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Initial treatment of paroxysmal atrial fibrillation with cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation and other atrial tachyarrhythmias over 3 years than rhythm-control medications.

Patients with symptomatic, paroxysmal, untreated atrial fibrillation were randomly assigned to antiarrhythmic drug therapy or cryoablation. At 1 year, there was a significantly lower rate of recurrence of atrial fibrillation with cryoablation than with drug therapy.

Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure. To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up. This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021. Baseline clinical factors, in-hospital care and LVEF, and site-specific features. The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy. This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%. In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.

IntroductionPercutaneous catheter ablation for atrial fibrillation (AF) is a procedure performed typically in an inpatient setting. The feasibility and safety of catheter ablation in patients with paroxysmal and persistent AF were evaluated on an outpatient basis.Methods230 AF ablation procedures were performed in 206 patients (74% male; mean age 56±9 years). Patients were admitted to the hospital outpatient facility in the morning for the AF ablation procedure on the same day. The ablation strategy consisted of wide area circumferential lines around both ipsilateral pulmonary veins. After monitoring in the outpatient service, patients were discharged on the same day, if they were clinically stable.ResultsMean procedure time was 201±31 min. Major complications occurred in seven patients (3%). One patient (0.4%) suffered a minor stroke and six patients had pericardial tamponade requiring percutaneous drainage. Patients could be discharged on the same day following 205 (89%) procedures. Among the 148 patients whose clinical outcome was assessed at 6 months, 127 (86%) had a reduction of the total symptomatic AF episodes, compared to pre-ablation, with a complete lack of symptoms in 101 patients (68%).ConclusionCatheter ablation of AF on the day of admission is feasible and safe with a low risk of complications. The vast majority of the patients can be discharged on the same day.

Background Although the incidence of atrial fibrillation (AF) progressively increases with age, the vast majority of AF ablation is done in middle-aged patients. We evaluated the feasibility and safety of catheter ablation in patients older than 65 years of age with paroxysmal and persistent AF. Methods Out of a total of 230 consecutive AF ablation procedures, 45 patients were older than 65 years of age and underwent 53 procedures. The ablation strategy consisted of wide-area circumferential lines around both ipsilateral pulmonary veins using a three-dimensional mapping system. Results The mean age was 69 ± 3.5 years (35 males). The mean duration for AF was 8.7 ± 6.5 years. Thirty-nine had paroxysmal and six persistent AF despite use of 1.38 ± 0.77 antiarrhythmic drugs. All patients had a structurally normal heart. Eleven had systemic hypertension. Mean procedure time was 187 ± 33 min. Acute procedural success rate with abolition of all pulmonary vein potentials was achieved in all patients. Pericardial tamponade requiring percutaneous drainage occurred in one (1.9%) patient. There were no cardioembolic events. Among the 43 patients whose clinical outcome was assessed at 6 months, 34 (79%) had a significant reduction (>90%) of the total symptomatic AF burden, compared to pre-ablation, with a complete lack of symptomatic AF in 32 (74%) patients. The success rate was higher for patients with paroxysmal versus persistent AF (81 vs. 67%). Six patients (11%) underwent repeat procedures. Conclusions Catheter ablation is a safe and effective treatment for patients over the age of 65 years with symptomatic, drug-refractory AF. Therefore, patients should not be excluded from undergoing AF catheter ablation on the basis of age alone.

Abstract BackgroundTransseptal puncture to achieve left atrial access is necessary for many cardiac procedures, including atrial fibrillation ablation. More recently, there has been an increasing need for left atrial access using large caliber sheaths, which increases risk of perforation associated with the initial advancement into the left atrium. We compared the effectiveness of a radiofrequency needle-based transseptal system versus conventional needle for transseptal access.MethodsThis prospective controlled trial randomized 161 patients with symptomatic paroxysmal atrial fibrillation undergoing cryoballoon pulmonary vein isolation to transseptal access with a commercially available transseptal system (radiofrequency needle plus stiff pigtail wire; RF + Pigtail group) versus conventional transseptal access (standard group). The primary outcome was time required for left atrial access. Secondary outcomes included failure of the assigned transseptal system, radiation exposure, and complications.ResultsThe median transseptal puncture time was significantly shorter using the radiofrequency needle plus stiff pigtail wire transseptal system compared with conventional transseptal (840 ± 323 vs. 956 ± 407 s, P = 0.0489). Compared to conventional transseptal puncture, fewer transseptal attempts were required (1.0 ± 0.5 RF applications vs. 1.3 ± 0.8 mechanical punctures, P = 0.0123) and the fluoroscopy time was significantly shorter (72.0 [IQR 48.0, 129.0] vs. 93.0 [IQR 60.0, 171.0] s, P = 0.0490) with the radiofrequency needle plus stiff pigtail wire transseptal system. Failure to achieve transseptal LA access with the assigned system was rarely observed (1.3% vs. 5.7%, P = 0.2192). There were no procedural complications observed with either system.ConclusionsThe use of a radiofrequency needle plus stiff pigtail wire resulted in shorter time to left atrial access and reduced fluoroscopy time compared to left atrial access using conventional transseptal equipment.Trial registrationClinicalTrials.gov identifier NCT03199703.

This volume in the groundbreaking 6 Principles series focuses on English for specific purposes (ESP) and how it plays a critical role internationally as adult learners acquire English for study, work, and life. The field of ESP has come into increasing prominence as globalization has motivated adult learners to advance their English language skills.

METHODS: Patients with HF were approached for inclusion in the randomized control trial if they were hospitalized, seen in the emergency department (ED) or in an outpatient clinic (with a HF hospitalization in the past 6 months). The COPE educational program consisted of a 20-minute video, supplementary booklet and 3 bimonthly newsletters focusing on 3 previously identified key areas of knowledge deficiency: salt and fluid restriction, daily weights and medications. Patients randomized to the intervention group watched the video at least once and were encouraged to review it at home, along with the booklet/newsletters and discuss questions with their physicians. Patients in the usual care group received the booklet only and were encouraged to speak with their physicians.

Both ST resolution and Q-wave development postfibrinolysis provide important prognostic insights in patients with acute myocardial infarction (MI). However, the relative contributions of these 2 factors to risk assessment have not been examined prospectively. ST resolution and Q development were evaluated 24 to 36 hours (24–36h) postfibrinolysis in ASSENT-2: 13,100 out of 16,949 patients who had both baseline and 24–36h electrocardiograms free of confounders (left bundle branch block, ventricular rhythm, reinfarction before 24–36h electrocardiograms) were included in this analysis. Q-wave MI evolved in 10,466 patients (79.9%) and 2634 patients (20.1%) had non-Q–wave MI at 24–36h postfibrinolysis. Mortality rates at 1-year were 7.0% for patients with Q-wave MI and 5.8% for non-Q–wave MI patients, respectively ( P = .046). Patients with Q-wave MI versus those without were less likely to have complete ST-segment resolution (49.1% vs 59.1%) and more likely to have partial (37.1% vs 27.8%) or no resolution (13.8% vs 13.1%) at 24 to 36 hours postfibrinolysis ( P < .001). Mortality rates at 1 year for Q-wave MI with complete, partial, and no resolution were 5.2%, 8.1%, and 10.1%, respectively ( P < .001), and for non-Q–wave MI with complete, partial, and no resolution were 4.5%, 7.6%, and 8.0% ( P = .003). These results demonstrate the additional prognostic significance of ST-segment resolution to Q-wave development at 24 to 36 hours after fibrinolysis.