title: Electrocardiographic Features of Arrhythmogenic Right Ventricular Dysplasia Esophageal Capsule Endoscopy After Radiofrequency Catheter Ablation for Atrial Fibrillation: Documented Higher Risk of Luminal Esophageal Damage With General Anesthesia as Compared With Conscious Sedation The First Evaluation of a Novel Vitamin K Antagonist, Tecarfarin (ATI-5923), in Patients With Atrial Fibrillation Antiarrhythmics After Ablation of Atrial Fibrillation (5A Study) Propranolol Decreases Tachycardia and Improves Symptoms in the Postural Tachycardia Syndrome: Less Is More Analysis of Stroke in ATHENA: A Placebo-Controlled, Double-Blind, Parallel-Arm Trial to Assess the Efficacy of Dronedarone 400 mg BID for the Prevention of Cardiovascular Hospitalization or Death From Any Cause in Patients With Atrial Fibrillation/Atrial Flutter Impact of Implantable Cardioverter-Defibrillator, Amiodarone, and Placebo on the Mode of Death in Stable Patients With Heart Failure: Analysis From the Sudden Cardiac Death in Heart Failure Trial Primary Results From the SmartDelay Determined AV Optimization: A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy (SMART-AV) Trial: A Randomized Trial Comparing Empirical, Echocardiography-Guided, and Algorithmic Atrioventricular Delay Programming in Cardiac Resynchron Outcomes of early risk stratification and targeted implantable cardioverter-defibrillator implantation after ST-elevation myocardial infarction treated with primary percutaneous coronary intervention. Long-Term Prognosis of Patients Diagnosed With Brugada Syndrome: Results From the FINGER Brugada Syndrome Registry Left Atrial Appendage: An Underrecognized Trigger Site of Atrial Fibrillation Complication Rates Associated With Pacemaker or Implantable Cardioverter-Defibrillator Generator Replacements and Upgrade Procedures: Results From the REPLACE Registry Dynamic Interactions Between Musical, Cardiovascular, and Cerebral Rhythms in Humans Performance of a New Leadless Implantable Cardiac Monitor in Detecting and Quantifying Atrial Fibrillation Results of the XPECT Trial Atrial Fibrillation Ablation Strategies for Paroxysmal Patients: Randomized Comparison Between Different Techniques Mechanisms Underlying the Lack of Effect of Implantable Cardioverter-Defibrillator Therapy on Mortality in High-Risk Patients With Recent Myocardial Infarction: Insights from the Defibrillation in Acute Myocardial Infarction Trial (DINAMIT)
abstract: Background — The purpose of this study was to reevaluate the ECG features of arrhythmogenic right ventricular dysplasia ( ARVD ) . The second objective was to evaluate the sensitivity and specificity of the st and ard and newly proposed diagnostic ECG markers in the presence of a right bundle-branch block ( RBBB ) . Methods and Results — One hundred patients with ARVD ( 57 men ; aged 39±15 years ) and 57 controls ( 21 men ; aged 40±17 years ) were included . Among the 100 patients with ARVD , a complete RBBB was present in 17 patients , and 15 patients had an incomplete RBBB . T-wave inversion through V3 demonstrated optimal sensitivity and specificity in both ARVD patients without a complete RBBB or incomplete RBBB ( 71 % [ 95 % confidence interval , 58 % to 81 % ] and 96 % [ 95 % confidence interval , 81 % to 100 % ] , respectively ) and in ARVD patients with incomplete RBBB ( 73 % [ 95 % confidence interval , 45 % to 92 % ] and 95 % [ 95 % confidence interval , 77 % to 100 % ] , respectively ) . Between ARVD patients and controls with a complete RBBB , the only 2 parameters that differed were the prevalence of T-wave inversion through V4 ( 59 % versus 12 % , respectively ; P<0.05 ) and an r′/s ratio in V1 < 1 ( 88 % versus 14 % , respectively ; P<0.005 ) . In ARVD patients with complete RBBB , the most sensitive and specific parameter was an r′/s ratio < 1 . Conclusions — We evaluated comprehensively the diagnostic value of ECG markers for ARVD . On the basis of the findings , we propose an algorithm , with examination of QRS morphology being the first step , for ECG evaluation of ARVD patients . Definite criteria are then applied on the basis of the presence of no RBBB , incomplete RBBB , and complete RBBB to obtain the best diagnostic utility of the ECG Background —Left atrioesophageal fistula is a rare but devastating complication that may occur after  catheter ablation of atrial fibrillation . We used capsule endoscopy to assess esophageal injury after catheter ablation for atrial fibrillation in a population r and omized to undergo general anesthesia or conscious sedation . Methods and Results —Fifty patients undergoing atrial fibrillation ablation for paroxysmal symptomatic atrial fibrillation refractory to antiarrhythmic drugs were enrolled and r and omized , including those undergoing the procedure under general anesthesia ( 25 patients , group 1 ) and those receiving conscious sedation with fentanyl or midazolam ( 25 patients , group 2 ) . All patients underwent esophageal temperature monitoring during the procedure . The day after ablation , all patients had capsule endoscopy to assess the presence of endoluminal tissue damage of the esophagus . We observed esophageal tissue damage in 12 ( 48 % ) patients of group 1 and 1 esophageal tissue damage in a single patient ( 4 % ) of group 2 ( P<0.001 ) . The maximal esophageal temperature was significantly higher in patients undergoing general anesthesia ( group 1 ) versus patients undergoing conscious sedation ( group 2 ) ( 40.6±1 ° C versus 39.6±0.8 ° C ; P < 0.003 ) . The time to peak temperature was 9±7 seconds in group 1 and 21±9 seconds in group 2 , and this difference was statistically significant ( P<0.001 ) . No complication occurred during or after the administration of the pill cam or during the procedures . All esophageal lesions normalized at the 2-month repeat endoscopic examination . Conclusion —The use of general anesthesia increases the risk of esophageal damage detected by capsule endoscopy Background — Tecarfarin ( ATI-5923 ) is a novel oral vitamin K antagonist . Unlike warfarin , it is metabolized by esterases , escaping metabolism by the cytochrome P450 system and thereby avoiding cytochrome P450–mediated drug-drug or drug-food interactions as well as genetic variations found in the cytochrome P450 system . Both tecarfarin and warfarin can be monitored with the international normalized ratio . We hypothesized that the time in therapeutic range for tecarfarin will exceed values usually experienced with warfarin . Methods and Results — This was a 6- to 12-week open-label , multicenter , phase IIA study of 66 atrial fibrillation patients with a mild to moderate risk of stroke to determine the safety and tolerability of tecarfarin and to ascertain an optimal tecarfarin dosing regimen . Sixty-four subjects ( 97 % ) were taking warfarin at enrollment and were switched to tecarfarin . After the initial 3 weeks of tecarfarin treatment , the mean interpolated time in therapeutic range was 71.4 % . Only 10.9 % of patients had time in therapeutic range of < 45 % . Times in extreme international normalized ratio ranges of < 1.5 and > 4.0 were 1.2 % and 1.2 % , respectively . The median daily dose ( for an individual patient ) to maintain an international normalized ratio between 2 and 3 was 15.6 mg ( range , 6 to 29 mg ) . Conclusions — This is the first study of tecarfarin in patients with atrial fibrillation . It appears that tecarfarin may possess advantages over the currently available st and ard of care , warfarin , by improving time in therapeutic range . Adequately powered prospect i ve trials are warranted to definitively compare tecarfarin with warfarin in clinical setting s for which warfarin is indicated Background — Atrial arrhythmias are common early after atrial fibrillation ( AF ) ablation . We hypothesized that empirical antiarrhythmic drug ( AAD ) therapy for 6 weeks after AF ablation would reduce the occurrence of atrial arrhythmias . Methods and Results — We r and omized consecutive patients with paroxysmal AF undergoing ablation to empirical antiarrhythmic therapy ( AAD group ) or no antiarrhythmic therapy ( no-AAD group ) for the first 6 weeks after ablation . In the no-AAD group , only atrioventricular nodal blocking agents were prescribed . All patients wore a transtelephonic monitor for 4 weeks after discharge and were reevaluated at 6 weeks . The primary end point of the study was a composite of ( 1 ) atrial arrhythmias lasting more than 24 hours ; ( 2 ) atrial arrhythmias associated with severe symptoms requiring hospital admission , cardioversion , or initiation/change of antiarrhythmic drug therapy ; and ( 3 ) intolerance to antiarrhythmic agent requiring drug cessation .  Of 110 enrolled patients ( age 55±9 years , 71 % male ) , 53 were r and omized to AAD and 57 to no-AAD . There was no difference in baseline characteristics between groups . During the 6 weeks after ablation , fewer patients reached the primary end point in the AAD compared with the no-AAD group ( 19 % versus 42 % ; P=0.005 ) . There remained fewer events in the AAD group ( 13 % versus 28 % ; P=0.05 ) when only end points of AF > 24 hours , arrhythmia-related hospitalization , or electrical cardioversion were compared . Conclusions — AAD treatment during the first 6 weeks after AF ablation is well tolerated and reduces the incidence of clinical ly significant atrial arrhythmias and need for cardioversion/hospitalization for arrhythmia management Background — Postural tachycardia syndrome ( POTS ) induces disabling chronic orthostatic intolerance with an excessive increase in heart rate on st and ing . β-Blockade is an appealing treatment approach , but conflicting preliminary reports are conflicting . We tested the hypothesis that propranolol will attenuate the tachycardia and improve symptom burden in patients with POTS . In protocol 1 , a low dose ( 20 mg ) was compared with placebo , and the dose response was assessed in protocol 2 . Methods and Results — In protocol 1 , patients with POTS ( n=54 ) underwent acute drug trials of propranolol 20 mg orally and placebo , on separate mornings , in a r and omized crossover design . Blood pressure , heart rate , and symptoms were assessed while the patients were seated and after st and ing for up to 10 minutes before and hourly after the study drug . Supine ( P<0.001 ) and st and ing ( P<0.001 ) heart rates were significantly lower after propranolol compared with placebo . The symptom burden improvement from baseline to 2 hours was greater with propranolol than placebo ( median , −4.5 versus 0 arbitrary units ; P=0.044 ) . In protocol 2 , 18 patients with POTS underwent similar trials of high-dose ( 80 mg ) versus low-dose ( 20 mg ) propranolol . Although the high dose elicited a greater decrease than the low dose in st and ing heart rate ( P<0.001 ) and orthostatic tachycardia ( P<0.001 ) , the improvement in symptoms at 2 hours was greater with low-dose propranolol ( −6 versus −2 arbitrary units ; P=0.041 ) . Conclusions — Low-dose oral propranolol significantly attenuated tachycardia and improved symptoms in POTS . Higher-dose propranolol did not further improve , and may worsen , symptoms Background — Many patients with atrial fibrillation are at high risk for stroke and require antithrombotic therapy . Antiarrhythmic drugs have not previously been shown to reduce the risk of stroke in atrial fibrillation . The effect of dronedarone , a new multichannel-blocking antiarrhythmic drug , on stroke has been evaluated in a r and omized , double-blind clinical trial , ATHENA ( A placebo-controlled , double-blind , parallel-arm Trial to assess the efficacy of dronedarone 400 mg BID for the prevention of cardiovascular Hospitalization or death from any cause in patiENts with Atrial fibrillation/atrial flutter ) . Methods and Results — Patients with persistent or paroxysmal atrial fibrillation and at least 1 risk factor for cardiovascular hospitalization were r and omized to receive dronedarone ( 400 mg BID ) or double-blind matching placebo and followed up for a minimum of 1 year to a common termination at 30 months . All strokes that occurred during the study were included in the present post hoc analysis . There were 4628 patients r and omized to placebo or dronedarone .  The baseline risk factors for stroke were well balanced between the 2 groups , and the baseline mean CHADS2 score was 2 . The baseline use of either oral anticoagulant therapy or antiplatelet agent alone was 60 % . Dronedarone reduced the risk of stroke from 1.8 % per year to 1.2 % per year ( hazard ratio 0.66 , 95 % confidence interval 0.46 to 0.96 , P=0.027 ) . The effect of  dronedarone  was similar whether or not patients were receiving oral anticoagulant therapy , and there was a significantly greater effect of  dronedarone  in patients with higher CHADS2 scores . Conclusions — In this post hoc analysis , a reduction in stroke was observed in patients with atrial fibrillation who were receiving usual care , which included antithrombotic therapy and heart rate control , who were r and omized to dronedarone . Further studies to investigate the effect of dronedarone and other antiarrhythmic agents on stroke are indicated Background — The Sudden Cardiac Death in Heart Failure Trial ( SCD-HeFT ) demonstrated that implantable cardioverter-defibrillator ( ICD ) therapy reduces all-cause mortality in patients with New York Heart Association class II/III heart failure and a left ventricular ejection fraction ≤35 % on optimal medical therapy . Whether ICD therapy reduced sudden death caused by ventricular tachyarrhythmias without affecting heart failure deaths in this population is unknown . Methods and Results — SCD-HeFT r and omized 2521 subjects to placebo , amiodarone , or shock-only , single-lead ICD therapy .  Over a median follow-up of 45.5 months , a total of 666 deaths occurred , which were review ed by an Events Committee and initially categorized as cardiac or noncardiac . Cardiac deaths were further adjudicated as result ing from sudden death presumed to be ventricular tachyarrhythmic , bradyarrhythmia , heart failure , or other cardiac causes . ICD therapy significantly reduced cardiac mortality compared with placebo ( adjusted hazard ratio , 0.76 ; 95 % confidence interval , 0.60 to 0.95 ) and tachyarrhythmia mortality ( adjusted hazard ratio , 0.40 ; 95 % confidence interval , 0.27 to 0.59 ) and had no impact on mortality result ing from heart failure or noncardiac causes . The cardiac and tachyarrhythmia mortality reductions were evident in subjects with New York Heart Association class II but not in subjects with class III heart failure . The reduction in tachyarrhythmia mortality with ICD therapy was similar in subjects with ischemic and nonischemic disease . Compared with placebo , amiodarone had no significant effect on any mode of death . Conclusions — ICD therapy reduced cardiac mortality and sudden death presumed to be ventricular tachyarrhythmic in SCD-HeFT and had no effect on heart failure mortality . Amiodarone had no effect on all-cause mortality or its cause-specific components , except an increase in non-cardiac mortality in class III patients . Clinical Trial Registration Information— URL : http://www . clinical trials.gov . Unique identifier : NCT00000609 Background — One variable that may influence cardiac resynchronization therapy response is the programmed atrioventricular ( AV ) delay . The SmartDelay Determined AV Optimization : A Comparison to Other AV Delay Methods Used in Cardiac Resynchronization Therapy ( SMART-AV ) Trial prospect ively r and omized patients to a fixed empirical AV delay ( 120 milliseconds ) , echocardiographically optimized AV delay , or AV delay optimized with SmartDelay , an electrogram-based algorithm . Methods and Results — A total of 1014 patients ( 68 % men ; mean age , 66±11 years ; mean left ventricular ejection fraction , 25±7 % ) who met enrollment criteria received a cardiac resynchronization therapy defibrillator , and 980 patients were r and omized in a 1:1:1 ratio . All patients were programmed ( DDD-60 or DDDR-60 ) and evaluated after implantation and 3 and 6 months later . The primary end point was left ventricular end-systolic volume . Secondary end points included New York Heart Association class , quality -of-life score , 6-minute walk distance , left ventricular end-diastolic volume , and left ventricular ejection fraction . The medians ( quartiles 1 and 3 ) for change in left ventricular end-systolic volume at 6 months for the SmartDelay , echocardiography , and fixed arms were −21 mL ( −45 and 6 mL ) , −19 mL ( −45 and 6 mL ) , and −15 mL ( −41 and 6 mL ) , respectively . No difference in improvement in left ventricular end-systolic volume at 6 months was observed between the SmartDelay and echocardiography arms ( P=0.52 ) or the SmartDelay and fixed arms ( P=0.66 ) . Secondary end points , including structural ( left ventricular end-diastolic volume and left ventricular ejection fraction ) and functional ( 6-minute walk , quality of life , and New York Heart Association classification ) measures , were not significantly different between arms . Conclusions — Neither SmartDelay nor echocardiography was superior to a fixed AV delay of 120 milliseconds . The routine use of AV optimization techniques assessed in this trial is not warranted . However , these data do not exclude possible utility in selected patients who do not respond to cardiac resynchronization therapy . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00677014 BACKGROUND Methods to identify high-risk patients and timing of implantable cardioverter-defibrillator ( ICD ) therapy after ST-elevation myocardial infa rct ion need further optimization . METHODS AND RESULTS We evaluated outcomes of early ICD implantation in patients with inducible ventricular tachycardia . Consecutive patients treated with primary percutaneous coronary intervention for acute ST-elevation myocardial infa rct ion underwent early left ventricular ejection fraction ( LVEF ) assessment . Patients with LVEF > 40 % were discharged ( group 1 ) ; patients with LVEF < or = 40 % underwent risk stratification with electrophysiological study . If no ventricular tachycardia was induced , patients were discharged without an ICD ( group 2 ) . If sustained monomorphic ventricular tachycardia ( > or = 200-ms cycle length ) was induced , an ICD was implanted before discharge ( group 3 ) . Follow-up was obtained up to 30 months in all patients and up to 48 months in a subgroup of patients with LVEF < or = 30 % without an ICD . The primary end point was total mortality .  Group 1 ( n=574 ) had a mean LVEF of 54+/-8 % ; group 2 ( n=83 ) , 32+/-6 % ; and group 3 ( n=32 ) , 29+/-7 % . At a median follow-up of 12 months , there was no significant difference in survival between the 3 groups ( P=0.879 ) , with mortality rates of 3 % , 3 % , and 6 % for groups 1 through 3 , respectively . In the subgroup of group 2 patients with LVEF < or = 30 % and no ICD ( n=25 ) , there was 9 % mortality at a median follow-up of 25 months . In group 3 , 19 % had spontaneous ICD activation result ing from ventricular tachycardia . CONCLUSIONS Early ICD implantation limited to patients with inducible ventricular tachycardia enables a low overall mortality in patients with impaired LVEF after primary percutaneous coronary intervention for ST-elevation myocardial infa rct ion Background — Brugada syndrome is characterized by ST-segment elevation in the right precordial leads and an increased risk of sudden cardiac death ( SCD ) . Fundamental questions remain on the best strategy for assessing the real disease-associated arrhythmic risk , especially in asymptomatic patients . The aim of the present study was to evaluate the prognosis and risk factors of SCD  in Brugada syndrome patients in the FINGER ( France , Italy , Netherl and s , Germany ) Brugada syndrome registry . Methods and Results — Patients were recruited in 11 tertiary centers in 4 European countries . Inclusion criteria consisted of a  type 1 ECG  present either at baseline or after drug challenge , after exclusion of diseases that mimic Brugada syndrome . The registry included 1029 consecutive individuals ( 745 men ; 72 % ) with a median age of 45 ( 35 to 55 ) years . Diagnosis was based on ( 1 ) aborted SCD ( 6 % ) ; ( 2 ) syncope , otherwise unexplained ( 30 % ) ; and ( 3 ) asymptomatic patients ( 64 % ) . During a median follow-up of 31.9 ( 14 to 54.4 ) months , 51 cardiac events ( 5 % ) occurred ( 44 patients experienced appropriate implantable cardioverter-defibrillator shocks , and 7 died suddenly ) . The cardiac event rate per year was 7.7 % in patients with aborted SCD , 1.9 % in patients with syncope , and 0.5 % in asymptomatic patients . Symptoms and spontaneous type 1 ECG were predictors of arrhythmic events , whereas gender , familial history of SCD , inducibility of ventricular tachyarrhythmias during electrophysiological study , and the presence of an SCN5A mutation were not predictive of arrhythmic events . Conclusions — In the largest series of Brugada syndrome patients thus far , event rates in asymptomatic patients were low . Inducibility of ventricular tachyarrhythmia and family history of SCD were not predictors of cardiac events Background — Together with pulmonary veins , many extrapulmonary vein areas may be the source of initiation and maintenance of atrial fibrillation . The left atrial appendage ( LAA ) is an underestimated site of initiation of atrial fibrillation . Here , we report the prevalence of triggers from the LAA and the best strategy for successful ablation . Methods and Results — Nine hundred eighty-seven consecutive patients ( 29 % paroxysmal , 71 % nonparoxysmal ) undergoing redo catheter ablation for atrial fibrillation were enrolled . Two hundred sixty-six patients ( 27 % ) showed firing from the LAA and became the study population . In 86 of 987 patients ( 8.7 % ; 5 paroxysmal , 81 nonparoxysmal ) , the LAA was found to be the only source of arrhythmia with no pulmonary veins or other extrapulmonary vein site reconnection . Ablation was performed either with focal lesion ( n=56 ; group 2 ) or to achieve LAA isolation by placement of the circular catheter at the ostium of the LAA guided by intracardiac echocardiography ( 167 patients ; group 3 ) . In the remaining patients , LAA firing was not ablated ( n=43 ; group 1 ) . At the 12±3-month follow-up , 32 patients ( 74 % ) in group 1 had recurrence compared with 38 ( 68 % ) in group 2 and 25 ( 15 % ) in group 3 ( P<0.001 ) . Conclusions — The LAA appears to be responsible for arrhythmias in 27 % of patients presenting for repeat procedures . Isolation of the LAA could achieve freedom from atrial fibrillation in patients presenting for a repeat procedure when arrhythmias initiating from this structure are demonstrated Background — Prospect i ve studies defining the risk associated with  pacemaker or implantable cardioverter-defibrillator replacement surgeries do not exist . These procedures are generally considered low risk despite results from recent retrospective series reporting higher rates . Methods and Results — We prospect ively assessed predefined procedure-related complication rates associated with  elective pacemaker or implantable cardioverter-defibrillator generator replacements  over 6 months of follow-up . Two groups were studied : those without ( cohort 1 ) and those with ( cohort 2 ) a planned transvenous lead addition for replacement or up grade to a device capable of additional therapies . Complications were adjudicated by an independent events committee . Seventy-two US academic and private practice centers participated .  Major complications occurred in 4.0 % ( 95 % confidence interval , 2.9 to 5.4 ) of 1031 cohort 1 patients and 15.3 % ( 95 % confidence interval , 12.7 to 18.1 ) of 713 cohort 2 patients . In both cohorts , major complications were higher with implantable cardioverter-defibrillator compared with pacemaker generator replacements .  Complications were highest in patients who had an up grade to or a revised cardiac resynchronization therapy device ( 18.7 % ; 95 % confidence interval , 15.1 to 22.6 ) . No periprocedural deaths occurred in either cohort , although 8 later procedure-related deaths occurred in cohort 2 . The 6-month infection rates were 1.4 % ( 95 % confidence interval , 0.7 to 2.3 ) and 1.1 % ( 95 % confidence interval , 0.5 to 2.2 ) for cohorts 1 and 2 , respectively . Conclusions — Pacemaker and implantable cardioverter-defibrillator generator replacements are associated with a notable complication risk , particularly those with lead additions . These data support careful decision making before device replacement , when managing device advisories , and when considering up grade s to more complex systems . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00395447 Background — Reactions to music are considered subjective , but previous studies suggested that cardiorespiratory variables increase with faster tempo independent of individual preference . We tested whether compositions characterized by variable emphasis could produce parallel instantaneous cardiovascular/respiratory responses and whether these changes mirrored music profiles . Methods and Results — Twenty-four young healthy subjects , 12 musicians ( choristers ) and 12 nonmusician control subjects , listened ( in r and om order ) to music with vocal ( Puccini 's “ Tur and ot ” ) or orchestral ( Beethoven 's 9th Symphony adagio ) progressive crescendos , more uniform emphasis ( Bach cantata ) , 10-second period ( ie , similar to Mayer waves ) rhythmic phrases ( Giuseppe Verdi 's arias “ Va pensiero ” and “ Libiam nei lieti calici ” ) , or silence while heart rate , respiration , blood pressures , middle cerebral artery flow velocity , and skin vasomotion were recorded . Common responses were recognized by averaging instantaneous cardiorespiratory responses regressed against changes in music profiles and by coherence analysis during rhythmic phrases . Vocal and orchestral crescendos produced significant ( P=0.05 or better ) correlations between cardiovascular or respiratory signals and music profile , particularly skin vasoconstriction and blood pressures , proportional to crescendo , in contrast to uniform emphasis , which induced skin vasodilation and reduction in blood pressures . Correlations were significant both in individual and group-averaged signals . Phrases at 10-second periods by Verdi entrained the cardiovascular autonomic variables . No qualitative differences in recorded measurements were seen between musicians and nonmusicians . Conclusions — Music emphasis and rhythmic phrases are tracked consistently by physiological variables . Autonomic responses are synchronized with music , which might therefore convey emotions through autonomic arousal during crescendos or rhythmic phrases Background —Current methods for detecting atrial fibrillation ( AF ) have limited diagnostic yield . Continuous monitoring with automatic arrhythmia detection and classification may improve detection of symptomatic and asymptomatic AF and subsequent patient treatment . The study purpose was to quantify the performance of the first implantable leadless cardiac monitor ( ICM ) with dedicated AF detection capabilities . Methods and Results — Patients ( n=247 ) with an implanted ICM ( Reveal XT , Medtronic Inc , Minneapolis , Minn ) who were likely to present with paroxysmal AF were selected . A special Holter device stored 46 hours of subcutaneously recorded ECG , ICM markers , and 2 surface ECG leads . The ICM  automatic arrhythmia classification was compared with the core laboratory classification of the surface ECG . Of the 206 analyzable Holter recordings collected , 76 ( 37 % ) contained at least 1 episode of core laboratory classified AF . The sensitivity , specificity , positive predictive value , and negative predictive value for identifying patients with any AF were 96.1 % , 85.4 % , 79.3 % , and 97.4 % , respectively . The AF burden measured with the ICM was very well correlated with the reference value derived from the Holter ( Pearson coefficient=0.97 ) . The overall accuracy of the ICM for detecting AF was 98.5 % . Conclusions —In this ICM validation study , the dedicated AF detection algorithm reliably detected the presence or absence of AF and the AF burden was accurately quantified . The ICM is a promising new diagnostic and monitoring tool for the clinician to treat AF patients independently of symptoms . Long-term studies are needed to evaluate the clinical benefits of the technology . Clinical Trial Registration — clinical trials.gov Identifier NCT00680927 Background —Whether different ablation strategies affect paroxysmal atrial fibrillation ( AF ) long-term freedom from AF/atrial tachyarrhythmia is unclear . We sought to compare the effect of 3 different ablation approaches on the long-term success in patients with paroxysmal AF . Methods and Results —One hundred three consecutive patients with paroxysmal AF scheduled for ablation and presenting in the electrophysiology laboratory in AF were selected for this study . Patients were r and omized to pulmonary vein antrum isolation ( PVAI ; n=35 ) versus biatrial ablation of the complex fractionated atrial electrograms ( CFAEs ; n=34 ) versus PVAI followed by CFAEs ( n=34 ) . Patients were given event recorders and followed up at 3 , 6 , 9 , 12 , and 15 months postablation . There was no statistical significant difference between the groups in term of sex , age , AF duration , left atrial size , and ejection fraction . At 1 year follow-up , freedom from AF/atrial tachyarrhythmia was documented in 89 % of patients in the PVAI group , 91 % in the PVAI plus CFAEs group , and 23 % in the CFAEs group ( P<0.001 ) after a single procedure and with antiarrhythmic drugs . Conclusion —No difference in terms of success rate was seen between PVAI alone and PVAI associated with defragmentation . CFAEs ablation alone had the smallest impact on AF recurrences at 1-year follow-up . These results suggest that antral isolation is sufficient to treat most patients with paroxysmal AF Background — Although implantable cardioverter-defibrillators ( ICDs ) lower mortality in stable patients with low ejection fraction late after myocardial infa rct ion , r and omized trials of ICD versus control subjects implanted early after myocardial infa rct ion do not show mortality benefit . Our objective was to investigate possible mechanisms underlying the lack of mortality benefit in the Defibrillation in Acute Myocardial Infa rct ion Trial ( DINAMIT ) . Methods and Results — This is a secondary analysis of the prospect i ve r and omized clinical trial . Out patients with recent ( 6 to 40 days ) acute myocardial infa rct ion , left ventricular dysfunction ( ejection fraction < 35 % ) , and low heart rate variability were r and omized to ICD ( n=311 ) or to st and ard medical therapy  ( n=342 ) . In a competing-risks analysis , those factors that increased the risk of arrhythmic death also increased the risk of nonarrhythmic deaths . After adjustment for these factors , receiving an ICD was associated with a decreased risk of arrhythmic death ( hazard ratio , 0.33 ; 95 % confidence interval , 0.15 to 0.71 ) but an increase in nonarrhythmic death ( hazard ratio , 1.70 ; 95 % confidence interval , 1.00 to 2.80 ) . In an adjusted time-dependent analysis , patients receiving an ICD and having appropriate ICD therapy had a 15.1 % yearly hazard of mortality compared with 5.2 % in ICD patients with no appropriate therapy ( P<0.001 ) . The reduction in sudden death in ICD patients was completely offset by increased nonarrhythmic deaths , which were greatest in patients receiving ICD shock therapy ( hazard ratio , 6.0 ; 95 % confidence interval , 2.8 to 12.7 ) . Conclusions — In patients receiving ICDs early after myocardial infa rct ion , those factors that are associated with arrhythmia requiring ICD therapy are also associated with a high risk of nonsudden death , negating the benefit of ICDs in this setting
target: Studies of RFA for treatment of atrial fibrillation report higher efficacy rates than do studies of AAD therapy and a lower rate of complications
background: BACKGROUND Although radiofrequency catheter ablation ( RFA ) has evolved from an experimental procedure to an important treatment option for atrial fibrillation , the relative safety and efficacy of catheter ablation relative to that of antiarrhythmic drug ( AAD ) therapy has not been established .