Sorajja, Dan

Background: A blanking period allowing for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has historically been standardized to 90 days. With the recent introduction of pulsed field ablation (PFA) for PVI and emerging in vitro data suggesting a shorter inflammatory timeframe, it remains unclear whether recurrences during this 90-days period reflect incomplete procedural success or merely transient inflammatory changes. Research Question: In patients undergoing PVI with PFA, do early AF recurrences at 30, 60, and 90 days predict late AF recurrences beyond the standardized 90-day blanking period? Methods: Patients undergoing PFA for AF were retrospectively included. Procedures were performed under general anesthesia, and high-density (HD) mapping, with PVI and additional ablation lines applied at the operator’s discretion. PFA catheters included Farawave, PulseSelect, and Sphere-9. AF recurrences were defined as documented episodes on 12-lead ECG or cardiac monitoring devices, confirmed by interpretation from an experienced cardiologist. Survival analyses were conducted based on the occurrence of early recurrences at 30, 60, and 90 days post-ablation. Kaplan-Meier curves and hazard ratios were reported. This study was approved by our institutional review board. Results: To the best of our knowledge, this is the largest real-world study reporting outcomes of PFA for AF in the United States. A total of 1,214 patients were included in the analysis. Mean age was 66.4 years; 31.9% were female, and 22.4% underwent redo PVI. Six-month AF recurrence-free survival was 79% (95% CI, 75–83%) for the overall cohort. Patients experiencing early recurrence at 30, 60, and 90 days had a significantly higher risk of AF recurrence beyond the standardized 90-day blanking period (HR 4.0, 95% CI 2.7–5.9, P < 0.01; HR 5.0, 95% CI 3.6–7.1, P < 0.01; and HR 6.9, 95% CI 4.9–9.6, P < 0.01, respectively). Conclusion: Early recurrences at 30, 60, and 90 days post-ablation are strongly associated with atrial fibrillation recurrence beyond the 90-day blanking period. These findings challenge the traditional concept of blanking period after PFA and suggest that early recurrence may indicate incomplete procedural success rather than transient inflammation.

Background: Patients with cardiac implantable electronic devices (CIEDs) undergoing radiation therapy face potential risks of device malfunction. Proton beam therapy (PBT), with its reduced neutron scatter, has emerged as a potentially safer alternative, yet real-world safety data remain scarce. Methods: We conducted a retrospective cohort study of 100 patients with CIEDs (76 pacemakers, 24 ICDs) who underwent PBT from 2016 to 2023 at a quaternary center. Baseline and serial device interrogations were performed before, during, and after treatment to assess lead impedance, capture thresholds, battery function, and arrhythmic events. Patients were stratified by pacemaker dependence and monitored accordingly. Primary outcomes included device malfunction and new-onset arrhythmias during treatment. Secondary outcomes included device parameter changes, one-year arrhythmia incidence, and cardiac-related hospitalizations. Results: No treatment-related deaths or major device failures occurred. Device malfunction was rare (2 pacemaker patients, 2.6%), with no malfunctions in ICD recipients. Transient, non-clinically significant changes in lead impedance and capture thresholds were observed. Arrhythmias during treatment occurred in 26% of pacemaker and 25% of ICD patients, but only 4% developed new arrhythmias. At one year, device-related complications and cardiac outcomes remained comparable across groups. Independent predictors of arrhythmias during treatment included a higher radiation dose per fraction (OR 1.45; p=0.001), a longer treatment duration (OR 1.12; p=0.04), and a higher number of fractions (OR 1.20; p=0.01). Conclusion: Proton beam therapy appears safe in patients with CIEDs, with a low incidence of clinically significant device malfunctions or arrhythmias. These findings support the integration of PBT into routine practice for this population and underscore the importance of structured monitoring protocols and prospective guideline refinement.

Background: Syncope is a leading cause of transient loss of consciousness, especially in older adults. Post-syncopal driving restrictions are widely recommended, but the required duration varies by state. The impact of these policies on motor vehicle crash outcomes remains unclear. Methods: We conducted a cross-sectional analysis of 45 U.S. states, comparing crash and fatality data between states requiring < 6 months vs. ≥ 6 months of driving restriction following a syncopal episode. Data were obtained from Fatality Analysis Reporting System, National Highway Traffic Safety Administration, state Department of Motor Vehicles, and medical boards. Crash rates were normalized by licensed drivers and population. Statistical comparisons were made using Welch’s t-tests. Results: States with ≥ 6-month restrictions had significantly lower crash rates among older drivers (0.0171 vs. 0.0256, p = 0.0076). Relative crash ratios comparing older to younger drivers were also lower (0.220 vs. 0.306, p = 0.067). Overall crash rates trended lower in states with ≥ 6-month restrictions in both per licensed driver ( p = 0.054) and per population ( p = 0.099). No significant differences were observed in fatality rates. Conclusions: Longer post-syncope driving restriction durations (≥ 6 months) are associated with reduced crash risk among older drivers and a narrowing of age-related disparities in crash rates. These findings suggest potential public health value in adopting more uniform, evidence-based restriction policies following syncopal events for older drivers.

Background: Transvenous lead extraction (TLE) is the standard of care for cardiac implantable electronic device (CIED) infections. Data regarding the optimal timing of CIED reimplantation after TLE are not well established. Objective: This study aims to assess the 5-year outcomes of early (≤7 days) versus non-early (>7 days) CIED reimplantation following TLE for CIED infection using a multi-national database. Methods: Using the TriNetX Analytics Research Network, we included patients aged ≥18 years who underwent TLE for CIED infection between 1/1/2014 and 1/1/2020. Patients were further categorized into two groups: early CIED reimplantation (≤7 days from TLE) and non-early CIED reimplantation. Propensity score matching (PSM) was performed by including patient demographics, LVEF, cardiac comorbidities and medications. The study outcomes included all-cause mortality and cardiac adverse events during a 5-year study period. Results: A total of 1668 patients in the early CIED reimplantation group and 1550 in the non-early group were identified. After PSM, 1327 patients in each group were analyzed. Compared to non-early group, early CIED reimplantation group was associated with significantly higher odds of all-cause hospitalization (odds ratio [OR]: 1.837, 95% confidence interval [CI]: 1.532-2.203) and repeated device infection (OR: 1.569, 95% CI: 1.314-1.873) at 5-year follow-up. However, no significant differences were observed in all-cause mortality (OR: 0.927, 95% CI: 0.778-1.104), HF exacerbation (OR: 1.021, 95% CI: 0.855-1.218), cardiac arrest (OR:0.924, 95% CI: 0.739-1.157), stroke (OR: 1.169, 95% CI: 0.915-1.494), cardiac thrombus (OR: 1.163, 95% CI: 0.749-1.808), major bleeding (OR: 1.079, 95% CI: 0.857-1.358) and venous thromboembolism (OR: 0.923, 95% CI: 0.759-1.123) between the two groups. Conclusion: Early reimplantation of CIED following TLE of infected devices was associated with worse outcomes in all-cause hospitalization and repeated device infection. Further large prospective studies are needed to define the optimal timing of device reimplantation.

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated with increased morbidity, mortality, and healthcare expenses. Meanwhile, effective management of AF requires a comprehensive, patient-centered approach that includes risk factor modification, rate and rhythm control strategies, and prevention of thromboembolic events. Multidisciplinary AF clinics have emerged as a model for comprehensive management to improve patient outcomes and reduce healthcare burden. This review discusses the rationale, structure, benefits, challenges, and future directions of multidisciplinary AF clinics, emphasizing their role in optimizing AF management.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, contributing to significant morbidity and mortality worldwide. The relationship between physical exercise and AF is complex, with studies showing both beneficial and potentially adverse effects. Moreover, evidence suggests a U-shaped association between exercise intensity and AF risk. Moderate exercise has been shown to reduce AF burden by improving cardiovascular risk factors, enhancing autonomic regulation, and mitigating atrial fibrosis. In contrast, excessively high-intensity endurance exercise may increase AF risk, particularly in young athletes, due to atrial stretching, dilation, fibrosis, autonomic imbalances, and heightened inflammation. The current guidelines emphasize exercise as a core lifestyle intervention for AF management, recommending moderate-intensity aerobic activity for optimal outcomes. This review examines the current evidence on the effects of exercise on AF, identifies knowledge gaps, and proposes potential future research directions.