UNASSIGNED: Conventional medicine (CM) for paroxysmal atrial fibrillation (PAF) have limitations and side effects. Integrative approaches, including traditional herbal medicines like Liriope Tuber, are being explored for potential benefits, although evidence remains limited.
UNASSIGNED: In April 2023, a literature search was conducted across nine databases, focusing on randomized controlled trials assessing the effects of Liriope Tuber in traditional herbal medicine (LTHM) on PAF. The risk of bias was evaluated using Version 2 of the Cochrane risk-of-bias tool for randomized trials. A random-effects model was employed for the meta-analysis.
UNASSIGNED: A total of 43 studies with 3,743 participants were included. The meta-analysis indicated that adding LTHM to CM reduced PAF frequency (SMD = -0.99, 95 % CI = -1.40 to -0.57, I² = 88 %, N = 16, n = 1266), left atrium diameter (LAD) (MD = -2.39 mm, 95 % CI = -3.09 to -1.68), P-wave dispersion (Pd) (MD = -6.41 ms, 95 % CI = -8.44 to -4.37), high sensitive C-Reactive Protein (hs-CRP) (MD = -1.10 mg/l, 95 % CI = -1.73 to -0.47), and improved left ventricular ejection fraction (LVEF) (MD = 4.71 %, 95 % CI = 3.17 to 6.25). Thirty-four studies raised concerns about bias, with eight showing high risk. Certainty of evidence was rated as \"low\" for PAF frequency, LAD, Pd, hs-CRP, and LVEF.
UNASSIGNED: LTHM combined with CM may reduce PAF frequency. However, due to the complexity of interventions, with Liriope Tuber being only one component of the regimen, high risk of bias, substantial heterogeneity, and indirectness, interpretations should be cautious.
UNASSIGNED: PROSPERO (ID: CRD42023477926).

BACKGROUND: Atrial fibrillation (AF) is the most common type of arrhythmia. Heart rate variability (HRV) may be associated with AF risk. The aim of this study was to test HRV indices and arrhythmias as predictors of paroxysmal AF based on 24-hour dynamic electrocardiogram recordings of patients.
METHODS: A total of 199 patients with paroxysmal AF (AF group) and 204 elderly volunteers over 60 years old (Control group) who underwent a 24-hour dynamic electrocardiogram from August 2022 to March 2023 were included. Time-domain indices, frequency-domain indices, and arrhythmia data of the two groups were classified and measured. Binary logistic regression analysis was performed on variables with significant differences to identify independent risk factors. A nomogram prediction model was established, and the sum of individual scores of each variable was calculated.
RESULTS: Gender, age, body mass index and low-density lipoprotein (LDL) did not differ significantly between AF and Control groups (p > 0.05), whereas significant group differences were found for smoking, hypertension, diabetes, and high-density lipoprotein (HDL) (p < 0.05). The standard deviation of all normal to normal (NN) R-R intervals (SDNN), standard deviation of 5-minute average NN intervals (SDANN), root mean square of successive NN interval differences (rMSSD), 50 ms from the preceding interval (pNN50), low-frequency/high-frequency (LF/HF), LF, premature atrial contractions (PACs), atrial tachycardia (AT), T-wave index, and ST-segment index differed significantly between the two groups. Logistic regression analysis identified rMSSD, PACs, and AT as independent predictors of AF. For each unit increase in rMSSD and PACs, the odds of developing AF increased by 1.0357 and 1.0005 times, respectively. For each unit increase in AT, the odds of developing AF decreased by 0.9976 times. The total score of the nomogram prediction model ranged from 0 to 110.
CONCLUSIONS: The autonomic nervous system (ANS) plays a pivotal role in the occurrence and development of AF. The individualized nomogram prediction model of AF occurrence contributes to the early identification of high-risk patients with AF.

UNASSIGNED: Although Takotsubo syndrome (TTS) is generally considered a benign disease, recent reports showed the incidence of cardiogenic shock due to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and primary pump failure was estimated to be 6-20%.
UNASSIGNED: A 78-year-old woman presented with chest pain and cold sweats 2 days after surgery for lung cancer. Acute coronary syndrome was suspected based on her symptoms, electrocardiography, transthoracic echocardiography (TTE), and laboratory data; thus, emergency catheterization was performed. Normal coronaries were observed, with hyperkinesis at the base of the left ventricle and akinesis at its apex, leading to the diagnosis of the apical ballooning type of TTS. Pressure differences between the apex of the left ventricle (168/8/28 mmHg) and aorta (94/50/64 mmHg) indicated the presence of LVOTO. Two days after TTS onset, she developed cardiogenic shock (blood pressure was 54/38 mmHg). Transthoracic echocardiography showed acute MR due to systolic anterior motion of the mitral valve caused by LVOTO, which was further exacerbated by paroxysmal atrial fibrillation. Fluid resuscitation, intravenous β-blockers, and amiodarone were administered for reduction of the pressure gradient in the left ventricular outflow, rate control, and sinus rhythm maintenance. Her condition improved along with the MR, thereby improving LVOTO and maintaining sinus rhythm.
UNASSIGNED: Takotsubo syndrome should be kept in mind as a potential cause of acute MR due to LVOTO. Catheterization and multiple follow-up TTE play a major role in early detection for this condition.

UNASSIGNED: Recent advancements in artificial intelligence (AI) have significantly improved atrial fibrillation (AF) detection using electrocardiography (ECG) data obtained during sinus rhythm (SR). However, the utility of printed ECG (pECG) records for AF detection, particularly in developing countries, remains unexplored. This study aims to assess the efficacy of an AI-based screening tool for paroxysmal AF (PAF) using pECGs during SR.
UNASSIGNED: We analyzed 5688 printed 12-lead SR-ECG records from 2192 patients admitted to Beijing Chaoyang Hospital between May 2011 to August 2022. All patients underwent catheter ablation for PAF (AF group) or other electrophysiological procedures (non-AF group). We developed a deep learning model to detect PAF from these printed SR-ECGs. The 2192 patients were randomly assigned to training (1972, 57.3% with PAF), validation (108, 57.4% with PAF), and test datasets (112, 57.1% with PAF). We developed an applet to digitize the printed ECG data and display the results within a few seconds. Our evaluation focused on sensitivity, specificity, accuracy, F1 score, the area under the receiver-operating characteristic curve (AUROC), and precision-recall curves (PRAUC).
UNASSIGNED: The PAF detection algorithm demonstrated strong performance: sensitivity 87.5%, specificity 66.7%, accuracy 78.6%, F1 score 0.824, AUROC 0.871 and PRAUC 0.914. A gradient-weighted class activation map (Grad-CAM) revealed the model\'s tailored focus on different ECG areas for personalized PAF detection.
UNASSIGNED: The deep-learning analysis of printed SR-ECG records shows high accuracy in PAF detection, suggesting its potential as a reliable screening tool in real-world clinical practice.

Background: Low-voltage area (LVA) ablation, in addition to pulmonary vein isolation (PVI), has been proposed as a new strategy in patients with atrial fibrillation (AF), but clinical trials have shown conflicting results. We performed a systematic review and meta-analysis to assess the impact of LVA ablation in patient undergoing AF ablation (PROSPERO-registered CRD42024537696). Methods: Randomized clinical trials investigating the role of LVA ablation in addition to PVI in patients with AF were searched on PubMed, Embase, and the Cochrane Library from inception to 22 April 2024. Primary outcome was atrial arrhythmia recurrence after the first AF ablation procedure. Secondary endpoints included procedure time, fluoroscopy time, and procedure-related complication rate. Sensitivity analysis including only patients with LVA demonstration at mapping and multiple subgroups analyses were also performed. Results: 1547 patients from 7 studies were included. LVA ablation in addition to PVI reduced atrial arrhythmia recurrence (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52-0.81, p < 0.001) with a number needed to treat to prevent recurrence of 10. No difference in procedure time (mean difference [MD] -5.32 min, 95% CI -19.01-8.46 min, p = 0.45), fluoroscopy time (MD -1.10 min, 95% CI -2.48-0.28 min, p = 0.12) and complication rate (OR 0.81, 95% CI 0.40-1.61, p = 0.54) was observed. Consistent results were demonstrated when considering only patients with LVA during mapping and in prespecified subgroups for AF type (paroxysmal vs. persistent), multicentric vs. monocentric trial, and ablation strategy in control group. Conclusions: In patients with AF, ablation of LVAs in addition to PVI reduces atrial arrhythmia recurrence without a significant increase in procedure time, fluoroscopy time, or complication rate.

BACKGROUND: High-frequency low-tidal-volume (HFLTV) ventilation during radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) has been shown to be superior to standard ventilation (SV) in terms of procedural efficiency, acute and long-term clinical outcomes. Our study aimed to compare ablation lesions characteristics utilizing HFLTV ventilation versus SV during RFCA of PAF.
METHODS: A retrospective analysis was conducted on patients who underwent pulmonary vein isolation (PVI) for PAF between August 2022 and March 2023, using high-power short-duration ablation. Thirty-five patients underwent RFCA with HFLTV ventilation and were matched with another cohort of 35 patients who underwent RFCA with SV. Parameters including ablation duration, contact force (CF), impedance drop, and ablation index were extracted from the CARTONET database for each ablation lesion.
RESULTS: A total of 70 patients were included (HFLTV = 35/2484 lesions, SV = 35/2830 lesions) in the analysis. There were no differences in baseline characteristics between the groups. While targeting the same ablation index, the HFLTV ventilation group demonstrated shorter average ablation duration per lesion (12.3 ± 5.0 vs. 15.4 ± 8.4 s, p < .001), higher average CF (17.0 ± 8.5 vs. 10.5 ± 4.6 g, p < .001), and greater impedance reduction (9.5 ± 4.6 vs. 7.7 ± 4.1 ohms, p < .001). HFLTV ventilation group also demonstrated shorter total procedural time (61.3 ± 25.5 vs. 90.8 ± 22.8 min, p < .001), ablation time (40.5 ± 18.6 vs. 65.8 ± 22.5 min, p < .001), and RF time (15.3 ± 4.8 vs. 22.9 ± 9.7 min, p < .001).
CONCLUSIONS: HFLTV ventilation during PVI for PAF was associated with improved ablation lesion parameters and procedural efficiency compared to SV.

Pulmonary vein isolation (PVI) is the established cornerstone for atrial fibrillation (AF) ablation, indeed current guidelines recognize PVI as the gold standard for first-time AF ablation, regardless of if it is paroxysmal or persistent. Since 1998 when Haïssaguerre pioneered AF ablation demonstrating a burden reduction after segmental pulmonary vein (PV) ablation, our approach to PVI was superior in terms of methodology and technology. This review aims to describe how paroxysmal atrial fibrillation ablation has evolved over the last twenty years. We will focus on available techniques, a mechanistic understanding of paroxysmal AF genesis and the possibility of a tailored approach for the treatment of AF, before concluding with a future perspective.

Three techniques of catheter ablation (CA; radiofrequency, cryoballoon, and pulsed-field ablation) are available to treat patients with paroxysmal atrial fibrillation (PAF) who do not adequately respond to pharmacological treatments. Our study was aimed at comparing these techniques based on the data of randomized studies because these are considered the best sources of efficacy data. After selecting pertinent trials, our analysis studied the time-to-event data published for these three techniques. An artificial intelligence method was used that reconstructs individual patient data from the Kaplan-Meier curves. The endpoint was an arrhythmia recurrence. A preliminary heterogeneity analysis was performed. Then, our main analysis was based on individual patient data reconstructed from Kaplan-Meier graphs. The hazard ratio (HR) was its main parameter. Three randomized trials were included. Our heterogeneity analysis confirmed an acceptable level of between-trial heterogeneity that allowed us to pool the curves from the different trials; however, cryoballoon ablation with a two-minute duration fared worse than the other techniques. Then, our main analysis estimated the following values of HR: pulsed-field ablation versus radiofrequency ablation, 0.549 (95%CI, 0.413-0.730; p<0.001); pulsed-field ablation versus cryoballoon ablation, 0.478 (95%CI, 0.364-0.633); radiofrequency ablation versus cryoballoon ablation, HR=0.871 (95%CI, 0.585-1.295; p=0.506). In conclusion, radiofrequency ablation and cryoballoon ablation showed similar effectiveness (except for the two-minute cryoballoon ablation, which fared worse). Our results showing the superiority of pulsed-field ablation versus thermal ablation must be interpreted with caution because the patients given pulsed-field ablation were limited, and their follow-up was shorter than that of patients receiving thermal ablation.

BACKGROUND: Paroxysmal atrial fibrillation (pAF) may progress through cardiac remodeling to persistent atrial fibrillation (psAF). However, some may present in psAF without a preceding history of pAF. A preceding history of pAF may affect recurrence after direct current cardioversion (DCCV).
OBJECTIVE: The aim of this study was to determine whether a preceding history of pAF is associated with a difference in recurrence rates after DCCV compared with patients without a preceding history of pAF.
METHODS: A prospective procedural database at a Veterans Affairs center identified 565 patients who underwent their first DCCV for psAF. Initial rhythm history was separated by prior pAF, and those with none were considered primary psAF. Electrocardiography follow-up was standardized at 1 month and 3 months after cardioversion.
RESULTS: Patients who underwent their first DCCV for psAF were more likely to have presented with primary psAF (81.6%). Those with pAF had a similar left atrial size but were more likely to have chronic kidney disease, sleep apnea, previous stroke, and use of antiarrhythmic drugs at the time of cardioversion. Patients with pAF had earlier recurrence and shorter median AF survival time, 1.6 months compared with 5 months (Kaplan-Meier plot, P = .0101). This difference persisted in controlling for antiarrhythmic drug use. Recurrence type was mostly persistent AF, similar in both groups.
CONCLUSIONS: Patients with primary psAF may have a more sustained response to DCCV compared with those with a preceding history of pAF. Thus, those patients with pAF may benefit from a more aggressive, early rhythm control strategy because of higher likelihood of recurrence with DCCV.

BACKGROUND: Paroxysmal atrial fibrillation (pAF) occurs sporadically and can impair athletic performance. Gold standard for diagnosis is surface electrocardiography (ECG), however, this requires AF to be sustained. Implantable loop recorders (ILRs) are routinely used for AF detection in human medicine. While ILR placement has been studied in horses, its AF detection performance is unknown.
OBJECTIVE: (I) Validation of ILRs for AF detection in horses. (II) Determining pAF incidence using ILRs and estimate the positive predictive value (PPV).
METHODS: (I) Experimental study; (II) Longitudinal observational study.
METHODS: (I) Implantation of ILRs in 15 horses with AF and 13 horses in sinus rhythm. Holter ECGs were recorded at: 1, 4, 8, 12 and 16 weeks of AF. The ILR ECGs were compared with surface ECGs to assess diagnostic sensitivity and specificity. (II) Eighty horses (43 Warmbloods, 37 Standardbreds) with ILRs were monitored for 367 days [IQR 208-621].
RESULTS: (I) ILRs detected AF on all recording days, in horses with AF, with a sensitivity of 66.1% (95% CI: 65.8-66.5) and a specificity of 99.99% (95% CI: 99.97-99.99). The sensitivity remained consistent across all time points. (II) The incidence of pAF was 6.3% (5/80). In horses with pAF, the PPV ranged from 8% to 87%. Increased body condition score (BCS > 6/9) was associated with an increased number of false positive episodes (p = 0.005).
CONCLUSIONS: (I) Horses were stabled during the ECG recordings, and AF was induced, rather than naturally occurring pAF. (II) Integrated algorithm in this ILR is optimised for AF detection in humans using remote monitors. Additionally, sensing is affected by motion artefacts.
CONCLUSIONS: The ILR reliably detected AF in resting horses, particularly in horses with normal BCS (6/9). The ILR proved useful to detect pAF and is recommended alongside Holter monitoring for diagnostic workup of horses with suspected pAF.
UNASSIGNED: Paroxysmales Vorhofflimmern (pAF) tritt sporadisch auf und kann die athletische Leistungsfähigkeit beeinträchtigen. Goldstandard für die Diagnose ist die Oberflächen‐Elektrokardiographie (ECG), die jedoch ein anhaltendes Vorhofflimmern voraussetzt. Implantierbare Loop‐Recorder (ILRs) wurden in der Humanmedizin routinemäßig zur Erkennung von Vorhofflimmern (AF) eingesetzt. Während die Platzierung von ILRs bei Pferden untersucht wurde, ist deren Fähigkeit in der Erkennung von Vorhofflimmern unbekannt. ZIELSETZUNG: (I) Validierung von ILRs zur Erkennung von AF bei Pferden. (II) Bestimmung der pAF‐Inzidenz mit ILRs und Schätzung des positiven prädiktiven Werts (PPV).
METHODS: (I) Experimentelle Studie; (II) Längsschnittliche Beobachtungsstudie.
METHODS: (I) Implantation von ILRs bei 15 Pferden mit AF und 13 Pferden mit Sinusrhythmus. Holter‐ECGs wurden aufgezeichnet nach: 1 Woche, 4 Wochen, 8 Wochen, 12 Wochen und 16 Wochen mit AF. Die ILR‐ECGs wurden mit Oberflächen‐ECGs verglichen, um die diagnostische Sensitivität und Spezifität zu beurteilen. (II) Achtzig Pferde (43 Warmblüter, 37 Standardbreds) mit ILR wurden 367 Tage lang überwacht [IQR 208‐621]. ERGEBNISSE: (I) ILRs erkannten AF an allen Aufzeichnungstagen bei Pferden mit AF mit einer Sensitivität von 66.1% (95% CI: 65.8–66.5) und einer Spezifität von 99.99% (95% CI: 99.97–99.99). Die Sensitivität blieb über alle Zeitpunkte hinweg konstant. (II) Die Inzidenz von pAF betrug 6.3% (5/80). Bei Pferden mit pAF reichte der PPV von 8% bis 87%. Ein höherer Body Condition Score (BCS > 6/9) war mit einer höheren Anzahl falsch positive Episoden verbunden (P = 0.005). HAUPTEINSCHRÄNKUNGEN: (I) Pferde waren während der ECG‐Aufzeichnungen im Stall, und es handelte sich um induziertes AF und nicht um natürlich vorkommende pAF. (II) Der Integrierte Algorithmus der ILR ist für die Erkennung von AF bei Menschen mit Fernüberwachung optimiert. Außerdem wird die Erkennung durch Bewegungsartefakte beeinträchtigt.
UNASSIGNED: Mit den ILR wurde AF bei ruhenden Pferden zuverlässig erkannt, insbesondere bei Pferden mit normalem BCS (6/9). Der ILR erwies sich als nützlich für den Nachweis von pAF und wird neben der Holter‐Überwachung für die diagnostische Abklärung von Pferden mit Verdacht auf pAF empfohlen.