AimsTo collect information on the use of the Reveal implantable loop recorder (ILR) in the patient care pathway and to investigate its effectiveness in the diagnosis of unexplained recurrent syncope in everyday clinical practice.Methods and resultsProspective, multicentre, observational study conducted in 2006–2009 in 10 European countries and Israel. Eligible patients had recurrent unexplained syncope or pre-syncope. Subjects received a Reveal Plus, DX or XT. Follow up was until the first recurrence of a syncopal event leading to a diagnosis or for ≥1 year. In the course of the study, patients were evaluated by an average of three different specialists for management of their syncope and underwent a median of 13 tests (range 9–20). Significant physical trauma had been experienced in association with a syncopal episode by 36% of patients. Average follow-up time after ILR implant was 10 ± 6 months. Follow-up visit data were available for 570 subjects. The percentages of patients with recurrence of syncope were 19, 26, and 36% after 3, 6, and 12 months, respectively. Of 218 events within the study, ILR-guided diagnosis was obtained in 170 cases (78%), of which 128 (75%) were cardiac.ConclusionA large number of diagnostic tests were undertaken in patients with unexplained syncope without providing conclusive data. In contrast, the ILR revealed or contributed to establishing the mechanism of syncope in the vast majority of patients. The findings support the recommendation in current guidelines that an ILR should be implanted early rather than late in the evaluation of unexplained syncope.

Eighty-six patients were treated with an implantable cardioverter defibrillator (ICD) because of sustained ventricular tachycardia (VT) or ventricular fibrillation (VF). In 27 patients an epicardial system was used, in 59 patients a transvenous system with a subcutaneous patch electrode was implanted. During a mean follow-up time of 17 +/- 9 months, inappropriate activations of the ICD due to supraventricular tachycardia were documented by Holter monitoring in 14 patients (16%). In 8 patients paroxysmal atrial fibrillation (AF), in 2 patients chronic AF, in 1 patient atrial flutter, and in 3 patients sinus tachycardia triggered antitachycardia pacing functions (12 patients) or internal defibrillation (2 patients). In 3 patients (5%) VT was induced by inappropriate antitachycardia pacing. In an additional 18 patients (21%) inappropriate activation of antitachycardia functions due to atrial tachyarrhythmias were suspected based on telemetry readouts or the patient's history. Inappropriate activation of ICD therapy triggered by intermittent supraventricular tachyarrhythmias is common. Further improvements of detection algorithms for supraventricular tachycardia are required in future device generations.

The absence of strategies to consistently and effectively address nonparoxysmal atrial fibrillation by nonpharmacological interventions has represented a long-standing treatment gap. A combined epicardial/endocardial ablation strategy, the hybrid Convergent procedure, was developed in response to this clinical need. A subxiphoid incision is used to access the pericardial space facilitating an epicardial ablation directed at isolation of the posterior wall of the left atrium. This is followed by an endocardial ablation to Funding sources: The authors have no funding sources to disclose. Disclosures: Dr Makati serves as a consultant, advisor, and proctor for AtriCure, Boston Scientific, and Medtronic and has received research grants from AtriCure, Boston Scientific, and Medtronic. He serves on speakers bureau for Abbott. Dr Sood serves as a consultant for AtriCure. Dr Lee serves as a consultant for AtriCure. Dr Yang serves as a consultant for AtriCure. Dr Shults serves as a consultant for AtriCure and Medtronic and as a proctor for AtriCure. Dr DeLurgio serves as a consultant for AtriCure, Boston Scientific, and Medtronic and on speakers bureau for AtriCure and Boston Scientific. Dr Gill has received research funding from Abbott and lecture honoraria from AtriCure. Dr Kaba serves as a consultant for AtriCure and Biotronik and on speakers bureau for Daiichi Sankyo and Bayer. Dr Ahsan serves on speakers bureau for AtriCure, Biosense Webster, and Boston Scientific. Dr Lellouche serves as a consultant for Medtronic, Abbott, Boston Scientific, and AtriCure. Dr Blaauw has received department research funding from AtriCure and Medtronic and serves as a proctor for AtriCure, Medtronic, Boston Scientific, and Abbott. Dr Zannis serves as a proctor for AtriCure. Dr Sebag serves as a consultant for AtriCure. Dr Gauri serves as a consultant for Medtronic, IRhythm, and AtriCure. Dr Zembala serves as a proctor for AtriCure and as a consultant for Balton, Abbott, and Boston Scientific.

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Over the last 10 years the treatment of atrial fibrillation has changed dramatically. Catheter ablation of atrial fibrillation has emerged from experimental procedure to a very commonly performed procedure in patients with paroxysmal, persistent and long-standing persistent atrial fibrillation. There is considerable evidence available demonstrating that catheter ablation of atrial fibrillation is more effective than antiarrhythmic drug therapy in controlling atrial fibrillation and that ablation of atrial fibrillation improves quality of life.Although great progress has been made in improving the techniques and outcomes of catheter ablation of atrial fibrillation there are a number of important unanswered questions. 1. The optimal approach for ablation in patients with long-standing persistent atrial fibrillation need to be better defined. 2. Safety and efficacy of catheter ablation in common patients population need to be defined. 3. More information is needed on impact of atrial fibrillation ablation on mortality and stroke prevention.To improve the safety and efficacy of atrial fibrillation ablation the great interest is currently focused on the development of new ablation tools that allow creation of more permanent lesions and therefore diminish the problem of pulmonal venen reconduction and reduce the need for repeat ablation procedures. Another area of intense research focus on procedures that target and ablate ganglionated plexi. Substantial progress has also been made on developing the tools to allow remote/automatic/robotic ablation procedures and to allow electrophysiology studies and catheter ablation to be performed in magnetic resonance scanner. ConclusionThe techniques and tools of atrial fibrillation ablation continue to improve. This positive development makes a good perspective for the treatment of patients with atrial fibrillation.