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Aims: Cardiac implantable electronic device (CIED) infection carries a substantial burden of morbidity, mortality, and cost. The Prevention of Arrhythmia Device Infection Trial (PADIT) risk score improves identification of high-risk patients and may guide targeted strategies to reduce infection. Recent work has categorized CIED infection into localized pocket vs. systemic infection, with early reports suggesting different risk factors for each. However, no current risk score has been validated for infection subtypes.ObjectivesIndependently validate the PADIT infection risk score.Compare risk factors for infection subtypes.Assess PADIT performance in predicting subtype-specific infection.

Methods and results: A prospective registry was initiated at the University of Ottawa Heart Institute in 2007 to capture all CIED procedures and prospectively identify infections in collaboration with the infection prevention team. PADIT risk score components were documented for each procedure. All suspected infections were adjudicated independently by two physicians (with a third if required), blinded to PADIT score and baseline variables, and subclassified as pocket or systemic infection. Logistic regression models were generated to validate PADIT performance for each subtype, with evaluation using Akaike and Bayesian information criteria (AIC/BIC), C-statistics, and calibration slope. Between 2007 and 2020, 14,225 procedures were performed (mean age 72 ± 14 years, 35% female, 70% new implants, 18% generator changes, 11% upgrades). A total of 103 infections (0.73%) were adjudicated, of which 71 (69%) were pocket and 32 (31%) systemic. The PADIT score showed good predictive performance with a C-statistic of 0.687 (95% CI 0.655-0.743), similar to the derivation cohort (0.702, 95% CI 0.661-0.741). Notably, the number of prior procedures was strongly associated with pocket infection but not systemic infection. PADIT discrimination was consistent across subtypes: pocket infection C-statistic 0.691 (95% CI 0.649-0.761) and systemic infection 0.746 (95% CI 0.707-0.848). Calibration slopes demonstrated good agreement between predicted and observed events, with the best fit for systemic infection.

Conclusion: The PADIT score was independently validated with discrimination and calibration similar to the original derivation cohort. Importantly, prior procedures predicted pocket but not systemic infection. Overall, PADIT performed well in predicting both subtypes, with the strongest model fit observed for systemic infection.

Aims: Procurement of cardiac implantable electronic devices (CIEDs) across the European Union is shaped by diverse healthcare systems, reimbursement mechanisms and levels of clinician involvement. Despite a shared legal framework, limited comparative data are available on how procurement is implemented across countries.

Objective: The objectives of this study are to examine CIED procurement strategies in 22 European countries where public tendering is mandatory and to explore how clinical, economic and structural factors influence procurement processes.

Methods and results: We conducted 23 structured interviews with cardiologists and one industry expert across 22 European countries. A thematic analysis was used to synthesize procurement models, clinical involvement and reimbursement structures. No formal outcome or cost-effectiveness analysis was performed. Procurement models varied widely, encompassing centralized, decentralized and hybrid systems. Clinician involvement ranged from leading device selection based on clinical criteria to being excluded from decision-making in systems driven primarily by price. Reimbursement pathways also differed, with procedure tariffs for single-chamber pacemakers ranging from €1059 to €14 889. A single region in Finland had implemented a pilot value-based procurement model linking payment to patient outcomes.

Conclusion: Cardiac implantable electronic device procurement across Europe is heterogeneous and predominantly cost driven, with limited integration of clinical outcomes or value-based principles. While not designed to evaluate cost-effectiveness directly, this study identifies procurement structures that may support or hinder value-based decision-making. Further research is needed to assess how procurement impacts clinical outcomes, innovation adoption and system sustainability.

Aims: Obesity adversely affects atrial fibrillation (AF) outcomes and is associated with higher recurrence after catheter ablation. Glucagon-like peptide-1 receptor agonists (GLP-1RAs) promote weight loss and improve metabolic inflammation, but their role as adjuncts to ablation has not been completely defined. This study investigated the impact of semaglutide on post-ablation rhythm outcomes in obese patients with AF.

Methods and results: This single-centre, propensity-matched study included obese patients [body mass index (BMI) ≥ 30 kg/m²] undergoing first-time catheter ablation for paroxysmal AF (2019-2024). Patients who initiated semaglutide within 3 months before or 1 month after ablation were compared with matched controls who did not receive GLP-1RA therapy. All patients underwent continuous rhythm monitoring using implantable cardiac monitors. The primary endpoint was any atrial tachyarrhythmia recurrence beyond a 2-month blanking period. The final cohort included 181 semaglutide-treated patients and 181 controls with matched clinical and procedural characteristics. At 18-month follow-up, freedom from recurrence was 80.2% vs. 65.2%; semaglutide was associated with a significantly lower risk of recurrence (hazard ratio 0.52; 95% confidence interval 0.34-0.78; P = 0.002). Weight and BMI decreased significantly in the semaglutide group (-11.8 ± 3.8 kg; -4.0 ± 1.4 kg/m²) compared with controls (-1.9 ± 1.2 kg; -0.3 ± 0.8 kg/m²; both P < 0.001). A substantial proportion of treated patients achieved ≥10% weight reduction.

Conclusion: Glucagon-like peptide-1 receptor agonist therapy using semaglutide is associated with a reduced risk of AF recurrence in obese patients undergoing AF catheter ablation, indicating its potential as an adjunctive treatment. Further studies are needed to confirm these findings and elucidate the effects of GLP-1RA on AF recurrence.

Aims: A dual-chamber leadless pacemaker (LP) system relies on a beat-to-beat, wireless, implant-to-implant (i2i™) communication between implanted devices in the right atrium and right ventricle (A-to-V and V-to-A). Atrioventricular (AV) synchrony was evaluated during an ambulatory 24 h period of daily living to determine if its effectiveness can be maintained under real-world conditions.

Methods and results: A prospective, single-arm, multicentre clinical study (ClinicalTrials.gov identifier NCT05252702) evaluated the overall safety and performance of the dual-chamber LPs in patients with standard indications for dual-chamber pacing. Following the 3-month visit, eligible patients wore 12-lead Holter monitors for 24 h while resuming the activities of daily living while under clinically driven programmed settings. Leadless pacemaker diagnostic data were interrogated when patients returned to the clinic. An independent Holter core laboratory adjudicated the proportion of synchronous beats (PR intervals within paced and sensed AV delay bounds). Relationships between AV synchrony and i2i communication success rate, implant indication, heart rate, and AV event type were evaluated. Among 47 analysable patients, mean AV synchrony was achieved in 96.7% of beats, exceeding mean A-to-V and V-to-A transmission success rates of 93.4% and 92.1%, respectively. There were no significant differences in AV synchrony between sinus node and AV block patients. Across all AV paced/sensed cycle combinations and heart rate ranges (including >100 b.p.m.), AV synchrony was sustained >90% in an ambulatory real-world setting.

Conclusion: A dual-chamber leadless pacing system demonstrated >96% overall AV synchrony for a 24 h period of daily living while programmed to clinically appropriate settings, thus showing that true dual-chamber DDD(R) pacing can be maintained in a real-world environment.

Aims: The rising popularity of endurance races underscores the need to explore the risks of sports-related sudden cardiac arrest (Sr-SCA). Although rare, Sr-SCA is significantly more prevalent in men than in women. The mechanisms underlying these sex differences remain unclear.We aimed to investigate the incidence rates, clinical characteristics, aetiologies, sex differences, and exercise performances among SCA cases during major endurance races in Paris over a 10-year period.

Methods and results: We Analysed the Paris Sudden Death Expertise Centre Registry Data (Covering 2011-2024, excluding 2020). This included SCA cases from the half marathon, full marathon and 20 km Parisian race events. We calculated the incidence rates for men and women, with performance analyses focusing on acceleration patterns and the relative risk of SCA in the final kilometre. Among the 1.2 million participants, 17 SCA cases (88% male) were identified, yielding crude incidences of 16.9 and 5.7 per million for men and women, respectively. Sr-SCA was overrepresented in the final kilometres of short races. Men exhibited twice the acceleration rate that women did. Despite extensive medical investigations, no cause was identified in 47.1% of the cases, underscoring the idiopathic nature of Sr-SCA. After hospitalization, 88% (15/17) of the cases survived, all with excellent neurological outcomes [cerebral performance category (CPC) 1], except for one CPC 2.

Conclusion: SCA incidences during endurance races are low, with male predominance, high survival rates, and a high proportion of unexplained cases. The male-specific acceleration in the final kilometre may suggest that physiological and behavioural factors influence SCA risk.

Aims: Perforation during left bundle branch area pacing (LBBAP) results in a fall in the current of injury (COI) amplitude in the unipolar unfiltered electrogram (iEGM), but systematic waveform analyses have not been performed. Our aim was to investigate unipolar iEGM waveforms during perforation and to compare them to those at the final lead position.

Methods and results: The iEGMS of consecutive patients who had perforation during LBBAP implantation were systematically analysed. A total of 92 patients with perforation were included. In the unfiltered channel, sensed COI amplitude was lower with perforation [3.0 (1.5-4.1) mV] than at the final lead position [14.0 (9.2-17.5) mV, P < 0.0001], as was also the case during pacing. Patients with narrow QRS/non-LBBB typically had wide negative (QS) waveforms during sensing (in 67% of cases), whereas those with LBBB/paced rhythm had positive (wide R/RS) morphologies (in 93% of cases). In the former subgroup, a sensed Q or S amplitude > COI amplitude (which is easy to eyeball during lead deployment) had a sensitivity of 86% and a specificity of 93% for diagnosing perforation. Waveforms during macroperforation (with loss of capture, n = 27) differed compared to microperforation (with preserved capture, n = 65), with significantly lower COI amplitudes, more frequent QS morphology, and rarer sharp multiphasic components in the ventriculogram of the filtered channel.

Conclusion: Beyond COI amplitude, additional iEGM waveform parameters may be used to evaluate the presence of LBBAP perforation and should be carefully monitored during lead deployment to improve safety.

Ventricular tachycardia (VT) and ventricular fibrillation remain major contributors to sudden cardiac death, with current therapies limited by our incomplete understanding of the arrhythmogenic substrate. This narrative review explores recent developments in computer-aided techniques for characterizing the arrhythmogenic substrate, focusing on post-myocardial infarction VT. High-resolution cardiac imaging now enables detailed visualization of structural abnormalities, including heterogeneous scar architecture and fatty infiltration. Sophisticated invasive mapping techniques provide insights into local electrophysiological properties, while novel non-invasive mapping approaches offer complementary views of global electrical patterns. Integration of these modalities through computational simulations allows for mechanistic insights into arrhythmia initiation and maintenance, particularly in post-myocardial infarction VT, where structural and functional substrates interact in complex ways. Emerging artificial intelligence applications enhance substrate analysis through automated feature extraction and pattern recognition, enabling more sophisticated risk stratification. These computer-aided approaches are advancing from research tools to clinical applications, with early evidence suggesting improved ablation outcomes and better risk prediction. However, significant challenges remain in validation, standardization, and clinical implementation of these innovations. This narrative review highlights recent methodological advances and clinical applications of computer-aided substrate characterization, and conceptualizes future directions towards personalized arrhythmia management, also beyond post-infarction VTs.

Aims: Concomitant pulsed field ablation (PFA) for atrial fibrillation (AF) with left atrial appendage closure (LAAC) offers a single-procedure approach for arrhythmia control and thromboembolic risk reduction. This study assessed the workflow, safety, and feasibility of combined PFA and LAAC in routine practice.

Methods and results: We prospectively analysed patients undergoing zero-fluoroscopy PFA, with low fluoroscopy for LAAC. Pre-procedural planning used CT imaging and AI-based models for device selection and landing-zone assessment. A single transseptal puncture facilitated intracardiac echocardiography, PFA catheter, and LAAC sheath. A total of 209 patients were included (56% male; mean age 76.5 ± 7.8 years), with 59.3% paroxysmal AF, 40.7% persistent AF, and 50% de novo AF. The mean CHA2DS2-VASc score was 4.5. Mean procedure and left atrial dwell times were 57.3 ± 17 and 45.1 ± 13.6 min, respectively; fluoroscopy averaged 3.4 ± 0.8 min for LAAC. A single LAAC device was used in 94% of cases, achieving adequate seal in all. No pericardial effusion, phrenic nerve injury, kidney, or oesophageal injury occurred; two patients had minor groin bleeding. All were discharged same day on oral anticoagulation for 90 days. Follow-up CT (80%) or TEE (20%) at 111.6 ± 16.5 days showed no leaks >2 mm, a 4.7% small-leak rate, and two device-related thrombi without stroke, managed with extended anticoagulation.

Conclusion: Combined PFA and LAAC is feasible and safe with favourable early outcomes. Multi-centre studies are warranted to confirm findings and standardize this workflow for broader clinical adoption.

Inherited mutations in the KCNH2 gene, which encodes the cardiac hERG potassium channel, are major contributors to arrhythmogenic syndromes such as long QT and short QT syndromes. However, clinical interpretation of the growing number of missense variants - many of which are classified as variants of uncertain significance (VUS) - remains a pressing challenge. Here, we present a semi-automated in silico pipeline for predicting hERG variant pathogenicity, acting as a binary classifier and integrating five structural metrics - residue volume, hydrophobicity, charge, steric clashes, and proximity to pathogenic hotspots - into a composite structural pathogenicity score (SPS) scaled from 1 to 5. Applied to 1727 hERG variants from ClinVar and from a French nationwide cohort, this binary classifier, termed SPARC, identified 260 variants as high risk of pathogenicity with SPS ≥3.25, of which a representative subset from the French cohort was functionally validated using high-throughput automated patch-clamp. Functional phenotyping confirmed the structural predictions, including for several VUS, demonstrating that comprehensive structural scoring can reliably stratify variant pathogenicity. This approach, benchmarked with Alpha Missense and Revel, offers a superior scalable, cost-effective pre-screening tool to guide clinical variant interpretation and prioritization for experimental validation.

Coronary artery spasm can be life-threatening. Clinically significant complications include myocardial infarction, ventricular arrhythmias and sudden cardiac arrest. Although challenging to diagnose, new international guidelines have been published to guide the diagnosis of coronary artery spasm when this is the suspected cause of cardiac arrest. The aim of this review is to consider existing knowledge for the diagnosis and management of coronary artery spasm in survivors of sudden cardiac arrest. Twenty-seven original research articles (written in English) involving a total of 1541 survivors of sudden cardiac arrest associated with coronary artery spasm form the basis of this review. Most cohorts included >75% male participants with a mean age range of 45-63 years. A positive family history or coronary risk factors of coronary artery disease are not commonly found, albeit many survivors are smokers (ranged 17%-100% across cohorts). Provocative testing for coronary spasm was reported in 25 of the evaluated papers, but the indications for testing were inconsistently specified. A high recurrence rate (up to 45%) of life-threatening ventricular arrhythmias was reported, and implantable cardioverter-defibrillator placement varied markedly. In conclusion, diagnosing coronary artery spasm as a cause of sudden cardiac arrest is challenging. The pathophysiological understanding is limited. Knowledge gaps include the incidence and prevalence, as well as the usefulness of provocative testing in survivors. More data are needed regarding patient risk stratification, indications for implantable cardioverter-defibrillator insertion, and optimal pharmacological therapy.