Edwin Kevin Heist

Purpose of Review: The left atrial appendage (LAA) is nowadays recognized as both an arrhythmogenic substrate and the dominant source of thromboembolism in atrial fibrillation (AF). In this review we tried to summarize recent data on the anatomy, physiology, and imaging of the LAA, and examine how these findings help guide rhythm-control and stroke-prevention strategies. Recent Findings: High-resolution mapping confirms the LAA as a non–pulmonary-vein trigger source in persistent and post-ablation AF, supporting LAA electrical isolation in selected patients, though isolation may induce mechanical standstill and mandate continued thromboprophylaxis. The 2024 ESC guidelines reframed stroke-risk assessment around the sex-neutral CHA₂DS₂-VA score within the AF-CARE pathway. An important recent study was the OPTION trial, which showed that LAA closure after AF ablation was as effective as oral anticoagulation for preventing death, stroke, or systemic embolism and was associated with less non–procedure-related bleeding. These findings support the use of LAA closure in selected patients after ablation. New imaging and emerging computational tools may also improve patient selection and help guide device sizing. Summary: A comprehensive assessment of the anatomy, function, and electrical activity of the LAA can help adapt AF treatment to each patient.

Aims: Guidelines recommend continuing oral anticoagulation (OAC) after atrial fibrillation (AF) ablation based on stroke risk, yet real-world post-procedural OAC management remains poorly characterized. We aimed to evaluate contemporary patterns of OAC use after AF ablation and identify predictors of OAC discontinuation. Methods and results: Using Medicare claims from 2013–2022, we established a cohort of patients undergoing a first AF ablation and assessed patterns of OAC discontinuation during the subsequent year. We defined OAC discontinuation as a dispensing gap ≥60 days. Baseline characteristics were evaluated as predictors of discontinuation using least absolute shrinkage and selection operator Cox regression. Among 208 232 AF patients (mean age 74.5, 47% women) undergoing ablation, 58% were taking OAC following ablation, 24% discontinued between 3 and 12 months, 8% discontinued within 3 months, and 10% did not use OAC within 3 months. Apixaban was the most commonly used OAC agent, while the use of warfarin declined over time. The overall rate of repeated ablation was 26%. We found that 44% of patients with CHA2DS2-VASc score ≥3 discontinued OAC within 1 year after ablation. Higher CHA2DS2-VASc scores and longer pre-ablation OAC use were associated with lower discontinuation, whereas pre-ablation major bleeding, frailty, and use of warfarin (vs. direct OACs) increased the likelihood of discontinuation. Conclusion: OAC discontinuation after AF ablation is common, including among patients at elevated stroke risk despite guideline recommendations for continued therapy. More data are needed on the clinical consequences of post-ablation OAC discontinuation.

Background: Analysis of the National Inpatient Sample database for the safety of procedures that are primarily outpatient in nature can be biased due to the selective hospitalization of patients who have complications during these procedures. Methods: This is a retrospective cross‐sectional analysis of hospitalized patients in the National Inpatient Sample data set who underwent an atrial fibrillation catheter ablation between 2016 and 2022. Patients were divided into 2 groups based on the day of hospitalization on which the ablation was performed: day 1 of admission or before (group 1), versus day 2 of admission or later (group 2). Patient baseline characteristics and procedural complication rates were compared. Results: The analysis included 47 925 weighted hospitalizations of patients who underwent atrial fibrillation catheter ablation. Group 1 had significantly fewer octagenerians (6.9% versus 10.4%), lower rates of renal disease (12.6% versus 20.0%), heart failure (28.3% versus 45.8%), and ischemic heart disease (16.0% versus 20.5%), P P P <0.001). Conclusions: Patients undergoing procedures on the day of admission or before were younger and had fewer comorbidities. Despite this, these patients had a significantly higher rate of procedural complications. The likely explanation for these results is selection bias, where patients undergoing outpatient procedures who are at higher risk or develop complications are admitted as inpatients, thus falsely inflating the complication rate of patients in the National Inpatient Sample data set.

BACKGROUND: Intracardiac echocardiography (ICE) is increasingly used to guide left atrial appendage occlusion as an alternative to transesophageal echocardiography (TEE), particularly in elderly patients for whom general anesthesia may pose additional risks. Real-world comparative safety data in older adults remain limited, with prior studies including only small ICE cohorts. We aimed to compare short- and long-term outcomes of ICE- versus TEE-guided left atrial appendage occlusion in adults aged ≥80 years. METHODS: We queried the TriNetX US Collaborative Network to identify patients aged ≥80 years with atrial fibrillation who underwent percutaneous left atrial appendage occlusion from 2015 to 2025. Patients were stratified by imaging modality: ICE- versus TEE-guided approach. Propensity score matching (1:1) was performed across demographics and comorbidities, yielding 2913 patients per group. Outcomes were assessed from the index procedure through 7 days, 90 days, and 1 year using Cox proportional hazards models to generate hazard ratios with 95% CIs. Outcomes included mortality, stroke, device thrombosis, pericardial effusion, pericardiocentesis, tamponade, and device leak. RESULTS: Baseline characteristics were well balanced after matching, with a mean age of 83 years and 44% women. At 90 days, ICE and TEE demonstrated no significant differences in mortality (hazard ratio, 1.18 [95% CI, 0.81–1.73]), stroke, device thrombosis, pericardial effusion, pericardiocentesis, tamponade, or device leak. At 1-year follow-up, mortality (hazard ratio, 0.93 [95% CI, 0.76–1.13]), stroke, and device thrombosis remained similar between groups. However, ICE was associated with a higher incidence of device leak compared with TEE (hazard ratio, 1.81 [95% CI, 1.11–2.97]). CONCLUSIONS: In this large propensity-matched cohort of very elderly patients undergoing left atrial appendage occlusion, ICE and TEE demonstrated comparable rates of mortality, stroke, and device thrombosis at 90 days and 1 year. ICE was associated with a higher rate of device leak at 1 year, warranting careful procedural technique and follow-up surveillance. Prospective studies are needed to define optimal intraprocedural imaging strategies in this high-risk population.

Background: Functional mitral regurgitation results from interacting mechanisms whose contributions vary between atrial and ventricular subtypes and shift within each heartbeat, producing temporal patterns static analyses cannot capture. Objectives: To identify which structural determinants predict mitral regurgitation variability beat to beat using Granger causality within vector autoregression, focusing on papillary muscle dynamics across subtypes. Methods: Frame-level echocardiographic time series from 41 patients (21 atrial, 20 ventricular; 1,959 frames) were z-score standardised within patient. Individual (lag 3) and pooled panel vector autoregression models, with supplementary full-cycle analysis across lags 1–20, tested whether LV volume, left atrial volume, papillary muscle length, and annulus diameter Granger-predict mitral regurgitation area. Results: Individual models revealed marked heterogeneity. In pooled analysis, LV volume was the strongest Granger predictor at the shortest lag (atrial p=0.011; ventricular p=0.006), while left atrial volume reached significance at longer lags (lag 6 atrial p=0.033, ventricular p=0.004). Systolic papillary muscle length was not predictive at any lag. Full-cycle analysis revealed an asymmetric subtype dissociation: papillary muscle length Granger-predicted regurgitation only in the ventricular subtype (lag 1 p<0.001) whereas regurgitation predicted papillary muscle deformation at every lag in the atrial subtype (20/20) but at none in the ventricular subtype. Cross-sectional comparisons of the four determinants did not distinguish MR severity within subtypes. Conclusions: Beat-to-beat vector autoregression and Granger modelling reveals heterogeneous, subtype-specific temporal patterns and a strong directional asymmetry between regurgitation and papillary muscle dynamics across subtypes. This disease-agnostic framework may support patient-specific temporal phenotyping of functional mitral regurgitation. Graphical

Importance Analysis of the National Inpatient Sample (NIS) database for the procedural safety of interventions that are primarily outpatient in nature can be inherently biased due to the selective hospitalization of patients who suffer complications during their outpatient procedures. Objective Using atrial fibrillation (AF) ablation as an example of a procedure typically performed in the outpatient setting, we will test the hypothesis that the population of patients who had their procedure prior to, or on the day of hospital admission (some being outpatient cases, eventually admitted to hospital) will show a significantly higher rate of procedural complications, compared to patients who had a true inpatient ablation, from day 2 of hospital stay and later. Design This study is a retrospective analysis of hospitalizations in the NIS dataset, including patients aged 18 and older, who underwent an AF ablation between 2016-2022. Patients were divided into two groups based on the day of hospitalization on which the ablation was performed – day 1 of admission or prior (group 1), vs. day 2 of admission or later (group 2). Patient baseline characteristics and procedural complication rates were compared. Setting Hospitals that performed AF ablations in the United States between January 1, 2016, and December 31, 2022. Participants A weighted selection of patients aged 18 years and older who underwent an in-patient AF ablation, as identified by the NIS database (N = 47,925). Exposures Catheter ablation for AF. Main Outcome(s) and Measure(s) In-hospital procedural complications, length of stay and mortality Results The analysis included 47,925 weighted hospitalizations in patients that underwent AF ablation. Most patients (n= 33,925, 70.8%) underwent catheter ablation (CA) on the day of admission or the days before (group 1). Group 1 was younger, with fewer octogenarians, 6.9% vs. 10.4% (pConclusions and Relevance Patients undergoing their procedure on the day of admission or prior were younger and had significantly fewer comorbidities, consistent with a population that includes outpatient profile characteristics. Despite the younger and healthier population, these patients suffered from a significantly higher rate of procedural complications. The most plausible explanation to these results is a selection bias, where patients undergoing an outpatient procedure who are at higher risk, or develop complications are admitted as inpatients, thus falsely inflating the complication rate among the patients in the NIS database. The NIS database in its current form, has important limitations when used to assess procedures that are primarily outpatient in nature, requiring careful interpretation of the complication rates arising from such analyses.

Aims: Ventricular tachycardia (VT) ablation has been shown to reduce the recurrence of VT episodes, but the timing of performing VT ablation (early; at the time of implantable cardioverter defibrillator implantation) or (deferred: after the patient has received ICD shocks) remains controversial. The objective is to conduct a systematic review and meta-analysis of published data from randomized controlled trials (RCTs) in patients with ischaemic cardiomyopathy (ICM) with the aim of comparing outcome of VT ablation stratified by procedural timing. Methods and results: We conducted a meta-analysis of seven landmark RCTs which included patients with ICM who were either at a high risk of VT or experienced VT/ICD shocks. The primary outcome of VT recurrence was compared according to the timing of performing VT ablation (early vs. deferred). In addition, we also compared the secondary outcome of cardiac mortality. Following a comprehensive search strategy, a total of seven RCTs were included within the final analysis. Based on a pooled analysis, early VT ablation was associated with a significant reduction in the primary outcome [pooled odds ratio (OR) of 0.72, 95% confidence interval (CI): 0.55–0.95, P < 0.05] in comparison with a ‘deferred VT ablation’ strategy. The cumulative absolute risk reduction (ARR) for the primary outcome was 0.21, and number needed to treat (NNT) to prevent the outcome of VT recurrence was 4.81. Furthermore, the effect size of early VT ablation compared to a deferred VT ablation approach was more pronounced in reduction of ICD shocks in the subgroup of patients with LVEF > 30% vs. those with LVEF < 30% (pooled OR of 0.65, 95% CI of 0.54–0.79, P = 0.01). For the secondary outcomes, we observed that an earlier timing of VT ablation was also associated with both a decrease in cardiac mortality (pooled OR of 0.59, 95% CI of 0.43–0.82) and in the subsequent risk of VT storm (pooled OR of 0.63, 95% CI of 0.51–0.78) when compared with a deferred timing. The cumulative ARR for cardiac mortality was 0.07 and NNT was 15. Conclusion: The findings from this pooled analysis of seven major RCTs suggest that performing early VT ablation may be beneficial in reducing recurrent VT, ICD shocks, and electrical storm and could also improve cardiac mortality. The benefit of performing early VT ablation was greater in patients with LVEF of >30% amongst this ICM cohort.

Terlipressin has been recently approved in the United States to treat hepatorenal syndrome, a feared complication of both acute and chronic liver diseases. Side effects of the medication have been studied through clinical trials and the precedent use in Europe, as well as extrapolation from its analog vasopressin. As its use is becoming more prevalent, unforeseen complications have arisen. We report a case of complete heart block associated with terlipressin use in presumed hepatorenal syndrome in acute liver injury.

Purpose of Review: This review aims to synthesize current knowledge on the angiographic anatomy of the coronary sinus and its tributaries veins, with focus on venous branches other than classical ones used in cardiac resynchronization therapy. It also presents common anatomical aspects that could impact the clinical outcome. Recent Findings: Recent advancements in the electrophysiology field, like epicardial arrhythmia mapping and ablation through coronary sinus or cardiac pacing from atypical veins requires a detailed angiographic assessment of cardiac veins. There is an increased interest for the veins coursing in the left ventricular summit (LVS) area and could potentially provide a pathway to reach the LVS arrhythmogenic foci. However, there is no consensus regarding the nomenclature and classification of these veins. Summary: This review could offer a better understanding of the coronary sinus and its tributary veins distribution, dimensions and relationship with nearby structures that could help the development of new ablation and pacing tools and strategies, with higher success rates.