Botros, Michael

Abstract Background and Aims Stroke and systemic embolism are recognized but poorly characterized complications of atrial fibrillation (AF) and left atrial flutter (AFL) catheter ablation. Their incidence, outcomes, and procedural associations remain insufficiently defined. Methods Retrospective global registry was initiated by the European Heart Rhythm Association Scientific Committee. A secure database captured data from ablation centres worldwide on general AF and left AFL ablation activity, as well as detailed information on patients with symptomatic embolic events between 2017 and 2024. Results Overall, 204 centres reported 335 743 ablation procedures and 550 embolic events (incidence 0.16%). Centre-level rate ranged from 0% to 3.1%. Most events were cerebral (94%), followed by peripheral (5%), and combined (1%). Coronary air embolism accounted for 62% of all peripheral events. Intraprocedural events occurred in 93 patients (17%), within 72 h in 357 (78%) and beyond 72 h in 100 (22%); 128 cases (23%) were diagnosed after hospital discharge. Nonparoxysmal AF (0.23% vs 0.15%; P < .001), centre experience, and ablation energy source (radiofrequency, 0.16%; cryoballoon, 0.16%; pulsed field ablation, 0.25%; laserballoon, 0.88%; P < .001) were associated with embolic risk. Median NIHSS score after stroke was 4 (interquartile range, 2–9). Three-month follow-up was available for 518 patients with embolism (95%): 181 (35%) had sequelae and 16 (3%) died. Conclusions Symptomatic embolic events are infrequent but associated with significant morbidity and mortality. Most events occur early, though a substantial proportion arise later. Higher event rates were observed with laser and possibly with pulsed field ablation. A greater centre experience was associated with a lower embolism incidence.

Mediastinal radiation potentiates aortic stenosis and complicates its treatment. We compared the short and midterm-outcomes with transcatheter aortic valve replacement (TAVR) versus surgical aortic valve replacement (SAVR) in patients with prior mediastinal radiation. Electronic databases were searched from inception through December 2024. Dichotomous outcomes were pooled as risk ratios (RRs), and continuous outcomes were pooled as mean differences (MDs) with respective 95% confidence intervals (CIs). Six observational studies were identified, including 2458 TAVR patients and 1873 SAVR patients. In the short-term, TAVR was associated with lower rate of mortality (RR: 0.54; 95% CI: 0.34–0.88), atrial fibrillation (RR: 0.31; 95% CI: 0.15–0.65), acute kidney injury (RR: 0.75; 95% CI: 0.59–0.95), bleeding (RR: 0.37, 95% CI: 0.33–0.42), and shorter length of hospital stay (MD: −4.30; 95% CI: −5.45 to −3.15). One-year mortality was comparable between the 2 groups (RR: 1.04; 95% CI: 0.50–2.13). This meta-analysis of observational studies of patients with prior mediastinal radiation demonstrated that TAVR was associated with better short-term outcomes compared to SAVR. While 1-year mortality appeared similar between the 2 interventions, this finding should be interpreted with caution. However, randomized controlled trials are needed to validate these findings.

Introduction: The consequences of external cardiovascular compression and cardiac displacement from pectus excavatum (PEx) are debated. The complex geometry of the right (RV) and left ventricle (LV) along with distortion from the extrinsic chest deformity pose significant limitations to reliable assessment of LV and RV volumes and function using transthoracic 2D-echocardiography in this population. Hypothesis: A 3D-echocardiography approach can reliably assess the effects of external cardiac compression and the benefits of surgical correction on RV and LV function in PEx patients. Methods: Adult patients undergoing minimally invasive repair of PEx between Oct-2021 and Feb-2023 were included in this prospective study. Intraoperative transesophageal (TEE) 6 beat full volume video loops incorporating LV and RV were captured and compared before and after surgical correction of the PEx. TomTec Software® was used for offline 3D/4D reconstruction ( Figure 1 shows changes in 3D RV and LV shape pre- and post-surgery). Result: The study included 102 patients (mean age of 32.1 ±11.8 years; Haller index 4.9 ±2.5; 60.8% males). Post PEx repair, there was a significant (p<0.001) increase in the 3D RV volumes, RV ejection fraction (EF), RV stroke volume and RV strain ( Figure 1 ). Additionally, there was a significant improvement in 3D LVEF, 3D LV strain (longitudinal and circumferential), LV twist, and torsion ( Figure 1 ). Conclusion: In this PEx cohort, 3D/4D TEE imaging demonstrated significant increases in RV volumes and in RV and LV systolic function after surgical repair. These findings support the negative cardiovascular consequences of PEx compression and benefits of surgical repair.