A Simple Improvement on Existing Technology to Enhance Transseptal Puncture and Left Atrial Access Using Large Diameter Sheaths for Mapping, Ablation and LAA Occlusion ProceduresGregory K. Feld, MD, Jonathan C. Hsu, MD, MASFrom the University of California San Diego Health System, Department of Medicine,Division of CardiologyFunding Source: NoneEditorial CommentWord Count: 870Address for Correspondence:9452 Medical Center DriveMC7411, Altman Bldg, 3rd Floor, Room 3E-313La Jolla, CA 92037Disclosures:Dr. Feld, as Director of the UCSD EP Fellowship Training program, has received fellowship stipend support from Boston Scientific, Biotronik, Biosense Webster, Medtronic, and Abbott Medical, is co-founder and co-owner of Perminova, has received consulting fees from Acutus Medical, Vektor Medical, and Irysis Pharmaceuticals, and has equity interest in Medwaves and Acutus Medical.Dr. Hsu has received honoraria from Medtronic, Abbott, Boston Scientific, Biotronik, Biosense-Webster, Zoll Medical, Janssen Pharmaceuticals, Bristol-Myers Squibb, and Pfizer, has research grants with Biotronik and Biosense-Webster, and has equity interest in Acutus Medical and Vektor Medical.Since the earliest description of transseptal catheterization techniques by Ross, et.al. in the late 1950’s, to the modern era of cardiac electrophysiology which relies heavily on the same technique, the evolution of technology has been critical to transseptal catheterization improvement, including ease of performance and safety1-3. In this issue of the Journal of Cardiac Electrophysiology4, Inohara, et.al. report their benchtop research and first in human experience with a new transseptal dilator (ExpanSure Large Access Transseptal Dilator®, Baylis Medical, Montreal, Canada) used to aid left atrial (LA) access for large sheaths commonly employed in procedures such as the Watchman™ LA appendage occluder deployment.The authors employed a standard test system (Instron Testing System, Norwood, MA) to measure force and displacement in-vitro while advancing the new ExpanSure® dilator compared to a standard 8.5F Swartz™ SL1 sheath and dilator (Abbott Medical, St. Paul, MN) through a model silicone septum. In addition, during in-vivo studies in man, they determined time to positioning of a Watchman™ delivery sheath (Boston Scientific, St. Paul, MN) in the LA during a standard LA appendage occlusion procedure and administered a survey to the operators to subjectively assess crossing force and tissue resistance observed after predilating with the Expansure® dilator.The authors found during their in-vitro studies that use of the Expansure® dilator reduced peak crossing force and total work by 20% and 38%, respectively, compared to a standard SL1 sheath when advanced through the silicone septum, and a 12% reduction in peak crossing force and 20% reduction in total work for the Watchman ™ sheath when advanced through the silicone septum after pre-dilatation with the Expansure® dilator compared to the SL1 sheath. They also found during their in-vivo studies in patients that prior to deployment of the Watchman™ device in the LA appendage, delivery of the initial large guiding sheath to the LA was accomplished in a short time, and subjectively with a low crossing force and tissue resistance in most cases. However, there was no statistical comparison of these objective or subjective variables during the Watchman™ procedures performed following pre-dilation with the Expansure® dilator to those following pre-dilation with a standard SL1 sheath or without pre-dilation.While the use of a large dilator to transition from a standard transseptal crossing tool (e.g. 8.5 French SL1 sheath) to one of several large diameter transseptal sheaths commonly in use today (e.g. Watchman™ guide sheath 14 French OD, Flexcath Medtronic guide sheaths 13 or 15 French OD, Acutus guide sheath 16 French OD) is obviously logical to allow for greater ease in crossing the inter-atrial septum, until now this technology has not been commercially available5-7. Theoretical approaches for septal dilatation after initial puncture have been proposed using balloons, stents, and expanding sheaths, but these approaches would involve use of additional complex equipment and be time consuming. A simple approach such as that described in this paper using the Expansure® dilator alone with a transseptal needle (i.e. without the need for another standard 8.5 French sheath system first followed by a dilator exchange) is technically appealing, potentially cost saving, and if the results are reproducible, may enhance delivery of a large diameter sheath into the LA. Transseptal catheterization can be difficult in contemporary practice (particularly in a repeat procedure where the septum may be stiff due to fibrosis from previous healing of the access point) when transitioning from a standard size sheath such as an 8.5 French transseptal sheath to a large diameter 13-16 French sheath for mapping, ablation, or LAA occluder device delivery. Perhaps the only potential concern if using the Expansure® dilator alone versus a standard 8.5 French SL1 sheath would be the larger profile of the system when performing initial transseptal catheterization, and the maneuverability of this larger system in achieving the desired transseptal access site. However, this did not appear to be a concern from subjective operator responses during this study.In summary, while randomized clinical trials comparing the Expansure® dilator to a standard transseptal sheath for inter-atrial septal crossing prior to upsizing to a large diameter sheath for ease and safety would provide definitive evidence supporting its use, the data presented in this paper, in addition to the logic behind this approach and low probability of any increased risk, make it reasonable to adopt in clinical practice without mandating further investigation.References Ross J Jr. Transseptal left heart catheterization: a new method of left atrial puncture. Ann Surg 1959;149:395-401.Ross J Jr. Transseptal left heart catheterization: A 50-year odyssey. J Am Coll Cardiol 2008;51:2107-15. Feld GK, Tiongson J, Oshodi G. Particle formation and risk of embolization during transseptal catheterization: comparison of standard transseptal needles and a new radiofrequency transseptal needle. J Interven Card Electrophysiol 2011;30:31-36.Inohara T, Gilhofer T, Al-Dujaili S, Leung L, Yeung D, Tsang M, Saw J. A new transseptal solution for enabling left atrial access of large delivery sheaths. J Card Electrophysiol 2021;??:??-??Holmes D, Doshi S, Kar S, Price MJ, Sanchez JM, Sievert H, Valderrabano M, Reddy VY J. Left Atrial Appendage Closure as an Alternative to Warfarin for Stroke Prevention in Atrial Fibrillation: A Patient-Level Meta-Analysis. J Am Coll Cardiol 2015;65:2624-7.Ströker E, De Greef Y, Schwagten B, Kupics K, Coutiño HE, Takarada K, Abugattas JP, Salghetti F, De Cocker J, Stockman D, Sieira J, Brugada P, Chierchia GB, de Asmundis C. Over-the-needle trans-septal access using the cryoballoon delivery sheath and dilator in atrial fibrillation ablation. Pacing Clin Electrophysiol 2019;42:868-873.Shi R, Parikh P, Chen Z, Angel N, Norman M, Hussain W, Butcher C, Haldar S, Jones DG, Riad O, Markides V, Wong T. Validation of Dipole Density Mapping During Atrial Fibrillation and Sinus Rhythm in Human Left Atrium. JACC Clin Electrophysiol 2020;6:182-184.
Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for atrial fibrillation (AF) However AF recurrence after a single ablation procedure is common and often attributed to ineffective lesion delivery during PVI. In this issue of the Journal of Cardiovascular Electrophysiology, Chen et al reported their experience with 122 patients who underwent an ablation index-high power (AI-HP) strategy RF ablation for AF using 50W power, targeting AI values of 550 on the anterior left atrium (LA), 400 on the posterior wall and inter-lesion distance (ILD) 6mm. They achieved 1st pass PVI in 96.7% of cases, mean RF time was 11.5min and total procedure time was only 55.8min. All patients had 72h-Holter monitor and trans-telephonic follow up. They reported 89.4% arrhythmia free survival among patients with paroxysmal AF and 80.4% among patients with persistent AF at 15-month follow up. Sixty (49%) patients had luminal esophageal temperature (LET) >390C out of which 3 (2.5%) had asymptomatic endoscopic esophageal erosions/erythema. Four (3%) patients had clinically apparent steam pops during ablation with no adverse clinical sequela. While AI-HP guided RF ablation may be an attractive strategy for PVI that likely reduces procedure times and probably has comparable efficacy to conventional ablation settings, its safety requires further evaluation. Feedback from the ablated tissue may need to be incorporated into optimized ablation energy parameters to further improve outcomes.
The role of isolation of left posterior wall in patients with persistent atrial fibrillation on top of pulmonary vein isolation is still debatable. There are still technical issues for achieving complete left posterior wall isolation and durability of the lesions is probably the main limiting factor for promoting a successful clinical outcome
Demonstration that the myocardial sleeves of the pulmonary veins (PVs) are the main triggering and maintaining foci for paroxysmal atrial fibrillation (AF) have stimulated studies investigating electrophysiological properties of PVs and the adjacent left atrial (LA) myocardium. It has been shown that PV myocytes have a shorter action potential duration and are more prone to effects of local autonomic nerve stimulation in terms of shortening of action potential duration, early after depolarization formation and triggered firing compared to left atrial myocytes (1). The intrinsic cardiac autonomic nervous system (ICANS) forms clusters of neurons called ganglionic plexi (GPs), and studies using histologic examination of heart sections have shown that these GPs are localized preferentially at certain epicardial sites adjacent to the left and right atria (2). The precise role of ICANS in AF continues to be an area of intense research (3), and matters are not helped by the uncertainty regarding the best way to identify and target ICANS peri-procedurally. As there can be significant variability of GP sites in individual patients, endocardial high-frequency stimulation (HFS) has been used to aid their localization in the electrophysiology laboratory (4).
While pulmonary vein isolation (PVI) remains the cornerstone for invasive treatment of atrial fibrillation (AF), patients with persistent AF still have a high rate of recurrence with this method. Stochastic Trajectory Analysis of Ranked signals (STAR) mapping uses data from multiple individual wavefronts during ongoing AF to identify local drivers of persistent AF. In this non-randomized study, STAR mapping and ablation showed significantly lower recurrence of atrial arrhythmias compared to a consecutive PVI-only cohort and a propensity-matched ‘conventional ablation’ cohort (consisting of PVI plus complex fractionated atrial electrogram ablation or linear ablation). This benefit was driven by a much lower rate of AF recurrence in the STAR (6.2%) cohort vs PVI-only (44%) or ‘conventional’ (40%) with no significant difference in atrial tachycardia recurrence. Additionally, AF termination rates during ablation were approximately three times higher in the STAR cohort. While the analysis is retrospective and not randomized, the STAR cohort was also the only cohort with complete cessation of anti-arrhythmic drugs at three months and Holter monitoring at 6 and 12 months post-ablation per protocol. While STAR mapping appears to be a very promising new tool for treating persistent AF, history predicts at least some regression to the mean when future randomized comparisons are made. The authors have planned a multicenter randomized trial of PVI plus STAR mapping vs PVI-only for persistent AF. The global community of electrophysiologists and patients with AF eagerly awaits the results.
Title: Misleading Title and Communication.Regarding Brief Communication: First clinical use of real-time remote programming in cardiac implantable electronic devices. Dr. Toshimasa Okabe et al. J Cardiovascular Electrophysiol. 2020;31:2759-2761. DOI:10.1111/jce.14698Author: Dr. Esteban Martin Kloosterman
Monitoring following catheter or surgical ablation for atrial fibrillation (AF) is an essential tool used to assess outcomes for research purposes and help guide clinical decision making. The most commonly used methods to monitor for post-intervention AF include a variety of ambulatory external electrocardiogram (ECG) monitors, cardiac implantable electronic devices (CIED), and more recently, direct to consumer digital health technologies. The traditional metric of ablation success, recurrence > 30 seconds at 1 year, is below the detection capabilities of almost all monitoring techniques yet still undervalues the efficacy of AF interventions. Measures of AF burden reduction and duration give a more complete assessment of the impact of AF surgeries and ablation. As it is increasingly being recognized that AF burden and duration is related to stroke risk, long-term, inexpensive, non-invasive monitoring methods are needed. Smart phones and watches with AF-detecting capabilities, which are increasingly being used by the majority of US adults, have emerged as viable options to achieve this goal, shifting the paradigm of AF monitoring to a more patient centered approach.
Esophageal injury still occurs with high frequency during ablation of atrial fibrillation (AF). The purpose of this study is to provide a review of methods to protect the esophagus from injury during AF ablation. Despite advances in imaging and ablation, the potential risk of esophageal injury during AF ablation remains an important concern with a high occurrence of esophageal injury (≈15%). There have been numerous studies evaluating varied techniques for esophageal protection including active cooling and displacement of the esophagus. These techniques are reviewed in this manuscript as well as the role of esophageal protection in managing patients undergoing AF ablation procedure.
Introduction: Catheter ablation is superior to drugs regarding atrial fibrillation (AF) recurrence, symptoms improvement, and mortality reduction in heart failure. POLARx™ is a novel cryoballoon, with technical improvements seeking to improve outcomes. So far, its clinical evidence is restricted to a case report. Methods: To compare the POLARx™ cryoballoon procedural safety and efficacy to the already established Arctic Front Advance PRO™ (AFAP) in a single-center cohort study, consecutive patients undergoing AF cryoablation with the POLARx™ were enrolled. Data were prospectively gathered. POLARx™ patients were compared to a historical cohort of patients submitted to AF cryoablation with the AFAP. Results: Seventy patients were analyzed, 20 in POLARx™, and 50 in the AFAP group. They all underwent first-time pulmonary vein isolation, 77% were male, 94% had paroxysmal AF, median age was 62.5 years, median CHA2DS2-VASc 1, left-atrium size 34ml/m², and 65% were receiving anticoagulation. The primary end-point, all pulmonary veins isolation, was 100% in both groups. The complication rate was similar (0% POLARx™ vs. 5.7% AFAP, p=0.39). The median total procedural time was longer in the POLARx™ group (90min vs. 60min, p<0.001), but the overall time-to-isolation (TTI) (44.8sec vs. 39sec, p=0.253) and ablation time (15min vs. 13.7min, p=0.122) was similar between POLARx™ and AFAP groups, respectively. Despite equal TTI, the POLARx™ had a lower minimal temperature reached (-57ºC vs -47ºC, p<0.001). Conclusion: The novel POLARx™ cryoballoon had similar efficacy and safety compared to the AFAP. It was also associated with longer procedural times, similar TTI, and lower minimum temperature reached.
Subclavian venous obstruction is a common complication after cardiac device placement. Patients typically remain asymptomatic but at times may present with acute symptoms due to thrombus formation immediately after device placement or years later, due to chronic obstruction, with pain and swelling. Various techniques have been attempted to resolve symptoms in patients with chronic lead-related subclavian obstruction but are associated with a high recurrence of restenosis. Drug coated balloons (DCB) have been used subsequently after pre-dilation with high-pressure balloons, of the stenosed region, in patients with arteriovenous fistula obstruction, and have shown promising results. We discuss the utilization of DCB in our patient with chronic subclavian obstruction due to a permanent pacemaker lead.
The sinoatrial node in medication-resistant inappropriate sinus tachycardia: to modify or to ablate?Khalil El Gharib1*1Hôtel-Dieu de France, Beirut, Lebanon*Author for correspondence: email@example.comKEYWORDS: IST, sinus node modification, sinus node ablation, radiofrequency ablation, surgical ablationNo conflict of interest to discloseFunding: noneInappropriate sinus tachycardia (IST) is defined as a resting heart rate >100 beats per minute (with a mean heart rate >90 beats per minute over 24 hours) associated with highly symptomatic palpitations(1). The syndrome is associated neither with structural heart disease nor with any secondary cause of sinus tachycardia(2) and evidence suggests that enhanced intrinsic automaticity of the sinoatrial node, which can be due to anti-β-adrenergic antibodies, is behind its genesis(3). However, it is benign in terms of clinical outcomes and echocardiographic evidence of ventricular dysfunction(4), being rarely associated with tachycardia-induced cardiomyopathy(3).Patients with IST are essentially treated with ß-blockers to alleviate their symptoms(5). Ivabradine, a drug that inhibits funny calcium channels, particularly abundant in the SA node, showed modest benefit, receiving class IIa recommendation in the treatment of IST(4). But, the duration of medical therapy might be indefinite, and, a considerable number of patients would respond inadequately, or have no response, even after prolonged therapy(5). Historically, such patients would have subtotal right atrial excision, atrioventricular junctional ablation with permanent pacemaker implantation, or chemical occlusion of the sinus node artery(6). These options are considered today unacceptable in this setting, and other therapeutic approaches should be unveiled when resistance to medical treatment appears.Electrophysiological study was initially purely diagnostic, but recent advances in technology have allowed us to intervene(7); patients with ventricular and supraventricular tachyarrhythmias are successfully treated with percutaneous catheter procedures. Of these, SA node ablation/ modification has been proposed as alternative approaches in IST that is not responding to medical treatment; trials reported auspicious results, highlighted here.Electrophysiologic mapping to the site of the earliest endocardial activation during either spontaneous sinus tachycardia or isoproterenol-induced sinus tachycardia has rendered these procedures feasible(8). Additionally, combination with intracardiac echocardiography permitted a more accurate electrophysiologic and anatomic localization of the sinoatrial node(9).Sinus node modification is not a focal ablation, but requires complete abolition of the cranial portion of the SA node complex, the one that exhibits the most of the autonomic activity(9). It is defined as successful when the heart rate decreases by 30 beats per minute (bpm) during isoproterenol infusion(8). Short-term success was also defined by other investigators when there was a reduction of the baseline sinus rate to less than 90 bpm and the sinus rate during isoproterenol infusion by more than 20% or by 25%(8). The acute success rate for modification has been varying between 76 and 100 % across trials, while long-term clinical outcomes are modest at best, with reported freedom from IST ranging from 23 to 85%(10).Complications specific to SA node modification include superior vena cava (SVC) syndrome, diaphragmatic paralysis, and sinus node dysfunction(10). And while modification with conventional methods has its setbacks, modification using laser energy can be considered in the setting of IST. This modality creates clear-cut homogenous transmural lesions of the myocardium that comprises the scattered “functional” SA node(11). The burnt myocardium will then heal into a dense fibrous scar, decreasing potential amplitudes. And when adapting laser energy settings to the thickness of the myocardial wall, collateral damages such as esophageal fistulae, lung burns, and phrenic nerve palsy will be avoided(11); thus, this technique may prove itself as a new intriguing alternative for the safe and effective treatment of IST.SA node modification is apt in achieving acute reductions in postprocedural heart rate. However, and as aforementioned, success rates are suboptimal in terms of symptomatic control with a significant recurrence rate(12). Catheter ablation aiming at either total exclusion and obliteration of the SA node has been described and performed, success being defined as a slowing of >50% from the baseline rate of tachycardia along with a junctional escape rhythm(12). With radiofrequency (RF) applications, the earliest local atrial activation time would shift from a cranial location to a more caudal one, usually at the mid-lateral right atrium(5). Reviews have reported that acute success rates were consistently to be as high as 88.9%, with an overall frequency of recurrence of 19.6%, the latter occurring within a wide range of post-ablation intervals, anywhere from a few weeks to several months after the procedure(12). Additionally, Takemoto and colleagues documented a significant drop in B-type natriuretic peptide levels, 6 to 12 months after ablation, suggesting fewer stretching shears on cardiac muscle.Two types of response of the sinus tachycardia to RFA were observed across studies, whether a step-wise reduction in sinus rate accompanying migration of the site of earliest atrial activation in a cranial-caudal direction along the lateral right atrial wall, or an abrupt drop in heart rate in response to RFA at a focal site of earliest atrial activation(13).However, RFA of inappropriate sinus tachycardia requires a large number of applications of radiofrequency energy and is, as in SA node modification, associated with a high recurrence rate(13). Complete remission is achieved only in approximately 50% of patients in some studies(14); longer history of IST and those reporting near syncope/syncope having a higher probability of recurrence(15).While other studies have shown that RF ablation of the SA node can achieve even longer-term reductions in the sinus rate and relief of symptoms in two-thirds of patients with drug-refractory, inappropriate sinus tachycardia(13), aiming specific sites related to the SA node should be elaborated, for better and optimal outcomes Killu and colleagues created a lesion in the arcuate ridge resulting in complete abolition of the tachycardia, since arrhythmias arising in this region may exhibit both electrocardiographic and clinical similarities to IST(16). This has led to consider ablation of the arcuate ridge as a treatment of refractory IST, necessitating larger trials to confirm its potential role.Phrenic nerve injury is a severe and dreaded complication of SN ablation(12). Pericarditis, right diaphragmatic paralysis, and SVC syndrome are other undesirable side effects of the procedures, variously reported in studies. but a common complication was observed in them all, atrial tachyarrhythmias(12). It has been hypothesized that myocardial pathology, such as inflammation and fibrosis, considered iatrogenic due to the ablation procedures, may be promoting arrhythmias both in the region of the SA node, as well as in remote locations(12). Through multivariable analysis, higher resting heart rates post-ablation and smaller cranial-to-caudal shifts have been defined as predictors of atrial arrhythmias(15). In conclusion, catheter ablation could be considered an effective treatment for highly symptomatic, drug-refractory patients, even for those who did not respond to SA node modification(5).The sinus node is located close to the epicardial surface and catheter-based ablations do not always make full-thickness lesions across the atrial muscle, leading to failure of the ablation(17), besides the numerous trabeculae and the widely variable anatomy.Surgical ablation is not a first-line or routine management strategy for IST, but it has been proposed when IST resists or recurs after SN modification/ endocardial ablation(17). Effectively, in several studies, epicardial lesions, through a single small incision in one of the intercostal spaces, successfully slowed heart rate and shifted activation to a more caudal location, and surprisingly, subsequent endocardial lesions led to an even greater drop in heart rate and more caudal site of earliest activation(18). These outcomes were again replicated when using minimally invasive thoracoscopic ablation of the epicardial site of the SA node, concluding of the promising efficacy and the safety of this approach, since it preserves the phrenic nerve(17), although continued follow-up after surgery is required.Medication-resistant IST remains a medical challenge for physicians and cardiologists; and in the era of great advances in interventional cardiology, its treatment remains debatable. Sinus node modification/ ablation is not recommended as first-line therapy in IST, this procedure should be considered only in drug-refractory patients who have severe symptoms(13). Although the number of patients in the available studies is generally small, both procedures have documented an encouraging success rate in the short-term, while being less impressive in the long-term. It has been hypothesized that this discrepancy is due to the relatively large potential area of atrial pacemaker cells(18); modification or ablation may fail to ablate or isolate all the pathways that comprise the functional SA node because they often target the anatomic part and the area of earliest atrial activation(19). Others have explained that the long-term slowing in rhythm fails because these procedures inconsistently produce transmural lesions in the right atrium. Surgical treatment of IST has proposed a solution to the latter conflict when isolating the SA node with a wide cuff of surrounding atrial muscle(19). And with the advent of bipolar RF clamps and minimally invasive cardiac surgical techniques with thoracoscopic guidance, this approach appears more appealing than before, especially when combined with endocardial ablation(19). But again, current data specifies employing these techniques in highly selected cases.
Xiaodong Zhang1, MD, PhD, Ruike Yang1 2, MD, Luigi Di Biase1, MD, PhD, FHRS1 Division of Cardiology, Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York2 Division of Cardiology, Department of Medicine, Henan Provincial People’s Hospital, Zhengzhou, ChinaCorrespondence : Dr Luigi Di Biase, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467. E-mail address: firstname.lastname@example.org .Keywords : narrow complex tachycardia, dual atrioventricular nodal non-re-entrant tachycardia, dual atrioventricular nodal re-entrant tachycardia, autonomic nervous system
Background: Computer simulation model demonstrated that atrial fibrillation (AF) driver attached to the patchy fibrosis assessed by late gadolinium enhancement magnetic resonance imaging (LGE-MRI). However, it has not been well elucidated in patients with persistent AF. The aim of this study is to investigate whether radiofrequency (RF) application on the patchy LGE site (PLS) could terminate AF or convert to atrial tachycardia (AT) and improve the rhythm outcome. Methods: A total of 31consecutive persistent AF patients with PLS were enrolled (PLS ablation group, mean age: 69 ± 8 years, mean left atrial diameter: 42 ± 6 mm). AF direct termination or AT conversion during RF application on the PLS were defined as favorable response. The rhythm outcome was compared between the PLS ablation group and the propensity matched conventional ablation group. Results: Favorable response was found in 15 (48%) of 31 patients (AF termination in 7, AT conversion in 8 patients). AF recurrence at 12 months follow-up was significantly less in the PLS group as compared to the control group (4 (13%) of 31 patients vs. 11 (35%) of 31 patients, log-rank p = 0.019). In patients with favorable response, AT recurred in 1 (7%) of 15 patients but AF. Conclusions: The PLS ablation could terminate AF or convert to AT in half of the patients and improve the rhythm outcome as compared to the conventional ablation. No AF recurrence was documented in patients with a favorable response.
Underrecognized consequence of three-dimensional mapping tool selection for atrial fibrillation ablation: when the operators’ decision determines the amount of silent micro-embolic burden Thomas Rostock MD, Torsten Konrad MD, Raphael Spittler MDFrom the University Hospital Mainz, Center for Cardiology,Cardiology II / Electrophysiology, Mainz, GermanyWord count: 1460Funding: (None)Disclosures: (None)
EDITORIAL: Modern Atrial Fibrillation Care: Becoming a Pro at Using PROsSamuel F. Sears, PhD,1,2 Scarlett Anthony, BA,1 & Aditi Naniwadekar, MD21 Department of Psychology, East Carolina University, Greenville, NC2 Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC