Joris Ector

Aims: Chronotropic incompetence (CI), defined as the inability of the heart to appropriately increase its rate in response to exercise, is associated with exercise intolerance and adverse events. However, the diagnostic criteria for CI vary widely, limiting their clinical applicability and comparability across studies. Here we aim to systematically map the current definitions of CI and the prediction models used to estimate age-predicted maximal heart rate (APMHR). We illustrate how this diagnostic variability affects the identification of CI in patients enrolled in a cardiac rehabilitation program. Methods and results: A scoping review systematically identified all published definitions of CI and prediction models for APMHR. A retrospective study evaluated the agreement between definitions in patients participating in cardiac rehabilitation. A total of 86 studies were included. Seventeen distinct methods to define CI were identified, ranging from absolute or relative peak heart rate parameters to approaches incorporating workload. In many cases, the applied cut-off values lacked a rationale. In parallel, numerous APMHR formulas were identified, differing by sex, age category, fitness level, clinical status, and the use of beta-blocker therapy, showing limited accuracy. In the clinical setting agreement between four major definitions was poor and pairwise comparisons between them showed significant differences in classification. Conclusion: Current methods to define CI and predict APMHR are inconsistent and problematic. This review provides a practical framework for selecting a context-appropriate definition and formula. It identifies current methodological gaps and highlights the need for future research to establish a consensus definition of CI.

Background: Catheter ablation for atrial arrhythmias is a common procedure with the possibility of causing complications, typically involving vascular access sites or cardiac tamponade. However, hepatic haemorrhage as a complication of cardiac catheter ablation is extremely rare. We present a case of life-threatening intra-abdominal bleeding originating from a hepatic vein following a catheter ablation for atrial tachycardia. Case summary: A 67-year-old man with a history of mitral valve repair and multiple ablation procedures for atrial fibrillation, atrial flutter, and macro-reentrant atrial tachycardia (MRAT) underwent a redo catheter ablation for MRAT. After the procedure, he developed right flank pain, hypotension, and a drop in haemoglobin. Imaging revealed extensive hemoperitoneum, originating near the right hepatic vein. Angiography of the visceral arteries was performed on which no major source of bleeding was identified. Because of persisting haemodynamic instability, the patient underwent emergency laparoscopy during which a capsular venous bleeding on the caudal liver surface was identified, likely caused by transient guidewire passage and injury in the hepatic veins. The bleeding was cauterized, and abdominal lavage was performed to clear the hemoperitoneum. He was transferred to the ICU for vasopressor support. Anticoagulation was restarted 1 week later, and the patient was discharged in stable condition. Conclusion: This case highlights a rare but serious complication of catheter ablation. Prompt recognition of intra-abdominal haemorrhage and a multidisciplinary approach involving cardiology, radiology, and surgery were crucial for a successful outcome. Operators should remain vigilant for atypical bleeding complications in ablation procedures and be prepared to initiate rapid intervention.

Advances in surgical techniques have substantially improved survival in patients with repaired tetralogy of Fallot (ToF). However, residual lesions following repair may lead to long-term complications, including arrhythmias and the need for device therapy. We conducted a retrospective single-center cohort study including patients who underwent surgical repair of ToF between 1960 and the present. Patients were categorized into three treatment eras (2000). Data on surgical strategy, mortality, arrhythmias, and cardiac implantable electronic device (CIED) implantation were collected from institutional databases. A total of 640 patients were included, of whom 360 (56.3%) underwent transannular patch (TAP) repair and 280 (43.7%) underwent non-TAP repair. Overall mortality was 7.2%, with cardiac causes accounting for 41.3% of deaths. Arrhythmias occurred in 14.4% of patients and were more frequently observed in those who underwent TAP repair (18.8%). CIED implantation was required in 7.5% of patients, most commonly implantable cardioverter defibrillators. The incidence of arrhythmias decreased across treatment eras, whereas overall survival did not differ significantly between eras. Long-term survival after surgical repair of ToF is favorable. Arrhythmias remain an important late complication, particularly in patients who underwent TAP repair, although their frequency appears to have decreased in more recent treatment eras. These findings underscore the long-term impact of initial surgical strategy on arrhythmic outcomes.

Background: VEXAS syndrome is a newly described autoinflammatory condition; cardiac involvement is exceedingly rare. This case illustrates a reversible complete heart block due to myocarditis in VEXAS, successfully treated with targeted therapy. Case summary: A 69-year-old man with known VEXAS syndrome presented with dizziness and syncope. Workup revealed third-degree atrioventricular (AV) block and imaging consistent with myocarditis. Standard therapy (atropine, isoprenaline infusion) stabilized the patient, and ruxolitinib (a JAK inhibitor) was initiated alongside corticosteroids to treat the underlying inflammatory syndrome. Within days, the patient’s AV conduction was restored without the need for pacemaker insertion. He was discharged with improved cardiac function and ongoing immunomodulatory therapy. Discussion: Targeted immunomodulation can reverse cardiac conduction block caused by inflammation in VEXAS syndrome. This case underscores the importance of recognizing autoinflammatory syndromes as a cause of heart block and suggests a potential role for JAK inhibitors in treating inflammatory myocarditis.

Atrial fibrillation (AF) is a common arrhythmia with high morbidity and mortality. Pulsed-field ablation (PFA) is an emerging non-thermal treatment for AF, offering potential advantages over conventional radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in terms of safety and efficacy. This systematic review, registered in PROSPERO and conducted in line with PRISMA-P guidelines, assessed the efficacy and safety of PFA compared to conventional ablation methods (radiofrequency and cryoballoon) for treating paroxysmal AF in adults. A comprehensive literature search (2019-2025) was performed across multiple databases, with independent screening, data extraction, and bias assessment conducted by two reviewers using validated tools (RoB 2 and ROBINS-I), culminating in a qualitative synthesis due to study heterogeneity. PFA demonstrates promising efficacy in paroxysmal AF, with freedom from atrial arrhythmias at 12 months comparable to CBA and RFA. It also shows comparable first-pass pulmonary vein isolation (PVI) rates and shorter procedure time. Safety outcomes are favourable, with low incidence of adverse events, including no reported atrioesophageal fistulas, low rates of coronary spasm (0.14%) and haemolysis-related kidney injury (0.03%). PFA is an effective and safe alternative to traditional ablation techniques in paroxysmal AF. Further research through large-scale registries and long-term surveillance is needed to address rare complications and fully assess its safety profile.

Aims: Developing an integrated care pathway for atrial fibrillation (AF) patients is of pivotal importance, given the different treatment strategies. Moreover, knowledge about the condition is an important factor in engaging patients in their care. Patient education formed the core of the integrated AF-EduCare/AF-EduApp approach. The main aim of this manuscript is to report the impact of this approach on AF and risk factor (RF)–related knowledge and self-care awareness. Methods and results: Atrial fibrillation patients (n = 1232) were randomized to standard care (SC) or three educational interventions: in-person, online, or app-based education. Patients in the intervention groups received targeted education based on their responses to the Jessa Atrial fibrillation Knowledge Questionnaire (JAKQ) and a Self-Care Questionnaire (SCQ) presented at different time points. Patients who received educational follow-up reached a significantly higher knowledge score (in-person: 86.5 ± 13.2%; online: 82.5 ± 19.3%; app: 80.1 ± 15.0%) than the SC group (65.3 ± 16.6%) after 12/18 months (P < 0.001). The knowledge rapidly improved with the first sessions (i.e. 3 months) and remained sustained in all education groups. Patients with RF at baseline showed a slight but significant increase in awareness about their RF through education [e.g. no knowledge of last measured systolic blood pressure compared between education vs. SC: odds ratio of 0.45 (P = 0.012)], a change that was not seen in SC patients. Nevertheless, patients keep under-estimating the presence of their own RFs compared with objective documentation in their medical record (e.g. hypertension). Conclusion: The JAKQ and SCQ are good instruments to provide targeted education to AF patients in daily clinical care. Knowledge level increases clinically significantly, but the impact on awareness about personal risk factors remains unsatisfactory. Registration: ClinicalTrials/gov: NCT03707873NCT03788044.

Aims: Trials on integrated care for atrial fibrillation (AF) showed mixed results in different AF populations using various approaches. The multicentre, randomized AF-EduCare trial evaluated the effect of targeted patient education on unplanned cardiovascular outcomes. Methods and results: Patients willing to participate were randomly assigned to in-person education, online education, or standard care (SC) and followed for minimum 18 months. Education focused on four aspects of integrated AF care: (i) knowledge on AF and oral anticoagulation; (ii) reinforcement of medication adherence; (iii) awareness about risk factors; and (iv) reachability for AF-related questions. The primary endpoint was the composite of cumulative events of unplanned cardiovascular hospitalizations and consultations, emergency department visits for cardiovascular reasons, and cardiovascular death. A total of 1038 patients (69.8 ± 9.2 years) were followed up for 26.9 ± 9.4 months. Education (both in-person and online) significantly improved AF-related knowledge compared to SC (P < 0.001), increased patient awareness about risk factors, led to high medication adherence, and encouraged patients to ask health-related questions. However, in-person education did not show an effect on the primary outcome compared to SC [HR 1.02 (0.91–1.14); P = 0.80] that was also not the case when comparing online education vs. SC [HR 1.18 (0.95–1.46), P = 0.65]. Exploratory subgroup analyses showed a heterogeneous effect over the centres, but a positive impact of in-person education in patients with asymptomatic AF, being 70 years old or younger, and without a history of heart failure. Conclusion: AF-EduCare showed that intensive targeted patient education did not lead to less unplanned cardiovascular events in the AF patient population as a whole, although subgroups might benefit.

Patients presenting with or alerting emergency networks due to acute heart failure (AHF) form a diverse group with a plethora of symptoms, risks, comorbidities, and aetiologies. During AHF, there is an increased risk of destabilizing the functional substrate and modulatory adding to the risk of ventricular arrhythmias (VAs) already created by the structural substrate. New VAs during AHF have previously identified patients with higher intra-hospital and 60-day morbidity and mortality. Risk stratification and criteria/best time point for coronary intervention and implantable cardioverter defibrillator implantation, however, are still controversial topics in this difficult clinical setting. The characteristics and logistics of pre-hospital emergency medicine, as well as the density of centres capable of treating AHF and VAs, differ massively throughout Europe. Scientific guidelines provide clear recommendations for the management of arrhythmias in patients with chronic heart failure. However, the incidence, significance, and management of arrhythmias in patients with AHF have been less studied. This consensus paper aimed to address the identification and treatment of VAs that complicate the course of patients who have AHF, including cardiogenic shock.