Explore the vast range of titles available.

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.

Understanding the initiating role of pulmonary veins in atrial fibrillation (AF) has led to the development of pulmonary vein isolation (PVI). The efficacy of PVI is high for paroxysmal AF, whereas it is limited for non-paroxysmal AF. This fact highlights the necessity of understanding the mechanism through which AF is maintained, to develop ablation strategies that would be required in addition to the PVI. Mapping AF in animal models and humans has led to the identification of focal or rotational drivers. New technologies have been developed to identify those AF drivers and are used as a guide for catheter ablation. This review article aims to provide a comprehensive overview of the current state of knowledge regarding AF drivers and the various mapping approaches used to identify them.

The consensus of the Asia Pacific Heart Rhythm Society (APHRS) on stroke prevention in atrial fibrillation (AF) has been published in 2017 which provided useful clinical guidance for cardiologists, neurologists, geriatricians, and general practitioners in Asia‐Pacific region. In these years, many important new data regarding stroke prevention in AF were reported. The Practice Guidelines subcommittee members comprehensively reviewed updated information on stroke prevention in AF, and summarized them in this 2021 focused update of the 2017 consensus guidelines of the APHRS on stroke prevention in AF. We highlighted and focused on several issues, including the importance of AF Better Care (ABC) pathway, the advantages of non–vitamin K antagonist oral anticoagulants (NOACs) for Asians, the considerations of use of NOACs for Asian patients with AF with single 1 stroke risk factor beyond gender, the role of lifestyle factors on stroke risk, the use of oral anticoagulants during the “coronavirus disease 2019” (COVID‐19) pandemic, etc. 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. We aim to publish the APHRS consensus simultaneously with the APHRS annual scientific meeting.

Introduction Little evidence exists regarding cryoballoon ablation (CBA) of paroxysmal atrial fibrillation (PAF) in hemodialysis (HD) patients. We compared CBA and radiofrequency ablation (RFA) of PAF in HD patients, referring to CBA of PAF in non-HD patients. Methods and results This historical cohort study examined 88 patients who underwent catheter ablation of PAF, including 21 HD patients with a second-generation 28-mm cryoballoon (CB-HD group), 17 HD patients with a non-force-sensing radiofrequency catheter (RF-HD group), and 50 non-HD patients with a cryoballoon (CB-non-HD group). Pulmonary vein (PV) isolation alone aside from cavotricuspid isthmus ablation was performed in 14 (67%) in the CB-HD group, 12 (71%) in the RF-HD group, and 36 (72%) in the CB-non-HD group ( P  = 0.95), without isoproterenol-induced non-PV triggers. Non-PV trigger ablation was added to the other patients. The Kaplan–Meier estimated 1-year freedom from atrial tachyarrhythmia recurrence without antiarrhythmic drugs after a single procedure was 76%, 59%, and, 92% in the CB-HD, RF-HD, and CB-non-HD groups, respectively ( P  = 0.002). The mean procedure time was shorter in the CB-HD group than in the RF-HD group (127 vs. 199 min; P  < 0.001). In the second procedure, the median number of reconnected pulmonary veins was 0.5 in the CB-HD group versus 2.0 in the RF-HD group ( P  = 0.17). Conclusion For PAF in HD patients, CBA showed a comparable single-procedure efficacy to that of RFA with a short procedure time. CBA may be a reasonable initial procedure for HD patients suffering from symptomatic PAF.

Background Little evidence exists regarding the endpoint and optimum approach to catheter ablation for long‐standing persistent atrial fibrillation (LSPAF). We examined the efficacy of pulmonary vein isolation (PVI) plus left atrium posterior wall isolation (PWI) and additional non‐PV trigger ablation using high‐dose isoproterenol for LSPAF. Methods One‐hundred and fifty‐five patients (median AF duration, 36 months) underwent catheter ablation for LSPAF; After PVI plus PWI, they underwent provocation of non‐PV triggers by high‐dose isoproterenol and were divided into 3 groups based on the results: group A, PVI plus PWI alone, without induced non‐PV triggers (single procedure: 105 patients, multiple procedures: 90 patients); group B, mappable non‐PV triggers demonstrated and ablated (single procedure: 41 patients, multiple procedures: 45 patients); group C, if non‐PV triggers were unmappable or could not be induced in repeated procedures, adjunctive complex fractionated atrial electrogram ablation was performed (single procedure: 9 patients, multiple procedures: 20 patients). Results The Kaplan‐Meier estimate of the 1‐year freedom from atrial tachyarrhythmias without antiarrhythmic drugs was 65% in all patients, (73%, 56%, and 11% in groups A, B, and C, respectively) after a single procedure, which improved to 86% in all patients (93%, 86%, and 53% in groups A, B, and C, respectively) after multiple procedures. Conclusion Even for LSPAF, in approximately 60% of patients, non‐PV triggers were not elicited, and PVI plus PWI alone achieved good outcomes. Although the inducibility of non‐PV triggers was associated with recurrence of atrial tachyarrhythmias, additional non‐PV trigger ablation may improve the outcome after multiple procedures.

A 46‐year‐old female with a body mass index of 38.9 kg/m2 and no organic heart disease underwent a subcutaneous implantable cardioverter‐defibrillator implantation for secondary prevention of sudden cardiac death in the setting of idiopathic ventricular fibrillation. Defibrillation threshold (DFT) testing during implantation detected high shock impedance and high DFT. Fluoroscopy revealed subcoil fat between the lead and the sternum, which we suspected was the reason for the high shock impedance and high DFT. We repositioned the lead to a site just above the sternum and the shock impedance and DFT improved to within the respective normal ranges.

Background The peri‐outflow tract region could be the origin of ventricular tachycardia (VT) after aortic valve replacement (AVR). However, the clinical characteristics of outflow tract ventricular tachycardias (OTVTs) after AVR are yet to be clarified. This study investigated the incidence, risk factors, and clinical characteristics of patients with OTVTs after AVR. Methods We retrospectively analyzed the clinical course of 120 patients who had undergone surgical AVR (SAVR) between April 1980 and October 2018. The patients had no ischemic or diagnosed cardiomyopathies other than primary aortic valve diseases. Results Six patients (5.0%) developed OTVTs after SAVR. The average onset was at 10.8 ± 5.7 years after SAVR. All cases of VT arose from the inferior axis and included left and right bundle branch block configuration. Two patients who underwent cardiac magnetic resonance imaging (MRI) had late gadolinium enhancement (LGE) in the midlayer of the left ventricle basal anteroseptal wall. Patients with periaortic VTs had significantly larger left ventricular (LV) diameter at systole, lower LV ejection fraction, higher positive rates of signal‐averaged electrocardiogram (SAECG), and nonsustained VTs on Holter monitoring. On ablation, local fragmented potentials with low voltage zones were observed in accordance with the LGE distribution. Multiple VTs originating from the periaortic region were provoked in the sessions. Conclusions Acute OTVT was found in 5% of patients after SAVR. Arrhythmia risk stratification by SAECG, Holter ECG, and cardiac MRI should be considered for a long period in patients after SAVR. Based on our results, acute onset of OTVT was found in 5% of patients who received SAVR. Therefore, we suggest that arrhythmic risk stratification should be considered for patients who have undergone SAVR for a long period.

Background The feasibility and safety of pulmonary vein isolation (PVI) using cryoballoon (CB) for paroxysmal atrial fibrillation (PAF) with minimally interrupted apixaban has not fully explored. Methods In this multicenter, randomized prospective study, we enrolled patients with PAF undergoing CB or radiofrequency (RF) ablation with interrupted (holding 1 dose) apixaban. The primary composite end point consisted of bleeding events, including pericardial effusion and major bleeding requiring blood transfusion, or thromboembolic events at 4 weeks after ablation; secondary end points included early recurrence of AF and procedural duration. Results A total of 250 patients underwent PVI (125 assigned to the RF ablation and 125 assigned to the CB ablation). The primary end point occurred in 1 patient in the CB ablation group (0.8%; 90% confidence interval [CI], 0.04 to 3.70) and 3 patients in the RF group (2.4%, P = .622; risk ratio, 0333; 90% CI, 0.05 to 2.20). All events were pericardial effusion, all of whom recovered after pericardiocentesis. Early recurrence of AF occurred in 4 patients (3.2%) in the RF group and in 6 patients (4.8%) in the CB group (P = .749). The procedural duration was shorter in the CB group than that in the RF group (136.5 ± 39.9 vs 179.5 ± 44.8 min, P < .001). Conclusion CB ablation with minimally interrupted apixaban was feasible and safe in patients with PAF undergoing PVI, which was equivalent to RF ablation. Comparison of Safety and Feasibility of Apixaban between Cryoballoon and Radiofrequency pulmonary vein isolation for paroxysmal atrial fibrillation

Pulmonary vein isolation (PVI) is the cornerstone of ablation strategies for atrial fibrillation (AF), and noninferiority of cryoballoon (CB) over radiofrequency (RF) ablation has been previously reported. One of the risk factors of recurrence is left atrium (LA) enlargement. This study aimed to analyze the impact of LA enlargement on the selection of CB or RF ablation for AF patients. A total of 2,224 AF patients (64.4 ± 10.7 years, 65.5% male) who underwent PVI were analyzed retrospectively. Left atrial diameter (LAD) and volume (LAV) were measured using echocardiography before the procedures. LA enlargement was defined as LAD ≥40 mm and LAV index (LAVI) ≥35 mL/m2. Patients undergoing CB and RF ablation were propensity score matched, and 376 matched pairs were evaluated. Cox proportional hazard analysis revealed that LAD (95% CI, 1.01-1.05), LAV (95% CI, 1.01-1.02), and LAVI (95% CI, 1.01-1.03) were independent predictors of recurrence. CB showed equivalent clinical outcomes to those of RF with shorter procedure time required for patients without LA enlargement. CB was inferior to RF in patients with LA enlargement (LAD, 74.5% vs 84.6%, P = .028; LAVI, 74.7% vs 83.4%, P = .015), and large LAVI was associated with a higher prevalence of non-PV foci (35% vs 29%, P = .008). CB ablation may be recommended for patients without enlarged LA based on the short procedure time and efficacy, whereas RF would be more appropriate in large LAs. LAVI may be a valuable reference to predict PVI outcomes and in selecting the ablation method.

Recent studies have demonstrated the utility of cardiac sympathetic denervation (CSD) in patients with ventricular tachycardia (VT) refractory to antiarrhythmic drugs and catheter or surgical ablation. We present our experience with bilateral CSD in a patient with a recurrent VT despite attempts at treatment with catheter ablation and antiarrhythmic drugs, and this is the first description of the successful management of an idiopathic refractory VT with a bilateral CSD and concomitant oral amiodarone, occurring after catheter ablation of persistent atrial fibrillation and idiopathic outflow tract premature ventricular contractions.