Table 2Baseline comparison of right sided parametersRox CouplerControlP value RV ESV (ml)15.3 ± 2.99.7 ± 4.70.05RV EDV (ml)39.0 ± 6.928.0 ± 8.50.05RV (EF%)58.6 ± 5.865.7 ± 9.00.15RV SV (ml)22.3 ± 5.518.7 ± 5.90.37RA ESV (ml)34.7 ± 12.644.8 ± 16.50.17RA EDV (ml)55.7 ± 2028.5 ± 9.70.003Abbreviations: ESV end systolic volume; EDV end diastolic volume; EF ejection fraction; SV stroke volume. Values given as mean ± Standard deviationDuring active stand there was a significant decrease in systolic blood pressure from baseline in controls (p=0.04) however in ROX Coupler patients systolic blood pressure was non-significantly different from baseline (p = 0.59) as shown in figure 1. There was no significant difference in indexed total peripheral resistance from baseline in either group. Cardiac index and total thoracic content significantly reduced from baseline in both groups.Abstract 102 Figure 1Change in systolic blood pressure during active standThere was no significant difference in RV ESV, RV EDV, RV ejection fraction, RA EDV or RA ESV during active stand.ConclusionsThe Rox Coupler resulted in a reduction in immediate orthostatic hypotension compared to age matched controls. Cardiac index was higher in ROX Coupler patients, which is expected given the higher pre load effects of the anastomosis. The higher cardiac output and right-sided volumes may explain the maintenance in systolic blood pressure during orthostasis and warrants further investigation.Conflict of InterestNone

Background Catheter ablation of the atrioventricular node (AVN) is an effective treatment for patients with symptomatic atrial fibrillation. This study compares the success rate, procedure time, radiation time, and complication rates of retrograde left‐sided (LSA) and anterograde right‐sided (RSA) AVN ablation in a randomised controlled trial. Methods Thirty‐one patients undergoing AVN ablation were randomized to either LSA (15 patients) or RSA (16 patients). Crossover occurred after six unsuccessful radiofrequency (RF) applications. Results The LSA cohort had a mean age of 77.00 ± 5.17 and the RSA cohort was 79.44 ± 6.08 (p = .0240). There were five crossovers from LSA to RSA and there was one crossover from RSA to LSA. There was no significant difference in ablation time between LSA and RSA (210.40 ± 179.77 vs. 192.19 ± 130.29 seconds, p = .748). There was no significant difference in procedure time, fluoroscopy time, radiation dose, or number of RF applications between the two groups. There was 1 (6.67%) serious adverse event in the LSA group and 1 (6.25%) in the RSA group due to femoral hematomas requiring blood transfusion or intervention. There was no significant difference in patient‐reported discomfort between LSA and RSA (16.43 ± 20.67 vs. 17.87 ± 28.08, p = .877). The study was stopped before full recruitment due to futility. Conclusions Retrograde LSA of the AVN does not reduce RF applications, procedure time, or radiation exposure compared with conventional RSA and cannot be recommended as a first‐line clinical approach. Retrograde left‐sided atrioventricular node ablation does not reduce radiofrequency ablation time compared with the conventional right‐sided approach and cannot be recommended as a first‐line clinical approach.

Introduction Pulmonary vein (PV) isolation has been shown to reduce atrial fibrillation (AF) burden and symptoms in patients. However, to date previous studies have been unblinded raising the possibility of a placebo effect to account for differences in outcomes. Hypothesis & Methods The objective of this study is to compare PV isolation to a sham procedure in patients with symptomatic AF. The SHAM‐PVI study is a double blind randomized controlled clinical trial. 140 patients with symptomatic paroxysmal or persistent AF will be randomized to either PV isolation (with cryoballoon ablation) or a sham procedure (with phrenic nerve pacing). All patients will receive an implantable loop recorder. The primary outcome is total AF burden at 6 months postrandomisation (excluding the 3 month blanking period). Key secondary outcomes include (1) time to symptomatic and asymptomatic atrial tachyarrhythmia (2) total atrial tachyarrhythmia episodes and (3) patient reported outcome measures. Results Enrollment was initiated in January 2020. Through April 2023 119 patients have been recruited. Results are expected to be disseminated in 2024. Conclusion This study compares PV isolation using cryoablation to a sham procedure. The study will estimate the effect of PV isolation on AF burden. The SHAM‐PVI study timeline. One hundred forty patients will be enrolled and randomized in a 1:1 ratio to receive cryoablation or a sham procedure. All patients will receive an implantable loop recorder. Outcomes will be assessed at 3 and 6 months post‐randomisation with the first 3 months constituting the blanking period.