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  • FiiO K15 is a versatile, feature-packed headphone amp and streaming DAC

    FiiO K15 is a versatile, feature-packed headphone amp and streaming DAC

    The FiiO K15 isn’t just a DAC and headphone amplifier. The new unit also acts as a preamplifier and a streamer, with a host of flexible connections and streaming methods available.

    Set for release on 1st August, this versatile model will cost $549 / £499 / €599 (Australian release and pricing information TBC).

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  • French air traffic controllers' strike disrupts flights for second day – Reuters

    1. French air traffic controllers’ strike disrupts flights for second day  Reuters
    2. Ryanair cancels flights for 30,000 passengers due to French strike  BBC
    3. Europe’s Airline Sector Grounded by Strikes: Why Investors Must Seek Diversification and Regulatory Solutions  AInvest
    4. Traffic jams and strikes: Travel in France on first summer holiday weekend  The Local France
    5. Ryanair calls for EU chief’s head, following French ATC chaos  Aviation Business News

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  • Prognostic Value of Spontaneous Potential in Long-Term Outcomes Follow

    Prognostic Value of Spontaneous Potential in Long-Term Outcomes Follow

    Introduction

    Pulmonary vein isolation (PVI) serves as the cornerstone of atrial fibrillation (AF) catheter ablation and remains one of the most widely used treatments for paroxysmal atrial fibrillation (PAF). Currently, PVI combined with linear ablation represents the primary surgical approach for non-paroxysmal atrial fibrillation (NPAF).1–4 In clinical practice, the long-term efficacy of standalone PVI for NPAF remains suboptimal. Advancements in cardiac electrophysiology suggest that AF development is associated with myocardial sleeves of the pulmonary veins, with the left atrial posterior wall also identified as a key abnormal site.5 Pulmonary vein isolation combined with left atrial posterior wall isolation (PVI+BOX) ablation involves linear ablation of the left atrial apex line and left atrial posterior wall line in addition to bilateral pulmonary vein isolation, thereby isolating both the pulmonary veins and the left atrial posterior wall from other atrial regions. However, data on BOX ablation remain limited, and existing conclusions are inconsistent.6–9

    Clinical findings indicate that spontaneous potential (SP) can be detected in the left atrial posterior wall of some patients with NPAF who have undergone PVI+BOX ablation. Previous studies indicated that most atrial premature beats (APBs) responsible for triggering AF originate from the pulmonary veins and induce AF through rapid discharges.4 During embryonic development, the left atrial posterior wall and pulmonary veins originate from the same site.10 However, whether the left atrial posterior wall SP is equivalent to spontaneous pulmonary vein potential and whether it can trigger AF remains unclear. Therefore, the relationship between left atrial posterior wall SP and long-term outcomes following PVI+BOX in patients with NPAF was investigated in this study.

    Data and Methods

    Objects

    The clinical data in this study were retrospectively collected from 140 patients with symptomatic NPAF who underwent radiofrequency ablation for the first time between 2022 and 2023. Based on the surgical approach, patients were categorized into the PVI group and the PVI+BOX group. The PVI+BOX group was further subdivided into the SP group and the no-SP group based on the presence of left atrial posterior wall SP following BOX. All patients provided informed consent before treatment, and the study received approval from the local ethics committee.

    NPAF that can be treated with catheter ablation includes persistent AF (PerAF) and long-standing persistent AF (LSPAF), as defined by the 2020 European Society of Cardiology (ESC) and European Association for Cardio-Thoracic Surgery (EACTS) guidelines for the management of AF.11 Before catheter ablation, all patients underwent transesophageal echocardiography (TEE) or left atrial computed tomography angiography (CTA) to exclude left atrial and/or left auricular thrombosis. Additionally, pulmonary vein CTA was performed to assess the anatomical structure of the pulmonary veins. All antiarrhythmic drugs were discontinued for at least five half-life periods before the procedure.

    Patients were excluded if they met any of the following criteria: (1) age younger than 18 years or older than 80 years; (2) diagnosis of valvular AF; (3) presence of hyperthyroidism; (4) history of cerebrovascular accidents or other neurological diseases within the past three months; (5) presence of other systemic diseases or tumors; (6) left atrial and/or left auricular thrombus; (7) AF of non-pulmonary vein origin; (8) prior cardiac surgery or heart disease requiring surgical intervention; (9) incomplete clinical data or failure to complete follow-up.

    The radiofrequency ablation procedure was performed with the patient in a supine position under local anesthesia with 1% lignocaine. Bilateral femoral vein punctures were made, and a 10-pole electrode was advanced into the coronary sinus via the left femoral vein, while the interatrial septum was punctured via the right femoral vein. Two 8.5F Swartz sheaths were inserted into the left atrium for the administration of 100 μg/kg heparin. A ring electrode (Biosense-Webster, USA) and a saline-irrigated electrode catheter (Biosense-Webster, USA) were introduced into the left at rium via the Swartz sheath for modeling (CARTO 3D electroanatomic mapping system), mapping, and ablation. In the PVI group, linear ablation was performed around the circumferential bilateral pulmonary vein antrum to achieve PVI. In the PVI+BOX group, linear ablation targeted the circumferential bilateral PVI, left atrial apex line, and left atrial posterior wall line to achieve posterior wall isolation. Pulmonary vein isolation was confirmed by the absence of pulmonary vein potential or the presence of SP within the pulmonary vein, with pulmonary vein pacing unable to conduct to the left atrium. Left atrial posterior wall isolation was confirmed by the absence of atrial potential (Figure 1A) or the presence of SP (Figure 1B) in the left atrial posterior wall, with left atrial posterior wall pacing unable to conduct to other atrial sites. If AF persisted following PVI or BOX ablation, synchronized electrical cardioversion (100–150 J) was administered. Ablation parameters included power (35–45 W), saline flow rate (20–30 mL/min), and impedance (140–170 Ω).

    Figure 1 (A) Absence of spontaneous potential in the left atrial posterior wall following PVI + BOX. (B) Presence of spontaneous potential in the left atrial posterior wall following PVI + BOX.

    Follow-Up

    The clinical condition of all patients was continuously monitored through 24-hour electrocardiography (ECG), blood pressure measurement, and oxygen saturation assessment after the procedure. On the first postoperative day, patients were initiated to either warfarin or a novel oral anticoagulant based on personal preference, and were informed to use it mandatorily for at least three months. Anticoagulation therapy was then continued according to the CHA2DS2-VASc score (≥ 2 for males, ≥ 3 for females). Anti-arrhythmic medications, such as amiodarone or propafenone, with or without metoprolol, were routinely administered postoperatively and discontinued after three months. Regular follow-up was conducted through clinic visits or monthly telephone consultations to evaluate AF recurrence, assessed through symptoms including palpitations, chest discomfort, shortness of breath, and fatigue. Patients underwent routine ECG examinations at local healthcare facilities, and in cases of the aforementioned symptoms, either a standard 12-lead ECG or dynamic ECG monitoring was performed. At three and twelve months postoperatively, cardiac ultrasound and 72-hour ECG monitoring were conducted at the clinic to detect AF recurrence. Follow-up data, including recurrence occurrences within three months postoperatively, were systematically documented.

    The study’s primary endpoint was the late recurrence of AF, defined as atrial tachyarrhythmia—including AF, atrial flutter, or atrial tachycardia—lasting more than 30 seconds on either a standard or dynamic ECG after all anti-arrhythmic medications were discontinued three months postoperatively.

    Statistical Analysis

    Categorical data were presented as frequency (percentage) and analyzed using the chi-square test. The Kolmogorov–Smirnov test was used to assess the normality of baseline characteristics. An independent sample t-test was conducted to compare data between the two groups, while non-normally distributed variables were expressed as median (25th–75th percentile) and analyzed using the Mann–Whitney U-test. The recurrence rate between the two groups was assessed using Kaplan-Meier survival analysis. Logistic regression was used to evaluate correlations between variables. A two-sided P < 0.05 was considered statistically significant. All statistical analyses were performed using SPSS 26.0 software.

    Results

    Basic Clinical Data

    Among the 140 patients, 78 received PVI+BOX treatment, while 62 underwent PVI only. No significant differences were observed in the clinical characteristics between these groups (Table 1). Of the 78 patients treated with PVI+BOX, 33 exhibited SP in the left atrial posterior wall, whereas 45 did not. Similarly, no significant differences were noted in the clinical characteristics between these subgroups (Table 2).

    Table 1 Baseline Characteristics of the PVI Group and PVI+BOX Group

    Table 2 Baseline Characteristics of the SP Group and No-SP Group

    Long-Term Effect

    Patients were monitored for 12 months postoperatively. In the PVI+BOX group, 24 patients (30.8%) experienced late recurrence, compared to 26 patients (41.9%) in the PVI group, with no statistically significant difference (p = 0.145; Figure 2A). In contrast, late recurrence occurred in 6 patients (18.2%) in the SP group and 18 patients (40%) in the no-SP group, showing a significant difference (p = 0.041; Figure 2B). Further analysis among the SP group, no-SP group, and PVI group indicated that the late recurrence rate was lower in the SP group than in the PVI group (p = 0.020), while no significant difference was found between the no-SP and PVI groups (p = 0.780; Figure 2B). Table 3 presents the late recurrence rates.

    Table 3 Late Recurrence Rate

    Figure 2 (A) Late recurrence-free survival curves comparing the PVI + BOX group and the PVI group. (B) Late recurrence-free survival curves comparing the SP group, no-SP group, and PVI group.

    Complications

    In the PVI+BOX group (n = 78), postoperative complications included pneumonia in 4 patients and pericardial effusion in 2 patients. In the PVI group (n = 62), 2 patients developed pneumonia, and 1 patient experienced pericardial effusion. No statistically significant difference in complication rates was observed between the groups (p > 0.05). All affected patients recovered before discharge. Table 4 presents the details on patient complications.

    Table 4 Complication Rate

    Analysis of Risk Factors for Postoperative Recurrence

    Patients who underwent PVI+BOX treatment were categorized based on late AF recurrence. Univariate analysis results are presented in Table 5. The analysis identified AF duration (p = 0.013), total cholesterol (TC) (p = 0.038), white blood cell count (WBC) (p = 0.032), and SP (p = 0.039) as risk factors for post-ablation late recurrence of NPAF (p < 0.05).

    Table 5 Single-Factor Analysis of Postoperative Recurrence

    No statistically significant differences were observed between the two groups in gender, age, body mass index (BMI), echocardiographic parameters, including left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), left atrial diameter (LAD), and ejection fraction (EF), as well as comorbidities and other factors.

    Multivariate logistic regression analysis (Table 6) identified the course of AF (odds ratio (OR): 1.026, 95% CI: 1.007–1.046, p =0.006) and SP (OR: 0.219, 95% CI: 0.057–0.835, p =0.026) as independent predictors of late AF recurrence.

    Table 6 Risk Factor Analysis for Late Recurrence

    Discussion

    Application of PVI+BOX in AF Ablation

    Since the identification of anomalous pulmonary venous activities as the primary trigger of AF, PVI has become the cornerstone of AF ablation. Over nearly two decades, it has been established as the standard procedure for AF catheter ablation, achieving a long-term success rate of 50% to 70% for paroxysmal AF. However, its effectiveness in NPAF remains limited, necessitating the incorporation of various linear ablation and substrate modification strategies. In recent years, growing recognition of the left atrial posterior wall’s role in AF occurrence and maintenance has led researchers to explore left atrial posterior wall isolation, with BOX being a commonly used approach. Nevertheless, available data on BOX ablation remain scarce, and study conclusions are inconsistent. Yamaji et al reported that left atrial posterior wall isolation could reduce postoperative recurrence in patients with NPAF.6,7 In contrast, Tamborero et al found no statistically significant difference between pulmonary vein isolation alone and its combination with left atrial posterior wall isolation in preventing arrhythmia recurrence.8,9

    While recent studies, such as Yan et al, have compared radiofrequency ablation (RFA) guided by ablation index (RFCA-AI) and second-generation cryoballoon ablation (CBA-2) in AF treatment, the role of spontaneous potential (SP) in the left atrial posterior wall following PVI+BOX ablation remains unexplored.12 Our study addresses this gap by evaluating SP as a novel predictor of long-term success after PVI+BOX, providing new insights into AF ablation strategies for NPAF patients.

    Analysis of Risk Factors for Postoperative Recurrence

    Several factors contribute to atrial substrate changes in patients with AF; however, the specific underlying mechanism remains unclear. Structural, electrical, and neural remodeling of the atrium are known to influence this process. Research has indicated a correlation between AF duration and post-ablation recurrence, with prolonged AF duration associated with a higher recurrence rate. The likely explanation is that an extended AF course increases the likelihood of atrial electrical and anatomical remodeling, making these changes irreversible and thereby significantly elevating the recurrence rate. In this study, univariate analysis of AF duration revealed that patients in the recurrence group had a significantly longer AF duration (30.5 [12–90] months) compared to the non-recurrence group (13 [7–36] months). Furthermore, multivariate analysis identified AF duration as an independent risk factor for post-ablation AF recurrence.

    Distribution and Generation Mechanism of SP

    Pulmonary veins exhibit distinct electrophysiological properties that contribute to the initiation and maintenance of AF. Pulmonary vein SP refers to spontaneous electrical activity generated by the pulmonary vein independent of the left atrium following PVI, with bidirectional PVI serving as a recognized endpoint of pulmonary vein ablation.13,14 Pulmonary vein SP commonly manifests in three forms: sporadic isolated ectopic beats, slow and regular ectopic rhythms, and rapid fibrillation potential activity.13,15 The primary mechanisms underlying pulmonary vein SP include (1) the focal mechanism, in which Jiang et al identified autorhythmic electrical activity as its principal cause.16 Studies have indicated the presence of P cells, transitional cells, and Purkinje cells within the myocardial sleeves of pulmonary veins, suggesting that pulmonary vein SP may result from electrical activity produced by autorhythmic cells.17 (2) The reentrant mechanism, characterized by pronounced spatial heterogeneity in atrial action potential duration and a shortened plateau phase, elevates the risk of reentrant arrhythmias. (3) The AF trigger mechanism, as described by Yves et al, suggests that an AF-triggered pulmonary vein predicts AF recurrence following pulmonary vein isolation.18 In such cases, pulmonary vein conduction is restored, leading to the occurrence of pulmonary vein SP, which has been frequently observed in AF-triggered pulmonary veins after circumferential PVI.19

    There are currently limited studies on left atrial posterior wall SP. The left atrial posterior wall shares an embryological origin with the pulmonary vein, and its distinct histology and anatomical structures make it a crucial substrate for sustaining AF. It serves as a trigger for AF, with its electrophysiological properties contributing to AF maintenance. Prolonged AF episodes induce both electrophysiological and structural alterations, further facilitating AF persistence.20 Embryologically, the smooth posterior wall is anatomically adjacent to the surrounding muscle trabecular tissue derived from the primitive left atrium. Due to this embryological origin, its electrophysiological characteristics more closely resemble the myocardial sleeves of pulmonary veins rather than the adjacent superior and inferior tissues.20

    Electrophysiologically, pulmonary veins and cardiomyocytes in the posterior wall exhibit distinct electrophysiological and ion channel properties, which may contribute to arrhythmogenesis.21 Anatomically, the cardiac muscle fibers of the left atrial posterior wall, particularly near the pulmonary vein junction, are oriented in varying directions. Consequently, conduction velocity and depolarization between adjacent tissues differ, and the transition between the epicardial and endocardial layers may exhibit heterogeneous anisotropy, potentially resulting in conduction delays, unidirectional blocks, and localized reentry.22 These features of the posterior wall of the left atrium may cause SP in the left atrial posterior wall to trigger reentrant mechanism or focal mechanism similar to pulmonary vein potentials. These unique characteristics of the left atrial posterior wall may contribute to AF initiation and maintenance.

    Analysis of Risk Factors for Postoperative Recurrence

    In this study, pulmonary vein isolation combined with posterior wall isolation did not show a significant difference in reducing NPAF compared to pulmonary vein isolation alone. Among patients with NPAF who underwent pulmonary vein isolation with posterior wall isolation, the recurrence rate was lower in the left atrial posterior wall SP group than in the left atrial posterior wall no-SP group. Additionally, the recurrence rate in the SP group was lower than in the simple PVI group, whereas no significant difference was observed between the no-SP group and the PVI group. This finding suggests that left atrial posterior wall SP may indicate the presence of a trigger focus outside the pulmonary vein, leading to posterior wall isolation and subsequently reducing AF recurrence. Patients without SP of the posterior left atrial wall may have other unknown lesions or triggering mechanisms, and posterior wall isolation has a relatively unsatisfactory therapeutic effect on them.

    Unlike Yan et al, which primarily focused on comparing different ablation techniques, our study introduces SP as a novel factor influencing AF recurrence after PVI+BOX ablation.12 By identifying SP as a potential predictor of improved ablation success, this study provides new mechanistic insights into the role of left atrial substrate properties in AF recurrence.

    White blood cells and neutrophils, as important indicators of the inflammatory system, their counts also reflect the degree of the inflammatory response. Previous studies have shown that patients with postoperative atrial fibrillation have significantly elevated peripheral blood white blood cells, and patients with significantly elevated white blood cells also have a longer duration of atrial fibrillation attacks. The increase of white blood cell count and neutrophil count, which are important indicators of the inflammatory system, is a risk factor for the maintenance of atrial fibrillation.

    Limitations

    In this study, SP has a certain degree of variability, the length of the recording time may affect the incidence of spontaneous potential. It is a single-center, small-sample, retrospective study, and postoperative AF recurrence was not recorded for some patients, potentially leading to discrepancies between the observed and actual long-term recurrence rates. Further multi-center studies are required to investigate the optimal degree of PVI+BOX.

    Conclusion

    SP following left atrial posterior wall isolation suggests a better long-term outcome for NPAF after PVI with BOX catheter ablation. The long-term outcome of non-paroxysmal atrial fibrillation refers to the free recurrence rate after 3 months of ablation.

    Abbreviations

    AF, Atrial Fibrillation; BMI, Body Mass Index; CAD, Coronary Artery Disease; CTA, Computerized Tomography Angiography; HCM, Hypertrophic Cardiomyopathy; HDL-C, High density lipoprotein cholesterol; LAD, Left Atrial Diameter; LDL-C, Low density lipoprotein cholesterol; LSPAF, Long-standing Persistent Atrial Fibrillation; LVEDD, Left Ventricular End-diastolic Diameter; LVEF, Left Ventricular Ejection Fraction; LVESD, Left Ventricular End-systolic Diameter; NE, Number of central granulocytes; NT-proBNP, N-terminal pro-B-type Natriuretic Peptide; PAF, Paroxysmal Atrial Fibrillation; PerAF, Persistent Atrial Fibrillation; PVI, Pulmonary Vein Isolation; Scr, Serum Creatinine; SP, Spontaneous potential; TC, Total cholesterol; TG, Triglyceride; WBC, White blood cell count.

    Data Sharing Statement

    All data generated or analyzed during this study are included in this article. Further enquiries can be directed to the corresponding author.

    Ethics Approval and Consent to Participate

    This study was conducted with approval from the Ethics Committee of Fujian Medical University Union Hospital (Approval Number: 2024KY085). This study was conducted in accordance with the declaration of Helsinki. Written informed consent was obtained from all participants.

    Funding

    This work was supported by the Fujian Provincial Health Technology Project (2021CXB003) and Fujian Provincial Natural Science Foundation of China (2023J01663).

    Disclosure

    The authors declare that they have no conflicts of interest in this work.

    References

    1. Kuck KH, Hoffmann BA, Ernst S; Gap-AF–AFNET 1 Investigators*, et al. Impact of complete versus incomplete circumferential lines around the pulmonary veins during catheter ablation of paroxysmal atrial fibrillation: results from the gap-atrial fibrillation-German atrial fibrillation competence network 1 trial. Circ Arrhythm Electrophysiol. 2016;9(1):e003337. doi:10.1161/CIRCEP.115.003337

    2. McLellan AJ, Ling LH, Azzopardi S, et al. A minimal or maximal ablation strategy to achieve pulmonary vein isolation for paroxysmal atrial fibrillation: a prospective multi-centre randomized controlled trial (the Minimax study). Eur Heart J. 2015;36(28):1812–1821. doi:10.1093/eurheartj/ehv139

    3. Nakagawa H, Scherlag BJ, Patterson E, Ikeda A, Lockwood D, Jackman WM. Pathophysiologic basis of autonomic ganglionated plexus ablation in patients with atrial fibrillation. Heart Rhythm. 2009;6(12 Suppl):S26–34. doi:10.1016/j.hrthm.2009.07.029

    4. Haïssaguerre M, Jaïs P, Shah DC, et al. Spontaneous initiation of atrial fibrillation by ectopic beats originating in the pulmonary veins. N Engl J Med. 1998;339(10):659–666. doi:10.1056/NEJM199809033391003

    5. Oral H, Scharf C, Chugh A, et al. Catheter ablation for paroxysmal atrial fibrillation: segmental pulmonary vein ostial ablation versus left atrial ablation. Circulation. 2003;108(19):2355–2360. doi:10.1161/01.CIR.0000095796.45180.88

    6. Yamaji H, Higashiya S, Murakami T, et al. Efficacy of an adjunctive electrophysiological test-guided left atrial posterior wall isolation in persistent atrial fibrillation without a left atrial low-voltage area. Circ Arrhythm Electrophysiol. 2020;13(8):e008191. doi:10.1161/CIRCEP.119.008191

    7. McLellan AJA, Prabhu S, Voskoboinik A, et al. Isolation of the posterior left atrium for patients with persistent atrial fibrillation: routine adenosine challenge for dormant posterior left atrial conduction improves long-term outcome. Europace. 2017;19(12):1958–1966. doi:10.1093/europace/euw231

    8. Conti S, Sabatino F, Fortunato F, Ferrara G, Cascino A, Sgarito G. High-power short-duration lesion index-guided posterior wall isolation beyond pulmonary vein isolation for persistent atrial fibrillation. J Clin Med. 2023;12(16):5228. doi:10.3390/jcm12165228

    9. Tamborero D, Mont L, Berruezo A, et al. Left atrial posterior wall isolation does not improve the outcome of circumferential pulmonary vein ablation for atrial fibrillation: a prospective randomized study. Circ Arrhythm Electrophysiol. 2009;2(1):35–40. doi:10.1161/CIRCEP.108.797944

    10. Buijtendijk M, Barnett P, van den Hoff M. Development of the human heart. Am J Med Genet C. 2020;184(1):7–22. doi:10.1002/ajmg.c.31778

    11. Hindricks G, Potpara T, Dagres N; ESC Scientific Document Group, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): the task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) Developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC. Eur Heart J. 2021;42(5):373–498. doi:10.1093/eurheartj/ehaa612

    12. Yan QD, Gong KZ, Chen XH, et al. Comparison of second-generation cryoballoon ablation and quantitative radiofrequency ablation guided by ablation index for atrial fibrillation. Angiology. 2024;75(5):462–471. doi:10.1177/00033197231159254

    13. Weerasooriya R, Jaïs P, Scavée C, et al. Dissociated pulmonary vein arrhythmia: incidence and characteristics. J Cardiovasc Electrophysiol. 2003;14(11):1173–1179. doi:10.1046/j.1540-8167.2003.02583.x

    14. Mukai Y, Kawai S, Inoue S, et al. Bigeminal potentials in the pulmonary vein indicate arrhythmogenic trigger of atrial fibrillation. J Arrhythm. 2021;37(2):331–337. doi:10.1002/joa3.12462

    15. Kabra R, Heist EK, Barrett CD, et al. Incidence and electrophysiologic properties of dissociated pulmonary vein activity following pulmonary vein isolation during catheter ablation of atrial fibrillation. J Cardiovasc Electrophysiol. 2010;21(12):1338–1343. doi:10.1111/j.1540-8167.2010.01832.x

    16. Jiang CY, Fu JW, Matsuo S, et al. Dissociated pulmonary vein rhythm may predict the acute pulmonary vein reconnection post-isolation in patients with paroxysmal atrial fibrillation. Europace. 2011;13(7):949–954. doi:10.1093/europace/eur093

    17. Perez-Lugones A, McMahon JT, Ratliff NB, et al. Evidence of specialized conduction cells in human pulmonary veins of patients with atrial fibrillation. J Cardiovasc Electrophysiol. 2003;14(8):803–809. doi:10.1046/j.1540-8167.2003.03075.x

    18. De Greef Y, Tavernier R, Vandekerckhove Y, Duytschaever M. Triggering pulmonary veins: a paradoxical predictor for atrial fibrillation recurrence after PV isolation. J Cardiovasc Electrophysiol. 2010;21(4):381–388. doi:10.1111/j.1540-8167.2009.01646.x

    19. Miyazaki S, Kuwahara T, Kobori A, et al. Prevalence, electrophysiological properties, and clinical implications of dissociated pulmonary vein activity following pulmonary vein antrum isolation. Am J Cardiol. 2011;108(8):1147–1154. doi:10.1016/j.amjcard.2011.06.015

    20. Ioannidis P, Katsaras D, Zografos T, et al. Box lesion isolation of the left atrial posterior wall with radiofrequency ablation restricted in predetermined lines for the treatment of persistent atrial fibrillation: the prognostic role of acute interventional outcome and trigger identification. J Innov Card Rhythm Manag. 2023;14(11):5642–5653. doi:10.19102/icrm.2023.14115

    21. Pothineni NVK, Lin A, Frankel DS, et al. Impact of left atrial posterior wall isolation on arrhythmia outcomes in patients with atrial fibrillation undergoing repeat ablation. Heart Rhythm O2. 2021;2(5):489–497. doi:10.1016/j.hroo.2021.07.004

    22. Kaba RA, Momin A, Camm J. Persistent atrial fibrillation: the role of left atrial posterior wall isolation and ablation strategies. J Clin Med. 2021;10(14):3129. doi:10.3390/jcm10143129

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  • Russia pounds Kyiv with largest drone attack, hours after Trump-Putin call – World

    Russia pounds Kyiv with largest drone attack, hours after Trump-Putin call – World

    Russia pummelled Kyiv with the largest drone attack of the war, injuring at least 23 people and damaging buildings across the Ukrainian capital hours after US President Donald Trump spoke to Russia’s Vladimir Putin, officials said on Friday.

    Air raid sirens, the whine of kamikaze drones and booming detonations reverberated from early evening until dawn as Russia launched what Ukraine’s Air Force said was a total of 539 drones and 11 missiles.

    Families huddled in underground metro stations for shelter. Acrid smoke hung over the city centre. Outside a high-rise apartment block damaged by a drone, residents stood around surveying the scene as the clean-up job began. Some cried. Others looked on silently.

    “I woke up to the sound of explosions, first the Shahed drones started buzzing, and then the explosions began,” said 40-year-old resident Maria Hilchenko. “Then people started screaming outside. The explosions from the Shaheds kept coming.”

    Ukrainian President Volodymyr Zelensky called the attack “deliberately massive and cynical”.

    “Notably, the first air raid alerts in our cities and regions yesterday began to blare almost simultaneously with media reports discussing a phone call between President Trump and Putin,” Zelensky said on X.

    “Yet again, Russia is showing it has no intention of ending the war and terror,” he added, calling for increased pressure on Russia and more air defence equipment.

    Kyiv officials said the attack damaged about 40 apartment blocks, passenger railway infrastructure, five schools and kindergartens, cafes and many cars in six of Kyiv’s 10 districts. Poland said the consular section of its embassy was damaged in central Kyiv, adding that staff were unharmed.

    Mayor Vitali Klitschko said on Telegram that 14 of the injured were taken to the hospital.

    Ukraine’s state-owned railway Ukrzaliznytsia, the country’s largest carrier, said on Telegram that the attack on Kyiv forced them to divert a number of passenger trains, causing delays.

    Damage was recorded on both sides of the wide Dnipro River bisecting the capital, and falling drone debris set a medical facility on fire in the leafy Holosiivskyi district, Klitschko said.

    Russian airstrikes on Kyiv have intensified in recent weeks and included some of the deadliest assaults of the war on the city of 3 million people.

    Call for sanctions

    Trump said that the call with Putin on Thursday resulted in no progress at all on efforts to end the war, and the Kremlin reiterated that Moscow would keep pushing to solve the conflict’s “root causes”.

    Speaking to reporters on his return to Washington from a trip to Iowa, Trump said, “I’m very disappointed with the conversation I had today with President Putin, because I don’t think he’s there, and I’m very disappointed.

    “I’m just saying I don’t think he’s looking to stop, and that’s too bad.”

    The decision by Washington to halt some shipments of critical weapons to Ukraine prompted warnings by Kyiv that the move would weaken its ability to defend against intensifying airstrikes and battlefield advances.

    On Friday, Zelensky called for increased pressure on Moscow to change its “dumb, destructive behaviour”.

    “For every such strike against people and human life, they must feel appropriate sanctions and other blows to their economy, their revenues, and their infrastructure,” he said.

    Ukraine’s Air Force said it destroyed 478 of the air weapons Russia launched overnight. However, airstrikes were recorded in eight locations across Ukraine, with nine missiles and 63 drones, it added.

    Social media videos showed people running to seek shelter, firefighters fighting blazes in the dark and ruined buildings with windows and facades blown out.

    Both sides deny targeting civilians in the war that Russia launched with its full-scale invasion in February 2022. Thousands of civilians have been killed in the conflict, the vast majority of them Ukrainian. Many more soldiers are believed to have been killed on the front line, but neither side releases military casualty figures.

    Late on Thursday, Russian shelling killed five people in and near the eastern Ukrainian city of Pokrovsk, Ukraine said.

    Trump, Zelensky discuss weapons, escalating Russian strikes

    Zelensky said he discussed air defences in a conversation with Trump later on Friday, agreeing to work on increasing Kyiv’s capability to “defend the sky” as Russian attacks escalate.

    He added in a message on Telegram that he discussed joint defence production, as well as joint purchases and investments with the US leader.

    Ukraine has been asking Washington to sell it more Patriot missiles and systems that it sees as key to defending its cities from intensifying Russian air strikes.

    A decision by Washington to halt some shipments of weapons to Ukraine prompted warnings by Kyiv that the move would weaken its ability to defend against Russia’s airstrikes and battlefield advances. Germany said it is in talks on buying Patriot air defence systems to bridge the gap.

    One source briefed on the call told Reuters they were optimistic that supplies of Patriot missiles could resume after what they called a “very good” conversation between the presidents.

    US outlet Axios reported, citing unnamed sources, that the call lasted around 40 minutes, and that Trump told Zelensky he would check what US weapons due to be sent to Ukraine, if any, had been put on hold.

    Zelensky, speaking later in his nightly video address, said he and Trump had agreed to “arrange a meeting between our teams to strengthen air defences.

    “We had a very detailed discussion on joint production. We need it, America needs it.”

    Speaking to reporters as he left Washington for Iowa earlier on Friday, Trump said “we haven’t” completely paused the flow of weapons but blamed his predecessor, Joe Biden, for sending so many weapons that it risked weakening US defences.

    “We’re giving weapons, but we’ve given so many weapons. But we are giving weapons,” he said. “And we’re working with them and trying to help them, but we haven’t [completely stopped]. You know, Biden emptied out our whole country giving them weapons, and we have to make sure that we have enough for ourselves.”

    The pause in US weapons shipments caught Ukraine off guard and generated widespread confusion about Trump’s current views on the conflict, after saying last week he would try to free up a Patriot missile defence system for use by Kyiv.

    Ukrainian leaders called in the acting US envoy to Kyiv on Wednesday to underline the importance of military aid from Washington, and caution that the pause in its weapons shipments would weaken Ukraine’s ability to defend itself against Russia.

    The Pentagon’s move has meant a cut in deliveries of the Patriot defence missiles that Ukraine relies on to destroy fast-moving ballistic missiles, Reuters reported on Wednesday.

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  • At ECO Summit, PM Shehbaz calls for regional cooperation to confront global challenges – World

    At ECO Summit, PM Shehbaz calls for regional cooperation to confront global challenges – World

    Prime Minister Shehbaz Sharif on Friday urged stronger regional cooperation in the face of increasing geopolitical tensions, including the Iran-Israel conflict and Indian hostility towards Pakistan, stressing that the Economic Cooperation Organisation (ECO) offered the country its “best hope” for a unified response.

    Addressing the 17th ECO Summit in Azerbaijan’s Khankendi city, the prime minister said two recent events — the Iran-Israel war and the India-Pakistan conflict — showed that “the forces of instability and chaos continue to destabilise our region for geo-political agendas.

    “The evolving global landscape has made regional cooperation even more essential,” PM Shehbaz said while addressing the 10-nation Eurasian bloc. “ECO represents our best hope, and Pakistan is a proud partner in these collective efforts.”

    Speaking about the 12-day Iran-Israel war, he said that “the unlawful, uncalled for and unjustified Israeli attack on Iran was the most recent manifestation of this dangerous trend.”

    According to Iran’s health ministry, at least 627 people were killed and 4,870 wounded in Israeli strikes.

    “Pakistan condemns this act of Israeli aggression against Iran and offers our condolences to the martyrs,” he said.

    PM Shehbaz also condemned the recent Indian aggression against Pakistan and New Delhi’s attempts to weaponise water by holding the Indus Water Treaty in abeyance.

    “The unprovoked and reckless Indian hostility directed at Pakistan after an unfortunate incident in India’s illegally occupied Kashmir was yet another attempt to destabilise regional peace.

    “The world saw the steadfast determination of our armed forces under the leadership of Field Marshal Asim Munir and the unyielding spirit of our resilient people who stood firm in the face of provocation and responded with courage and professionalism.”

    India had launched missile attacks on several Pakistani cities after baselessly accusing Islamabad of backing an attack on held Kashmir’s Pahalgam town, which saw the killing of 26 tourists on April 22.

    In response, Pakistan downed five Indian jets and launched retaliatory strikes on India. It took US intervention on May 10 for both countries to reach a ceasefire.

    “We are witnessing a new and alarming trend with India’s weaponisation of water, illegal attempt to defy the World Bank-negotiated Indus Water Treaty and its blatant disregard for the recent ruling of the Permanent Court of Arbitration (PCA) are unacceptable and should be rejected with contempt.”

    Last week, the PCA in The Hague issued a “Supplemental Award of Competence” in the Indus Waters case, stating that India cannot unilaterally hold the treaty in abeyance. However, India “categorically rejected” the PCA’s supplemental award and stated that it did not recognise the court itself.

    PM Shehbaz said the Indus waters were the lifeline of Pakistan’s 240 million people and India couldn’t be allowed to “pursue this dangerous path that will be regarded as an act of aggression by the people of Pakistan”.

    The prime minister also voiced concerns over the situation in Gaza and the ongoing Israeli strikes there, which have killed more than 57,000 Palestinians since October 7, 2023.

    “The world is witnessing an unprecedented man-made catastrophe in Gaza, a region that has descended into an abyss of perpetual suffering,” the premier said.

    “It is as if humanity no longer exists as famine looms large, while humanitarian workers, including UN personnel, are being attacked with impunity by Israel to cut off the only lifeline of the helpless and starving people of Gaza.”

    He said Pakistan stood firmly against those who “perpetrate barbaric acts against innocent people, whether in Gaza, occupied Kashmir or Iran”.

    Regarding the effects of climate change, the prime minister said Pakistan had undertaken a series of climate-related policy initiatives focused on the government’s Resilience, Recovery, Rehabilitation and Reconstruction Framework (4RF).

    He proposed the development of low-emission corridors, ECO-wide carbon market platforms and a regional disaster resistance system.

    Earlier in the day, PM Shehbaz held a bilateral meeting with Azerbaijan President Ilham Aliyev on the sidelines of the ECO Summit.

    The two leaders expressed satisfaction over the progress made regarding investment prospects and agreed to enhance cooperation in the fields of trade and investment.

    They reiterated their resolve to strengthen the economic partnership, especially Azerbaijan’s investment in Pakistan, according to a statement by the PM’s Office.

    PM Shehbaz reaffirmed that the recent interactions between the leadership of both countries helped in making the relationship even stronger. He also invited President Aliyev to visit Pakistan.

    In a post on X, the prime minister said he congratulated President Aliyev on “successfully hosting the summit and lauded Azerbaijan’s proactive role in ECO”.

    He said they “reviewed the progress in Pakistan-Azerbaijan bilateral ties, which are growing stronger through our frequent and productive high-level exchanges”.

    “We reaffirmed our commitment to deepen cooperation across diverse sectors, particularly trade and investment,” he added.

    The prime minister also met Iran’s President Masoud Pezeshkian discussed regional developments following the recent Israel-Iran war, said a statement issued by the Press Information Department.

    “During the meeting, both leaders reviewed the ongoing bilateral cooperation across all areas and expressed satisfaction over the progress made on the decisions taken during their last meeting for further strengthening of Pakistan-Iran relations,” it added.

    PM Shehbaz appreciated Pezeshkian’s leadership and lauded Iran’s decision to reach a ceasefire during the recent conflict, according to the press release.

    The premier reaffirmed Pakistan’s “unwavering solidarity” with Iran’s government and people, as well as its strong commitment to continue working closely with Iran for “peace in the region through dialogue and diplomacy”.

    “President Pezeshkian appreciated Pakistan’s strong diplomatic support to Iran, including at the international forums, during the crisis and thanked him for Pakistan’s vital role in de-escalating the conflict,” according to the statement.

    The prime minister requested the Iranian president to convey his warm greetings and good wishes to Supreme Leader Ayatollah Ali Khamenei, it added.

    The premier also met Uzbek President Shavkat Mirziyoyev.

    “We agreed to deepen our robust partnership, on all areas of mutual interest especially in trade, connectivity, energy, culture and the landmark Trans-Afghan Railway Project.”

    Azerbaijan inks $2bn investment in Pakistan’s economic sector

    Later, Azerbaijan signed an agreement with Pakistan to invest $2 billion in its economic sector.

    Foreign Minister Ishaq Dar and Azerbaijan’s Minister of Economy Mikayil Jabbarov signed the agreement in the presence of PM Shehbaz and a Pakistani delegation.

    “Following a pleasant meeting today in Khankendi between the prime minister and the Azerbaijani president, the agreement was signed between the two countries, while the final and detailed agreement will be signed during the Azerbaijani president’s visit to Pakistan,” PTV reported.

    Though it did not provide details, PTV reported that the agreement “elevated the investment and trade relations between the two countries to a historic level”.

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  • ECP issues schedule for Senate elections in KP, Punjab

    ECP issues schedule for Senate elections in KP, Punjab



    Pakistan


    ECP announces new polling dates for Senate seats, including general, technocrat, women, Ulema



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    ISLAMABAD (Dunya News) – The Election Commission of Pakistan (ECP) on Friday officially announced the schedule for the long-delayed Senate elections in Khyber Pakhtunkhwa and Punjab.

    Polling for 11 Senate seats in Khyber Pakhtunkhwa will be held on July 21, while a separate election for the seat vacated by Senator Sania Nishtar is scheduled for July 31.

    The elections will cover a total of seven general seats, along with four reserved seats — including positions for women, technocrats, and Ulema.

    The seats had remained unfilled due to members’ failure to take the oath in the National Assembly, which caused a constitutional delay.

    More to read: Hammad Azhar, Rana Shehbaz declared proclaimed offenders

    Earlier, the Senate elections were postponed in April 2024, adding to political uncertainty in the provinces.

    With this announcement, the ECP aims to restore democratic continuity and representation in the upper house of Parliament, sources said. 

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  • Ahsan Iqbal urges AI push across key sectors in Pakistan

    Ahsan Iqbal urges AI push across key sectors in Pakistan

    Federal Planning and Development Minister Ahsan Iqbal on Thursday called for the integration of Artificial Intelligence (AI) into Pakistan’s national development strategy, announcing a new national AI fund and sector-specific action plans.

    Chairing a meeting of the National Task Force on AI, Ahsan Iqbal said AI adoption must be guided by cross-sectoral collaboration and alignment with the country’s strategic priorities.

    “AI adoption cannot be advanced in isolation and must instead be guided by cross-sectoral collaboration, in alignment with national priorities, and effective coordination across all relevant institutions,” according to a statement by the Press Information Department (PID).

    “It’s time for Pakistan to move forward with clarity and purpose.”

    The task force, formed in April 2023, is working to finalise a 10-year roadmap to accelerate AI use across multiple fields.

    Read: Top AI models show alarming traits, including deceit and threats

    Twelve key sectors have been identified—including education, health, agriculture, climate, business and governance—where AI can deliver measurable national gains. Each sector will form a multi-stakeholder working group with representatives from government, academia and industry to draft tailored AI roadmaps with clear objectives and timelines.

    The initiative also includes the establishment of a national AI fund aimed at supporting innovative ideas and pilot projects. Ahsan Iqbal called for a nationwide mapping of AI expertise and research infrastructure to guide resource allocation and policy design.

    Moreover, the task force has been instructed to organise a national AI workshop in collaboration with the Pakistan IT Industry Association (P@SHA) and other relevant bodies. The workshop will serve as a platform to develop practical AI solutions aligned with Pakistan’s developmental needs.

    The minister reaffirmed the government’s commitment to ensuring Pakistan is not left behind in the global race for technological leadership.


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  • Pavlyuchenkova battles past Osaka in three sets to make Wimbledon last 16

    Pavlyuchenkova battles past Osaka in three sets to make Wimbledon last 16

    WIMBLEDON — Anastasia Pavlyuchenkova returned to the second week of Wimbledon for the first time in nine years, overcoming Naomi Osaka 3-6, 6-4, 6-4 in a thrilling 2-hour, 3-minute third-round clash on No. 2 Court.

    Wimbledon: Scores | Order of play | Draws

    Pavlyuchenkova is making her 16th main-draw appearance at SW19 (compared to Osaka’s fifth), and reached the quarterfinals for the only time so far back in 2016. However, the World No. 50 is still hitting career milestones at the age of 34. Last week, she made her first career grass-court semifinal in Eastbourne.

    Having made her ninth Grand Slam quarterfinal at the Australian Open in January, Pavlyuchenkova has now reached the second week of multiple majors in a single season for just the third time in her career. In 2011, she was a quarterfinalist at Roland Garros at the US Open, and in 2021 she was the Roland Garros runner-up and made the US Open fourth round.

    Pavlyuchenkova had to withstand 15 aces from Osaka, who also mounted charges from 3-0 down to 4-4 in both the second and third sets.

    More to come…

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  • China imposes anti-dumping duties on European brandy as trade tensions rise

    China imposes anti-dumping duties on European brandy as trade tensions rise

    BEIJING — China on Friday imposed anti-dumping duties on European brandy, most notably cognac produced in France, as trade tensions between Beijing and United States allies continue to rise.

    The tariffs, effective on Saturday, will range from 27.7% to 34.9%, China’s Commerce Ministry said. They are to be in place for five years and will not be applied retroactively.

    The announcement came during a European visit by Chinese Foreign Minister Wang Yi aimed at ironing out trade differences. Wang was set to visit Paris after stops in Brussels and Berlin.

    The anti-dumping duties are the result of a probe China launched last year into European cognac, after the European Union undertook a probe into Chinese electric vehicles subsidies.

    “The investigative authority finally ruled that the dumping of related imported brandy from the EU has existed,” read a statement by China’s Commerce Ministry. “The domestic brandy industry faces a material threat of damage, and there is a causal relationship between the dumping and the substantial damage threat.”

    Besides cognac, China has also launched investigations into European pork and dairy products. The brandy probe was the first and targeted mainly French makers of cognac and similar spirits such as Armagnac.

    China initially announced provisional tariffs of 30.6% to 39% on French cognac producer Remy Martin and other European brandies after a majority of E.U. countries approved duties on electric vehicles made in China.

    Wang was set to meet his French counterpart, Jean-Noël Barrot, later Friday in Paris.

    His European tour comes ahead of a China-EU summit to be focused on trade later this month in Beijing.

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  • Understanding international travelers’ intentions to adopt protective behaviors against malaria during staying abroad: insights from a study of Chinese international travelers | Globalization and Health

    Understanding international travelers’ intentions to adopt protective behaviors against malaria during staying abroad: insights from a study of Chinese international travelers | Globalization and Health

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