BACKGROUND: Maintenance of sinus rhythm is challenging in patients with longstanding persistent atrial fibrillation (PeAF). Minimally invasive surgical AF ablation may improve outcomes when combined with catheter ablation (the 'convergent' procedure). This study evaluates the safety and efficacy of the convergent procedure versus catheter ablation alone in longstanding PeAF. METHODS: 43 consecutive patients with longstanding PeAF underwent subxiphoid endoscopic ablation of the posterior left atrium followed by catheter ablation from 2013-2018. The primary outcome was AF-free survival at 12 months; secondary outcomes included change in EHRA class, echocardiographic data, procedural complications, freedom from anti-arrhythmic drugs (AADs), and long term arrhythmia-free survival. Outcomes were compared with a matched group of 43 patients who underwent catheter ablation alone. Both groups underwent multiple catheter ablations as required. Baseline characteristics were similar between groups. RESULTS: After 12 months, the convergent procedure was associated with increased AF-free survival on AADs (60.5 % versus 25.6%, p=0.002) and off AADs (37.2% versus 13.9%, p=0.025), versus catheter ablation. Allowing for multiple procedures, after 30.5±13.3 months' follow-up the convergent procedure was associated with increased arrhythmia-free survival on AADs (58.1% versus 30.2%, p=0.016) and off AADs (32.5% versus 11.6%, p=0.036) versus catheter ablation. There were more complications in the convergent procedure group (11.6% versus 2.3%, p=0.2). Multivariate analysis identified only the convergent procedure (OR 3.06 (1.23-7.6), p=0.017) as predictive of arrhythmiafree survival long term. CONCLUSIONS: In longstanding PeAF, the convergent procedure is associated with improved arrhythmia-free survival versus catheter ablation alone. Complication rates are significant but have been shown to depreciate with experience.

Background: Diabetes mellitus (DM) is associated with increased risk of cardiovascular disease. Detection of early cardiac changes before manifest disease develops is important. We investigated early alterations in cardiac structure and function associated with DM using cardiovascular magnetic resonance imaging. Methods: Participants from the UK Biobank Cardiovascular Magnetic Resonance Substudy, a community cohort study, without known cardiovascular disease and left ventricular ejection fraction ≥50% were included. Multivariable linear regression models were performed. The investigators were blinded to DM status. Results: A total of 3984 individuals, 45% men, (mean [SD]) age 61.3 (7.5) years, hereof 143 individuals (3.6%) with DM. There was no difference in left ventricular (LV) ejection fraction (DM versus no DM; coefficient [95% CI]: −0.86% [−1.8 to 0.5]; P =0.065), LV mass (−0.13 g/m 2 [−1.6 to 1.3], P =0.86), or right ventricular ejection fraction (−0.23% [−1.2 to 0.8], P =0.65). However, both LV and right ventricular volumes were significantly smaller in DM, (LV end-diastolic volume/m 2 : −3.46 mL/m 2 [−5.8 to −1.2], P =0.003, right ventricular end-diastolic volume/m 2 : −4.2 mL/m 2 [−6.8 to −1.7], P =0.001, LV stroke volume/m 2 : −3.0 mL/m 2 [−4.5 to −1.5], P <0.001; right ventricular stroke volume/m 2 : −3.8 mL/m 2 [−6.5 to −1.1], P =0.005), LV mass/volume: 0.026 (0.01 to 0.04) g/mL, P =0.006. Both left atrial and right atrial emptying fraction were lower in DM (right atrial emptying fraction: −6.2% [−10.2 to −2.1], P =0.003; left atrial emptying fraction:−3.5% [−6.9 to −0.1], P =0.043). LV global circumferential strain was impaired in DM (coefficient [95% CI]: 0.38% [0.01 to 0.7], P =0.045). Conclusions: In a low-risk general population without known cardiovascular disease and with preserved LV ejection fraction, DM is associated with early changes in all 4 cardiac chambers. These findings suggest that diabetic cardiomyopathy is not a regional condition of the LV but affects the heart globally.

C ardiovascular MRI tissue tagging is the noninvasive reference standard for myocardial strain estimation (1-4). Although cardiovascular MRI feature tracking allows calculation of strain from standard steady-state free precession images, features are limited to myocardial edges (5) and structures outside the myocardium (6), whereas cardiovascular MRI tagging enables detection and tracking of features within the myocardium. Displacement encoding with stimulated echoes (7,8) has the potential to provide higher spatial resolution strain estimates (9) but, to date, has not been as widely used (10). The utility of cardiovascular MRI tagging has been demonstrated in many different patient groups (4). However, there is a lack of robust fully automated analysis tools for the quantification of strain from cardiovascular MRI-tagged images, leading to analysis times that are prohibitive in a high-throughput setting, such as studies with many hundreds of cases or high-volume clinical centers with more than 20 cases per week (4,11,12). The most common approaches for strain analysis of cardiovascular MRI-tagged images include profile matching and spline fitting (13), deformable contours (14), harmonic phase analysis (15), and sine wave modeling (16). However, these methods require manual initialization and lack robustness. Recently, deep learning methods, particularly convolutional neural networks

Aims Cardiac tamponade is a high morbidity complication of transseptal puncture (TSP). We examined the associations of TSP‐related cardiac tamponade (TRCT) for all patients undergoing left atrial ablation at our center from 2016 to 2020. Methods and Results Patient and procedural variables were extracted retrospectively. Cases of cardiac tamponade were scrutinized to adjudicate TSP culpability. Adjusted multivariate analysis examined predictors of TRCT. A total of 3239 consecutive TSPs were performed; cardiac tamponade occurred in 51 patients (incidence: 1.6%) and was adjudicated as TSP‐related in 35 (incidence: 1.1%; 68.6% of all tamponades). Patients of above‐median age [odds ratio (OR): 2.4 (1.19–4.2), p = .006] and those undergoing re‐do procedures [OR: 1.95 (1.29–3.43, p = .042] were at higher risk of TRCT. Of the operator‐dependent variables, choice of transseptal needle (Endrys vs. Brockenbrough, p > .1) or puncture sheath (Swartz vs. Mullins vs. Agilis vs. Vizigo vs. Cryosheath, all p > .1) did not predict TRCT. Adjusting for operator, equipment and demographics, failure to cross the septum first pass increased TRCT risk [OR: 4.42 (2.45–8.2), p = .001], whilst top quartile operator experience [OR: 0.4 (0.17–0.85), p = .002], transoesophageal echocardiogram [TOE prevalence: 26%, OR: 0.51 (0.11–0.94), p = .023], and use of the SafeSept transseptal guidewire [OR: 0.22 (0.08–0.62), p = .001] reduced TRCT risk. An increase in transseptal guidewire use over time (2016: 15.6%, 2020: 60.2%) correlated with an annual reduction in TRCT (R2 = 0.72, p < .001) and was associated with a relative risk reduction of 70%. Conclusions During left atrial ablation, the risk of TRCT was reduced by operator experience, TOE‐guidance, and use of a transseptal guidewire, and was increased by patient age, re‐do procedures, and failure to cross the septum first pass.

BackgroundHeart failure with preserved ejection fraction (HFpEF) causes significant cardiovascular morbidity and mortality. Current consensus guidelines reflect the neutral results from randomised controlled trials (RCTs). Adequate trial reporting is a fundamental requirement before concluding on RCT intervention efficacy and is necessary for accurate meta-analysis and to provide insight into future trial design. The Consolidated Standards of Reporting Trials (CONSORT) 2010 statement provides a framework for complete trial reporting. Reporting quality of HFpEF RCTs has not been previously assessed, and this represents an important validation of reporting qualities to date.ObjectivesThe aim was to systematically identify RCTs investigating the efficacy of pharmacological therapies in HFpEF and to assess the quality of reporting using the CONSORT 2010 statement.MethodsMEDLINE, EMBASE and CENTRAL databases were searched from January 1996 to November 2015, with RCTs assessing pharmacological therapies on clinical outcomes in HFpEF patients included. The quality of reporting was assessed against the CONSORT 2010 checklist.ResultsA total of 33 RCTs were included. The mean CONSORT score was 55.4% (SD 17.2%). The CONSORT score was strongly correlated with journal impact factor (r=0.53, p=0.003) and publication year (r=0.50, p=0.003). Articles published after the introduction of CONSORT 2010 statement had a significantly higher mean score compared with those published before (64% vs 50%, p=0.02).ConclusionsAlthough the CONSORT score has increased with time, a significant proportion of HFpEF RCTs showed inadequate reporting standards. The level of adherence to CONSORT criteria could have an impact on the validity of trials and hence the interpretation of intervention efficacy. We recommend improving compliance with the CONSORT statement for future RCTs.

No abstract

Introduction: The Heliostar™ ablation system is a novel RF balloon ablation technology with an integrated three-dimensional mapping system. Here, we describe our early experience and procedural outcomes using this technology for atrial fibrillation catheter ablation. Methods:We sought to comprehensively assess the first 60 consecutive patients undergoing pulmonary vein isolation using the novel HELISOTAR™ RF balloon technology including procedural outcomes. A comparison of the workflow between two different anaesthetic modalities (conscious sedation [CS] vs. general anaesthesia [GA]) was made. Procedural data were collected prospectively from two highvolume centers (Barts Heart Centre, UK and University Hospital of Zurich, Zurich). A standardized approach for catheter ablation was employed.Results: A total of 35 patients had the procedure under CS and the remaining under GA. Mean procedural and fluoroscopy times were 84 ± 33 min and 1.1 min.The median duration of RF energy application was 7 (5-9.8) mins per patient. All veins were successfully isolated, and the median isolation time was 10 (7-15) seconds. Our cohort's rate of procedural complications was low, with no mortality within 30 days postprocedure. Conclusion:Our early experience shows that catheter ablation using the Heliostar™ technology can be performed efficiently and safely; however, long-term data is yet to be established. Low fluoroscopy requirements, short learning curves and use of this technology with CS is possible, including the use of an oesophageal temperature probe.

Reporting standards for diagnostic accuracy studies of non-invasive cardiac imaging are at most satisfactory and have improved since the introduction of STARD. Adherence to STARD should be mandatory for authors of diagnostic accuracy studies.