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In this trial, patients receiving oral anticoagulation therapy who required pacemaker or defibrillator surgery were assigned to heparin bridging or continuation of warfarin. Patients receiving warfarin had a markedly lower risk of clinically significant device-pocket hematoma. Each year, an estimated 1.25 million pacemakers and 410,000 implantable cardioverter–defibrillators (ICDs) are implanted worldwide. 1 Between 14 and 35% of patients receiving these devices require long-term oral anticoagulation therapy, 2 – 5 and their periprocedural treatment presents a dilemma to physicians. This is particularly true for the subset of patients at moderate-to-high risk (≥5% per year) for thromboembolic events. 6 Current guidelines recommend interruption of oral anticoagulation therapy and the use of bridging therapy with intravenous unfractionated heparin or subcutaneous low-molecular-weight heparin around the time of surgery. 6 However, there are a number of potential drawbacks to bridging with heparin in the perioperative period. . . .

Ovarian hormones affect cardiovascular health yet few sufficient-sized studies with reliable ovulatory documentation have assessed the QTc-hormonal relationship. This study investigated QTc changes across ovulatory and anovulatory menstrual cycle phases. This prospective cohort investigation, a cardiac sub-study of the Menstruation and Ovulation Study 2 (MOS2), involved 62 healthy, regularly menstruating community-dwelling women during spontaneous menstrual cycles. Electrocardiographic recordings were obtained within-woman during different cycle phases: mid-follicular for all, and luteal (ovulatory) or premenstrual (anovulatory), documented by the validated Quantitative Basal Temperature© method. Fridericia's formula rate-corrected the QT interval (QTc). A subsequent meta-analysis was conducted, pooling data from three additional studies to evaluate ovulatory follicular-luteal phase QTc changes. In the 26 ovulatory cycles, QTc minimally decreased from the mid-follicular to the luteal phases (383.0 ± 12.8 vs 382.6 ± 12.8 msec, P = .859). QTc in the 36 anovulatory cycles tended to increase from mid-follicular to premenstrual phases (381.7 ± 13.1 vs 385.0 ± 16.1 msec, P = .166). The meta-analysis in ovulatory cycles yielded a random-effects weighted mean QTc shortening of 1.67 msec (P = .53) in the luteal vs the follicular phase, aligning with our cohort data. In confirmed ovulatory cycles, QTc changes were minimal, showing no meaningful luteal phase QTc shortening. QTc changes in anovulatory cycles were also insignificant, with a small QTc prolongation likely due to longer estradiol exposure not counterbalanced by progesterone. Under normal physiological conditions, QTc changes during the menstrual cycle are trivial, and menstrual status does not need to be considered when interpreting the QT interval.

In 4 of 15 patients with idiopathic atrial fibrillation, four novel, heterozygous mutations in GJA5 — the gene for the gap-junction protein connexin 40 — were identified. These supplement the list of mutations that cause atrial fibrillation and will improve our understanding of the molecular basis of atrial fibrillation. In 4 of 15 patients with idiopathic atrial fibrillation, four novel, heterozygous mutations in GJA5 — the gene for the gap-junction protein connexin 40 — were identified. Atrial fibrillation is characterized by rapid, erratic electrical activation of the atrial myocardium, resulting in the loss of effective contractility, an increased likelihood of clot formation, and an increased risk of stroke. 1 The rapid atrial activity may be conducted to the ventricles, resulting in the deterioration of heart function. In addition to causing substantial morbidity, atrial fibrillation confers an increased risk of mortality that is independent of coexisting risk factors. 2 In the United States, more than 2 million adults have atrial fibrillation, with the prevalence increasing with age (5.9 percent among those older than 65 years). 3 Thus, the socioeconomic burden . . .

There is growing appreciation of oligogenic disorders, 2,3 the role of modifier genes, 2 and the use of genetic testing for risk stratification, even in common cardiac diseases such as coronary artery disease or atrial fibrillation (AFib), including a proposal for a score awaiting validation. 4 This document reviews the state of genetic testing at the present time, and addresses the questions of what tests to perform and when to perform them. Additionally, the document presents the state of genetic testing for inherited arrhythmia syndromes, cardiomyopathies, sudden cardiac death (SCD), congenital heart disease (CHD), coronary artery disease, and heart failure. The writing committee recognizes that the feasibility of genomic testing by gene panel testing or by WES or WGS depends on the availability of genomic technology and on regional reimbursement policy. [...]the recommendation ‘should do this’ can be read as ‘should do this when available’. Table 2 Relevant clinical practice documents or guidelines Title Publication year Consensus documents/guidelines of scientific societies APHRS/HRS expert consensus statement on the investigation of decedents with sudden unexplained death and patients with sudden cardiac arrest, and of their families 6 2021 HRS/EHRA/APHRS/LAHRS Expert Consensus Statement on Catheter Ablation of Ventricular Arrhythmias 7 2020 Genetic Testing for Inherited Cardiovascular

Vasovagal syncope (VVS) is a common problem associated with a poor quality of life, which improves when syncope frequency is reduced. Effective pharmacological therapies for VVS are lacking. Metoprolol is a β-adrenergic receptor antagonist that is ineffective in younger patients, but may benefit older (≥40 years) VVS patients. Given the limited therapeutic options, a placebo-controlled clinical trial of metoprolol for the prevention of VVS in older patients is needed. The POST5 is a multicenter, international, randomized, placebo-controlled study of metoprolol in the prevention of VVS in patients ≥40 years old. The primary endpoint is the time to first recurrence of syncope. Patients will be randomized 1:1 to receive metoprolol 25 to 100 mg BID or matching placebo, and followed up for 1 year. Secondary end points include syncope frequency, presyncope, quality of life, and cost analysis. Primary analysis will be intention to treat, with a secondary on-treatment analysis. A sample size of 222, split equally between the groups achieves 85% power to detect a hazard rate of 0.3561 when the event rates are 50% and 30% in the placebo and metoprolol arms. Allowing for 10% dropout, we propose to enroll 248 patients. This study will be the first adequately powered trial to determine whether metoprolol is effective in preventing VVS in patients ≥40 years. If effective, metoprolol may become the first line pharmacological therapy for these patients.

PurposeThe purpose of this study was to evaluate the impact of steerable sheaths on multiple contact force parameters during atrial fibrillation (AF) ablation. Steerable sheaths are commonly used during AF ablation, at an additional cost to standard fixed-curve sheaths. However, there is little data on their incremental value in the era of contact force-guided radiofrequency ablation.MethodsThis multi-center cohort study included consecutive patients undergoing index pulmonary vein (PV) isolation with a force-sensing catheter. Operators employed either only steerable or only fixed-curve sheaths. Operators targeted a force of 10–40 g for each ablation lesion. Automated ablation lesion assessment software with standardized settings was employed.ResultsOf 85 subjects, 52 and 33 underwent ablation with steerable and fixed-curve sheaths, respectively. The steerable sheath group showed significantly higher average and maximum forces, but predominantly for the right PVs. The proportion of lesions with ≥ 10% of time with less than 10 g of force was lower in the steerable sheath group (adjusted odds ratio 0.56, steerable vs. fixed; 95% confidence interval 0.35, 0.89, p = 0.01). Improved stability was seen in the posterior aspect of both PV pairs. The proportion of RF time-in-target (the proportion of RF time meeting lesion criteria) was not different between the two groups (p = 0.176).ConclusionsEven with contemporary contact force targets, steerable sheath use in AF ablation is associated with better average and maximum contact force and increased stability in comparison to fixed-curve sheaths.

ObjectivePatients with Fontan surgery experience late complications in adulthood. We studied the factors associated with the development and maintenance of atrial arrhythmias and thromboembolic complications in an adult population with univentricuar physiology post Fontan surgery.MethodsSingle centre retrospective cohort study of patients ≥18 years of age with Fontan circulation followed at our quaternary care centre for more than 1 year were included. Univariate and multivariate regression models were used where applicable to ascertain clinically significant associations between risk factors and complications.Results93 patients were included (age 30.2±8.8 years, 58% men). 28 (30%) had atriopulmonary Fontan connection, 35 (37.6%) had lateral tunnel Fontan and 29 (31.1%) had extracardiac Fontan pathway. After a mean of 7.27±5.1 years, atrial arrhythmia was noted in 37 patients (39.8%), of which 13 developed had atrial fibrillation (14%). The presence of atrial arrhythmia was associated with the number of prior cardiac surgeries/procedures, increasing age and prior atriopulmonary Fontan operation. Thromboembolic events were present in 31 patients (33%); among them 14 had stroke (45%), 3 had transient ischaemic attack (9.7%), 7 had pulmonary embolism (22.6%) and 5 had atrial thrombus with imaging (16.1%). The presence of thromboembolic events was only associated with age and the presence of cirrhosis in multivariate analysis.ConclusionsAtrial arrhythmias are common in adults with Fontan circulation at an early age, and are associated with prior surgical history and increasing age. Traditional risk factors may not be associated with atrial arrhythmia or thromboembolism in this cohort.

This international multidisciplinary document intends to provide clinicians with evidence‐based practical patient‐centered recommendations for evaluating patients and decedents with (aborted) sudden cardiac arrest and their families. The document includes a framework for the investigation of the family allowing steps to be taken, should an inherited condition be found, to minimize further events in affected relatives. Integral to the process is counseling of the patients and families, not only because of the emotionally charged subject, but because finding (or not finding) the cause of the arrest may influence management of family members. The formation of multidisciplinary teams is essential to provide a complete service to the patients and their families, and the varied expertise of the writing committee was formulated to reflect this need. The document sections were divided up and drafted by the writing committee members according to their expertise. The recommendations represent the consensus opinion of the entire writing committee, graded by Class of Recommendation and Level of Evidence. The recommendations were opened for public comment and reviewed by the relevant scientific and clinical document committees of the Asia Pacific Heart Rhythm Society (APHRS) and the Heart Rhythm Society (HRS); the document underwent external review and endorsement by the partner and collaborating societies. While the recommendations are for optimal care, it is recognized that not all resources will be available to all clinicians. Nevertheless, this document articulates the evaluation that the clinician should aspire to provide for patients with sudden cardiac arrest, decedents with sudden unexplained death, and their families.

Increasing numbers of patients requiring arrhythmia device implantation are taking warfarin. The common practice of warfarin interruption and perioperative bridging with heparin is associated with a high rate of postoperative hemorrhagic complications. We assessed the safety of device implantation without interruption of warfarin therapy. Three patient groups were studied: Group 1 consisted of 117 consecutive patients on long-term warfarin therapy with significant risk of thromboembolism (atrial fibrillation with CHADS 2 score ≥2, mechanical heart valve, recent venous thromboembolism) who underwent arrhythmia device implantation without interruption of warfarin. Group 2 was 117 patients who served as age- and sex-matched controls matched to procedure type not taking warfarin. Group 3 consisted of 38 similar thromboembolic risk historical control patients who underwent interruption of warfarin therapy and bridging with dalteparin before and 24 hours after surgery. Active fixation leads were used by subclavian or axillary vein puncture, with septal fixation in the ventricle in 56% of patients. Hemorrhagic and thromboembolic complications were assessed at discharge and at 7 and 30 days after surgery. During an 18-month period, 1,562 consecutive adult patients underwent heart rhythm device implantation or replacement. One hundred seventeen of the 447 patients on warfarin were considered high risk and remained on warfarin for their procedure. The mean international normalized ratio in group 1 patients was 2.2 ± 0.4 (age 79 ± 11 years, 73 male). Significant hematoma was noted in 9 patients (7.7%), and one required surgical revision (0.9%). Five group 2 patients (control) had significant hematomas (4.3%), none of which required revision ( P = .41). In group 3, 9 patients developed significant hematomas (23.7%, P = .012), 3 of whom required reoperation (7.9%, P = .046). There were no deaths, thromboembolic events, cardiac tamponade, or hemothorax in any patient. The only risk factor for hematoma in the warfarin patients was the number of leads implanted. Arrhythmia devices can be implanted safely in patients with high thromboembolic risk without interruption of warfarin. This strategy may be associated with reduced risk of significant pocket hematoma compared with dalteparin bridging.

On May 27, 2022, the Asia Pacific Heart Rhythm Society and the Heart Rhythm Society convened a meeting of leaders from different professional societies of healthcare providers committed to arrhythmia care from the Asia Pacific region. The overriding goals of the meeting were to discuss clinical and health policy issues that face each country for providing care for patients with electrophysiologic issues, share experiences and best practices, and discuss potential future solutions. Participants were asked to address a series of questions in preparation for the meeting. The format of the meeting was a series of individual country reports presented by the leaders from each of the professional societies followed by open discussion. The recorded presentations from the Asia Summit can be accessed at https://www.heartrhythm365.org/URL/asiasummit‐22. Three major themes arose from the discussion. First, the major clinical problems faced by different countries vary. Although atrial fibrillation is common throughout the region, the most important issues also include more general issues such as hypertension, rheumatic heart disease, tobacco abuse, and management of potentially life‐threatening problems such as sudden cardiac arrest or profound bradycardia. Second, there is significant variability in the access to advanced arrhythmia care throughout the region because of differences in workforce availability, resources, drug availability, and national health policies. Third, collaboration in the area already occurs between individual countries, but no systematic regional method for working together is present.