Heart

BackgroundAlthough morbidity and mortality from COVID-19 have been widely reported, the indirect effects of the pandemic beyond 2020 on other major diseases and health service activity have not been well described. MethodsAnalyses used national administrative electronic hospital records in England, Scotland and Wales for 2016-2021. Admissions and procedures during the pandemic (2020-2021) related to six major cardiovascular conditions (acute coronary syndrome, heart failure, stroke/transient ischaemic attack, peripheral arterial disease, aortic aneurysm, and venous thromboembolism) were compared to the annual average in the pre-pandemic period (2016-2019). Differences were assessed by time period and urgency of care. ResultsIn 2020, there were 31,064 (-6%) fewer hospital admissions (14,506 [-4%] fewer emergencies, 16,560 [-23%] fewer elective admissions) compared to 2016-2019 for the six major cardiovascular diseases combined. The proportional reduction in admissions was similar in all three countries. Overall, hospital admissions returned to pre-pandemic levels in 2021. Elective admissions remained substantially below expected levels for almost all conditions in all three countries (-10,996 [-15%] fewer admissions). However, these reductions were offset by higher than expected total emergency admissions (+25,878 [+6%] higher admissions), notably for heart failure and stroke in England, and for venous thromboembolism in all three countries. Analyses for procedures showed similar temporal variations to admissions. ConclusionThis study highlights increasing emergency cardiovascular admissions as a result of the pandemic, in the context of a substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years. Key QuestionWhat is the impact in 2020 and 2021 of the COVID-19 pandemic on hospital admissions and procedures for six major cardiovascular diseases in England, Scotland and Wales? Key FindingIn 2020, there were 6% fewer hospital admissions (emergency: -4%, elective: -23%) compared to 2016-2019 for six major cardiovascular diseases, across three UK countries. Overall, admissions returned to pre-pandemic levels in 2021, but elective admissions remained below expected levels. Take-home MessageThere was increasing emergency cardiovascular admissions as a result of the pandemic, with substantial and sustained reduction in elective admissions and procedures. This is likely to increase further the demands on cardiovascular services over the coming years.

BackgroundPatients undergoing cardiac surgery face an increased risk of infective endocarditis (IE), a risk that may be further exacerbated by implantation of cardiac implantable electronic devices (CIED). This study aimed to assess the risk of IE after CIED implantation within 30 days of cardiac surgery and identify associated risk factors. MethodsAll patients in Sweden, with no previous CIED, who underwent first-time cardiac surgery between 2006 and 2020 were included in this nationwide registry-based study. Cox proportional hazards models adjusted for demographic and clinical covariates were used to estimate the association between CIED implantation and the risk of IE. ResultsOut of 73,367 patients, 2,302 (3.1%) received a CIED within 30 days. Over a median follow-up of 6.5 years (interquartile range, 3.2-10.1 years), 1,556 patients (2.1%) developed IE. CIED implantation was associated with an increased IE risk (adjusted Hazard ratio (aHR) 1.46; 95% confidence interval (CI) 1.20-1.77). Patients with IE had a significantly higher risk of mortality compared to those without IE (aHR 1.80; 95% CI 1.67-1.94; p<0.001). The type of cardiac surgery influenced IE risk, with valvular surgeries showing a higher incidence than coronary artery bypass grafting. Risk factors independently associated with IE included male sex, age at surgery, diabetes mellitus, and peripheral vascular disease. ConclusionsCIED implantation within 30 days after cardiac surgery is associated with an increased long-term risk of IE and subsequent mortality. The type of surgery and patient comorbidities influence the risk. CLINICAL PERSPECTIVE What is new?O_LIIn this large nationwide registry study, cardiac implantable electronic devices (CIEDs) placed within 30 days after cardiac surgery were associated with a substantial and persistent risk of infective endocarditis. C_LIO_LIThe risk of infective endocarditis was influenced by the type of cardiac surgery and patient-specific factors, rather than the timing of device implantation. C_LI What are the clinical implications?O_LIAmong post-cardiac surgery patients at elevated risk for infective endocarditis (e.g., those undergoing valvular procedures) who require a CIED, selecting devices associated with lower infection risk--such as leadless pacemakers or non-transvenous ICDs--may be a preferable strategy when appropriate. C_LIO_LIThe optimal timing of CIED implantation after cardiac surgery remains uncertain. When delaying implantation, the rationale should center on allowing for potential recovery of conduction abnormalities, rather than attempting to mitigate the risk of device-related infection. C_LI

BackgroundAortic stenosis requires timely treatment with either surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). This study aimed to investigate the indirect impact of COVID-19 on national SAVR and TAVR activity and outcomes. MethodsThe UK TAVR Registry and the National Adult Cardiac Surgery Audit were used to identify all TAVR and SAVR procedures in England, between January 2017 and June 2020. The number of isolated AVR, AVR+coronary artery bypass graft (CABG) surgery, AVR+other surgery and TAVR procedures per month was calculated. Separate negative binomial regression models were fit to monthly procedural counts, with functions of time as covariates, to estimate the expected change in activity during COVID-19. ResultsWe included 13376 TAVR cases, 12328 isolated AVR cases, 7829 AVR+CABG cases, and 6014 AVR+Other cases. Prior to March 2020 (UK lockdown), monthly TAVR activity was rising, with a slight decrease in SAVR activity during 2019. We observed a rapid and significant drop in TAVR and SAVR activity during the COVID-19 pandemic, especially for elective cases. Cumulatively, over the period March to June 2020, we estimated an expected 2294 (95% CI 1872, 2716) cases of severe aortic stenosis who have not received treatment. ConclusionThis study has demonstrated a significant decrease in TAVR and SAVR activity in England following the COVID-19 outbreak. This situation should be monitored closely, to ensure that monthly activity rapidly returns to expected levels. There is potential for significant backlog in the near-to-medium term, and potential for increased mortality in this population.

BackgroundHeart Rate Score (HRSc), the percent of all atrial paced and sensed event in the largest 10 bpm rate histogram bin of a pacemaker, predicts survival in patients with cardiac devices. No correlation between HRSc and development of atrial fibrillation (AF) has been reported. ObjectiveTo evaluate the relationship between pacemaker post-implantation HRSc and newly-developed AF incidence. MethodsPatients with dual-chamber pacemakers, implanted 2013-2017, with ALTITIUDE remote monitoring data with [&ge;]600,000 beats of histogram data collected at baseline were included (N=34,543). HRSc was determined from the post-implantation histogram data during the initial 3 months. Patients were excluded if they had AF, defined as atrial high-rate episodes >5 minutes or >1% of right atrial beats >170 bpm during the initial 3-months post-implantation. New AF, after the baseline period, was defined by each of the following: >1%, >10% or >25% of atrial beats >170 bpm or Atrial Tachycardia Response (ATR) events >24 hr. ResultsPatients were followed a median of 2.8 (1.0-4.0) years. Patients with initial HRSc[&ge;]70% were older, had higher %RA pacing, had lower %RV pacing and were more likely programmed with rate-response vs subjects with HRSc<70%. The incidence of AF increased in proportion to HRSc (Log-Rank P-value <0.001); results were insensitive to AF definition. Initial HRSc (HR:1.07, 95% CI:1.05-1.09; P<0.0001) independently predicted AF after adjusting for age, gender, % RV pacing and rate-response programming. The %RA pacing and initial HRSc correlated. ConclusionHRSc predicts subsequent AF independent of well-known risk factors in pacemaker patients.

BackgroundDirect current cardioversion is frequently used to return patients with atrial fibrillation (AF) to sinus rhythm. Chest pressure during cardioversion may improve the efficacy of cardioversion through decreasing transthoracic impedance and increasing cardiac energy delivery. We aimed to assess the efficacy and safety of upfront chest pressure during direct current cardioversion for atrial fibrillation with anterior-posterior pad positioning. Design, Setting and ParticipantsThis was a multi-center, investigator-initiated, patient and analysis blinded, randomised clinical trial. Recruitment occurred from 2021 to 2023. Follow-up was until hospital discharge. Recruitment occurred across three centers in New South Wales, Australia. Inclusion criteria were age [&ge;]18, referred for cardioversion for AF, and anticoagulation for three weeks or transoesophageal echocardiography excluding left atrial appendage thrombus. Exclusion criteria were other arrhythmias requiring cardioversion, such as atrial flutter and atrial tachycardia. Intervention and OutcomesThe intervention arm received chest pressure during cardioversion from the first shock. The primary efficacy outcome was total joules required per patient encounter. Secondary efficacy outcomes included first shock success, transthoracic impedance, cardioversion success and sinus rhythm at 30 minutes post cardioversion. Results311 patients were randomised, 153 to control and 158 to intervention. There was no difference in total joules applied per encounter in the control arm versus intervention arm (356.4 {+/-} 301 vs 413.8 {+/-} 347, P=0.25). There was no difference in first shock success, total shocks provided, average impedance and cardioversion success. Conclusions and RelevanceThis study does not support the routine application of chest pressure for direct current cardioversion in atrial fibrillation. Reducing the complexity of cardioversion will improve the efficiency of the procedure for patients and healthcare systems. FundingNone to disclose Trial RegistrationACTRN12620001028998

ObjectivesTo examine short-term primary causes of death after percutaneous coronary intervention (PCI) in a national cohort before and during COVID-19. BackgroundPublic reporting of PCI outcomes is a performance metric and a requirement in many healthcare systems. There are inconsistent data on the causes of death after PCI, and what proportion of these are attributable to cardiac causes. MethodsAll patients undergoing PCI in England between 1st January 2017 and 10th May 2020 were retrospectively analysed (n=273,141), according to their outcome from the date of PCI; no death and in-hospital, post-discharge, and 30-day death. ResultsThe overall rates of in-hospital and 30-day death were 1.9% and 2.8%, respectively. The rate of 30-day death declined between 2017 (2.9%) and February 2020 (2.5%), mainly due to lower in-hospital death (2.1% vs. 1.5%), before rising again from 1st March 2020 (3.2%) due to higher rates of post-discharge mortality. Only 59.6% of 30-day deaths were due to cardiac causes, the most common being acute coronary syndrome, cardiogenic shock and heart failure, and this persisted throughout the study period. 10.4% of 30-day deaths after 1st March 2020 were due to confirmed COVID-19. ConclusionsIn this nationwide study, we show that 40% of 30-day deaths are due to non-cardiac causes. Non-cardiac deaths have increased even more from the start of the COVID-19 pandemic, with one in ten deaths from March 2020 being COVID-19 related. These findings raise a question of whether public reporting of PCI outcomes should be cause-specific.

BackgroundPermanent pacemaker implantation (PPI) is required in up to 30% of patients following transcatheter aortic valve replacement (TAVR), mainly due to conduction disturbances. While transvenous pacemakers (TVPM) have traditionally been used, leadless pacemakers (LLPM) could improve outcomes and reduce complications, especially in high-risk populations. MethodsWe conducted a retrospective, observational, propensity-matched cohort study using the TriNetX Global Collaborative Network. Patients who underwent TAVR followed by single chamber PPI within 30 days were identified and divided into two groups: LLPM and TVPM. Those with pre-existing pacemakers or concomitant cardiac surgery were excluded. Propensity score matching (1:1) was performed on demographic, clinical, laboratory, echocardiographic, and medication variables. Clinical outcomes such as all-cause mortality, heart failure, atrial fibrillation, procedural and device-related complications during follow-up were assessed. Kaplan-Meier analyses and Cox proportional hazards models were used. ResultsAmong 1,425 identified patients (469 LLPM, 956 TVPM), 367 matched pairs were analyzed. At 5-year follow-up, there was no significant difference in all-cause mortality (27.2% LLPM vs. 29.4% TVPM; HR 1.07, 95% CI 0.81-1.40; p=0.637). LLPM was associated with a significantly lower incidence of heart failure (16.1% vs. 25.6%; HR 0.61, 95% CI 0.44-0.84; p=0.002). Atrial fibrillation during follow-up was lower in the LLPM group (18.0% vs. 25.6%; HR 0.69, 95% CI 0.50-0.95; p=0.018). Procedure and device-related complication rates were low and similar between groups. ConclusionsIn this large real-world cohort, LLPM was associated with a reduced risk of heart failure and atrial fibrillation compared to TVPM, without differences in overall mortality or safety. These data support considering leadless pacing in selected post-TAVR patients, although prospective randomized studies are required to confirm these findings. Clinical PerspectiveO_ST_ABSWhat Is KnownC_ST_ABSO_LIPermanent pacemaker implantation is frequent after transcatheter aortic valve replacement (TAVR) and may negatively impact outcomes through device related complications, pacing-induced dyssynchrony and tricuspid interference. C_LIO_LILeadless pacemakers eliminate transvenous leads and pockets, reducing the risk of lead-related and infectious complications. C_LI What the Study AddsO_LIIn this large real-world propensity-matched analysis, leadless pacemakers were associated with fewer heart failure and atrial fibrillation events compared with transvenous devices, without differences in mortality or procedural safety. C_LIO_LIThese findings support the use of leadless pacing as a safe and potentially morbidity-sparing option in selected post-TAVR patients. C_LI

BackgroundCardiac rehabilitation (CR) uptake for heart failure (HF) in the UK remains low at around 15%, with evidence of disparities based on sex, ethnicity, socioeconomic status, availability of staffing and financial constraints. We analysed data from the Pumping Marvellous Foundation online home CR programme to understand who accesses this service and whether inequities persist, to help guide strategies to achieve equitable rehabilitation delivery. MethodsThe PMF online home CR platform was launched in August 2024 along with an educational booklet available for order (at no cost) by HF or CR teams. We analysed anonymised data (n=673) of registrants from August 2024 to July 2025. Variables analysed included demographics, ethnicity, deprivation index, HF type based on ejection fraction, referral source, time since diagnosis and prior CR participation. We also analysed CR booklet orders and assessed correlation with HF admissions as per national HF audit data. Descriptive statistics summarised distributions. Results673 participants (median age 62 years; IQR 18 to 90 years, 12% aged >76 years) registered for the online CR classes from August 2024 to July 2025. The majority (63%) were women, and 6% were from minority ethnic communities. 35% of registrants had either mildly reduced (HFmrEF) or preserved (HFpEF) ejection fraction. 30% of referrals were from HF or CR teams, 29% obtained information via social media, and around 25% obtained information directly from PMF groups. There were also direct referrals from GPs (4%) and around 10% obtained referral information via Google search or YouTube. Analysis of the time since HF diagnosis demonstrated late entry to CR: 343 (51%) registered >12 months post-diagnosis, 88 (13%) within 3 months, and 130 (19%) within 6 to 12 months. Only 38 (6%) reported any prior CR participation. We also correlated CR booklet orders from hospitals with National HF Audit HF admissions. Within the limitations of the spread of the scatter, there was a general positive relationship: hospitals with more HF admissions tended to order more booklets. 33% of registrants came from the top 20 most deprived cities in England. ConclusionsBy providing free lifetime access to online cardiac rehabilitation, widening the access of cardiac rehab to more women and people without access to standard cardiac rehabilitation (due to staffing, cost constraints, accessibility issues) and reaching areas with socio-economic deprivation, the PMF online cardiac rehab platform can help to increase CR uptake and reduce the inequity in access to CR in the UK.

BackgroundWhilst anti-coagulation is typically recommended for thromboprophylaxis in atrial fibrillation (AF), it is often never prescribed, or prematurely discontinued, due to concerns regarding bleeding risk. The aim of this study was to assess both stroke/systemic embolism (SSE) and bleeding risk, comparing people with AF who continue anticoagulation with those who stop transiently, stop permanently or never start. MethodsThis retrospective cohort study utilised linked Scottish administrative healthcare data to identify adults diagnosed with AF between January 2010 and April 2016, with a CHA2DS2- VASC score of [&ge;]2. They were sub-categorised into cohorts based on anti-coagulant exposure: never started, continuous, discontinuous, and cessation. Inverse probability of treatment weighting-adjusted Cox regression and competing-risks regression were utilised to compare the risks of SSE and major bleeding between cohorts during a five year follow-up period. Sub-group analyses evaluating risk of SSE, bleeding and mortality, were undertaken for people commenced on anti-coagulation that experienced a major bleeding event ResultsOf an overall cohort of 47,427 people, 26,277 (55.41%) were never anti-coagulated, 7,934 (16.72%) received continuous anti-coagulation, 9,107 (19.2%) temporarily discontinued and 4,109 (8.66%) permanently discontinued. Initiation and continuation of anti-coagulation was less likely in people with a lower socio-economic status, elevated frailty score, or aged [&ge;]75. SSE risk was significantly greater in those with discontinuous anti-coagulation, compared to continuous (SHR: 2.65; 2.39-2.94). In the context of a major bleeding event, there was no significant difference in bleeding risk between the cessation cohort compared to those that continued anti-coagulation (SHR 0.94; 0.42-2.14). ConclusionOur data suggest significant inequalities in anti-coagulation prescribing for people with AF, with substantial opportunity to improve initiation and continuation. Anti-coagulation decision-making must be patient-centered and recognise that discontinuation or cessation is associated with a substantial risk of thromboembolic events not offset by a reduction in bleeding. What is Known?O_LIDespite a high thromboembolic risk, anti-coagulation in people with atrial fibrillation is frequently not initiated, or prematurely discontinued C_LI What is New?O_LIOur data suggest considerable inequalities in anti-coagulation prescribing in people with atrial fibrillation; people with a lower socio-economic status, elevated frailty score, or aged [&ge;]75 were less likely to initiate or continuation anti-coagulation C_LIO_LIWhilst non-initiation and cessation of anti-coagulation are associated with elevated thromboembolic risk, this risk is particularly high in people with atrial fibrillation that transiently discontinue anti-coagulation C_LIO_LIIn the context of a major bleeding event, permanent discontinuation of anti-coagulation in people with atrial fibrillation is not associated with a significantly reduced risk of recurrent bleeding compared to those that are continuously anti-coagulated. C_LI

BackgroundNo firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the COVID-19 pandemic. Systematic appraisal of national expert consensus can be used to generate interim recommendations until data from clinical observations will become available. Hence, we aimed to collect and quantitatively appraise nationwide UK senior surgeons opinion on clinical decision making for patients requiring cardiac surgery during the COVID-19 pandemic. MethodsWe mailed a web-based questionnaire to all consultant cardiac surgeons through the Society for Cardiothoracic Surgery in Great Britain and Ireland (SCTS) mailing list on the 17th April 2020 and we pre-determined to close the survey on the 21st April 2020. This survey was primarily designed to gather information on UK surgeons opinion using 12 items. Strong consensus was predefined as an opinion shared by at least 60% of responding consultants. ResultsA total of 86 consultant surgeons undertook the survey. All UK cardiac units were represented by at least one consultant. Strong consensus was achieved for the following key questions:1) before hospital admission every patient should receive nasopharyngeal swab, PCR and chest CT; 2) the use of full PPE should to be adopted in every case by the theatre team regardless patients COVID-19 status; 3) the risk of COVID-19 exposure for patients undergoing heart surgery should be considered moderate to high and likely to increase mortality if it occurs; 4) cardiac procedure should be decided based on ad-hoc multidisciplinary team discussion for every patient. The majority believed that both aortic and mitral surgery should be considered in selected cases. The role of CABG surgery during the pandemic was more controversial. ConclusionsIn the current unprecedented scenario, the present survey provides information for generating interim recommendations until data from clinical observations will become available. Perspective statementSystematic appraisal of national expert consensus can be used to generate interim recommendations for patients undergoing cardiac surgery during COVID-19 pandemic until data from clinical observations will become available. Central messageNo firm recommendations are currently available to guide decision making for patients requiring cardiac surgery during the pandemic. This can translate into significant variability in clinical practice and patients outcomes across cardiac units. Systematic appraisal of national expert consensus can represent a rapid and efficient instrument to provide support to heath policy makers and other stakeholders in generating interim recommendations until data from clinical observations will become available.

Background and aimsEvidence of the impact of frailty on oral anticoagulant (OAC) prescription in older people with atrial fibrillation (AF) is conflicting. This study aimed to examine the prevalence of frailty in hospitalised older patients with AF and its relationship with OAC prescription during admission. The secondary aim was to examine the association between frailty and rate/rhythm control medication prescriptions. MethodsThis retrospective observational study included adults aged [&ge;]65 with AF admitted to six hospitals in Australia in 2022. Frailty was defined by a Frailty Index [&ge;]0.25. Logistic regression models were applied to examine the association between frailty and the prescriptions of OAC, rate-control and rhythm-control drugs during hospitalisation. Results are presented as odds ratios and 95% confidence intervals (CI). ResultsThere were 685 patients, with a mean age of 82.6(SD 8.3), 49.8% female and 42.8% identified as frail. Overall, 75.6% were prescribed OAC (67.9% in the frail versus 81.4% in the non-frail, p<0.001), 37.7% received rate-control drugs (42.0% in the frail versus 34.4% in the non-frail, p=0.044), 27.3% received rhythm-control drugs (22.9% in the frail versus 30.6% in the non-frail, p=0.024). The adjusted odds ratios of frailty on prescriptions were 0.58 (95% CI 0.39-0.86) for OAC, 1.75 (95%CI 1.22-2.52) for rate-control drugs, and 0.83 (95%CI 0.55-1.24) for rhythm-control drugs. ConclusionsThe study revealed a high prevalence of frailty in older inpatients with AF. Frailty was associated with reduced likelihood of prescription of OAC during admission and increased likelihood of prescribing rate-control medications, with no independent impact on rhythm-control therapy. Further studies are needed to understand these prescribing patterns.

ObjectiveTo compare the NHS Health Check Programme with the Polypill Prevention Programme in the primary prevention of heart attacks and strokes. DesignUse of published data and methodology to produce flow charts of the two programmes to determine screening performance and heart attacks and strokes prevented. SettingThe UK population. InterventionThe NHS Health Check Programme using a QRisk score on people aged 40-74 to select those eligible for a statin is compared with the Polypill Prevention programme in people aged 50 or more to select people for a combination of a statin and 3 low dose blood pressure lowering agents. In both programmes people had no history of heart attack or stroke. Main outcome measuresIn 1000 people the number of heart attacks and strokes prevented in the two programmes. ResultsAssuming 100% uptake and adherence to the screening protocol, in every 1000 persons, the NHS Health Check Programme would prevent 287 cases of a heart attack or stroke in individuals who would gain on average about 4 years of life without a heart attack or stroke, the precise gain depending on the extent of treatment for those with raised blood pressure, and 136 would be prescribed statins with no benefit. The corresponding figures for the Polypill Prevention Programme are 316 individuals who would, on average, gain 8 years of life without a heart attack or stroke with 260 prescribed the polypill with no benefit. Based on published estimates of uptake and adherence to of the NHS Health Check programme, only 24 cases per 1000 are currently benefitting instead of 287. This result could be achieved in the Polypill Prevention Programme with just 8% (24/316) of the eligible population taking part. ConclusionsThe Polypill Prevention Programme is by design simpler with the potential of preventing many more heart attacks and strokes; even an uptake of 40% would represent a 5-fold greater preventive effect than the NHS Health Check Programme.

BackgroundInternational guidelines recommend the use of a vitamin K antagonist (VKA, e.g. warfarin) for the first three months after mitral repair as a Class IIa recommendation with Level of Evidence C. High rates of atrial fibrillation, thrombogenicity of the non-endothelialised repair components, and high rates of antiplatelet resistance are cited as rationale. However, surveys of practice indicate that surgeon compliance is low, suggesting uncertainty of the evidence. We sought to establish the best current evidence by conducting a systematic review as a precursor to a randomised trial. MethodsWe included prospective randomised and retrospective observational studies of adult patients undergoing mitral valve repair with no other indications for anticoagulation. Studies had to compare a VKA to a non-vitamin K antagonist oral anticoagulants (NOAC), anti-platelet or placebo/null treatment ("Other"). Outcomes had to include thromboembolic complications, major bleeding or mortality within three months. The Cochrane Register, Medline, Embase and Clinical Trials Registries were checked. Risk of Bias assessments were conducted using the ROBINS-I tool as part of the GRADE Pro methodology. Quantitative synthesis was agreed following review of the methodology and a random effects model using the Mantel-Haenszel method employed. ResultsThere were no randomised controlled trials comparing VKA to other treatment strategies. Six observational studies comprising 5291 patients (2925 receiving VKA, 807 antiplatelet, 104 NOAC and 1455 null treatment) were included. Four studies reporting early thromboembolic risk found that the use of a VKA may not be associated with a reduction in risk (relative risk [RR] 0.54, 95% CI 0.13 - 2.35, p=0.41, I2 = 68%, overall certainty of evidence = very low). Three studies reporting late thromboembolism also showed that use of VKA may not be associated with risk reduction (RR 0.84, 95% CI 0.57 - 1.24, p=0.37, I2 = 23%). Two studies reported on early risks of major bleeding and found VKA treatment had very uncertain effects (RR 0.60, 95% CI 0.36 - 1.02, p=0.06, I2=0%, certainty of evidence = very low). Late bleeding reported by four studies was uncertain but seemed to show no risk reduction with VKA (RR 0.97, 95% CI 0.37 - 2.52, p=0.95, I2=73%). Three studies found an unclear effect of VKA use on early mortality (RR 0.39, 95% CI 0.10 - 1.51, p=0.17, I2=35%, certainty of evidence = low). Two studies comparing VKA with antiplatelets and no thromboprophylaxis respectively, showed there may be risk reduction in late mortality (RR 0.72, 95% CI 0.59 - 0.87, p=0.0006, I2=0%, certainty of evidence = very low), although this effect was weighted by a single study. ConclusionThere is insufficient good quality evidence to inform anticoagulation, anti-platelet or null treatment practices following mitral valve repair. A high-quality trial is therefore required in this setting, with particular methodological focus on aspects found to increase risk of bias in current studies. FundingThere was no funding for this systematic review. RegistrationThe review protocol was published in PROSPERO (CRD42021271198).

IntroductionAtrial fibrillation (AF), a common arrhythmia, is associated with impaired quality of life (QoL) and increased stroke risk and mortality. Clinical guidelines recommend leveraging digital technologies to support patient education and AF self-management. Conversational artificial intelligence (AI) technologies may support patient engagement with self-management by enabling human-like conversations. This study aims to evaluate the effectiveness of a conversational AI intervention (Conversational HeAlth supporT in Atrial Fibrillation Self-Management - CHAT-AF-S) in improving QoL in patients with AF. Methods and analysisCHAT-AF-S is a 3-month randomised controlled trial with 1:1 allocation and embedded process evaluation. We will randomise 480 adults (18 years of age and older) with documented AF to the CHAT-AF-S intervention or usual care. Primary outcome is the Atrial Fibrillation Effect on QualiTy-of-life (AFEQT) overall score. We will follow intention-to-treat principles and data analysts will be blinded. Intervention participants will be invited to complete a user experience survey and take part in an interview to explore the feasibility, acceptability, perceived utility, and barriers and enablers to implementing the intervention. Qualitative data will be analysed thematically. Ethics and disseminationEthics approval was obtained from the Western Sydney Local Health District Human Ethics Research Committee (2023/ETH00765). Written and informed consent will be obtained from all study participants before commencing any study procedures. Results will be disseminated via peer-reviewed publications and presentations at international conferences. Declaration of InterestsAll investigators report nil conflicts of interest. Data AvailabilityThe data that supports this project are available from the corresponding author upon reasonable request. Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12623000850673 https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=386249

BackgroundThe aim of this single-center retrospective study is to evaluate the long-term outcome after convergent procedure (CP) for patients with paroxysmal atrial fibrillation (AF), persistent AF and long-standing persistent AF. Methods and resultsWe analyzed outcomes of patients that underwent CP from January 2009 until July 2020. 119 patients with paroxysmal AF (23.5%), persistent AF (5.9%) or long-standing persistent AF (70.6%) that attended long-term follow up were included. The outcome was assessed at 1-year after CP and at long-term follow up. At 1-year follow up rhythm and daily AF burden were assessed for patients with implantable loop recorder (61.2%). For others rhythm was assessed by clinical presentation and 12-lead ECG recording. At long-term follow up patients having sinus rhythm or unclear history of AF were monitored with 7-day ECG Holter and AF burden was determined. Long-term success was defined as freedom from AF/atrial flutter (AFL) with sinus rhythm on 12-lead ECG recording and AF/AFL burden <1% on 7-day Holter ECG. Repeat catheter ablations (RFA) prior to long-term follow up were documented. At 1-year follow up 91.4% of patients had sinus rhythm and 76.1% of patients had AF/AFL burden <1%. At long-term follow up (8.3 {+/-} 2.8 years) 65.5% of patients had sinus rhythm and 53.8% patients had AF/AFL burden <1% on 7-day holter ECG. Additional RFAs were performed in 32.8% of patients who had AF or AFL burden <1%. At long-term follow up age, body mass index and left atrial volume index were associated with increased risk of AF recurrence. ConclusionsCP resulted in high long-term probability of sinus rhythm maintenance. During long-term follow-up additional RFAs were required to maintain sinus rhythm in a substantial number of patients.

BackgroundClinical experience with minimally invasive hybrid ventricular tachycardia (VT) ablation remains limited, particularly regarding video-assisted thoracoscopic (VATS) access. ObjectivesTo describe procedural characteristics, feasibility, and outcomes of minimally invasive hybrid VT ablation for complex substrates. MethodsConsecutive patients undergoing minimally invasive hybrid VT ablation at a single tertiary center (2014-2025) were retrospectively analyzed. Multidisciplinary preprocedural evaluation was consistently performed, and from 2022 onward, this was formalized within the VT-TRACT (ventricular tachyarrhythmias: a multidisciplinary clinical-translational approach) care pathway. ResultsTwenty-two patients (86% male, median age 70 years, median PAINESD score 13, 68% VT storm) underwent minimally invasive hybrid VT ablation: left- or right-sided VATS (n=13 vs 1), subxiphoid access (n=3), double access (n=2), and anterolateral minithoracotomy (n=3). Indications were prior cardiac surgery in 7 (32%), extensive scar in 3 (14%), concomitant left-sided sympathectomy in 2 (9%) and hybrid atrial fibrillation ablation in 1 (5%), failed epicardial access in 2 (9%), pericarditis/tamponade in 2 (9%), while 5 (23%) underwent ablation under direct visualization by preference. Pericardial adhesions (45%) were bluntly dissected. Mean procedure time was 312{+/-}98 minutes. At one year, median VT burden decreased from 16.5 [9.5-37.0] to 0 [0-5.8] (-81%, P<0.001), and ICD shocks from 2 [0-5] to 0 [0-0] (-90%, P<0.001). One hemothorax required reoperation; no other major complications occurred. One-year survival was 82%. ConclusionsMinimally invasive, patient-tailored hybrid VT ablation--guided by multidisciplinary planning--achieves marked reductions in VT burden and ICD shocks with a favorable safety profile, even in complex post-surgical patients.

BackgroundArtificial intelligence (AI) has emerged as a promising tool for interpreting 12-lead electrocardiograms (ECGs), with the potential to enhance diagnostic accuracy for arrhythmia detection. However, published studies vary widely in methodology and validation strategy, warranting a quantitative synthesis of diagnostic performance. MethodsA systematic review and meta-analysis was conducted according to the PRISMA-DTA 2018 guidelines and registered in PROSPERO (CRD420251027264). Searches were performed in MEDLINE, Embase, and Cochrane Library through September 2025 without language restrictions. Studies evaluating AI algorithms for arrhythmia detection using 12-lead ECGs were included. Data on sensitivity, specificity, and area under the curve (AUC) were extracted. Pooled estimates were generated using a bivariate random-effects model. Risk of bias was assessed with QUADAS-2, and the certainty of evidence was quantified using GRADE. Results20 studies were included in the meta-analysis, encompassing over 5.5 million ECGs. The pooled sensitivity, specificity, and AUC for AI-based arrhythmia detection were 94.0% (95% CI 90.8-96.2; I{superscript 2} = 96.9%), 98.7% (95% CI 97.3-99.3; I{superscript 2} = 98.3%), and 0.982 (95% CI 0.965-0.986), respectively. Detection of atrial fibrillation (AF) yielded a sensitivity of 92.6% (95% CI 86.4-96), a specificity of 99.1% (95% CI 98.4-99.5), and an AUC of 0.988. Convolutional neural networks (CNN) specifically demonstrated a sensitivity of 97.6%, specificity of 98.7%, and an AUC of 0.982 for overall arrhythmia detection. When limited to external validation (n=6), the sensitivity was 96.9% (95% CI 89.2-99.1), specificity was 95.6% (95% CI 77.6-99.3), and AUC was 0.983. No significant publication bias was detected, and the overall certainty of evidence was rated as high. ConclusionsAI models applied to 12-lead ECGs demonstrate excellent diagnostic performance for arrhythmia detection. Findings support potential integration into clinical workflows, particularly in settings with limited cardiology expertise. Given substantial heterogeneity, standardized datasets and multicenter prospective validation are essential to ensure effective and equitable implementation. What is KnownO_LIArtificial intelligence has been increasingly applied to 12-lead electrocardiograms for arrhythmia detection, with multiple studies reporting high diagnostic accuracy. C_LI What the Study AddsO_LIThis meta-analysis demonstrates consistently high diagnostic performance of artificial intelligence for arrhythmia detection on 12-lead ECGs, including atrial fibrillation and externally validated models. C_LIO_LIThe substantial heterogeneity observed underscores the need for standardized datasets and multicenter prospective validation before widespread clinical implementation. C_LI

ImportanceThe COVID-19 pandemic has resulted in a decline in admissions with cardiovascular (CV) emergencies. The fatal consequences of this are unknown. ObjectivesTo describe the place and causes of acute CV death during the COVID-19 pandemic. DesignRetrospective nationwide cohort. SettingEngland and Wales. ParticipantsAll adult (age [&ge;]18 years) acute CV deaths (n=580,972) between 1st January 2014 and 2nd June 2020. ExposureThe COVID-19 pandemic (defined as from the onset of the first COVID-19 death in England on 2nd March 2020). Main outcomesPlace (hospital, care home, home) and acute CV events directly contributing to death as stated on the first part of the Medical Certificate of Cause of Death. ResultsAfter 2nd March 2020, there were 22,820 acute CV deaths of which 5.7% related to COVID-19, and an excess acute CV mortality of 1752 (+8%) compared with the expected daily deaths in the same period. Deaths in the community accounted for nearly half of all deaths during this period. Care homes had the greatest increase in excess acute CV deaths (1065, +40%), followed by deaths at home (1728, +34%) and in hospital (57, +0%). The most frequent cause of acute CV death during this period was stroke (8,290, 36.3%), followed by acute coronary syndrome (ACS) (5,532, 24.2%), heart failure (5,280, 23.1%), pulmonary embolism (2,067, 9.1%) and cardiac arrest (1,037, 4.5%). Deep vein thrombosis had the greatest increase in cause of excess acute CV death (18, +25%), followed pulmonary embolism (340, +19%) and stroke (782, +10%). The greatest cause of excess CV death in care homes was stroke (700, +48%), compared with cardiac arrest (80, +56%) at home, and pulmonary embolism (126, +14%) and cardiogenic shock (41, +14%) in hospital. Conclusions and relevanceThe COVID-19 pandemic has resulted in an inflation in acute CV deaths above that expected for the time of year, nearly half of which occurred in the community. The most common cause of acute CV death was stroke followed by acute coronary syndrome and heart failure. This is key information to optimise messaging to the public and enable health resource planning.

ObjectiveTo validate case number correctness and time interval agreement in the Swedish Registry of Cardiopulmonary Resuscitation (SRCR) for out-of-hospital cardiac arrest (OHCA) by linkage to Emergency Medical Dispatch Centre (EMDC) data between 2015 and 2024. MethodsIn this retrospective validation study, OHCA records reported to the SCRC were linked with EMDC-indexed OHCA for validation and correction of EMS case numbers. We quantified the proportion of correct EMS case numbers reported as agreement for fully correct and partially correct EMS case numbers in SRCR. Time interval agreement was assessed by comparing dispatch to arrival (unit response time) and call start to arrival (total response time) between SRCR and EMDC. For each linked case, time differences were calculated as (SRCR - EMDC) in seconds. Median differences were estimated using Bayesian quantile regression. ResultsEMS case number completeness was high, but the proportion of fully correct case numbers was limited. Among 56,969 SRCR records, 1,004 (1.8%) lacked an EMS case number. The proportion of SRCR records with partially correct EMS case numbers was around 90% up to the year 2020 and declined to 85% in 2022-2024. Dispatch-related time intervals showed high agreement between sources, with a median difference of -0.3 seconds (95% CrI -3.9 to 4.0). In contrast, SRCR total response time (from dispatch call answer to arrival at scene) was shorter than EMDC, with a median difference of 80.9 seconds (95% CrI -84.7 to -77.0). ConclusionSRCR unit response time reflects EMDC operational recording. The SRCR total response times were consistently shorter than the interval at the EMDC, indicating a potential underestimation of the total EMS response time in the registry.

Structured AbstractO_ST_ABSObjectivesC_ST_ABSThis study assessed safety and feasibility of a novel extravascular (EV) implantable cardioverter-defibrillator (ICD) lead when inserted anteriorly through a rib space and connected to various commercially available ICD pulse generators (PGs) placed in either a left mid-axillary or left pectoral pocket. BackgroundCurrently available or investigational, EV-ICDs include a subcutaneous or subxiphoid lead connected to customized EV-ICD PGs. This novel EV-ICD (AtaCor Medical, Inc, San Clemente, CA) employs a unique intercostal implant technique and is designed to function with commercial DF-4 ICD PGs. MethodsIn this non-randomized, single-center, acute study, 36 de novo or replacement transvenous (TV) ICD patients enrolled to receive a concomitant EV-ICD lead inserted through an intercostal space along the left parasternal margin. EV-ICD leads were connected to DF-4 compatible ICD PGs positioned in either a left mid-axillary or pectoral pocket for acute sensing and defibrillation testing. Defibrillation testing started at 30 Joules (J) and stepped down in 10 J increments following conversion success and stepped up in 5 J increments following conversion failure. ResultsSuccessful acute defibrillation using [&le;] 35 J was noted in 100% of left mid-axillary PG subjects (n=27, mean 16.3 {+/-} 8.6 J) and 83% of left pectoral PG subjects (n=6, mean 21.0 {+/-} 8.4 J). All evaluable episodes (n=93) were automatically sensed, detected, and shocked. No serious device-related intraoperative adverse events were observed. ConclusionsThis first-in-human study documented safe and reliable placement of a novel extravascular ICD lead with effective sensing and defibrillation of induced ventricular fibrillation using commercial DF-4 ICD pulse generators. Condensed AbstractThis study assessed feasibility of intercostal implantation of a novel extravascular implantable cardioverter-defibrillator (ICD) lead designed to function with commercial DF-4 pulse generators (PGs). Lead placement was successful in 33 of 36 attempts (94%). Acute defibrillation with [&le;]35 J was successful in 27 of 27 left mid-axillary PG subjects (100%) and 5 of 6 left pectoral PG subjects (83%). All evaluable episodes (n=93) were automatically detected. No serious device-related intraoperative adverse events were observed. This study demonstrates feasibility of a novel extravascular ICD lead with effective sensing and defibrillating of induced ventricular fibrillation using commercial DF-4 PGs.