Dawid Miśkowiec

Background: The balance between thromboembolic complications and bleeding risk in anticoagulated patients with atrial fibrillation remains challenging, with left atrial appendage occlusion (LAAO) representing a potential alternative. Our prospective multicenter study aimed to evaluate the feasibility, safety, technical, and procedural outcomes of the contemporary practice of stand‐alone LAAO. Methods: The SALAMANDER (Stand‐Alone Left Atrial Appendage Occlusion for Thromboembolism Prevention in Nonvalvular Atrial Fibrillation Disease) registry is a real‐world, multicenter, observational cohort study conducted at 16 cardiac centers in Europe between 2010 and 2024, evaluating the safety and efficacy of LAAO using contemporary devices. Results: A total of 1660 patients were enrolled, with a median age of 76 (interquartile range, 70–81) years and 38% being women. The median CHA ₂ DS ₂ ‐VASc score was 4 (interquartile range, 3–5). The most common indication for LAAO was significant bleeding (83.7% of patients), most frequently during treatment with direct oral anticoagulants (68.8%) more than vitamin K antagonists (24.9%). The predominant bleeding sites were the lower (27.9%) and upper (21.7%) gastrointestinal tracts, with 17.4% having a history of hemorrhagic stroke. The most common antithrombotic regimen before the procedure was direct oral anticoagulants (48.9%), while postprocedural therapy most often included dual antiplatelet therapy (50%). The technical success rate was 95.5%, with residual leak (2.2%) and tamponade (1.4%) as the main causes of failure. Procedural success was 90.5%, most often limited by vascular complications (3.7%), periprocedural death (1.1%), and major bleeding (0.7%). Technical and procedural success rates did not differ significantly between the devices used. Conclusions: In this large prospective cohort, technical and procedural success rates were similar across all LAAO devices, suggesting comparable safety and efficacy. Postprocedural therapy typically involves dual antiplatelet therapy, with all patients requiring some pharmacological treatment. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05144958.

We present a case of 73-year-old man with a dual-chamber pacemaker implanted in 2008 for complete atrioventricular block (elective generator replacement in 2016) was transferred to our center for lead extraction due to cardiac device related infective endocarditis (CDRIE) [1, 2]. His medical history included heart failure with mildly reduced left ventricular ejection fraction (45%-48%, reference range ≥54%), chronic kidney and obstructive pulmonary disease, and history of ischemic strokes. Initially, the patient was treated in the local internal medicine ward for 47 days for feverish infection of unknown source, with elevated infectious biomarkers (patient's course summarized in Figure 1A).

Background/Objectives: Available data suggest the diagnostic potential of testing microRNAs (miRs) in myocardial infarction, but their prognostic value remains unclear. To evaluate the prognostic value of circulating miRs (miR-1, miR-21, miR-133a, miR-208 and miR-499) for predicting major adverse cardiac events (MACEs), including death, non-fatal myocardial infarction (MI) or cardiovascular rehospitalization, in patients with non-ST segment elevation acute coronary syndromes (NSTE-ACS). Methods: Our prospective, single-center, observational study included patients (pts) with NSTE-ACS admitted median). Results: Overall, 103 NSTE-ACS (52 NSTEMI/51 UA) and 47 SCAD pts (median age 66 years, 67% male) were included. During the median 895 (581–1134) days of the follow-up, MACE occurred in 75 (50%) patients: 20 (13%) died, 28 (19%) presented with MI, and 65 (43%) were readmitted due to cardiovascular reasons. Incidence of MI, rehospitalization and MACE was significantly higher in pts with elevated (>median) miR-499 [MI: 34.3% vs. 7.3%; HR = 6.0 (2.8–12.7) for rehospitalization; 53.7% vs. 36.2%, HR = 2.3 (1.4–3.8) for MACE; 62.7% vs. 42%, HR = 2.4 (1.5–3.8)] for hospital readmission. In the Cox proportional hazards regression model, miR-499 expression above the median level [HR = 1.8 (1.1–3.1)], high-sensitivity cardiac troponin T [HR = 1.2 (1.02–1.5)], diabetes [HR = 1.7 (1.1–2.8)] and percutaneous intervention during hospital stay [HR = 2.1 (1.1–3.8)] were identified as independent predictors of MACE in long-term observation, even after adjustment for covariates. Conclusions: Elevated miR-499 level on hospital admission in NSTE-ACS is related to an increased rate of MACE in the 2.5-year follow-up.

Background: Transseptal puncture is one of the most challenging steps in catheter ablation of atrial fibrillation (AF) because of the potential risk of complication. While single TSP reduces the puncture-related risk, double TSP simplifies the procedure (immediate signal visualization in pulmonary veins, avoidance of multiple changes of catheters through the single sheath). The purpose of this study was to analyze the impact of single versus double TSP during pulmonary vein isolation (PVI) with radiofrequency (RF) catheter ablation for AF on the fluoroscopy usage and procedure time. Methods: Data reported from the international, multicenter prospective „Go For Zero Fluoroscopy Registry" performed in years 2018–2019 were analyzed. Overall 25 European electrophysiology centers from 14 countries and up to 5 operators from each center were enrolled. Only isolated PVI procedures were analyzed. Results: A total data of 393 PVI RF procedures were collected from 25 centers. The median dose-area-product (DAP), fluoroscopy time and overall procedure time were: 810 (325 – 1839) cGy*cm2, 8 (4 – 14) minutes and 124 (92 – 168) minutes, respectively. Single TSP was associated with significantly higher DAP: 984 (459 – 1939) vs 667 (227 – 1469) cGy*cm2 (p=0.002), longer fluoroscopy time: 11 (6 – 19) vs 6 (3 – 11) minutes (p0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p<0,001). Conclusions: Double TSP is related with lower fluoroscopy usage and shorter overall procedure time of pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation.

Pharmacological cardioversion (PCV) is commonly a primary option for termination of recent-onset atrial fibrillation (AF) in emergency departments (ED). This is a subanalysis of the CANT II study, evaluating the effectiveness and safety of antazoline in patients (n = 777) at three stages of chronic kidney disease (CKD): Group I > 60 mL/min (n = 531), Group II 45–59 mL/min (n = 149), and Group III < 45 mL/min (n = 97). Patients in Group III were older and with a higher prevalence of co-morbidities; however, we did not find statistically significant differences in the overall effectiveness of PCV in comparison with the other groups. In patients receiving amiodarone, the PCV success rate was similar in all the studied groups, but along with a renal function decline, it decreased in patients receiving antazoline (79.1 vs. 35%; p < 0.001), and it increased almost significantly in patients receiving propafenone (69.9 vs. 100%; p = 0.067). In patients in Group I, antazoline restored a sinus rhythm as effectively as propafenone and amiodarone; however, in patients in Group III, both antazoline and amiodarone became less effective in restoring a sinus rhythm than propafenone (p = 0.002 and p = 0.034, respectively). The rate of safety endpoint was the highest in patients in Group III (eGFR < 45 mL/min), and it was significantly higher than in patients in Groups I and II (p = 0.008 and p = 0.036, respectively). We did not observe antazoline-related adverse events in any of the studied groups of patients. This real-world registry analysis revealed a different influence of CKD on the effectiveness of individual drugs, and while propafenone and amiodarone maintained their AF termination efficacy, antazoline became significantly less effective in restoring sinus rhythm.

Purpose: Pharmacological cardioversion (PCV) is commonly a primary option for termination of recent-onset atrial fibrillation (AF) at the emergency departments (ED), and there are reports proving that antazoline is a noteworthy agent to restore sinus rhythm. This is a sub-analysis of the CANT study evaluating the effectiveness and safety of antazoline in patients with AF at different stages of chronic kidney disease (CKD). Methods: Total n=777 patients admitted to ED for the urgent termination of AF were included into this analysis. We analysed the results concerning effectiveness and safety of PCV with special consideration of antazoline, in patients at 3 stages of CKD defined on the basis of eGFR (CKD-EPI): Group I ≥60 mL/min (n=531), Group II 45–59 mL/min (n=149), and Group III <45 mL/min (n=97). Primary end-point was the termination of AF, a restoration of a sinus rhythm and its persistence until discharge. Results: Patients of group III were older and with higher prevalence of comorbidities, however, we have not found statistically significant differences in overall effectiveness of PCV in comparison with the other groups. In patients receiving amiodarone, the PCV success rate was similar in all the studied groups, but along with a renal function decline, it decreased in patients receiving antazoline (79.1 vs 35%; p<0.001), and it increased close to a significant manner in patients receiving propafenone (69.9 vs 100%; p=0.067; Figure). In patients of Group I, antazoline restored a sinus rhythm as effectively as propafenone and amiodarone, however in patients of Group III, both antazoline and amiodarone became less effective in restoring a sinus rhythm than propafenone (p=0.002 and p=0.034, respectively). The rate of safety endpoint was highest in patients of Group III (eGFR<45 mL/min), and it was significantly higher than in patients of Group I and II (p=0.008 and p=0.036, respectively). We have not observed antazoline-related adverse events in any of studied groups of patients. Conclusion: This real-world registry analysis revealed a different influence of CKD on individual drug effectiveness, and while propafenone and amiodarone maintained their AF termination efficacy, antazoline became significantly less effective in restoring sinus rhythm. Its favourable safety profile has not changed. Funding Acknowledgement: Type of funding sources: Public Institution(s). Main funding source(s): The study received no external funding

Introduction: Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of atrial fibrillation (AF) to sinus rhythm (SR) and is widely used in Poland for this purpose in the last years. However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim: To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods: Our single center, retrospective, observational study included patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results: A total of 176 pts (mean age 68.4±12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7–432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9±65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting <48h vs others: 75.3% vs 12.0%, p<0.001). In multivariable logistic regression model AF duration (for every 24h in AF – OR=0.97; 95% CI 0.96–0.98), the left atrium antero-posterior diameter (OR=0.92; 95% CI 0.86–0.99) and the serum creatinine level (OR=0.15; 95% CI 0.03–0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT's effectiveness was 48h (AUC=0.876; 95% CI 0.815–0.922) – Figure 1. There were only one episode of bradycardia <45 bpm related to ANT administration. Conclusions: Antazoline is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (<48 hours) and in patients without the left atrium enlargement and significant renal disease. Funding Acknowledgement: Type of funding sources: None. Figure 1. ROC curve analysis

Funding Acknowledgements: Type of funding sources: None. Introduction: Antazoline (ANT) is an old antihistaminic medication with antiarrhythmic properties. After intravenous administration ANT exerts rapid antiarrhythmic effect often resulting in conversion of persistent atrial fibrillation (AF) to sinus rhythm (SR). However, published data on its effectiveness, safety and clinical utility for rapid AF termination are limited and ANT is not recognized as a cardioversion drug. Aim: To assess the real-world efficacy of ANT for pharmacological cardioversion of paroxysmal and persistent non-valvular AF. Methods: We conducted a single center, retrospective, observational study including patients (pts) with history paroxysmal or persistent AF episode lasting less than 6 months, in stable cardiopulmonary condition who were qualified for elective pharmacological cardioversion with intravenous ANT. The primary end-point was the conversion of AF to SR confirmed in electrocardiography (ECG) during the 6-hours observation. Results: A total of 176 pts (mean age 68.4 ± 12.0 years, 49% male) were enrolled into the study. In 93 patients (52%) AF duration was shorter than 48 hours and median AF duration time was 24 (7 – 432) hours. The overall success rate of pharmacological cardioversion of AF with intravenous ANT was 45.5% (80/176 pts). The mean used dose of ANT was 250.9 ± 65.4mg. The subgroup analysis, regarding the AF duration, suggested the effectiveness of ANT mainly in in short-lasting AF (effectiveness of antazoline based cardioversion for AF lasting <48h vs others: 75.3% vs 12.0%, p < 0.001). In multivariable logistic regression model AF duration (for every 24h in AF - OR = 0.97; 95% CI 0.96 – 0.98), the left atrium antero-posterior diameter (OR = 0.92; 95% CI 0.86 – 0.99) and the serum creatinine level (OR = 0.15; 95% CI 0.03 – 0.73) were identified as independent predictors of antazoline based pharmacological cardioversion effectiveness, even after adjustment for comorbidities. The ROC curves revealed that the optimal cut-off value for AF duration time predicting ANT’s effectiveness was 48h (AUC = 0.876; 95% CI 0.815 – 0.922). There were only one episode of bradycardia <45 bpm related to ANT administration. Conclusions: Intravenous antazoline administration is effective and safe in rapid pharmacological cardioversion of paroxysmal AF, especially in the short-lasting AF (<48 hours) and in patients without the left atrium enlargement and significant renal disease. Abstract Figure.

Background: Fluoroscopy has been an essential part of every electrophysiological procedure since its inception. However, till now no clear standards regarding acceptable x‐ray exposure nor recommendation how to achieve them have been proposed.Hypothesis: Current norms and quality markers required for optimal clinical routine can be identified.Methods: Centers participating in this Europe‐wide multicenter, prospective registry were requested to provide characteristics of the center, operators, technical equipment as well as procedural settings of consecutive cases.Results: Twenty‐five centers (72% university clinics, with a mean volume of 526 ± 348 procedures yearly) from 14 European countries provided data on 1788 cases [9% diagnostic procedures (DP), 38% atrial fibrillation (AF) ablations, 44% other supraventricular (SVT) ablations, and 9% ventricular ablations (VT)] conducted by 95 operators (89% male, 41 ± 7 years old).Mean dose area product (DAP) and time was 304 ± 608 cGy*cm², 3.6 ± 4.8 minutes, 1937 ± 608 cGy*cm², 15.3 ± 15.5 minutes, 805 ± 1442 cGy*cm², 10.6 ± 10.7 minutes, and 1277 ± 1931 cGy*cm², 10.4 ± 12.3 minutes for DP, AF, SVT, and VT ablations, respectively. Seven percent of all procedures were conducted without any use of fluoroscopy.Procedures in the lower quartile of DAP were performed more frequently by female operators (OR 1.707, 95%CI 1.257‐2.318, P = .001), in higher‐volume center (OR 1.001 per one additional procedure, 95%CI 1.000‐1.001, P = .002), with the use of 3D‐mapping system (OR 2.622, 95%CI 2.053‐3.347, P < .001) and monoplane x‐ray system (OR 2.945, 95%CI 2.149‐4.037, P < .001).Conclusion: Exposure to ionizing radiation varies widely in daily practice for all procedure. Significant opportunities for harmonization of exposure toward the lower range has been identified.