Faculty Bibliography

AIMS/UNASSIGNED:We aimed to develop and externally validate a convolutional neural network (CNN) using sinus rhythm electrocardiograms (ECGs) and CHARGE-AF features to predict incident paroxysmal atrial fibrillation (AF), benchmarking its performance against the CHARGE-AF score. METHODS AND RESULTS/UNASSIGNED:We curated 157 192 sinus ECGs from 76 986 patients within the New York University (NYU) Langone Health system, splitting data into training, validation, and test sets. Two cohorts, from suburban US outpatient practices and Greek tertiary hospitals, were used for external validation. The model utilizing the sinus ECG signal and all CHARGE-AF features achieved the highest test set area under the receiver operator curve (AUC) (0.89) and area under the precision recall curve (AUPRC) (0.69), outperforming the CHARGE-AF score alone. Model robustness was maintained in the external US cohort (AUC 0.90, AUPRC 0.67) and the European cohort (AUC 0.85, AUPRC 0.78). Subgroup analyses confirmed consistent performance across age, sex, and race strata. A CNN using ECG signals alone retained strong predictive ability, particularly when simulating missing or inaccurate clinical data. CONCLUSION/UNASSIGNED:Our CNN integrating sinus rhythm ECGs and CHARGE-AF features demonstrated superior predictive performance over traditional risk scoring alone for detecting incident paroxysmal AF. The model maintained accuracy across geographically and clinically diverse external validation cohorts, supporting its potential for broad implementation in AF screening strategies.

OBJECTIVES/OBJECTIVE:Assess the characteristics and management of patients with LAA thrombus despite compliance with oral anticoagulation (OAC). BACKGROUND:Atrial fibrillation guidelines consider 4 weeks of uninterrupted OAC sufficient to avoid transesophageal echocardiography to rule out left atrial appendage thrombus. However, some patients may exhibit persistent thrombus despite compliance with OAC. METHODS:Clinical history, management, and outcomes were reviewed for patients with LAA thrombus on preprocedural TEE presenting for an AF related procedure between 2021 and 2024. RESULTS:Sixty-five (1.8%) of 3653 preprocedural TEEs exhibited LAA thrombus. OAC compliance of at least 4 week was documented in 39 (60%) of these patients, including Apixaban 64%, Rivaroxaban 23%, Warfarin 8%, Dabigatran 5%. Two of these patients (3%) experienced an embolic event and 8 (12%) died during the follow up period. Resolution of LAA thrombus was documented in 12/32 patients, 6 who switched to Dabigatran, 2 to Eliquis, 1 to Warfarin, and 3 remained on Eliquis. LAA-occlusion was successfully performed in seven patients with persistent LAA thrombus. CHADS-VASc 3 or greater, HFrEF, or valvular AF were present in 37/39 of these patients. CONCLUSION/CONCLUSIONS:For 3653 patients who underwent Preprocedural TEE, 39 exhibited LAA thrombus despite compliance with OAC. Switching OAC or maintaining the same agent for longer period of time resolved the thrombus in 31% of cases. LAA-O was effective in cases where the thrombus did not resolve. Patients with non-valvular AF, compliance with OAC > 4 weeks, CHADS-VASc ≤ 2, and normal EF exhibited the lowest probability for not having a thrombus on TEE.

BACKGROUND:Left atrial appendage occlusion (LAA-O) with Amulet and Watchman FLX are approved for reducing stroke risk in patients with atrial fibrillation when oral anticoagulation is not tolerated. Real world clinical outcomes reported along with imaging data are needed to help clinicians choose between these two technologies and manage device-related complications. METHODS:The study retrospectively analyzed clinical, transesophageal (TEE), and available computed tomography (CT) data from 364 FLX and 292 Amulet procedures performed at an academic medical center over a 4-year period. RESULTS:were included. TTE LAA-orifice area correlated with CT-derived measurements. There were more late pericardial effusions for Amulet (3.1%) compared to FLX (0.3%), though the majority were conservatively managed. Mean procedure times were similar (FLX 64 ± 24, Amulet 65 ± 21 min) as were the rates of device related thrombus (FLX 1% and Amulet 1.4%). Clinically relevant peridevice leak (PDL) on follow-up TEE imaging was greater for FLX (16%) compared to Amulet (10%). Combined AF ablation-LAA-occlusion procedures exhibited lower rates of PDL and late pericardial effusions compared to solo procedures. CONCLUSIONS:Based on retrospective analysis, an initial strategy with Watchman FLX in patients with favorable LAA anatomy would reduce the risk of late pericardial effusions at the expense of a higher rate of clinically relevant PDL compared to Amulet. Combined AF ablation and LAA-O procedures exhibit less PDL.

BACKGROUND:Recent evidence suggests atrial fibrillation (AF) causes cardiomyopathy due to remodeling driven by both irregular rate and rhythm. Atrial fibrillation (AF) ablation in patients with reduced ejection fraction (EF) ≤ 35% has been shown to improve EF and mortality. It is unknown whether the benefits of AF ablation among patients with reduced EF are affected by the degree of pre-ablation rate control. OBJECTIVES/OBJECTIVE:To evaluate AF ablation echocardiographic outcomes for patients who have EF ≤ 35% with varying degrees of pre-ablation rate control. METHODS:Single-center, retrospective study of patients with EF ≤ 35% undergoing first-time ablation of persistent AF. Primary analyses evaluated the degree to which pre-ablation rate control impacted echocardiographic outcomes. Rates of EF recovery to > 35% were compared at three different cutoffs: 110 bpm, 90 bpm, and 70 bpm. A linear regression analysis was then performed to evaluate whether baseline heart rate (HR) predicted change in EF. RESULTS: = 0.05, p = 0.07). CONCLUSIONS:Catheter ablation of persistent AF in patients with reduced EF frequently resulted in recovery in EF > 35%, irrespective of pre-ablation achieved rate control. While patients with HR > 70 bpm experienced a greater improvement in EF compared to those ≤ 70 bpm, patients with baseline HR below this target still experienced significant EF improvements. Further investigation into irregularity-mediated cardiomyopathy is warranted.

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

BACKGROUND:Combined catheter ablation (CA) with percutaneous left atrial appendage closure (LAAC) may produce comprehensive treatment for atrial fibrillation (AF) whereby rhythm control is achieved and stroke risk is reduced without the need for chronic oral anticoagulation. However, the efficacy and safety of this strategy is still controversial. METHODS:This meta-analysis was reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. The risk of bias was assessed using the Modified Newcastle-Ottawa scale and Cochrane risk of bias tool. Eligible studies reported outcomes in patients with AF who underwent combined CA and LAAC vs CA alone. Studies performing CA without pulmonary vein isolation were excluded. RESULTS:Eight studies comprising 1878 patients were included (2 RCT, 6 observational). When comparing combined CA and LAAC vs CA alone, pooled results showed no difference in arrhythmia recurrence (risk ratio (RR) 1.04; 95% confidence interval (CI) 0.82-1.33), stroke or systemic embolism (RR 0.78; 95% CI 0.27-2.22), or major periprocedural complications (RR 1.28; 95% CI 0.28-5.89). Total procedure time was shorter with CA alone (mean difference 48.45 min; 95% CI 23.06-74.62). CONCLUSION/CONCLUSIONS:Combined CA with LAAC for AF is associated with similar rates of arrhythmia-free survival, stroke, and major periprocedural complications when compared to CA alone. A combined strategy may be as safe and efficacious for patients at moderate to high risk for bleeding events to negate the need for chronic oral anticoagulation.

BACKGROUND:Genetic testing is a cornerstone in the assessment of many cardiac diseases. However, variants are frequently classified as variants of unknown significance, limiting the utility of testing. Recently, the DeepMind group (Google) developed AlphaMissense, a unique artificial intelligence-based model, based on language model principles, for the prediction of missense variant pathogenicity. We aimed to report on the performance of AlphaMissense, accessed by VarCardio, an open web-based variant annotation engine, in a real-world cardiovascular genetics center. METHODS AND RESULTS/RESULTS:<0.001). Genotype-phenotype concordance was highly aligned using VarCard.io predictions, at 95.9% (95% CI, 92.8-97.9) concordance rate. For 109 variants classified as pathogenic, likely pathogenic, benign, or likely benign by ClinVar, concordance with VarCard.io was high (90.5%). CONCLUSIONS:AlphaMissense, accessed via VarCard.io, may be a highly efficient tool for cardiac genetic variant interpretation. The engine's notable performance in assessing variants that are classified as variants of unknown significance in ClinVar demonstrates its potential to enhance cardiac genetic testing.