Introduction: Conduction system pacing (CSP) has emerged as an ideal physiologic pacing strategy for patients with permanent pacing indications. We sought to evaluate the safety and feasibility of CSP in a consecutive series of unselected patients with congenital heart disease (CHD). Methods: Consecutive patients with CHD in which CSP was attempted were included. Safety and feasibility, implant tools and electrical parameters at implant and at follow-up were evaluated. Results: A total of 20 patients were included (10 with a previous device). Ten patients had complex forms of CHD, 9 moderate defects and 1 a simple defect. His bundle pacing (HBP) or left bundle branch area pacing (LBBAP) were achieved in all patients (10 HBP, 5 LBBP and 5 left ventricular septal pacing). Procedure times and fluoroscopy times were prolongued (126±82 min and 27±30 min, respectively). CSP lead implant times widely varied ranging from 4 to 115 minutes, (mean 31±28 min) and the use of multiple delivery sheaths was frequent (50%). The QRS width was reduced from 144±32 ms at baseline to 116±16 ms with CSP. Implant electrical parameters included: CSP pacing threshold 0.85±0.61V; R wave amplitude 9.8±9.2mV and pacing impedance 735±253 Ohms, and remained stable at a median follow-up of 478 days (IQR 225-567). Systemic ventricle systolic function and NYHA class (1.50±0.51 vs 1.10±0.31; p=0.008) significantly improved at follow-up. Lead revision was required in one patient at day-4. Conclusions: Permanent CSP is safe and feasible in patients with CHD although implant technique is complex.

A document by Jon Lomasney. Click on the document to view its contents.

Background: Transvenous lead extraction (TLE) is standard of care for the management of patients with cardiac implantable electronic device infection or lead related complications. Currently, objective data on TLE in Latin America is lacking. Objective: To describe the current practice standards in Latin American centers performing TLE. Methods: An online survey was sent through the mailing list of the Latin American Heart Rhythm Association (LAHRS). Online reminders were sent through the mailing list; duplicate answers were discarded. The survey was available for one month, after which no more answers were accepted. Results: A total of 48 answers were received, from 44 different institutions (39.6% from Colombia, 27,1% from Brazil), with most respondents (83%) being electrophysiologists. Twenty-nine institutions (66%) performed less than 10 lead extractions/year, with 7 (15%) institutions not performing lead extraction. Although most institutions in which lead extraction is performed reported using several tools, mechanical rotating sheaths were cited as the main tool (73%), 13.5% reported the use of mechanical extraction sheaths and only 13.5% reporting the use of laser sheaths. Management of infected leads was performed according to current guidelines. Conclusion: This survey is the first attempt to provide information on TLE procedures in Latin America and could provide useful information for future prospective registries. According to our results, the number of centers performing high volume lead extraction in Latin America is smaller than that reported in other continents, with most interventions performed using mechanical tools. Future prospective registries assessing acute and long-term success are needed.

Backgroud The long-term outcomes of this combined procedure remain elusive. This meta-analysis aimed to assess the long-term efficacy and safety of combined procedure. Methods PubMed, Embase, Cochrane Library, and Web of Science were systematically searched from the establishment of databases to 1 January 2021. Studies on the long-term (defined as a mean follow-up of approximately 12 months or longer) efficacy and safety outcomes of combined ablation and LAAC were included for meta-analysis. Results A total of 16 studies comprising 1,428 patients were included in the meta-analysis. The pooled long term freedom rate from atrial arrhythmia was 0.66 (95% confidence interval [CI], 0.59-0.71), long-term successful rate sealing of LAAC was 1.00 (95% CI, 1.00-1.00), and ischemic stroke/transient ischemic attack/systemic embolism during follow-up was 0.01 (95% CI, 0.00-0.02). Meanwhile, the rates of peri-procedural adverse events included phrenic nerve palsy, intracoronary air embolus, device embolization, peri-procedural death of 0.00 (95% CI, 0.00-0.00), procedure-related bleeding events of 0.03 (95% CI, 0.02-0.04), and pericardial effusion requiring or not requiring intervention of 0.00 (95% CI, 0.00-0.01). Moreover, the rates of long-term adverse events rate included device dislocation, intracranial bleeding, and pericardial effusion requiring or not requiring intervention, and all-cause mortality of 0.00 (95% CI, 0.00-0.00), device embolization of 0.01 (95% CI, 0.00-0.01), and other bleeding events of 0.01 (95% CI, 0.00-0.03). Conclusion This meta-analysis suggests that the strategy of combined atrial ablation and LAAC is effective and safe during long-term follow-up

Interpreting Complex Atrial Tachycardia Maps Using Global Atrial VectorsEditorial on: The Utility of a Novel Mapping Algorithm Utilizing Vectors and Global Pattern of Propagation for Scar-Related Atrial TachycardiasMiguel Rodrigo, PhD1-2Sanjiv M. Narayan MD, PhD11Stanford University, Stanford, CA, USA2Electronic Engineering Department, Universitat de Valencia, Spain1500 words excluding title and references12 or less references1-3 tables/figures

Introduction. Atrial Fibrillation and Atrial Flutter (AF/AFL), the most common atrial arrhythmias, have never been examined in combat casualties. In this study, we investigated the impact of traumatic injury on AF/AFL among service members with deployment history. Methods. Sampled from the Department of Defense (DoD) Trauma Registry (n=10,000), each injured patient in this retrospective cohort study was matched with a non-injured service member drawn from the Veterans Affairs/DoD Identity Repository. The primary outcome was AF/AFL diagnosis identified using ICD-9-CM and ICD-10-CM codes. Competing risk regressions based on Fine and Gray subdistribution hazards model with were utilized to assess the association between injury and AF/AFL. Results. There were 130 reported AF/AFL cases, 90 of whom were injured and 40 were non-injured. The estimated cumulative incidence rates of AF/AFL for injured was higher compared to non-injured patients (HR = 2.04; 95% CI = 1.44, 2.87). After adjustment demographics and tobacco use, the association did not appreciably decrease (HR = 1.90; 95% CI = 1.23, 2.93). Additional adjustment for obesity, hypertension, diabetes, and vascular disorders, the association between injury and AF/AFL was no longer statistically significant (HR: 1.51; 95% CI = 0.99, 2.52). Conclusion. Higher AF/AFL incidence rate was observed among deployed service members with combat injury compared to servicemembers without injury. The association did not remain significant after adjustment for cardiovascular-related covariates. These findings highlight the need for combat casualties surveillance to further understand the AF/AFL risk within the military population and to elucidate the potential underlying pathophysiologic mechanisms.

Catheter Ablation of Accessory Pathways: Can We Do Better by Using Dual Chamber Mapping ?

A document by Anand Manickavasagam. Click on the document to view its contents.

Tissue Coverage MattersArvindh Kanagasundram, Travis D Richardson, and William G StevensonFrom the: Division of Cardiovascular Medicine, Arrhythmia Section,Vanderbilt University Medical Center. Nashville, TN

Background: Despite a proven mortality benefit in primary prevention (PP) patients, the utilization of implantable cardioverter-defibrillators (ICD) and cardiac resynchronization therapy-defibrillators (CRT-D) remains low in many geographies. Purpose: The objective of this analysis was to examine the mortality benefit in PP patients by guideline-indicated device type: implantable cardioverter-defibrillator (ICD) and cardiac resynchronization therapy-defibrillator (CRT-D). Methods: Improve SCA was a prospective, non-randomized, non-blinded multicenter trial that enrolled patients from regions where ICD utilization is low. PP patient’s CRT-D or ICD eligibility was based upon the 2008 ACC/AHA/HRS and 2006 ESC guidelines. Mortality was assessed according to guideline-indicated device type comparing implanted and non-implanted patients. Cox proportional hazards methods were used, adjusting for known factors affecting mortality risk. Results: Among 2,618 PP patients followed for a mean of 20.8 ± 10.8 months, 1,073 were indicated for a CRT-D, and 1,545 were indicated for an ICD. PP CRT-D-indicated patients who received CRT-D therapy had a 58% risk reduction in mortality compared to those without implant (adjusted HR 0.42, 95% CI: 0.28-0.61, P<0.0001). PP patients with an ICD indication had a 43% risk reduction in mortality with an ICD implant compared with no implant (adjusted HR 0.57, 95% CI: 0.41-0.81, P=0.002). Conclusions: This analysis confirms the mortality benefit of adherence to guideline-indicated implantable defibrillation therapy for PP patients in geographies where ICD therapy was underutilized. These results affirm that medical practice should follow clinical guidelines when choosing therapy for PP patients who meet the respective defibrillator device implant indication.

Significant changes or cancellation of MCIT could result in limiting access to breakthrough medical technologies that could improve the health and well-being of Medicare beneficiaries. For these reasons, we encourage federal agencies to work together and CMS to implement the MCIT rule without delay to ensure timely access to breakthrough technologies

Leadless Pacing with Mechanical Atrial Sensing and Variable AV ConductionJason Cook, MDTravis D. Richardson, MDFrom Vanderbilt University Medical Center. Nashville, TennesseeCorresponding author:Travis D. Richardson, MDAssistant Professor Cardiac ElectrophysiologyVanderbilt Heart and Vascular Institute1215 21st Ave S. Nashville, TNMedical Center East, South Tower, Suite 5209ph (615) 936-7537fax (615) 936-5064travis.d.richardson@vanderbilt.eduWord Count:1331Disclosures: The authors report no relevant financial disclosures.Funding: NoneThe MicraTM leadless transcatheter pacing system (Medtronic Inc., Mounds View, MN) has been shown to be an effective alternative to transvenous pacing with excellent implantation success rates and durable long-term performance.1–3 The first generation device provided single chamber right ventricular pacing with rate responsiveness enabled by a 3-axis accelerometer.Recently, the MARVEL 2 study (Micra Atrial tRacking using a Ventricular accELerometer 2) reported the ability of software enhancements to allow a leadless pacemaker to deliver single chamber atrioventricular (AV) synchronized pacing.4 In contrast to dual-chamber transvenous pacemakers which sense atrial electrograms, the MARVEL 2 algorithm adjudicates atrial events using mechanically sensed atrial activity from the 3-axis accelerometer. During initial programming, the relative timing of mechanical events to the ventricular electrogram allows for identification of A3 (passive ventricular filling) and A4 (atrial contraction). Atrial-sensed events are then defined by the A4 signal, and tracking may occur. MARVEL 2 reported VDD pacing was achieved at rest in an impressive 89.2% of patients.The Micra AVTM system’s unique programming includes three basic pacing modes: VDD, VVI and VDIR (Figure 1). Additionally, two mode switch algorithms are available and by default programmed on: the AV conduction mode switch and the activity mode switch. Unlike mode switch algorithms in dual chamber pacing systems, which are intended to avoid inappropriate tracking of atrial arrhythmias, these algorithms are intended to 1) minimize ventricular pacing, and 2) to improve rate support during patient activity respectively.When the AV conduction mode switch algorithm is enabled, the device periodically switches from VDD to VVI at 40 bpm to allow for intrinsic AV conduction. If ventricular sensing occurs above a rate of 40 bpm, in order to reduce right ventricular pacing, VVI 40 programming will continue regardless of the programmed lower rate limit. However, if two of any window of four beats are paced at VVI 40, the device reverts to VDD. Thereafter, reassessments of AV conduction are performed at increasing intervals starting at 2 minutes until either AV conduction is detected or 8 hours is reached at which point subsequent testing occurs at regular 8 hour intervals.The activity mode switch algorithm utilizes the sensor indicated rate in an attempt to ensure adequate ventricular rate support during patient activity regardless of AV conduction. The sensor in the MicraTM is always running. If at any time 1) the sensor indicated rate is above the device programmed ADL rate, and 2) the current ventricular rate is >20 BPM below the sensor rate, the activity mode switch will change the device to VDIR mode with heart rates determined by the sensor. This switch may occur from either the VDD mode or VVI in the setting of AV conduction. The device will revert to VDD mode when the sensor rate drops below the ADL rate.With the added functionality of atrial sensing and the incorporation of the MARVEL 2 algorithms described above, in this issue of the Journal of Cardiovascular Electrophysiology, Garweg et al. examined the pacing behavior of the Micra AVTM in the presence of variable AV conduction, atrial arrhythmias, sinus bradycardia (< 40 bpm), sinus arrhythmia, and periods of atrial and ventricular ectopy (Reference). During the data collection period in MARVEL 2, ECG, electrogram, accelerometer waveforms, and device marker data were obtained; this was collected either after initial implant and follow-up or, for patients with previously placed devices, during a single encounter. The average monitoring period was 153 minutes. The study included 73 patients with normal sinus node function and varying degrees of AV block.While the number of patients with variable AV conduction was small (5), the investigators found that the rhythm checks allowed for appropriate mode adjustments during the study period. During periods of AV block, as expected, 99.9% ventricular pacing was observed while during 1:1 AV conduction only 0.2% pacing was observed. Ventricular pacing was monitored in patients with 1:1 AV conduction using conventional VVI pacing and MARVEL 2 programming. MARVEL 2 programming using the AV conduction mode switch algorithm resulted in a reduction in ventricular pacing from 22.8% to 0.2% (n=18). Reducing the burden of ventricular pacing is an important enhancement to the system with the potential to minimize pacing-induced cardiomyopathy.5One potential pitfall of atrial sensing addressed by this study is tracking of atrial arrhythmias. While the sample size was small (n=7), tracking of atrial fibrillation resulting in pacing at the upper tracking rate was not observed in any of the patients. In one patient with atrial flutter, intermittent atrial tracking did occur but did not result in tachycardia. In contrast to atrial rate based mode switching used in conventional dual-chamber pacemakers, the behavior of the MARVEL 2 algorithm during atrial fibrillation is dictated by the sensed ventricular rate. With the AV conduction mode switch enabled, if the ventricular rate is above 40 bpm, the pacing mode will be VVI at 40 bpm. If rates are less than 40 bpm, the pacing mode will be VDD. In the context of atrial fibrillation, reduced atrial contractility results in lack of mechanical sensing, and pacing at the lower rate is observed. In this small sample size, atrial arrhythmias did not result in device tracking resulting in tachycardia. Further investigation in a larger number of patients is warranted to better characterize these findings and to assess pacing behavior during more organized atrial arrhythmias which could result in mechanical sensing (atrial tachycardia and atrial flutter, for example).While the MARVEL 2 programming seems to perform well in the setting of atrial fibrillation or intermittent complete AV block, there are some potential pitfalls. AV conduction mode switch behavior is based on sensed ventricular rates with a threshold of 40 bpm; this cutoff is not currently programmable. Any ventricular sensed rhythm with a rate greater than 40 bpm will result in the device continuing at VVI 40. For example, in a patient with sinus rhythm at 90 bpm and 2:1 AV conduction, the device would not track the atrium and pace at 90 bpm, but rather remain VVI 40 because the ventricular sensed rate is above 40 bpm. The same would be observed in patients with junctional or ventricular escape rhythms >40 bpm. In this sense, pacing could be inappropriately inhibited during a potentially hemodynamically significant rhythm. For this reason, in our opinion, the AV conduction mode switch algorithm should be disabled in the majority of patients with AV block as this physiology is dynamic and sudden loss of rate support can have deleterious consequences. While the activity mode switch algorithm may address some of these concerns real world data are needed for validation.There is no question that the functionality and indications for leadless pacemakers will continue to expand. In current guidelines, which predate the development of the Micra AVTM, single chamber ventricular pacing is only recommended in patients with AV block and permanent atrial fibrillation, a low burden of anticipated pacing, or substantial comorbidities.6 Given the potential for lower complication rates compared with transvenous systems, Micra AV may be a superior option in some patients with complete heart block and preserved ventricular function. However, with the advent of conduction system pacing, the decreased risks of a leadless system have to be balanced with the relative risk of long term right ventricular pacing. Although the results will need to be validated with larger, longer-term studies, which are underway (Clinical trials.gov NCT04245345), these data indicate that Micra AVTM is likely to perform well in the setting of atrial arrhythmias. In patients with variable AV conduction, there are certainly pitfalls to the AV conduction mode switch algorithm, many of which could be avoided by the ability to program the mode switch VVI rate. While leadless pacing is often considered in patients with multiple comorbidities at high risk of complications from a transvenous system, we may be on the cusp of a dramatic paradigm shift. The technological developments and success of leadless pacing to date prompt the question of when, and not if, leadless dual chamber pacing and potentially even cardiac resynchronization will be available.References:1. Reynolds D, Duray GZ, Omar R, et al. A Leadless Intracardiac Transcatheter Pacing System. https://doi.org/10.1056/NEJMoa1511643. doi:10.1056/NEJMoa15116432. El-Chami MF, Al-Samadi F, Clementy N, et al. Updated performance of the Micra transcatheter pacemaker in the real-world setting: A comparison to the investigational study and a transvenous historical control. Heart Rhythm . 2018;15(12):1800-1807. doi:10.1016/j.hrthm.2018.08.0053. Duray GZ, Ritter P, El-Chami M, et al. Long-term performance of a transcatheter pacing system: 12-Month results from the Micra Transcatheter Pacing Study. Heart Rhythm . 2017;14(5):702-709. doi:10.1016/j.hrthm.2017.01.0354. Steinwender C, Khelae SK, Garweg C, et al. Atrioventricular Synchronous Pacing Using a Leadless Ventricular Pacemaker: Results From the MARVEL 2 Study. JACC Clin Electrophysiol . 2020;6(1):94-106. doi:10.1016/j.jacep.2019.10.0175. Merchant FM, Mittal S. Pacing induced cardiomyopathy. J Cardiovasc Electrophysiol . 2020;31(1):286-292. doi:10.1111/jce.142776. Kusumoto Fred M., Schoenfeld Mark H., Barrett Coletta, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation . 2019;140(8):e382-e482. doi:10.1161/CIR.0000000000000628

Reply to “Additional Data Protection of the Esophagus During Catheter Ablation of Atrial Fibrillation”Mahmoud Houmsse, MD, and Emile G. Daoud, MDDepartment of Medicine, Division of Cardiology, Richard M. Ross Heart HospitalThe Ohio State University Medical Center, Columbus, OHRunning Title: Protection of EsophagusAddress for correspondence: Emile Daoud, MDDHLRI 473 W. 12th Avenue, Suite 200 Columbus, OH 43210-1252 Telephone: 877-478-2478 FAX : 614-293-5614E-Mail: emile.daoud@osumc.eduFunding: NoneDisclosure: Emile Daoud and The Ohio State University have equity ownership and serve as consultants to S4 Medical Corp, which is manufacturing the Esoultion esophageal retractor.Disclosure: Mahmoud Houmsse has no conflict of interestWe Thank Dr.Clark and Dr. Kulstad for their interest in our recent review manuscript “protection of the esophagus during catheter ablation of atrial fibrillation”We agree with Dr. Clark and Dr. Kulstad that utilization of luminal esophageal temperature (LET) monitoring during atrial fibrillation ablation is inadequate method to avoid esophageal injury. These have been reported in multiple studies that were referenced in our manuscript. The newer published studies regrading monitoring LET during atrial fibrillation ablation, which were reported by Dr. Clark and Dr. Kulstad, have been published during our manuscript publication process. Nevertheless, these studies that reported by Dr. Clark and Dr. Kulstad showed same conclusion of inadequate LET monitoring in preventing esophageal injury 1-3.Regarding active cooling, Dr. Clark and Dr. Kulstad reported recent published studies. First study small pilot study that showed active cooling is much more protective than manual liquid instillation4. The second pilot RCT that compared LET and active cooling showed same outcome like the IMPACT study that we reported in our manuscript 5,6.We agree with Dr. Clark and Kulstad, growing interest in the area of esophageal protection during atrial fibrillation ablation.We do believe, as we stated in the conclusion of our manuscript, that “a reliable method to protect the esophagus is of clinical value, but the ancillary value of reducing physician concern during AF ablation, reducing interruption to ablation work flow, perhaps enhancing AF ablation results and simplifying post procedure management of patient symptoms are also of high importance. Considering the ease of use, minimal side effects, and low costs associated with esophageal protection devices, these features offer compelling evidence for use of esophageal protection as routine care for AF ablation”.

Despite being first described over 30 years ago, focal radiofrequency (RF) continues to be the most widely used energy modality for catheter ablation. The fact that it has managed to hold its own against stiff competition from alternative energy sources used for pulmonary vein isolation (PVI) is down to continuous evolution based on enhancements in our understanding of its biophysical principles. In particular, the advent of contact-force (CF) based integrated indices such as Ablation Index have improved both efficacy and safety. However, a significant limitation of this approach is the absence of tissue feedback during lesion creation, which results in a blunt ‘one-size-fits-all’ approach. This limitation has been further brought into focus by the recent appreciation of the much greater importance of circuit impedance rather than delivered power as a fundamental determinant of RF lesion size.

We have read with great interest the article “Efficacy of Catheter Ablation for Premature Ventricular Contractions (PVC) in Arrhythmogenic Right Ventricular Cardiomyopathy (ARVC)” by Assis F.R. et. al. PVC ablation in ARVC was previously studied by Aras D. et al and they presented successful results.In this study, we believe that the study should not be considered as unsuccessful since 2 patients showed a decrease in PVC burden by more than 80% and in the other three patients between 45-70%. The demonstration of a decrease in PVC burden with catheter ablation in ARVD patients indicates that a second ablation may increase the success rate and decrease symptoms. The fact that ARVC has a complex substrate and the disease can progress is undoubtedly the most important factor in achieving the desired success with PVC ablation. Epicardial ablation with endocardial ablation has increased the chance of success in this patient group. In addition, given that BCSD ablation and basal heart rate are guaranteed by ICD implantation, we think that administration of the maximum dose of antiarrhythmic medication may create a significant improvement in these patients. And another factor, contact force sensing plays an important role in evaluating the effectiveness of the process. We suggest that with the current treatment modalities, a pharmacoablative combination therapy and re-ablation when necessary would be appropriate for such a complicated disease.

Introduction: Ablation Index guided ablation according to the CLOSE protocol is very effective in terms of chronic pulmonary vein isolation (PVI). However, the optimal RF power remains controversial. Here, we thought to investigate the efficiency and safety of an AI guided fixed circumferential 50W high power short duration (HPSD) PVI using the CLOSE protocol Methods and results: In a single-centre prospective “proof of concept” trial 40 patients underwent randomized PVI using AI guided RF ablation without oesophageal temperature monitoring. In 20 patient fixed 50W HPSD was used irrespective to the anatomical localization. 20 subjects were ablated with standard power settings (20W posterior and 40W roof and anterior wall). Additionally, 80 consecutive patients were treated according to the HPSD protocol to gather additional safety data. All patients underwent post-procedural oesophago-gastro-duodenoscopy to reveal oesophageal lesions (EDEL). The mean total procedural time was 80.3±22.5 minutes in HPSD compared to control 109.1±27.4 (p<0.001). The total RF-time was significantly lower in HPSD 1379±505 sec vs. control 2374±619 sec (p<0.001).There were no differences in periprocedural complications. EDEL occurred in 13% in the HPSD and 10% in control group. EDEL occurring in the 50W HSDP patients were smaller, more superficial and had a faster healing tendency. Conclusions: A fixed 50W HPSD circumferential PVI relying to the ablation index and CLOSE protocol reduces the total procedure time and the total RF time compared to standard CLOSE protocol, without increasing the complication rates. The incidence of oesophageal lesions was similar using 50W at the posterior atrial wall.

OBJECTIVES: To explore the value of detecting the peri-device leak (PDL) and device endothelialization after left atrial appendage closure (LAAC) by cardiac CT in patients with atrial fibrillation (AF), who underwent Watchman LAAC combined with radiofrequency ablation of atrial fibrillation (AFCA) METHODS: Patients with symptomatic drug-refractory atrial fibrillation at high risk of stroke (CHA2DS2-VASc Score ≥ 2), who underwent Watchman LAAC combined with AFCA in our center from March 2017 to December 2018 were enrolled Maximum diameter of LAA orifice was determined by preoperative CCTA A standardized view of Watchman device was obtained by postoperative CCTA multi-plannar reconstruction to evaluate the PDL and device endothelialization RESULTS: 84 patients post successful LAAC and AFCA were enrolled in this study Satisfactory LAA occlusion rate was 100% There were no death, bleeding, stroke, and device related thrombus (DRT) events At 6-month post procedure, CCTA images evidenced complete endothelialization in 44 patients (no contrast enhancement in LAA); contrast enhancement in LAA and visible PDL in 33 patients; contrast enhancement in LAA but without PDL in 7 patients (incomplete device endothelialization) Maximum diameter of LAA orifice could independently predict the occurrence of PDL (OR, 1.31; 95% CI, 1.11-1.55; P = 0.002), sensitivity was 69.7% and specificity was 80.4% with the cutoff value of maximum diameter of LAA orifice >28.2 mm on predicting PDL CONCLUSIONS: CCTA is feasible to evaluate PDL and device endothelialization after LAAC The maximum diameter of LAA orifice derived from CT can independently predict the occurrence of post-LAAC PDL

Using an Accelerated Junctional Rhythm to Predict the Success and Safety of Slow AV Nodal Pathway Ablation G. Neal Kay MD