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Atrial fibrillation (AF) is the most common sustained arrhythmia, causing a 2‐fold increase in mortality and a 5‐fold increase in stroke. The Asian population is rapidly aging, and in 2050, the estimated population with AF will reach 72 million, of whom 2.9 million may suffer from AF‐associated stroke. Therefore, stroke prevention in AF is an urgent issue in Asia. Many innovative advances in the management of AF‐associated stroke have emerged recently, including new scoring systems for predicting stroke and bleeding risks, the development of non‐vitamin K antagonist oral anticoagulants (NOACs), knowledge of their special benefits in Asians, and new techniques. The Asia Pacific Heart Rhythm Society (APHRS) aimed to update the available information, and appointed the Practice Guideline sub‐committee to write a consensus statement regarding stroke prevention in AF. The Practice Guidelines sub‐committee members comprehensively reviewed updated information on stroke prevention in AF, emphasizing data on NOACs from the Asia Pacific region, and summarized them in this 2017 Consensus of the Asia Pacific Heart Rhythm Society on Stroke Prevention in AF. This consensus includes details of the updated recommendations, along with their background and rationale, focusing on data from the Asia Pacific region. We hope this consensus can be a practical tool for cardiologists, neurologists, geriatricians, and general practitioners in this region. We fully realize that there are gaps, unaddressed questions, and many areas of uncertainty and debate in the current knowledge of AF, and the physician׳s decision remains the most important factor in the management of AF.

[...]while accurate initially, the shifts that can occur as described earlier renders the image no longer as accurate as initially. [...]Kistler et al in another report 2 years later reported that it did not significantly improve the clinical outcome. 3 The meta‐analysis by Mammadi et al 4 in this journal shows that image integration to guide RF ablation for AF does not improve clinical and procedural outcomes. BEYOND IMAGE INTEGRATION The advantage of a preprocedure cardiac CT is that it provides a clear definition of the number of pulmonary veins, presence of common ostium and accessory veins if any. [...]it allows the operator to quickly create the correct electroanatomical map and proceed with ablation with or without any attempt at image integration. [...]whilst image integration has significant limitations as demonstrated by the paper by Mammadi et al, it does not imply that the preoperative imaging is useless.

We aimed to investigate the sex-related differences in the clinical course of patients with Atrial Fibrillation (AF) enrolled in the Asia–Pacific-Heart-Rhythm-Society Registry. Logistic regression was utilized to investigate the relationship between sex and oral anticoagulant, rhythm control strategies and the 1-year chance to maintain sinus rhythm. Cox-regression was utilized to assess the 1-year risk of all-cause, and cardiovascular death, thromboembolic events, acute coronary syndrome, heart failure, and major bleeding. In the whole cohort (4121 patients, 69 ± 12 years,34.3% female), females had different cardiovascular risk factors, clinical manifestations, and disease perceptions than men, with more advanced age (72 ± 11 vs 67 ± 12 years, p < 0.001) and dyslipidemia (36.7% vs 41.7%, p = 0.002). Coronary artery disease was more prevalent in males (21.1% vs 16.1%, p < 0.001) as well as the use of antiplatelet drugs. Females had a higher use of oral anticoagulant (84.9% vs 81.3%, p = 0.004) but this difference was non-significant after adjustment for confounders. On multivariable analyses, females were less often treated with rhythm control strategies (Odds Ratio [OR] 0.44,95% Confidence Interval [CI] 0.38–0.51) and were less likely to maintain sinus rhythm (OR 0.27, 95% CI 0.22–0.34) compared to males. Cox-regressions analysis showed no sex-related differences for the risk of death, cardiovascular, and bleeding. The clinical management of Asian AF patients should consider several sex-related differences.

Aims. To evaluate the adverse events (and its clinical correlates) in a large prospective cohort of Asian patients with atrial fibrillation (AF) and diabetes mellitus (DM). Material and Methods. We recruited patients with atrial fibrillation (AF) from the Asia-Pacific Heart Rhythm Society (APHRS) AF Registry and included those for whom the diabetic mellitus (DM) status was known. We used Cox-regression analysis to assess the 1-year risk of all-cause death, thromboembolic events, acute coronary syndrome, heart failure and major bleeding. Results. Of 4058 patients (mean age 68.5 ± 11.8 years; 34.4% females) considered for this analysis, 999 (24.6%) had DM (age 71 ± 11 years, 36.4% females). Patients with DM had higher mean CHA2DS2-VASc (2.3 ± 1.6 vs. 4.0 ± 1.5, p < 0.001) and HAS-BLED (1.3 ± 1.0 vs. 1.7 ± 1.1, p < 0.001) risk scores and were less treated with rhythm control strategies compared to patients without DM (18.7% vs. 22.0%). After 1-year of follow-up, patients with DM had higher incidence of all-cause death (4.9% vs. 2.3%, p < 0.001), cardiovascular death (1.3% vs. 0.4%, p = 0.003), and major bleeding (1.8% vs. 0.9%, p = 0.002) compared to those without DM. On Cox regression analysis, adjusted for age, sex, heart failure, coronary and peripheral artery diseases and previous thromboembolic event, DM was independently associated with a higher risk of all-cause death (HR 1.48, 95% CI 1.00–2.19), cardiovascular death (HR 2.33, 95% CI 1.01–5.40), and major bleeding (HR 1.91, 95% 1.01–3.60). On interaction analysis, the impact of DM in determining the risk of all-cause death was greater in young than in older patients (p int = 0.010). Conclusions. Given the high rates of adverse outcomes in these Asian AF patients with DM, efforts to optimize the management approach of these high-risk patients in a holistic or integrated care approach are needed.

Among the many results noted in the survey are as follows: (1) there were large differences in the stance of using antiplatelet agents for low-risk patients with a CHADS2 score of 0–1; (2) warfarin was markedly underused in some countries; and (3) warfarin was quickly replaced by dabigatran, such that dabigatran was more frequently used than warfarin in some countries. Since antithrombotic therapy for patients with AF is rapidly changing with the increasing use of dabigatran, rivaroxaban, and apixaban, some of the primary issues that will influence the future revision of various guidelines (HRS [Heart Rhythm Society], ESC [European Society of Cardiology], ACC [American College of Cardiology], CCS [Canadian Cardiovascular Society], JCS [Japanese Circulation Society], etc.) would be how to use warfarin and other drugs for different indications and to determine the most accurate clinical position of each drug. In particular, there are data currently suggesting that the bleeding risk associated with newer anticoagulants is lower than that of warfarin [11–14]. [...]a central point in the new guidelines or statements would be to expand the indications of these newer anticoagulant drugs to include low-risk patients (CHADS2 score 0/1) and to reconsider the indications of antiplatelet agents, including acetylsalicylic acid (ASA). Under such circumstances, it is mandatory to publish the APHRS's “Statement on antithrombotic therapy of AF” with the aim of unifying the variety of antithrombotic therapies in Asia-Pacific countries and promoting the appropriate use of anticoagulants, including newly launched drugs. 2 Current status of international guidelines after launch of novel anticoagulants When developing guidelines on antithrombotic therapy, we must consider that novel anticoagulants are approved in different countries at different times. Since the primary role of guidelines is to describe how to use currently available drugs, guidelines used in a country should describe regimens of drugs currently available in that country. The ESC 2010 guidelines describe that dabigatran may be considered an alternative to warfarin; the “Quick Reference Guide: Atrial Fibrillation Information for the Health Practitioner” proposed by the government of Western Australia (referred to as the “Australian 2011” guidelines) [6] lists warfarin only; the evidence-based clinical practice guidelines for antithrombotic therapy for AF proposed by the American College of Chest Physicians (referred to as the “ACCP 2012” guidelines) [3] made recommendations only for dabigatran, which was approved for use in AF, among novel OACs as an alternative to warfarin; and the focused 2012 update of the CCS AF guidelines (referred to as the “CCS 2012” guidelines) [8] suggest that when OAC therapy is indicated, most patients should receive dabigatran, rivaroxaban, or apixaban in preference to warfarin, since all these drugs are associated with less intracranial hemorrhage (ICH) and are much simpler to use.

Dual-chamber pacing (atrial and ventricular) has been compared with single-chamber pacing (atrial or ventricular) in patients with bradycardia in 5 multicenter, parallel, randomized trials, in 1 meta-analysis of randomized trials, and in 1 systematic review that also included 30 randomized crossover comparisons and 4 economic analyses [3–9]. The net result is that the indications for programming the dual- chamber modes are weaker and the choice regarding the pacing mode should be individualized, taking into consideration the increased complication risk and costs of dual- chamber devices. Because ICD patients usually do not require bradycardia support, with the exception of patients who require cardiac resynchronization, programming choices should avoid pacing and in particular avoid single ventricular pacing, if possible [15,16]. 3 Programming of Rate Modulation The benefit of rate response programming has been evaluated in patients with bradycardia in 5 multicenter, randomized trials and in 1 systematic review that also included 7 single-center studies [17–22]. In 2 small studies on patients with chronotropic incompetence comparing DDD and DDDR pacing, the latter had improved quality of life and exercise capacity; however, a larger, multicenter randomized trial (Advanced Elements of Pacing Randomized Controlled Trial [ADEPT]) failed to show a difference in patients with a modest blunted heart rate response to exercise [17–19].

Abstract Background Percutaneous transcatheter radiofrequency ablation of atrial fibrillation with remote controlled magnetic navigation (RMN) has been shown to reduce radiation exposure to patients and physicians compared with conventional manual (MAN) ablation techniques. Methods Catheter ablation for atrial fibrillation was performed utilizing RMN in 214 consecutive patients and MAN ablation techniques in 229 patients. We compared the fluoroscopy and procedural times between RMN and MAN catheter ablation of atrial fibrillation. Secondary objectives included comparing acute procedural success and short-term complication rates between both ablation strategies. Results Fluoroscopy time was significantly shorter in the RMN group than the MAN group (53.5±30.1 vs 68.1±27.6 min, respectively; p <0.01); however, the total procedural time was longer in the RMN group (280.2±74.4 min vs 213.1±64.75, respectively; p >0.001). Further subgroup analysis of the most recent 50 ablations each from the RMN and MAN groups, to attenuate the RMN learning curve effect, showed an even greater difference in fluoroscopy time (RMN vs MAN: 53.5±30.1 vs 68.1±27.6 min), though a consistently longer procedure time with RMN (249.5±65.5 vs 186.3±65.6 min, respectively). The acute procedural success rate was comparable between the groups (98.6% vs 95.6%, respectively; p =0.07). The rates of acute complications were similar in both groups (2.3% vs 4.8%, respectively; p =0.16). Conclusions In radiofrequency ablation of atrial fibrillation, RMN appears to significantly reduce fluoroscopy time compared with conventional MAN ablation, though at a cost of increased total procedural time, with comparable acute success rates and safety profile. A reduction in procedure and fluoroscopy times is possible with gaining experience.

An end‐stage renal failure patient who was planned for a left brachioaxillary arteriovenous graft required an implantable cardioverter‐defibrillator for secondary prevention of ventricular tachycardia and a pacemaker for complete heart block but was found to have a right subclavian venous occlusion. Due to the lack of vascular access, we performed a successful subcutaneous implantable cardioverter‐defibrillator (S‐ICD) and leadless pacemaker implantation. There was no interaction between the devices at the time of implantation, during defibrillation testing and following an appropriate defibrillation therapy.

Abstract The combined use of an Amplatz guiding catheter and support catheter creates a progressively supportive rail to implant the left ventricular (LV) lead in difficult cardiac resynchronization therapy device implantation. We describe the case of a 32-year-old male with non-ischaemic cardiomyopathy, left bundle-branch block, and an LV ejection fraction of 30%, who was referred to our centre for a repeat attempt at an LV lead implant. Previously, the implanter had been unable to advance different guide catheters over the wire to the desired tributary of the coronary sinus (CS). At our centre, the CS was cannulated with a 6-Fr AL2 coronary guiding catheter. A 135-cm support catheter (Spectranetics Quick-Cross) was advanced via AL2 guiding over the 0.035 in. guide wire to the distal CS. The proximal luer fitting of the support catheter was cut and an inner sheath (Medtronic ATTAIN SELECT II) advanced over the support catheter into the CS. A 4-Fr over-the-wire LV lead was advanced through the inner sheath over a 0.014 in. percutaneous transluminal coronary angioplasty wire after removal of the support catheter. The use of a support catheter serves as rail for the placement of the inner sheath deep in the CS and facilitates implantation of the LV pacing lead. This technique is safe and easily applied.

Atrial fibrillation (AF) imposes substantial burdens of morbidity and impaired health-related quality of life, and significantly increases sufferers' risk of having a cardiovascular event, in particular a stroke. Prevalence of AF in Asia and the associated healthcare costs are likely to have been underestimated and are expected to increase due to greater awareness, population ageing and increasing prevalence of associated risk factors and comorbidities. The AF management paradigm is shifting from a conventional focus on achieving heart rate or rhythm control, towards endeavouring to use the safest agents available to reduce patients' symptoms and improve their quality of life and cardiovascular outcomes. No new anti-AF drugs have been introduced for decades and existing pharmacotherapeutic modalities have potentially serious side effects as well as sub-optimal efficacy in converting to and maintaining normal sinus rhythm and preventing recurrence. There is an unmet need for better anti-arrhythmic drugs that are well tolerated, efficacious, cost-effective and have a more favourable safety profile than current options. Although the perfect agent remains to be discovered, some promising new anti-arrhythmic drugs have the potential to overcome certain limitations of established approaches to AF management.