Partially anomalous pulmonary vein return (PAPVR) is a heterogeneous group of congenital heart defects. Here, we describe a 51-year-old patient with corrected PAPVR (cPAPVR) and atrioventricular canal defect who presented for AFL ablation. The right pulmonary veins were isolated, and the OP was heterogeneously fibrotic. Three left AFL and one cavo-tricuspid isthmus (CTI)-dependent AFL were induced and mapped using activation and Ablation at each site terminated the AFL. Subsequently, the entire OP was isolated. Post-ablation, she had no atrial arrhythmia at 6 months follow up. Genetic testing identified a pathological mutation in the TBX5 gene, consistent with Holt-Oram syndrome.

Preexisting atrial fibrillation (AF) or atrial flutter may impair cardiovascular reserve during septic shock, potentially leading to worse clinical outcomes; however, its independent association with short-term outcomes remains uncertain. Using the TriNetX U.S. Collaborative Network, we identified adults with septic shock and compared patients with preexisting AF/flutter, documented at least 1 month before the index event, with those without prior AF/flutter. Clinical outcomes were compared after 1:1 propensity score matching for demographic characteristics, comorbidities, and baseline cardiovascular medication use. Outcomes included 30-day all-cause mortality, cerebral infarction, renal replacement therapy, invasive mechanical ventilation, acute-care utilization, and vasopressor/inotrope use. Effect estimates were reported as relative risks (RRs) with 95% confidence intervals. After propensity score matching, 76,295 patients were included in each cohort. Preexisting AF/flutter was associated with significantly higher risks of all-cause mortality (RR 1.07, 95% CI, 1.06-1.09; P<0.001), renal replacement therapy (RR 1.30, 95% CI, 1.25-1.35; P<0.001), invasive mechanical ventilation (RR 1.14, 95% CI, 1.12-1.16; P<0.001), acute-care utilization (RR 1.06, 95% CI, 1.05-1.06; P<0.001), and vasopressor/inotrope use (RR 1.09, 95% CI, 1.08-1.10; P<0.001). There was no significant difference in cerebral infarction (RR 1.11, 95% CI, 1.00-1.24; P=0.054). Among patients with septic shock, preexisting AF/flutter was associated with higher mortality and greater use of organ-supportive therapies, including renal replacement therapy, invasive mechanical ventilation, and vasopressor/inotrope use, but not with a significant increase in cerebral infarction. Preexisting AF/flutter may serve as an important prognostic marker for early risk stratification in septic shock.

Beta-blockers are among the most widely prescribed drugs in the management of both supraventricular and ventricular arrhythmias, and they are frequently regarded as a homogeneous pharmacological class. They are not. The agents in current use differ substantially in beta1-receptor selectivity, lipophilicity, half-life, route of administration, intrinsic sympathomimetic activity, and ancillary properties, and arrhythmias themselves differ in mechanism, adrenergic dependence, anatomical origin, and structural substrate. This narrative review examines whether these pharmacological differences translate into clinically meaningful differences in efficacy and utility, asking not only whether a beta-blocker should be used but which one should be used. Evidence was drawn from a targeted search of PubMed, Web of Science, Scopus, Ovid, Embase, and the Cochrane Library, with priority given to randomized controlled trials, meta-analyses, large registries, and contemporary society guidelines, and was synthesized qualitatively by arrhythmia type. A class effect is apparent for many indications, particularly rate control in atrial fibrillation and atrial flutter, where metoprolol, bisoprolol, and carvedilol perform broadly similarly and the choice is driven mainly by comorbidity and tolerability. Drug-specific differences emerge in three settings. In adrenergically mediated inherited syndromes, namely catecholaminergic polymorphic ventricular tachycardia and long QT syndrome, nonselective agents and especially nadolol are clearly superior to beta1-selective agents, and the same principle appears to extend to ventricular electrical storm, in which propranolol has outperformed metoprolol in a randomized comparison. In acute care, pharmacokinetics dominate, and the ultra-short-acting agents esmolol and landiolol permit a degree of titration that longer-acting drugs cannot match. In patients with heart failure and reduced ejection fraction, carvedilol, metoprolol succinate, and bisoprolol should be preferred irrespective of arrhythmia subtype because of their established mortality benefit. Conversely, beta1-selective agents, including the highly selective agent nebivolol, improve tolerability in bronchospastic disease, although this reflects respiratory tolerability rather than any demonstrated antiarrhythmic advantage, and beta-blockers have little role in Brugada syndrome or in bradycardia-dependent acquired torsades de pointes. Beta-blockers should therefore not be treated as interchangeable. Selection should integrate arrhythmic mechanism, structural substrate, and patient characteristics, and head-to-head trials remain conspicuously scarce.