<div><h4>Impact of intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion procedures: A meta-analysis.</h4><i>Diaz JC, Bastidas O, Duque M, Marín JE, ... Sauer WH, Romero JE</i><br /><b>Background</b><br />Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE). The objective of this study is to evaluate the impact of ICE versus TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up.<br /><b>Methods</b><br />All studies comparing ICE-guided versus TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up.<br /><b>Results</b><br />Twelve studies (n = 5637) were included. There were no differences in procedural success (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p = .27; I<sup>2</sup>  = 0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p = .25; I<sup>2</sup>  = 0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-min reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p = 0.64); however, an increased prevalence of residual IASD was observed with ICE-guided versus TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p = 0.04).<br /><b>Conclusion</b><br />ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Nov 2023; epub ahead of print</small></div>

<div><h4>The impact of early cryoballoon ablation on clinical outcome in patients with atrial fibrillation: From the Korean cryoballoon ablation registry.</h4><i>Kwon CH, Choi JH, Oh IY, Lee SR, ... Cha MJ, Lim HE</i><br /><b>Introduction</b><br />Influence of early atrial fibrillation (AF) ablation, particularly cryoballoon ablation (CBA), on clinical outcome during long-term follow-up has not been clarified. The objective was to determine whether an early CBA (diagnosis-to-ablation of ≤6 months) strategy could affect freedom from AF recurrence after index CBA.<br /><b>Methods</b><br />The study included 2605 patients from Korean CBA registry data with follow-up >12 months after de novo CBA. The primary outcome was recurrence of atrial tachyarrhythmias (ATs) of ≥30-s after a 3-month blanking period.<br /><b>Results</b><br />Compared to patients in early CBA group, patients in late CBA group had higher prevalence of diabetes, congestive heart failure, and chronic kidney disease, and higher mean CHA<sub>2</sub> DS<sub>2</sub> -VAS score. During mean follow-up of >21 months, ATs recurrence was detected in 839 (32.2%) patients. The early CBA group showed a significantly lower 2-year recurrence rate of ATs than the late CBA group (26.1% vs. 31.7%, p = 0.043). In subgroup analysis, the early CBA group showed significantly higher 1-year and 2-year freedom from ATs recurrence than the late CBA group only in paroxysmal atrial fibrillation (PAF) patients in overall and propensity score matched cohorts. Multivariate analysis showed that early CBA was an independent factor for preventing ATs recurrence in PAF (hazard ratio: 0.637; 95% confidence intervals: 0.412-0.984).<br /><b>Conclusion</b><br />Early CBA strategy, resulting in significantly lower ATs recurrence during 2-year follow-up after index CBA, might be considered as an initial rhythm control therapy in patients with paroxysmal AF.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Nov 2023; epub ahead of print</small></div>

<div><h4>Mortality trends, disparities, and social vulnerability in cardiac arrest mortality in the young: A cross-sectional analysis.</h4><i>Ibrahim R, Shahid M, Srivathsan K, Sorajja D, Deshmukh A, Lee JZ</i><br /><b>Background</b><br />Cardiac arrest (CA) is a leading cause of death in the United States (US). Social determinants of health may impact CA outcomes. We aimed to assess mortality trends, disparities, and the influence of the social vulnerability index (SVI) on CA outcomes in the young.<br /><b>Methods</b><br />We conducted a cross-sectional analysis of age-adjusted mortality rates (AAMRs) related to CA in the United States from the Years 1999 to 2020 in individuals aged 35 years and younger. Data were obtained from death certificates and analyzed using log-linear regression models. We examined disparities in mortality rates based on demographic variables. We also explored the impact of the SVI on CA mortality.<br /><b>Results</b><br />A total of 4792 CA deaths in the young were identified. Overall AAMR decreased from 0.20 in 1999 to 0.14 in 2020 with an average annual percentage change of -1.3% (p = .001). Black (AAMR: 0.30) and male populations (AAMR: 0.14) had higher AAMR compared with White (AAMR: 0.11) and female (AAMR: 0.11) populations, respectively. Nonmetropolitan (AAMR: 0.29) and Southern (AAMR: 0.26) regions were also impacted by higher AAMR compared with metropolitan (AAMR: 0.11) and other US census regions, respectively. A higher SVI was associated with greater mortality risks related to CA (risk ratio: 1.82 [95% CI, 1.77-1.87]).<br /><b>Conclusions</b><br />Our analysis of CA in the young revealed disparities based on demographics, with a decline in AAMR from 1999 to 2020. There is a correlation between a higher SVI and increased CA mortality risk, highlighting the importance of targeted interventions to address these disparities effectively.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Nov 2023; epub ahead of print</small></div>

<div><h4>Long-term outcomes of patients with ventricular arrhythmias and negative programmed ventricular stimulation followed with implantable loop recorders: Impact of delayed-enhancement cardiac magnetic resonance imaging.</h4><i>Gupte T, Liang JJ, Latchamsetty R, Crawford T, ... Bogun F, Ghannam M</i><br /><b>Background</b><br />Programed ventricular stimulation (PVS) is a risk stratification tool in patients at risk for adverse arrhythmia outcomes. Patients with negative PVS may yet be at risk for adverse arrhythmia-related events, particularly in the presence of symptomatic ventricular arrhythmias (VA).<br /><b>Objective</b><br />To investigate the long-term outcomes of real-world patients with symptomatic VA without indication for device therapy and negative PVS, and to examine the role of cardiac scaring on arrhythmia recurrence.<br /><b>Methods</b><br />Patients with symptomatic VA, and late gadolinium enhancement cardiac magnetic resonance imaging (LGE-CMR), and negative PVS testing were included. All patients underwent placement of implantable cardiac monitors (ICM). Survival analysis was performed to investigate the impact of LGE-CMR findings on survival free from adverse arrhythmic events.<br /><b>Results</b><br />Seventy-eight patients were included (age 60 ± 14 years, women n = 36 (46%), ejection fraction 57 ± 9%, cardiomyopathy n = 26 (33%), mitral valve prolapse [MVP] n = 9 (12%), positive LGE-CMR scar n = 49 (62%), history of syncope n = 23 (29%)) including patients with primarily premature ventricular contractions (n = 21) or nonsustained VA (n = 57). Patients were followed for 1.6 ± 1.5 years during which 14 patients (18%) experienced VA requiring treatment (n = 14) or syncope due to bradycardia (n = 2). Four/9 patients (44%) with MVP experienced VA (n = 3) or syncope (n = 1). Baseline characteristics between those with and without adverse events were similar (p > 0.05); however, the presence of cardiac scar on LGE-CMR was independently associated with an increased risk of adverse events (hazard ratio: 5.6 95% confidence interval: [1.2-27], p = 0.03, log-rank p = 0.03).<br /><b>Conclusions</b><br />In a real-world cohort with long-term follow-up, adverse arrhythmic outcomes occurred in 18% of patients with symptomatic VA despite negative PVS, and this risk was significantly greater in patients with positive DE-CMR scar. Long term-monitoring, including the use of ICM, may be appropriate in these patients.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Nov 2023; epub ahead of print</small></div>

<div><h4>Clinical outcomes and predictors of delayed echocardiographic response to cardiac resynchronization therapy.</h4><i>Tsurumi N, Inden Y, Yanagisawa S, Hiramatsu K, ... Tsuji Y, Murohara T</i><br /><b>Introduction</b><br />The clinical outcomes and mechanisms of delayed responses to cardiac resynchronization therapy (CRT) remain unclear. We aimed to investigate the differences in outcomes and gain insight into the mechanisms of early and delayed responses to CRT.<br /><b>Methods</b><br />This retrospective study included 110 patients who underwent CRT implantation. Positive response to CRT was defined as ≥15% reduction of left ventricular (LV) end-systolic volume on echocardiography at 1 year (early phase) and 3 years (delayed phase) after implantation. The latest mechanical activation site (LMAS) of the LV was identified using two-dimensional speckle-tracking radial strain analysis.<br /><b>Results</b><br />Seventy-eight (71%) patients exhibited an early response 1 year after CRT implantation. Of 32 non-responders in the early phase, 12 (38%) demonstrated a delayed response, and 20 (62%) were classified as non-responders after 3 years. During the follow-up time of 10.3±0.5 years, the delayed and early responders had a similar prognosis of mortality and heart failure (HF) hospitalization. In contrast, non-responders had a worse prognosis. Multivariate analysis revealed that a longer duration (months) between initial HF hospitalization and CRT (odds ratio [OR], 1.126; 95% confidence interval [CI]: 1.036-1.222; p=0.005), non-exact concordance of LV lead location with LMAS (OR, 32.744; 95%CI: 1.101-973.518; p=0.044), and pre-QRS duration (OR, 0.901;95% CI: 0.827-0.981; p=0.016) were independent predictors of delayed response to CRT compared with early response.<br /><b>Conclusion</b><br />The prognoses were similar regardless of the response time after CRT. A longer history of HF, suboptimal LV lead position, and shorter pre-QRS duration were related to delayed response than early response. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Cardiac Resynchronisation using Fusion Pacing during Exercise.</h4><i>Green PG, Monteiro C, Holdsworth DA, Betts TR, Herring N</i><br /><b>Background:</b><br/>and aims</b><br />Fusion pacing requires correct timing of left ventricular pacing to right ventricular activation, although it is unclear whether this is maintained when AV conduction changes during exercise. We used cardiopulmonary exercise testing (CPET) to compare cardiac resynchronization therapy (CRT) using fusion pacing or fixed atrioventricular delays (AVD).<br /><b>Methods</b><br />Patients 6 months post-CRT implant with PR intervals less than 250 ms performed 2 CPET tests, using either the SyncAV™ algorithm or fixed AVD of 120 ms in a double blinded, randomised, crossover study. All other programming was optimised to produce the narrowest QRS duration (QRSd) possible.<br /><b>Results</b><br />Twenty patients (11 male, age 71 [65-77] years) were recruited. Fixed AVD and fusion programming resulted in similar narrowing of QRSd from intrinsic rhythm at rest (p=0.85). Overall, there was no difference in peak oxygen consumption (V̇O<sub>2</sub> <sup>PEAK</sup> , p=0.19), oxygen consumption at anaerobic threshold (VT1, p=0.42), or in the time to reach either V̇O<sub>2</sub> <sup>PEAK</sup> (p=0.81) or VT1 (p=0.39). The BORG rating of perceived exertion was similar between groups. CPET performance was also analysed comparing whichever programming gave the narrowest QRSd at rest (119 [96-136] vs 134 [119-142] ms, p<0.01). QRSd during exercise (p=0.03), peak O<sub>2</sub> pulse (ml/beat, a surrogate of stroke volume, p=0.03) and cardiac efficiency (watts/ml/kg/min, p=0.04) were significantly improved.<br /><b>Conclusion</b><br />Fusion pacing is maintained during exercise without impairing exercise capacity compared to fixed AVD. However, using whichever algorithm gives the narrowest QRSd at rest is associated with a narrower QRSd during exercise, higher peak stroke volume and improved cardiac efficiency. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Lower Contact Force Predicts Right Pulmonary Vein Carina Breakthrough after Ablation Index-guided Pulmonary Vein Isolation Using High-Power Short-duration.</h4><i>Chen WT, Chung FP, Lin YJ, Chang SL, ... Li CH, Chen SA</i><br /><b>Background</b><br />Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High-power short-duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established.<br /><b>Objectives</b><br />This study investigated predictors of RPV CB in patients undergoing ablation index (AI)-guided PVI with HPSD.<br /><b>Methods</b><br />The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI-guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation.<br /><b>Results</b><br />Out of the 62 patients, 21 (33.87%) experienced RPV CB (group 1), while 41 (66.13%) achieved first-pass RPV isolation (group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF <10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714).<br /><b>Conclusion</b><br />In patients undergoing AI-guided PVI with HPSD, lower CF adjacent to the carina were associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB. This article is protected by copyright. All rights reserved.<br /><br />This article is protected by copyright. All rights reserved.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Combining conventional technique with fluoroscopy integration module in accessory pathway ablation.</h4><i>Ozcan EE, Turan OE, Yilancioğlu RY, Inevi U, Akdemir B</i><br /><b>Introduction</b><br />Accessory pathway (AP) ablation is a straightforward approach with high success rates, but the fluoroscopy time (FT) is significantly longer in conventional technique. Electroanatomical mapping systems (EMS), reduce the FT, but anatomical and activation mapping may prolong the procedure time (PT). The fluoroscopy integration module (FIM) uses prerecorded fluoroscopy images and allows ablation similar to conventional technique without creating an anatomical map. In this study, we investigated the effects of combining the FIM with traditional technique on PT, success, and radiation exposure.<br /><b>Methods</b><br />A total of 131 patients who had undergone AP ablation were included in our study. In 37 patients, right and left anterior oblique (RAO-LAO) images were acquired after catheter placement and integrated with the FIM. The ablation procedure was then similar to the conventional technique, but without the use of fluoroscopy. For the purpose of acceleration, anatomical and activation maps have not been created. Contact-force catheters were not used. 94 patients underwent conventional ablation using fluoroscopy only.<br /><b>Results</b><br />FIM into AP ablation procedures led to a significant reduction in radiation exposure, lowering FT from 7.4 to 2.8 min (p < .001) and dose-area product from 12.47 to 5.8 μGym² (p < .001). While the FIM group experienced a reasonable longer PT (69 vs. 50 min p < .001). FIM reduces FT regardless of operator experience and location of APs <br /><b>Conclusion:</b><br/>Combining FIM integration with conventional AP ablation offers reduced radiation exposure without compromising success rates and complication.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of transseptal puncture using a dedicated RF wire versus a mechanical needle with and without electrification in an animal model.</h4><i>Knight BP, Wasserlauf J, Al-Dujaili S, Al-Ahmad A</i><br /><b>Introduction</b><br />Mechanical force to achieve transseptal puncture (TSP) using a standard needle may lead to overshooting and injury, and can potentially be avoided using a radiofrequency (RF)-powered needle or wire. Applying electrocautery to needles and guidewires as an alternative to purpose-built RF systems has been associated with safety risks, such as tissue coring and thermal damage. The commercially available AcQCross needle-dilator system (Medtronic) features a sharp open-ended needle for mechanical puncture, as well as a built-in connector to enable energy delivery for RF puncture. This investigation compares the safety and efficacy of the AcQCross needle to the dedicated VersaCross RF wire system and generator (Baylis Medical/Boston Scientific).<br /><b>Methods</b><br />In an ex vivo porcine model, VersaCross wire punctures were performed using 1 s, constant mode (approx. 10 W) with maximum two attempts. AcQCross punctures were performed by applying energy for 2 s using a standard electrosurgical generator at 10 W (max. five attempts), 20 W (max. two attempts), and 30 W (max. two attempts). Efficacy was assessed in terms of puncture success and a number of energy applications required for TSP. Safety was assessed quantitatively as force required for TSP, energy required to puncture, and incidence of tissue coring, as well as by qualitative assessment of puncture sites. Additional qualitative observation of tissue cores and debris were obtained from TSP performed in live swine.<br /><b>Results</b><br />RF TSP was 100% successful using the VersaCross wire with 1.0 ± 0.0 attempts. When power was used with the AcQCross needle, it failed to puncture at low (10 and 20 W) power settings; TSP was achieved with 30 W of energy with 91% success using 1.53 ± 0.51 attempts (p < .05 vs. VC) with greater variability (F<sub>1,33</sub>  = 9223.5, p < .0001). Compared to RF puncture using the VersaCross system, mechanical puncture, alone, using the AcQcross needle required six times more force (8 mm additional forward device displacement) to perforate the septum. Qualitative assessment of puncture sites revealed larger defects and more tissue charring with the AcQCross needle at 30 W compared to punctures with VersaCross wire. Tissue coring with the open-ended AcQCross needle was observed in vivo and measured to occur in 57% of punctures using the ex vivo model; no coring was observed with the closed-tip VersaCross wire.<br /><b>Conclusions</b><br />The AcQCross needle frequently required higher energy of 30 W to achieve RF TSP and was associated with tissue coring and charring, which have been, previously, reported when electrifying a standard open-ended mechanical needle or guidewire. These findings may limit safety and effectiveness compared to the VersaCross system.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of the effect of ethanol infusion into the vein of Marshall between with and without collateral veins.</h4><i>Ishimura M, Yamamoto M, Himi T, Kobayashi Y</i><br /><b>Background</b><br />Despite the potential benefits of ethanol infusion into the vein of Marshall (EIVOM) for atrial fibrillation (AF) ablation, concerns about its reversible and unpredictable effects persist.<br /><b>Objective</b><br />To assess the effectiveness of EIVOM in the vein of Marshall (VOM) with collateral veins (CVs) during mitral isthmus and AF ablation.<br /><b>Methods</b><br />We included 142 AF patients. EIVOM was performed before radiofrequency ablation, and low-voltage areas (<0.5 mV) were measured before, immediately after, and 1 h after EIVOM.<br /><b>Results</b><br />Among the 142 patients, 93 (65%) underwent EIVOM, and among these, 35 (37%) were found to have CVs. In the VOM with CVs group, areas with low voltage measured 0 (0-1.85) cm<sup>2</sup> before EIVOM, 6.9 (4.1-11.2) cm<sup>2</sup> immediately after EIVOM, and 5.7 (3.5-10.6) cm<sup>2</sup> 1 h after EIVOM. Conversely, in the group designated as VOM without CVs-from which the nine leakage cases were excluded-the areas measured 0 (0-1.35) cm<sup>2</sup> , 5.5 (2.6-11.8) cm<sup>2</sup> , and 4.7 (1.8-13.5) cm<sup>2</sup> at the respective time points. MI line block was fully achieved in 89% (31/35) of cases in the VOM with CVs group and 88% (44/49) in the VOM without CVs groups (p = .94). There was no significant difference in the outcome of AF ablation between these groups (log-rank p = .73). Additionally, no significant difference was observed between EIVOM (+) and EIVOM (-) groups (log-rank p = .59).<br /><b>Conclusion</b><br />EIVOM effectively creates MI line block, and its beneficial effects are sustained for at least 1 h after the procedure despite the low-voltage areas showing a slight reduction in size.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 27 Oct 2023; epub ahead of print</small></div>

<div><h4>Cardiovascular dysautonomia in postacute sequelae of SARS-CoV-2 infection.</h4><i>Ståhlberg M, Mahdi A, Johansson M, Fedorowski A, Olshansky B</i><br /><AbstractText>Coronavirus disease 2019 (COVID-19) has led to a worldwide pandemic that continues to transform but will not go away. Cardiovascular dysautonomia in postacute sequelae of severe acute respiratory syndrome coronavirus 2 infection has led to persistent symptoms in a large number of patients. Here, we define the condition and its associated symptoms as well as potential mechanisms responsible. We provide a careful and complete overview of the topic addressing novel studies and a generalized approach to the management of individuals with this complex and potentially debilitating problem. We also discuss future research directions and the important knowledge gaps to be addressed in ongoing and planned studies.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 25 Oct 2023; epub ahead of print</small></div>

<div><h4>RETRO-mapping: A novel algorithm automating wavefront categorization using activation mapping during persistent atrial fibrillation demonstrates a reduction in wavefront collisions following pulmonary vein isolation.</h4><i>Coyle C, Kanella I, Mann I, Qureshi N, Linton NWF, Kanagaratnam P</i><br /><AbstractText>RETRO-mapping was developed to automate activation mapping of atrial fibrillation (AF). We used the algorithm to study the effect of pulmonary vein isolation (PVI) on the frequency of focal, planar, and colliding wavefronts in persistent AF. An AFocusII catheter was placed on the left atrial endocardium to record 3 s of AF at six sites pre and post-PVI in patients undergoing wide circumferential PVI for persistent AF. RETRO-mapping analyzed each segment in 2 ms time windows for evidence of focal, planar, and colliding waveforms and the automated categorizations manually validated. Ten patients were recruited. A total of 360 s of data in 120 segments of 3 s from 60 left atrial locations were analyzed. RETRO-map was highly effective at identifying focal waves and collisions during AF. PVI significantly reduced collision frequency but not focal and planar activation frequency. However, there was a significant reduction in the dispersion of activation directions. Larger studies may help determine factors associated with successful clinical outcome.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Does asymptomatic atrial fibrillation exist?</h4><i>Carneiro HA, Knight B</i><br /><AbstractText>Atrial fibrillation (AF) is currently defined as symptomatic by asking patients if they are aware of when they are in AF and if they feel better in sinus rhythm. However, this approach of defining AF as symptomatic and asymptomatic fails to adequately consider the adverse effects of AF in patients who are unaware of their rhythm including progression from paroxysmal to persistent AF, and the development of dementia, stroke, sinus node dysfunction, valvular regurgitation, ventricular dysfunction, and heart failure. Labeling these patients as asymptomatic falsely suggests that their AF requires less intense therapy and puts into question the notion of truly asymptomatic AF. Because focusing on patient awareness ignores other important consequences of AF, clinical endpoints that are independent of symptoms are being developed. The concept of AF burden has more recently been used as a clinical endpoint in clinical trials as a more clinically relevant endpoint compared to AF-related symptoms or time to first recurrence, but its correlation with symptoms and other clinical outcomes remains unclear. This review will explore the impact of AF on apparently asymptomatic patients, the use of AF burden as an endpoint for AF management, and potential refinements to the AF burden metric. The review is based on a presentation by the senior author during the 2023 16th annual European Cardiac Arrhythmia Society (ECAS) congress in Paris, France.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Paroxysmal atrial fibrillation ablation with a novel temperature-controlled CF-sensing catheter: Q-FFICIENCY clinical and healthcare utilization benefits.</h4><i>Hussein AA, Delaughter MC, Monir G, Natale A, ... Osorio J, Q-FFICIENCY investigators</i><br /><b>Introduction</b><br />The prospective, nonrandomized, multicenter Q-FFICIENCY study demonstrated the safety and 12-month efficacy of paroxysmal atrial fibrillation (AF) ablation with the novel QDOT MICRO temperature-controlled, contact force-sensing, radiofrequency (RF) catheter. Participants underwent pulmonary vein isolation with very high-power short-duration (vHPSD) mode (90 W, ≤4 s) alone or combined with conventional-power temperature-controlled (CPTC) mode (25-50 W). This study aimed to assess quality-of-life (QOL) and healthcare utilization (HCU) benefits experienced by Q-FFICIENCY study participants.<br /><b>Methods</b><br />Besides evaluating procedural efficiency, QOL and HCU were assessed through 12 months postablation via Atrial Fibrillation Effect on Quality-of-Life Tool (AFEQT) score, antiarrhythmic drug (AAD) use, and incidence of cardioversion and cardiovascular hospitalization.<br /><b>Results</b><br />Of 191 participants enrolled, 166 were ablated with the new catheter. Compared to baseline, statistically significant, clinically meaningful improvements in composite and subcategories of AFEQT scores were observed at 3 months and sustained through 12 months (12-month increase, 29.3-44.2 points). Class I/III AAD use decreased from 97.6% (162/166) at baseline to 19.6% (31/158) during Months 6-12, representing a significant 79.9% reduction. The cardioversion rate significantly declined by 93.9% from 31.3% (12 months preablation) to 1.9% (evaluation period). One-year Kaplan-Meier estimates of freedom from all-cause and cardiovascular hospitalization were 80.9% (95% confidence interval [CI], 74.8%-86.9%) and 88.8% (95% CI, 84.0%-93.7%), respectively.<br /><b>Conclusions</b><br />Paroxysmal AF ablation with the novel temperature-controlled RF catheter in vHPSD mode, alone or with CPTC mode, led to clinically meaningful improvement in QOL and significant reduction in AAD use, cardioversion, and cardiovascular hospitalization.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 23 Oct 2023; epub ahead of print</small></div>

<div><h4>Successful ablation of a right concealed epicardial accessory pathway using ethanol infusion.</h4><i>Ma S, Zhu Q, Shu L, Lu Y, Liu C, Cai Z</i><br /><b>Introduction</b><br />This study describes a rare case of concealed epicardial accessory pathway (AP) successfully ablated using ethanol infusion (EI) through a variant vessel connecting the right atrium (RA) and the right ventricle (RV) surface.<br /><b>Methods and results</b><br />A 58-year-old male referred to our hospital for prior failed AP ablation. Cardiac-enhanced computerized tomography scan showed there was a variant vessel at the tip of right atrial appendage and a pulmonary artery (PA)-RA fistula at the roof of RA. The earliest activation was present at the site of the PA-RA fistula. A selective angiography showed that a small branch of the variant vessel covered the earliest excitation site of the AP. EI into this branch successfully repressed the AP without any recurrences within a follow-up period of 3 months.<br /><b>Conclusion</b><br />Endocardial ablation is challenging for epicardial APs related to cardiac structural variations. If small vascular branches near the earliest activation site can be found, EI can successfully ablate these types of epicardial APs.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>Very high-power short-duration catheter ablation for treatment of cardiac arrhythmias: Insights from the FAST and FURIOUS study series.</h4><i>Heeger CH, Kuck KH, Tilz RR</i><br /><AbstractText>The QDOT MICRO™ Catheter is a novel open-irrigated contact force-sensing radiofrequency ablation catheter. It offers very high-power short-duration (vHPSD) ablation with 90 W for 4 s to improve safety and efficacy of catheter ablation procedures. Although the QDOT MICRO™ Catheter was mainly designed for pulmonary vein isolation (PVI) its versatility to treat atrial fibrillation (AF) and other types of arrhythmias was recently evaluated by the FAST and FURIOUS study series and other studies and will be presented in this article. Available study and registry data as well as case reports concerning utilization of the QDOT MICRO™ Catheter for the treatment of cardiac arrhythmias including AF, focal and macroreentry atrial tachycardia, typical atrial flutter by cavotricuspid isthmus block, premature ventricular contractions, and accessory pathways were reviewed and summarized. In summary, the QDOT MICRO™ Catheter showed safety and efficacy for PVI and is able to treat also other types of arrhythmias as is was recently evaluated by case reports and the FAST and FURIOUS studies.</AbstractText><br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Oct 2023; epub ahead of print</small></div>

<div><h4>Comparison of pulsed-field ablation versus very high power short duration-ablation for pulmonary vein isolation.</h4><i>Wörmann J, Schipper JH, Lüker J, van den Bruck JH, ... Steven D, Sultan A</i><br /><b>Background</b><br />The newly introduced nonthermal pulsed field ablation (PFA) is a promising technology to achieve fast pulmonary vein isolation (PVI) with high acute success rates and good safety features. However, previous studies have shown that very high power short duration ablation (VHPSD) is also highly effective and fast to achieve PVI with potentially less arrhythmia recurrence compared to conventional radiofrequency ablation. Data comparing PFA to VHPSD-PVI is lacking.<br /><b>Objective</b><br />This study compared procedural and outcome data for PFA-PVI to VHPSD-PVI in patients with paroxysmal or persistent atrial fibrillation (PAF/persAF).<br /><b>Methods</b><br />Consecutive patients undergoing de novo PVI (PFA or VHPSD) were included in this analysis. For PFA-PVI a pentaspline 20 electrode catheter was used. For VHPSD-PVI an enhanced irrigated catheter with a power setting of 70 W/7 s (70 W/5 s at posterior wall) was employed in conjunction with electro-anatomical mapping. All procedures were performed in deep analgo-sedation.<br /><b>Results</b><br />A total of n = 114 patients (n = 57[50%] PFA, n = 17[30%] PAF; n = 40[70%] persAF) were included in this analysis. PVI was successful in all patients. The PFA group revealed a significantly shorter procedure duration (65 ± 17 min vs. 95 ± 23 min, p < 0.01) but longer fluoroscopy time (PFA 15 ± 5 min and VHPSD 12 ± 3 min; p < 0.001). At follow-up after median 125 days (interquartile range: 109-162) n = 46 PFA (80.7%) and n = 44 VHPSD pts (77.2%) were free from atrial arrhythmia after a single procedure (p = 0.819). Two tamponades occurred in the PFA while in VHPSD two pts suffered groin bleedings. One clinically nonsignificant PV stenosis occurred in the VHPSD group.<br /><b>Conclusion</b><br />Pulsed-field ablation and VHPSD-PVI seem to be highly effective and safe to achieve PVI in the setting of PAF and persAF with comparable arrhythmia-free survival. However, procedure duration for PFA PVI is significantly shorter and therefore may be of potential benefit. Compared to PFA VHPSD-PVI might ensure information on left atrial substrate allowing to target concomitant secondary tachycardias.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 17 Oct 2023; epub ahead of print</small></div>

<div><h4>Medical cardioversion of atrial fibrillation and flutter with class IC antiarrhythmic drugs in young patients with and without congenital heart disease.</h4><i>Przybylski R, Eberly LM, Alexander ME, Bezzerides VJ, ... Walsh EP, O\'Leary ET</i><br /><b>Introduction</b><br />The use of flecainide and propafenone for medical cardioversion of atrial fibrillation (AF) and atrial flutter/intra-atrial reentrant tachycardia (IART) is well-described in adults without congenital heart disease (CHD). Data are sparse regarding their use for the same purpose in adults with CHD and in adolescent patients with anatomically normal hearts and we sought to describe the use of class IC drugs in this population and identify factors associated with decreased likelihood of success.<br /><b>Methods</b><br />Single center retrospective cohort study of patients who received oral flecainide or propafenone for medical cardioversion of AF or IART from 2000 to 2022. The unit of analysis was each episode of AF/IART. We performed a time-to-sinus rhythm analysis using a Cox proportional hazards model clustering on the patient to identify factors associated with increased likelihood of success.<br /><b>Results</b><br />We identified 45 episodes involving 41 patients. As only episodes of AF were successfully cardioverted with medical therapy, episodes of IART were excluded from our analyses. Use of flecainide was the only factor associated with increased likelihood of success. There was a statistically insignificant trend toward decreased likelihood of success in patients with CHD.<br /><b>Conclusions</b><br />Flecainide was more effective than propafenone. We did not detect a difference in rate of conversion to sinus rhythm between patients with and without CHD and were likely underpowered to do so, however, there was a trend toward decreased likelihood of success in patients with CHD. That said, medical therapy was effective in >50% of patients with CHD with AF.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 17 Oct 2023; epub ahead of print</small></div>

<div><h4>Factors predicting the progression from paroxysmal to persistent atrial fibrillation despite an index catheter ablation.</h4><i>Li GY, Elimam AM, Lo LW, Lin YJ, ... Chen WT, Chen SA</i><br /><b>Introduction</b><br />Despite undergoing an index ablation, some patients progress from paroxysmal atrial fibrillation (PAF) to persistent AF (PersAF), and the mechanism behind this is unclear. The aim of this study was to investigate the predictors of progression to PersAF after catheter ablation in patients with PAF.<br /><b>Methods</b><br />This study included 400 PAF patients who underwent an index ablation between 2015 and 2019. The patients were classified into three groups based on their outcomes: Group 1 (PAF to sinus rhythm, n = 226), Group 2 (PAF to PAF, n = 146), and Group 3 (PAF to PersAF, n = 28). Baseline and procedural characteristics were collected, and predictors for AF recurrence and progression were evaluated.<br /><b>Results</b><br />The mean age of the patients was 58.4 ± 11.1 years, with 272 males. After 3 years of follow-up, 7% of the PAF cases recurred and progressed to PersAF despite undergoing an index catheter ablation. In the multivariable analysis, a larger left atrial (LA) diameter and the presence of non-pulmonary vein (PV) triggers during the index procedure independently predicted recurrence. Moreover, a larger LA diameter, the presence of non-PV triggers, and a history of thyroid disease independently predicted AF progression.<br /><b>Conclusion</b><br />The progression from PAF to PersAF after catheter ablation is associated with a larger LA diameter, history of thyroid disease, and the presence of non-PV triggers. Meticulous preprocedural evaluation, patient selection, and comprehensive provocation tests during catheter ablation are recommended.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Oct 2023; epub ahead of print</small></div>

<div><h4>LBBB and heart failure-Relationships among QRS amplitude, duration, height, LV mass, and sex.</h4><i>Manne M, Niebauer M, Tchou P, Varma N</i><br /><b>Background</b><br />Height, left ventricular (LV) size, and sex were proposed as additional criteria for patient selection for cardiac resynchronization therapy (CRT) but their connections with the QRS complex in left bundle branch block (LBBB) are little investigated. We evaluated these.<br /><b>Methods</b><br />Among patients with \"true\" LBBB, QRS duration (QRSd) and amplitude, and LV hypertrophy indices, were correlated with patient\'s height and LV mass, and compared between sexes.<br /><b>Results</b><br />In this study cohort (n = 220; 60 ± 12 years; left ventricular ejection fraction [LVEF] 21 ± 7%; mostly New York Heart Association II-III, QRSd 165 ± 19 ms; 57% female; 70% responders [LVEF increased ≥5%]), LV mass was increased in all patients. QRS amplitude did not correlate with LV mass or height in any individual lead or with Sokolow-Lyon or Cornell-Lyon indices. QRSd did not correlate with height. In contrast, QRSd correlated strongly with LV mass (r = .51). CRT response rate was greater in women versus men (84% vs. 58%, p < .001) despite shorter QRSd [7% shorter (p < .0001)]. QRSd normalized for height resulted in a 2.7% and for LV mass 24% greater index in women.<br /><b>Conclusion</b><br />True LBBB criteria do not exclude HF patients with increased LV mass. QRS amplitudes do not correlate with height or LV mass. Height does not affect QRSd. However, QRSd correlates with LV size. QRSd normalized for LV mass results in 24% greater value in women in the direction of sex-specific responses. LV mass may be a significant nonelectrical modifier of QRSd for CRT.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Oct 2023; epub ahead of print</small></div>

<div><h4>Cost-effectiveness analysis of leadless cardiac resynchronization therapy.</h4><i>Wijesuriya N, Mehta V, Vere F, Howell S, ... Niederer SA, Rinaldi CA</i><br /><b>Background</b><br />The Wireless Stimulation Endocardially for CRT (WiSE-CRT) system is a novel technology used to treat patients with dyssynchronous heart failure (HF) by providing leadless cardiac resynchronization therapy (CRT). Observational studies have demonstrated its safety and efficacy profile, however, the treatment cost-effectiveness has not previously been examined.<br /><b>Methods</b><br />A cost-effectiveness evaluation of the WiSE-CRT System was performed using a cohort-based economic model adopting a \"proportion in state\" structure. In addition to the primary analysis, scenario analyses and sensitivity analyses were performed to test for uncertainty in input parameters. Outcomes were quantified in terms of quality-adjusted life year (QALY) differences.<br /><b>Results</b><br />The primary analysis demonstrated that treatment with the WiSE-CRT system is likely to be cost-effective over a lifetime horizon at a QALY reimbursement threshold of £20 000, with a net monetary benefit (NMB) of £3781 per QALY. Cost-effectiveness declines at time horizons shorter than 10 years. Sensitivity analyses demonstrated that average system battery life had the largest impact on potential cost-effectiveness.<br /><b>Conclusion</b><br />Within the model limitations, these findings support the use of WiSE-CRT in indicated patients from an economic standpoint. However, improving battery technology should be prioritized to maximize cost-effectiveness in times when health services are under significant financial pressures.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Oct 2023; epub ahead of print</small></div>

<div><h4>Early recurrence of atrial tachyarrhythmia indicates pulmonary vein reconduction independent of blanking period duration in the RACE-AF trial.</h4><i>Sørensen SK, Johannessen A, Worck R, Hansen ML, Ruwald MH, Hansen J</i><br /><b>Introduction</b><br />Atrial tachyarrhythmia recurrence during the blanking period (early ATA) after pulmonary vein isolation (PVI) is associated with an increased risk of later recurrence, but its relationship with pulmonary vein reconduction (PVR) is poorly understood. The objective of the present study was to evaluate the relationship between early ATA and PVR. Second, to provide data on the optimal blanking period by (a) evaluating how the predictive values of ATA for PVR are affected by blanking period duration, and (b) assessing the temporal development in atrial fibrillation (AF) burden.<br /><b>Methods</b><br />In this RACE-AF substudy, 91 patients with paroxysmal AF undergoing PVI randomized to radiofrequency or cryoballoon ablation were included. All patients received an implantable cardiac monitor and underwent a protocol-mandated repeat procedure after 4-6 months for assessment of PVR. ATA ≥ 30 s. ≤ 90 days after PVI constituted early ATA.<br /><b>Results</b><br />PVR was found in 37/54 (69%) patients with early ATA and in 11/37 (30%) patients without (p < .001). The positive predictive value of ATA for PVR was independent of blanking period duration (range 0-90 days). In both patients with and without PVR, AF burden was higher in the first month after PVI, but AF burden from the second month was similar to AF burden after the conventional blanking period.<br /><b>Conclusion</b><br />Early ATA indicates PVR, and the positive predictive value is independent of the blanking period duration. Altogether, the results of this study support substantially shortening the blanking period after PVI for paroxysmal AF.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 09 Oct 2023; epub ahead of print</small></div>

<div><h4>Characteristics of tissue temperature during ablation with THERMOCOOL SMARTTOUCH SF versus TactiCath versus QDOT MICRO catheters (Qmode and Qmode+): An in vivo porcine study.</h4><i>Otsuka N, Okumura Y, Kuorkawa S, Nagashima K, ... Takahashi R, Taniguchi Y</i><br /><b>Introduction</b><br />High-power short-duration (HPSD) ablation at 50 W, guided by ablation index (AI) or lesion size index (LSI), and a 90 W/4 s very HSPD (vHPSD) setting are available for atrial fibrillation (AF) treatment. Yet, tissue temperatures during ablation with different catheters around venoatrial junction and collateral tissues remain unclear.<br /><b>Methods</b><br />In this porcine study, we surgically implanted thermocouples on the epicardium near the superior vena cava (SVC), right pulmonary vein, and esophagus close to the inferior vena cava. We then compared tissue temperatures during 50W-HPSD guided by AI 400 or LSI 5.0, and 90 W/4 s-vHPSD ablation using THERMOCOOL SMARTTOUCH SF (STSF), TactiCath ablation catheter, sensor enabled (TacthCath), and QDOT MICRO (Qmode and Qmode+ settings) catheters.<br /><b>Results</b><br />STSF produced the highest maximum tissue temperature (T<sub>max</sub> ), followed by TactiCath, and QDOT MICRO in Qmode and Qmode+ (62.7 ± 12.5°C, 58.0 ± 10.1°C, 50.0 ± 12.1°C, and 49.2 ± 8.4°C, respectively; p = .005), achieving effective transmural lesions. Time to lethal tissue temperature ≥50°C (t-T ≥ 50°C) was fastest in Qmode+, followed by TacthCath, STSF, and Qmode (4.3 ± 2.5, 6.4 ± 1.9, 7.1 ± 2.8, and 7.7 ± 3.1 s, respectively; p < .001). The catheter tip-to-thermocouple distance for lethal temperature (indicating lesion depth) from receiver operating characteristic curve analysis was deepest in STSF at 5.2 mm, followed by Qmode at 4.3 mm, Qmode+ at 3.1 mm, and TactiCath at 2.8 mm. Ablation at the SVC near the phrenic nerve led to sudden injury at t-T ≥ 50°C in all four settings. The esophageal adventitia injury was least deep with Qmode+ ablation (0.4 ± 0.1 vs. 0.8 ± 0.4 mm for Qmode, 0.9 ± 0.3 mm for TactiCath, and 1.1 ± 0.5 mm for STSF, respectively; p = .005), correlating with T<sub>max</sub> .<br /><b>Conclusion</b><br />This study revealed distinct tissue temperature patterns during HSPD and vHPSD ablations with the three catheters, affecting lesion effectiveness and collateral damage based on T<sub>max</sub> and/or t-T ≥ 50°C. These findings provide key insights into the safety and efficacy of AF ablation with these four settings.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 05 Oct 2023; epub ahead of print</small></div>

<div><h4>Quantitative assessment of transient autonomic modulation after single-shot pulmonary vein isolation with pulsed-field ablation.</h4><i>Del Monte A, Cespón Fernández M, Vetta G, Della Rocca DG, ... Chierchia GB, de Asmundis C</i><br /><b>Introduction</b><br />Pulmonary vein isolation (PVI) with thermal energy is characterized by concomitant ablation of the surrounding ganglionated plexi (GP). Pulsed-field ablation (PFA) selectively targets the myocardium and seems associated with only negligible effects on the autonomic nervous system (ANS). However, little is known about the dynamic effects of PFA on the GP immediately after PVI. This study sought to investigate the degree and acute vagal modulation induced by the Farapulse<sup>TM</sup> PFA system during PVI compared with single-shot thermal ablation.<br /><b>Methods</b><br />A total of 76 patients underwent first-time PVI with either Farapulse<sup>TM</sup> PFA (PFA group, n = 40) or cryoballoon ablation (thermal ablation group, n = 36) for paroxysmal atrial fibrillation (AF). The effect on the ANS in the two groups was assessed before and after PVI with extracardiac vagal stimulation (ECVS). To capture any transient effects of PFA on the ANS, in a subgroup of PFA patients ECVS was repeated at three predefined timepoints: (1) before PVI (T0); (2) immediately after PVI (T1); and (3) 10 min after the last energy application (T2).<br /><b>Results</b><br />Despite similar baseline values, the vagal response induced by ECVS after PVI almost disappeared in the thermal ablation group but persisted in the PFA group (thermal group: 840 [706-1090] ms, p < .001 compared to baseline; PFA group: 11 466 [8720-12 293] ms, p = .70 compared to baseline). Intraprocedural vagal reactions (defined as RR increase >50%, transitory asystole, or atrioventricular block) occurred more frequently with PFA than thermal ablation (70% vs. 28%, p = .001). Moreover, heart rate 24 h post-PVI increased more with thermal ablation than with PFA (16.5 ± 9.0 vs. 2.6 ± 6.1 beats/min, p < .001). In the subgroup of PFA patients undergoing repeated ANS modulation assessment (n = 11), ECVS demonstrated that PFA determined a significant acute suppression of the vagal response immediately after PVI (p < .001 compared to baseline), which recovered almost completely within 10 min.<br /><b>Conclusion</b><br />PVI with the Farapulse<sup>TM</sup> PFA system is associated with only transitory and short-lasting vagal effects on the ANS which recover almost completely within a few minutes after ablation. The impact of this phenomenon on AF outcome needs to be further investigated.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 04 Oct 2023; epub ahead of print</small></div>

<div><h4>Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome.</h4><i>Okamatsu H, Okumura K, Onishi F, Yoshimura A, ... Sakamoto T, Koyama J</i><br /><b>Introduction</b><br />Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection.<br /><b>Methods</b><br />Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167).<br /><b>Results</b><br />FPI in both PV sides in the first ablation procedure was significantly more frequent in the PV non-reconnection group (77.5%) than in the PV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in the PV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in the PV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test).<br /><b>Conclusion</b><br />FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Effects of parameters on radiofrequency guidewire ablation: In vitro and in vivo experiments.</h4><i>Zuo Z, Li S, Xuan F, Zhang J, ... Liang M, Wang Z</i><br /><b>Background</b><br />A novel ablation technique with guidewire has emerged as a promising approach for mapping and ablation of arrhythmias originating from left ventricular summit. However, its biophysical characteristics have not been fully clarified.<br /><b>Methods and results</b><br />In the in vitro experiment, guidewire ablation (GA) was performed in vessel models of 1.17 and 2.24 mm to determine the maximum safety power. Then with the maximum safety power, the predictive value of generator impedance (GI) drop on lesion radius was explored. In the in vivo experiment, the feasibility of the maximum safety power and lesion formation was verified in the living swine. It was found that in both groups, the incidence of steam pops increased along with the raise of ablation power, and the maximum safety power was 10 W for the 1.17-mm group and 15 W for the 2.24-mm group. There was a strong linear correlation between GI drop and maximum lesion radius (in 1.17 mm-10-W group: r = .961; in 2.24 mm-15-W group: r = .918). In the in vivo experiment, besides ventricular fibrillation happened once, no other complications were observed, and lesions were found at both 48-h and 8-week groups.<br /><b>Conclusions</b><br />The safety power of GA should be adjusted according to the diameter of the vessel. Besides, the GI drop can predict the lesion radius during GA.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Intracardiac thrombi fluttering like hair in the wind at VT ablation.</h4><i>Hasegawa K, Powers EM, Yoneda ZT, Richardson TD, Stevenson WG</i><br /><b>Introduction</b><br />Intracardiac echocardiography (ICE) reveals mobile thrombus on implantable electronic device leads in some patients undergoing electrophysiologic procedures.<br /><b>Methods</b><br />ICE was performed in a patient undergoing ventricular tachycardia (VT) ablation.<br /><b>Results</b><br />ICE showed extensive mobile thrombi on the implantable cardioverter defibrillator lead. Radiofrequency catheter ablation of VT from perimitral scar was safely performed via a retrograde aortic approach. After the procedure, chronic anticoagulation was initiated. CT-angiography of the chest 2 months later showed no pulmonary emboli.<br /><b>Conclusions</b><br />The significance of these thrombi, as related to chronic pulmonary embolization, warrants further study.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>The effect of weight loss on recurrence of atrial fibrillation after catheter ablation: A systematic review and meta-analysis.</h4><i>Akhtar KH, Jafry AH, Beard C, Nasir YM, ... Sanders P, Asad ZUA</i><br /><b>Background</b><br />Obesity is associated with an increased risk of developing recurrent atrial fibrillation (AF) after catheter ablation (CA). However, the current data on weight loss interventions show inconsistent results in preventing the recurrence of AF after CA.<br /><b>Methods</b><br />We conducted a systematic search in MEDLINE and EMBASE to identify studies that reported the outcome of recurrence of AF after CA in obese patients undergoing weight interventions. The subgroup analysis included: (1) Weight loss versus no weight loss, (2) >10% weight loss versus <10% weight loss, (3) <10% weight loss versus no weight loss, (4) Follow-up <12 months, and (5) Follow-up >12 months after CA. Mantel-Haenszel risk ratios with a 95% confidence interval (CI) were calculated using a random effects model and for heterogeneity, I<sup>2</sup> statistics were reported.<br /><b>Results</b><br />A total of 10 studies (one randomized controlled trial and nine observational studies) comprising 1851 patients were included. The recurrence of AF was numerically reduced in the weight loss group (34.5%) versus no weight loss group (58.2%), but no statistically significant difference was observed (risk ratio [RR] = 0.76; 95% CI: 0.49-1.18, p = .22). However, there was a statistically significant reduction in recurrence of AF with weight loss versus no weight loss at follow-up >12 months after CA (RR = 0.47; 95% CI: 0.32-0.68, p < .0001). At follow-up >12 months after CA, both >10% weight loss versus <10% weight loss (RR = 0.49; 95% CI: 0.31-0.80, p = .004) and <10% weight loss versus no weight loss (RR = 0.39; 95% CI: 0.31-0.49, p < .00001) were associated with a statistically significant reduction in recurrent AF.<br /><b>Conclusion</b><br />In patients with AF undergoing CA, weight loss is associated with reducing recurrent AF at > 12 months after ablation and these benefits are consistently seen with both >10% and <10% weight loss. The benefits of weight loss in preventing recurrent AF after CA should be examined in larger studies with extended follow-up duration.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Anteroseptal accessory pathways: Killing one bird with two stones.</h4><i>Abdelrahim E, Miller J, Maskoun W</i><br /><b>Background:</b><br/>and aims</b><br />Ablation of anteroseptal accessory pathways (AS-AP) is challenging, with lower success and more complications compared to other APs. AS-APs can be successfully ablated from the right atrium (RA) or the aortic valve\'s noncoronary cusp (NCC). We report two patients who required a hybrid ablation approach to achieve successful abolition of both anterograde and retrograde AS-AP conduction.<br /><b>Methods and results</b><br />A 21-year-old female with supraventricular tachycardia (SVT) and pre-excitation on electrocardiogram (ECG) underwent electrophysiology study (EPS) confirming an AS-AP with anterograde and retrograde conduction. Ablation in the NCC achieved immediate and persistent anterograde conduction block. Electrophysiological maneuvers showed persistent retrograde AP conduction and orthodromic reciprocating tachycardia (ORT) remained easily inducible. Additional ablation in the NCC did not eliminate retrograde conduction. Further ablation in the RA opposite the NCC at the site of earliest retrograde atrial activation during ORT restored sinus and eliminated retrograde AP conduction. A 52-year-old male with SVT and ECG with pre-excitation underwent EPS that confirmed an AS-AP with anterograde and retrograde conduction. Ablation was performed in the NCC resulting in immediate elimination of pre-excitation. Retrograde conduction was still present and confirmed by repeating electrophysiological maneuvers. Ablation was performed in the RA opposite the successful ablation site in the NCC, eliminating retrograde AP conduction.<br /><b>Conclusion</b><br />Two cases of AS-AP with anterograde and retrograde conduction and successful elimination of pathway conduction required a hybrid ablation approach from the NCC and RA. This approach may be helpful in other cases to improve success rates without using excessive ablation near the normal conduction system.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 03 Oct 2023; epub ahead of print</small></div>

<div><h4>Combined pulsed field ablation with ultra-low temperature cryoablation: A preclinical experience.</h4><i>Verma A, Feld GK, Cox JL, Dewland TA, ... Raju N, Haissaguerre M</i><br /><b>Background</b><br />Combining pulsed field ablation (PFA) with ultra-low temperature cryoablation (ULTC) represents a novel energy source which may create more transmural cardiac lesions. We sought to assess the feasibility of lesions created by combined cryoablation and pulsed field ablation (PFCA) versus PFA alone.<br /><b>Methods</b><br />Ablations were performed using a custom PFA generator, ULTC console, and an ablation catheter with insertable stylets. PFA was delivered in a biphasic, bipolar train. PFCA precooled the tissue for 30 s followed by a concurrent PFA train. Benchtop testing using Schlieren imaging and microbubble volume assessment were used to compare PFA and PFCA. PFA and PFCA lesions using pre-optimized and optimized ablation protocols were studied in 6 swine. Pre and post-ECGs were recorded for each ablation and a gross necropsy was performed at 14 days.<br /><b>Results</b><br />Consistent with benchtop comparisons of heat and microbubble generation, PFA deliveries in the animals were accompanied by muscle contractions and significant microbubbles (Grade 2-3) visible on intracardiac echo while neither occurred during PFCA at higher voltage levels. Both PFA and PFCA acutely eliminated or highly attenuated (>80%) local atrial electrograms. Histology of PFA and PFCA lesions indicated depth up to 6-7 mm and nearly all lesions were transmural. Optimized PFCA produced wider cavotricuspid isthmus lesions with evidence of tissue selectivity.<br /><b>Conclusion</b><br />A novel technology combining PFA and ULTC into one energy source demonstrated in-vivo feasibility for PFCA ablation. PFCA had a more favorable thermal profile and did not produce muscle contraction or microbubbles while extending lesion depth beyond cryoablation.<br /><br />© 2022 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Oct 2023; 34:2124-2133</small></div>

<div><h4>Atrial fibrillation recurrences during the blanking period after catheter ablation with the laser balloon technique.</h4><i>Schiavone M, Gasperetti A, Martignani C, Montemerlo E, ... Rovaris G, Forleo GB</i><br /><b>Introduction</b><br />Regardless of the catheter ablation (CA) for atrial fibrillation (AF) strategy, the role of early recurrences during the blanking period (BP) is still unclear. Our aim was to evaluate atrial tachyarrhythmias (ATAs) recurrences during the BP after CA with the laser-balloon (LB) technique.<br /><b>Methods</b><br />Consecutive patients undergoing LBCA were enrolled. Primary outcome of the study was the overall crude ATA recurrence rate during the BP. ATA recurrences after the BP and in-hospital readmissions during the BP were deemed secondary outcomes.<br /><b>Results</b><br />Two hundred and twenty-four patients underwent CA with the LB. Median age was 63.0 (55.5-69.5) years and 74.1% were males. 28.6% were persistent AF patients, and 34.8% of patients were followed up with a loop recorder. 15.6% of patients experienced at least an ATA recurrence during the BP. Male sex, chronic heart failure, persistent AF, and recurrences during the BP were found to be associated with long-term ATA recurrences. Recurrences during the BP remained associated with the outcome of interest at multivariate analysis (hazard ratio [HR] = 12.393, 95% confidence interval [95% CI] = 3.699-41.865, p < .001). An association over time was found between early and late recurrences, with 73.7%, 45.5%, and 10.8% of patients presenting with recurrences at 1-, 2-, and 3-month follow-up being free from recurrences after the BP, respectively. 8.0% of patients were readmitted during the BP: 4.5% for AF electrical cardioversion, and 1.8% for CA of other atrial arrhythmias; no redo CA was performed.<br /><b>Conclusion</b><br />After adjusting for confounders, ATA recurrences during the BP represent the most significant predictor of ATA recurrences after the BP, regardless of AF pattern.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>Effectiveness of conduction system pacing for cardiac resynchronization therapy: A systematic review and network meta-analysis.</h4><i>Tavolinejad H, Kazemian S, Bozorgi A, Michalski R, ... Sedding D, Arya A</i><br /><b>Introduction</b><br />Cardiac resynchronization therapy (CRT) with biventricular pacing (BiV-CRT) is ineffective in approximately one-third of patients. CRT with Conduction system pacing (CSP-CRT) may achieve greater synchronization. We aimed to assess the effectiveness of CRT with His pacing (His-CRT) or left bundle branch pacing (LBB-CRT) in lieu of biventricular CRT.<br /><b>Methods and results</b><br />The PubMed, Embase, Web of Science, Scopus, and the Cochrane Library were systematically searched until August 19, 2023, for original studies including patients with reduced left ventricular ejection fraction (LVEF) who received His- or LBB-CRT, that reported either CSP-CRT success, LVEF, QRS duration (QRSd), or New York Heart Association (NYHA) classification. Effect measures were compared with frequentist network meta-analysis. Thirty-seven publications, including 20 comparative studies, were included. Success rates were 73.5% (95% CI: 61.2-83.0) for His-CRT and 91.5% (95% CI: 88.0-94.1) for LBB-CRT. Compared to BiV-CRT, greater improvements were observed for LVEF (mean difference [MD] for His-CRT +3.4%; 95% CI [1.0; 5.7], and LBB-CRT: +4.4%; [2.5; 6.2]), LV end-systolic volume (His-CRT:17.2mL [29.7; 4.8]; LBB-CRT:15.3mL [28.3; 2.2]), QRSd (His-CRT: -17.1ms [-25.0; -9.2]; LBB-CRT: -17.4ms [-23.2; -11.6]), and NYHA (Standardized MD [SMD]: His-CRT:0.4 [0.8; 0.1]; LBB-CRT:0.4 [-0.7; -0.2]). Pacing thresholds at baseline and follow-up were significantly lower with LBB-CRT versus both His-CRT and BiV-CRT. CSP-CRT was associated with reduced mortality (R = 0.75 [0.61-0.91]) and hospitalizations risk (RR = 0.63 [0.42-0.96]).<br /><b>Conclusion</b><br />This study found that CSP-CRT is associated with greater improvements in QRSd, echocardiographic, and clinical response. LBB-CRT was associated with lower pacing thresholds. Future randomized trials are needed to determine CSP-CRT efficacy.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>Early recurrences predict late therapy failure after pulsed field ablation of atrial fibrillation.</h4><i>Plank K, Bordignon S, Urbanek L, Chen S, ... Chun KRJ, Schmidt B</i><br /><b>Introduction</b><br />Pulsed field ablation (PFA) is a new ablation technology for atrial fibrillation (AF). Data regarding early recurrences of atrial tachyarrhythmia (ERAT) after PFA-pulmonary vein isolation (PVI) are sparse.<br /><b>Methods</b><br />Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI. A dedicated catheter delivering bipolar energy (1.9-2.0 kV) was used. Late recurrence (LR) was defined as documented AF/atrial tachycardia (AT) lasting more than 30 s after a 90-day blanking period.<br /><b>Results</b><br />Two hundred and thirty-one patients (42% female, age 69 ± 12, 55% paroxysmal AF [PAF]) were included in this analysis. Median follow-up time was 367 days (interquartile range: 253-400). Forty-six patients (21%) experienced ERAT after a median of 23 days (46% in PAF and 54% in persistent AF [persAF]). Kaplan-Meier estimated freedom of AF/AT was 74.2% at 1 year, 81.8% for PAF, and 64.8% for persAF (p = .0079). Of patients experiencing ERAT, an LR was observed in 54%. There was no significant difference of LR between those who presented with very early ERAT (0-45 days) and those with ERAT (46-90 days) (p = .57). In multivariate analysis, ERAT (hazard ratio [HR]: 3.370; 95% confidence interval [95% CI]: 1.851-6.136; p < .001) and female sex (HR: 2.048; 95% CI: 1.114-3.768; p = .021) were the only independent predictors for LR.<br /><b>Conclusions</b><br />ERAT could be recorded in 21% of patients after PFA-PVI and was an independent predictor for LR. We found no difference in the rate of LRs among patients experiencing ERAT before or after 45 days.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>Robotic magnetic navigation-guided catheter ablation establishes highly effective pulmonary vein isolation in patients with paroxysmal atrial fibrillation when compared to conventional ablation techniques.</h4><i>Noten AME, Romanov A, De Schouwer K, Beloborodov V, ... Schwagten B, Szili-Torok T</i><br /><b>Introduction</b><br />Pulmonary vein isolation (PVI) is a pivotal part of ablative therapy for atrial fibrillation (AF). Currently, there are multiple techniques available to realize PVI, including: manual-guided cryoballoon (MAN-CB), manual-guided radiofrequency (MAN-RF), and robotic magnetic navigation-guided radiofrequency ablation (RMN-RF). There is a lack of large prospective trials comparing contemporary RMN-RF with the more conventional ablation techniques. This study prospectively compared three catheter ablation techniques as treatment of paroxysmal AF.<br /><b>Methods</b><br />This multicenter, prospective study included patients with paroxysmal AF who underwent their first ablation procedure. Procedural parameters (including procedural efficiency), complication rates, and freedom of AF during 12-month follow-up, were compared between three study groups which were defined by the utilized ablation technique.<br /><b>Results</b><br />A total of 221 patients were included in this study. Total procedure time was significantly shorter in MAN-CB (78 ± 21 min) compared to MAN-RF (115 ± 41 min; p < .001) and compared to RMN-RF (129 ± 32 min; p < .001), whereas it was comparable between the two radiofrequency (RF) groups (p = .062). A 3% complication rate was observed, which was comparable between all groups. At 12-month follow-up, AF recurrence was observed in 40 patients (19%) and was significantly lower in the robotic group (MAN-CB 19 [24%], MAN-RF 16 [23%], RMN-RF 5 [8%] AF recurrences, p = .045) (multivariate hazard ratio of RMN-RF on AF recurrence 0.32, 95% confidence interval: 0.12-0.87, p = .026).<br /><b>Conclusion</b><br />RMN-guided PVI results in high freedom of AF in patients with paroxysmal AF, when compared to cryoablation and manual RF ablation. Cryoablation remains the most time-efficient ablation technique, whereas RMN nowadays has comparable efficiency with manual RF ablation.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 28 Sep 2023; epub ahead of print</small></div>

<div><h4>How to perform effective cryoballooon ablation of the left atrial roof: Considerations after experiencing more than 1000 cases.</h4><i>Shigeta T, Okishige K, Murata K, Oda A, ... Sasano T, Yamauchi Y</i><br /><b>Introduction</b><br />Cryoballoon ablation (CBA) of the left atrial (LA) roof in addition to a pulmonary vein isolation has been expected to improve the clinical outcomes post-atrial fibrillation (AF) ablation. We demonstrated the characteristics and efficacy of CBA of the LA roof through our experience with a large volume of procedures.<br /><b>Methods</b><br />Among 1036 AF ablation procedures with CBA of the LA roof, 834 patients who underwent a de novo ablation were analyzed.<br /><b>Results</b><br />Complete LA roof line conduction block was obtained in 767 patients (92.0%) solely by CBA (Group A). Compared with the other patients (Group B), the mean nadir balloon temperature during CBA of the LA roof (-44.5 ± 5.6°C for Group A vs. -40.5 ± 7.5°C for Group B, p < .01) and number of cryoballoon applications during the LA roof ablation with a circular mapping catheter located in the left superior pulmonary vein (1.3 ± 0.8 for Group A vs. 1.6 ± 1.0 for Group B, p = .02) were significantly lower in Group A. A multivariate analysis revealed that those were predictors of a complete LA roof conduction block after only CBA. The 1-year Kaplan-Meier atrial arrhythmia free rate estimates were 80.6% for Group A and 59.0% for Group B (p < .01).<br /><b>Conclusion</b><br />Complete LA roof line conduction block could be obtained with a cryoballoon without touch-up ablation in most cases. The LA roof CBA with a circular mapping catheter located in the right superior pulmonary vein was preferable to obtaining complete LA roof conduction block, which was important with regard to the clinical outcomes.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 26 Sep 2023; epub ahead of print</small></div>

<div><h4>Catheter ablation approach and outcome in HIV+ patients with recurrent atrial fibrillation.</h4><i>La Fazia VM, Pierucci N, Mohanty S, Gianni C, ... Di Biase L, Natale A</i><br /><b>Introduction</b><br />Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients.<br /><b>Methods</b><br />This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge.<br /><b>Results</b><br />Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found.<br /><b>Conclusion</b><br />Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 25 Sep 2023; epub ahead of print</small></div>

<div><h4>Current and novel percutaneous epicardial access techniques for electrophysiological interventions: A comparison of procedural success and safety.</h4><i>Tonko JB, Lambiase PD</i><br /><AbstractText>Accessing the pericardial space safely and efficiently is an important skill for interventional cardiac electrophysiologist. With the increased recognition of the complexity of the 3-dimensional arrhythmogenic substrate due to advances in imaging and mapping technologies there has been an expansion of epicardial procedures in recent years. Equally, minimally invasive implantation of epicardial pacing, cardiac resynchronization, or defibrillation leads is expanding in specific patients where transvenous systems are contraindicated or their long term sequelae should be ideally avoided. Selective delivery of intrapericardial pharmacological antiarrhythmic therapy is yet another potential indication, albeit still investigational. The expanding indications for percutaneous epicardial procedures is contrasted by the still substantial risk and challenges associated with accessing the pericardial space. Myocardial perforation, coronary artery laceration, and damage to the surrounding organs are all recognized and feared complications. A number of innovative epicardial access techniques have been proposed to overcome the difficulties and risks of traditional dry subxiphoid punctures and may allow for more widespread use of epicardial access in the future. We review 10 different established and novel subxiphoidal epicardial access techniques describing procedural success rates, safety profile and overall experience. The technical aspects as well as access times and costs for extra equipment will be reviewed. Finally, an outlook of reported preclinical techniques awaiting in-human feasibility studies is provided.</AbstractText><br /><br />©2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 21 Sep 2023; epub ahead of print</small></div>

<div><h4>Outcomes of leadless pacemaker implantation after cardiac surgery and transcatheter structural valve interventions.</h4><i>Huang J, Bhatia NK, Lloyd MS, Westerman S, ... El-Chami MF, Merchant FM</i><br /><b>Introduction</b><br />Permanent pacing indications are common after cardiac surgery and transcatheter structural valve interventions. Leadless pacemakers (LPs) have emerged as a useful alternative to transvenous pacemakers. However, current commercially available LPs are unable to provide atrial pacing or cardiac resynchronization and relatively little is known about LP outcomes after cardiac surgery and transcatheter valve interventions.<br /><b>Methods</b><br />This retrospective study included patients who received a Micra VR (Micra<sup>TM</sup> MC1VR01) or Micra AV (Micra<sup>TM</sup> MC1AVR1) (Medtronic) leadless pacemaker following cardiac surgery or transcatheter structural valve intervention between September 2014 and September 2022. Device performance and clinical outcomes, including ventricular pacing burden, ejection fraction, and need for conversion to transvenous pacing systems, were evaluated during follow-up.<br /><b>Results</b><br />A total of 78 patients were included, of whom 40 received a Micra VR LP implant, and 38 received a Micra AV LP implant. The mean age of the cohort was 65.9 ± 17.9 years, and 48.1% were females. The follow-up duration for the entire cohort was 1.3 ± 1.1 years: 1.6 ± 1.3 years for the Micra VR group and 0.8 ± 0.5 years for the Micra AV group. Among the cohort, 50 patients had undergone cardiac surgery and 28 underwent transcatheter structural valve interventions. Device electrical performance was excellent during follow-up, with a small but clinically insignificant increase in ventricular pacing threshold and a slight decrease in pacing impedance. The mean right ventricle pacing (RVP) burden significantly decreased over time in the entire cohort (74.3% ± 37.2% postprocedure vs. 47.7% ± 40.6% at last follow-up, p < .001), and left ventricle ejection fraction (LVEF) showed a modest but significant downward trend during follow-up (55.0% ± 10.6% vs. 51.5% ± 11.2% p < .001). Patients with Micra VR implants had significantly reduced LVEF during follow-up (54.1% ± 11.9% vs. 48.8% ± 11.9%, p = .003), whereas LVEF appeared stable in the Micra AV group during follow-up (56.1% ± 9.0% vs. 54.6% ± 9.7%, p = .06). Six patients (7.7%) required conversion to transvenous pacing systems, four who required cardiac resynchronization for drop in LVEF with high RVP burden and two who required dual-chamber pacemakers for symptomatic sinus node dysfunction.<br /><b>Conclusion</b><br />Leadless pacemakers provide a useful alternative to transvenous pacemakers in appropriately selected patients after cardiac surgery and transcatheter structural valve interventions. Device performance is excellent over medium-term follow-up. However, a significant minority of patients require conversion to transvenous pacing systems for cardiac resynchronization or atrial pacing support, demonstrating the need for close electrophysiologic follow-up in this cohort.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Antidromic and orthodromic reciprocating tachycardias over a novel left-sided accessory pathway involving the vein of Marshall and coronary sinus musculature.</h4><i>Kanzaki Y, Morishima I, Miyazawa H, Shimojo K</i><br /><b>Introduction</b><br />Herein, we present a rare case of the successful ablation of an accessory pathway (AP) involving the Marshall Bundle (MB) and coronary sinus musculature (CSM) in a 40-year-old man with Wolff-Parkinson-White syndrome.<br /><b>Methods and results</b><br />An orthodromic reciprocating tachycardia (ORT) was inducible with the earliest atrial activation site located at the posterolateral mitral annulus. The local conduction and the cycle length of ORT was prolonged by peri-mitral ablation; however, it failed to block the AP. The atrial insertion of the AP was identified by remapping during ORT at the left atrial ridge, which was away from the mitral annulus, where ablation was successful. Together with the electrophysiological findings in CSM potentials, we conclude that the epicardial MB-CSM connection functioned as the AP in this patient.<br /><b>Conclusion</b><br />The novel variant form of AP comprised of MB and CSM should be noted. The atrial insertion of the MB may be the target of catheter ablation.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 20 Sep 2023; epub ahead of print</small></div>

<div><h4>Predictors and possible mechanisms of premature ventricular contraction induced cardiomyopathy.</h4><i>Pundi K, Marcus GM</i><br /><AbstractText>Premature ventricular complexes (PVCs) are encountered frequently in clinical practice. While PVCs may have various causes, a small number of individuals with PVCs develop cardiomyopathy in the absence of other potential etiologies. When correctly identified, patients with PVC-incuded cardiomyopathy can have dramatic improvement of their cardiomyopathy with treatment of their PVCs. In this focused review, we discuss potential predictors of PVC-induced cardiomyopathy, including PVC frequency, PVC characteristics, and modifiable patient risk factors. We also review some proposed mechanisms of PVC-induced cardiomyopathy and conclude with future directions for research and clinical practice.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 19 Sep 2023; epub ahead of print</small></div>

<div><h4>Feasibility and safety of left bundle branch area pacing in patients with septal hypertrophy.</h4><i>Özpak E, Van Heuverswyn F, Timmermans F, De Pooter J</i><br /><b>Introduction</b><br />Left bundle branch area pacing (LBBAP) aims to provide physiological ventricular activation during pacing. Left ventricular septal hypertrophy (LVSH) might be challenging for LBBAP due to the thickness of the interventricular septum and potential presence of septal scar. This study assesses the feasibility, safety, and outcome of LBBAP in patients with LVSH using primarily stylet-driven leads (SDL).<br /><b>Methods</b><br />Adult patients with LVSH who underwent LBBAP between March 2019 and November 2022 were enrolled. Baseline patient characteristics, procedural data and postprocedural results were collected. The feasibility of LBBAP in LVSH patients was compared to a cohort of LBBAP patients with normal septal wall thickness (NST).<br /><b>Results</b><br />Seventeen LVSH and 133 NST patients underwent LBBAP with successful implantation achieved in 15 LVSH patients (88%). Mean implant depth was 17.2 ± 1.9 mm, with 53% proven left bundle branch (LBB) capture. Paced QRS duration (146 ± 14 ms) and V6 R-wave peak time (V6 RWPT; 79 ± 20 ms) were comparable between patients with and without septal hypertrophy, although patients with NST had higher rates of proven LBB capture (71% vs. 53%). In LVSH pacing thresholds (0.6 ± 0.3 V at 0.4 ms) and R-wave amplitude (13.9 ± 5.6 mV) were favorable and remained stable at follow-up. At 12 months, 87% of patients had stable or improved left ventricular ejection fraction.<br /><b>Conclusion</b><br />The results of the study indicate that LBBAP in patients with LVSH is safe and feasible and no lead-related complications were observed despite a mean implant depth exceeding 15 mm. LBBAP using SDL results in favorable pacing and electrocardiographic characteristics in LVSH patients, comparable to patients with NST.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 17 Sep 2023; epub ahead of print</small></div>

<div><h4>Isolated JUP plakoglobin gene mutation with left ventricular fibrosis in familial arrhythmogenic right ventricular cardiomyopathy.</h4><i>Zinkovsky D, Sood MR</i><br /><b>Introduction</b><br />Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a rare inherited disorder usually affecting the right ventricle (RV), characterized by fibro-fatty tissue replacement of the healthy ventricular myocardium. It often predisposes young patients to ventricular tachycardia, heart failure, and/or sudden cardiac death. However, recent studies have suggested predominantly left ventricle (LV) involvement with variable and/or atypical manifestations. Cardiac magnetic resonance (CMR) imaging has emerged as the noninvasive gold standard for the diagnosis of ARVC.<br /><b>Case summary</b><br />A 21-year-old athletic male with a family history of unknown ventricular arrhythmias, presented with near syncope, chest pain, and exertional palpitations. He had an initial work-up that was grossly unremarkable including an electrocardiogram (ECG), echocardiogram and a CMR study. Six months later, he presented again with recurrent symptoms of presyncope during exercise and his ECG demonstrated new findings of a terminal activation delay in his precordial leads. He had markedly elevated cardiac biomarkers, (troponin I > 100 ng/dl, normal value < 0.04 ng/dl) and demonstrated ventricular tachycardia with a right bundle branch morphology. An endomyocardial biopsy did not reveal any pathology. A follow-up CMR demonstrated the new development and prominent left ventricular epicardial scar in the lateral wall. The patient underwent familial genetic testing, which confirmed the presence of an isolated junction plakoglobin (JUP) gene mutation and showed multiple genes consistent with ARVC in his mother. Thus, he manifested a partial transmission of only one abnormal gene for ARVC and exhibited a markedly different expression in his disease without evidence of typical right-sided heart pathology. A third CMR study was performed, which showed partial improvement in myocardial fibrosis after exercise cessation.<br /><b>Conclusion</b><br />We present a case of a young athletic male with a newly diagnosed isolated JUP gene mutation and a genetically diagnosed family history of ARVC. During his course, he demonstrated the progression of new, atypical, left ventricular fibrosis. This case demonstrates a complex interplay between genetic penetrance, phenotypical heterogeneity, and lifestyle factors such as exercise in disease progression and provides insight into the natural course of an isolated JUP mutation. Although rare, clinicians should have a high threshold for the clinical suspicion of ARVC or variants of this disorder even in the absence of classic right-sided pathologies.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 17 Sep 2023; epub ahead of print</small></div>

<div><h4>Unidirectional conduction characterizing epicardial connections in patients with atrial tachyarrhythmias.</h4><i>Yoshida K, Hasebe H, Hattori M, Hanaki Y, ... Nogami A, Takeyasu N</i><br /><b>Introduction</b><br />Electrophysiological characteristics of epicardial connections (ECs) in atria and pulmonary veins (PVs) are unclear despite their important contributions to atrial fibrillation (AF). Unidirectional conduction associated with source-sink mismatch can occur in ECs due to their fine fibers with abrupt changes in orientation. We detailed the prevalence and electrophysiological characteristics of unidirectional conduction in the atria and investigated its association with the clinical manifestation of AF.<br /><b>Methods</b><br />This study retrospectively reviewed electrophysiological studies and radiofrequency catheter ablation in 261 consecutive patients with AF.<br /><b>Results</b><br />Unidirectional conduction was observed during ablation encircling the PVs in eight (3.1%) patients, and all occurred in the suspected (N = 4) or definitively (N = 4) recognized ECs. These ECs included three intercaval bundles, four septopulmonary bundles, and one Marshall bundle, and were first manifested in a second procedure in 6 (75%) patients. The unidirectional property was from PV to atrium (exit conduction) in all intercaval bundles and three septopulmonary bundles, and from atrium to PV (entrance conduction) in the remaining two bundles. Intercaval bundles acted as a limb of bi-atrial macro-reentrant tachycardia (50%, three of the six including previous cases). Ablation of the exit outside the PVs, including the right atrium, eliminated ECs in three (38%) patients. All patients remain free from arrhythmia recurrence after a mean 13-month follow-up.<br /><b>Conclusion</b><br />A unidirectional conduction property was closely associated with the EC, as estimated by histological findings. Recognition of this fact by electrophysiologists may help to clarify mechanisms for AF and atrial tachycardia and guide the creation of efficient and safe ablation lesion sets.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Possible systolic fascicular potentials in patients with left bundle branch block undergoing left bundle branch area pacing: A case series.</h4><i>Coluccia G, Accogli M, Parlavecchio A, Palmisano P</i><br /><b>Introduction</b><br />In left bundle branch area pacing (LBBAP), several methods allow determination of lead depth during active fixation inside the septum: among these, visualization of a Purkinje potential indicates that the subendocardial area has been reached. In LBB block (LBBB) patients, fascicular potentials are visible as presystolic only in rare conditions.<br /><b>Methods and results</b><br />Since October 2022 until August 2023, LBBAP was attempted in 21 patients with LBBB at our Center: among the 18 consecutive patients (86%) in which it was successful, focusing on the terminal part of the unipolar ventricular electrogram (VEGM) recorded in the LBBA (where fixation beats occurred and conduction system (CS) capture was confirmed), we always observed discrete high-frequency, low-amplitude signals during spontaneous rhythm with LBBB morphology, showing a consistent coupling with the QRS onset, falling in a portion of QRS interval ranging from 58% to 80% of its overall duration, and disappearing during pacing. As found in a recently published case report, these sharp signals could represent the activation of left ventricular CS fibers, occurring passively from the septal working myocardium, and thus appearing lately in the VEGM.<br /><b>Conclusion</b><br />The possibility of recognizing discrete high-frequency, low-amplitude signals within the terminal portion of the unipolar VEGM, possibly representing left CS potentials, even in patients with LBBB, may constitute a useful additional means to notice operators about having reached the LBBA, thus helping to avoid perforation in the left ventricle.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Novel approaches for leadless pacemaker implantation in the extra-cardiac Fontan cohort: Options to avoid leaded systems or epicardial pacing.</h4><i>Goulden CJ, Khanra D, Llewellyn J, Rao A, Evans A, Ashrafi R</i><br /><b>Background</b><br />Fontan surgery, a palliative procedure for single ventricle patients, often leads to the need for permanent pacing. Epicardial pacing has limitations, while transvenous pacing carries risks in the Fontan circulation. This case series introduces a novel approach of leadless pacemaker implantation in the extra-cardiac Fontan (ECF) cohort to overcome these limitations.<br /><b>Methods</b><br />The study includes four cases of leadless pacemaker (Micra™) implantation in patients with ECF. Procedures were performed under general anesthesia with guidance from trans-esophageal echocardiography. Various access routes were used, including trans-carotid and trans-fenestration approaches. Procedural details, parameters, and follow-up data were collected.<br /><b>Results</b><br />All leadless pacemaker implantations were successful, with satisfactory electrical parameters and stable pacing postprocedural outcomes during short-term follow-up. One patient required closure of their fenestration for symptomatic desaturation post procedurally.<br /><b>Conclusions</b><br />Leadless pacemaker implantation via trans-carotid and trans-fenestration approaches appears to be a feasible back up option for pacing in Fontan patients where other options have been exhausted or there is a patient choice to avoid surgery. These techniques provide an option to avoid leaded systems or epicardial pacing, reducing the need for multiple thoracotomies and addressing challenges associated with surgical pacing leads. Further studies are needed to evaluate long-term outcomes and assess the broader application of leadless pacemakers in the Fontan population.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Pulsed field ablation for pulmonary vein isolation: Preclinical safety and effectiveness of a novel hexaspline ablation catheter.</h4><i>Yu F, Dong X, Ding L, Reddy V, Tang M</i><br /><b>Background</b><br />Pulsed-field ablation (PFA) has emerged as a nonthermal energy source for cardiac ablation, with potential safety advantages over radiofrequency ablation (RFA) and cryoballoon ablation.<br /><b>Objective</b><br />To report the preclinical results of a novel hexaspline PFA catheter for pulmonary vein isolation (PVI), and to verify the influence of PFA on esophagus by comparing with RFA.<br /><b>Methods</b><br />This study included a total of 15 canines for the efficacy and safety study and four swine for the esophageal safety study. The 15 canines were divided into an acute cohort (n = 3), a 30-day follow-up cohort (n = 5) and a 90-day follow-up cohort (n = 7), PVI was performed with the novel hexaspline PFA ablation catheter. In the esophageal safety study, four swine were divided into PFA cohort (n = 2) and RFA cohort (n = 2), esophageal injury swine model was adopted, the esophagus was intubated with an esophageal balloon retractor, under fluoroscopy, the DV8 device was inflated with a mixture of saline and contrast and rotated to displace the esophagus rightward and anteriorly toward the ablation catheter in the inferior vena cava (IVC) and right inferior pulmonary vein (PV). Nine PFA applications were delivered at four locations on IVC and two locations on the right inferior PV in the PFA cohort, six RFA applications were delivered at each location in the RFA group. Histopathological analysis of all PVs, esophagus, IVC, and the adjacent lungs was performed.<br /><b>Results</b><br />Acute PV isolation was achieved in all 15 canines (100%), with energy delivery times of less than 3 min/animal. In the 30 and 90 days group, the overall success rates were 88.9% and 88.5% per PVs, respectively. Two right superior pulmonary veins (RSPVs) in the 30-day group, two RSPVs and one left superior PV in the 90-day group with recovered potentials. At follow-up, gross pathological examination revealed the lesions around the PVs were continuous and transmural. Masson\'s trichrome staining revealed the myocardial cells in the PVs became fibrotic, but small arteries and nervous tissue were preserved. Results of swine esophageal injury model revealed the esophageal luminal surface was smooth and without evidence for esophageal injury in the PFA group, whereas obvious ulceration was detected on the esophagus tunica mucosa in the RFA group.<br /><b>Conclusion</b><br />In the chronic canine study, PFA-based PVI were safe and effective with demonstrable sparing of nerves and venous tissue. Compared with RFA, there was also good evidence for safety of PFA, avoiding PV stenosis and esophageal injury. This preclinical study provided the scientific basis for the first-in-human endocardial PFA studies.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 15 Sep 2023; epub ahead of print</small></div>

<div><h4>Venous anatomy of the left ventricular summit region: Insights from high-speed rotational retrograde angiography.</h4><i>Mi L, Zhang K, Zhang H, Ding L, ... Dong X, Tang M</i><br /><b>Introduction</b><br />Mapping and ablation through the coronary venous system (CVS) have shown potential for ventricular arrhythmias originating from the left ventricular summit (LVS). Multielectrode catheters and balloons are frequently used for mapping and venous ethanol ablation (VEA). However, there is limited data on the venous size and drainage condition in the LVS region. This study aimed to investigate the morphology, angiographic size, and drainage condition of LV summit veins via high-speed rotational angiography (RA).<br /><b>Methods</b><br />We measured and analyzed the size of the great cardiac vein (GCV), the anterior interventricular vein (AIV), veins near to the LVS, and other main tributaries of CVS in 102 patients undergoing electrophysiology study.<br /><b>Results</b><br />Rotational retrograde angiography of LVS was successfully performed in 81 patients. The diameter of GCV at the level of the Vieussens valve and the distal end of GCV (junction of GCV-AIV) was larger in males than females (6.8 ± 1.1 vs. 5.6 ± 1.2 mm, p < .001; 5.2 ± 0.9 vs. 4.6 ± 0.8, p = .002, respectively) while no significant gender differences were observed in other tributaries. The LV summit veins presented downward drainage direction in half of the patients, indicating potential anatomic adjacency with His bundle. Left anterior oblique (LAO) 45° projection might provide the practical and optimal view of the LV summit veins.<br /><b>Conclusions</b><br />The coronary veins of the LVS region present various anatomical morphologies and ostium sizes. We provide a systematic description and angiographic size spectrum of CVS. RA could facilitate assessing the feature of CVS comprehensively.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>A novel ablation strategy for recurrent atrial fibrillation: Fractionated signal area in the atrial muscle ablation 1-year follow-up.</h4><i>Hirokami J, Nagashima M, Fukunaga M, Korai K, ... Ando K, Hiroshima K</i><br /><b>Introduction</b><br />Treatment of recurrent atrial fibrillation (AF) is sometimes challenging due to non-pulmonary vein (PV) foci. Fractionated signal area in the atrial muscle (FAAM) is a valid predictor of the location of non-PV foci. FAAM ablation has the potential to decrease the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF. We compared the clinical impact of FAAM ablation for recurrent AF, using 1 year follow up date.<br /><b>Methods</b><br />A total of 230 consecutive patients with symptomatic recurrent AF who underwent catheter ablation specifically targeting non-PV foci as FAAM-guided ablation (n = 113) and non-FAAM-guided ablation (n = 117) were retrospectively analyzed. FAAM was assigned a parameter (peaks slider, which indicates the number of components of fractionated signals), ranging from 1 to 15, indicating the location of the FAAM (1: largest, 15: smallest). FAAM-guided ablation was performed by ablating FAAM until none inducibility of non-PV foci. On the other hand, non-FAAM-guided ablation was performed via linear ablation, complex fractionated atrial electrogram ablation, superior vena cava isolation, and focal ablation according to the location of the non-PV foci. The RHYTHMIA system was used to perform all the procedures. The primary endpoints were AF recurrence, atrial flutter, and/or atrial tachycardia.<br /><b>Results</b><br />After a 1-year follow up, freedom from atrial tachyarrhythmia was achieved in 90.3% and 75.2% of patients in the FAAM and non-FAAM groups, respectively (hazard ratio = 0.438 [95% confidence interval: 0.243-0.788], p  =  .005).<br /><b>Conclusions</b><br />FAAM ablation showed a promising decrease in the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF during a 1-year follow-up.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>Prospective validation of a risk score to predict pacemaker implantation after transcatheter aortic valve replacement.</h4><i>Black GB, Kim JH, Vitter S, Ibrahim R, ... Babaliaros VC, Kiani S</i><br /><b>Introduction</b><br />The need for pacemaker is a common complication after transcatheter aortic valve replacement (TAVR). We previously described the Emory Risk Score (ERS) to predict the need for new pacemaker implant (PPM) after TAVR. Metrics included in the score are a history of syncope, pre-existing RBBB, QRS duration ≥140 ms, and prosthesis oversizing ≥16%. To prospectively validate the previously described risk score.<br /><b>Methods</b><br />We prospectively evaluated all patients without pre-existing pacemakers, ICD, or pre-existing indications for pacing undergoing TAVR with the Edwards SAPIEN 3 prosthesis at our institution from March 2019 to December 2020 (n = 661). Patients were scored prospectively; however, results were blinded from clinical decision-making. The primary endpoint was PPM at 30 days after TAVR. Performance of the ERS was evaluated using logistic regression, a calibration curve to prior performance, and receiver operating characteristic (ROC) analysis.<br /><b>Results</b><br />A total of 48 patients (7.3%) had PPM after TAVR. A higher ERS predicted an increased likelihood of PPM (OR 2.61, 95% CI: 2.05-3.25 per point, p < 0.001). There was good correlation between observed and expected values on the calibration curve (slope = 1.04, calibration at large = 0.001). The area under the ROC curve was 0.81 (95% CI [0.74-0.88], p < 0.001).<br /><b>Conclusions</b><br />The ERS prospectively predicted the need for PPM in a serial, real-world cohort of patients undergoing TAVR with a balloon-expandable prosthesis, confirming findings previously described in retrospective cohorts. Notably, the prospective performance of the score was comparable with that of the initial cohorts. The risk score could serve as a framework for preprocedural risk stratification for PPM after TAVR.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>Association of leadless pacing with ventricular and valvular function.</h4><i>Arps K, Li B, Allen JC, Alenezi F, ... Thomas KL, Piccini JP</i><br /><b>Background</b><br />Traditional transvenous pacemakers are associated with worsening tricuspid valve function due to lead-related leaflet impingement, as well as ventricular dysfunction related to electromechanical dyssynchrony from chronic right ventricular (RV) pacing. The association of leadless pacing with ventricular and valvular function has not been well established. We aimed to assess the association of leadless pacemaker placement with changes in valvular regurgitation and ventricular function.<br /><b>Methods and results</b><br />Echocardiographic features before and after leadless pacemaker implant were analyzed in consecutive patients who received a leadless pacemaker with pre- and postprocedure echocardiography at Duke University Hospital between November 2014 and November 2019. Valvular regurgitation was graded ordinally from 0 (none) to 3 (severe). Among 54 patients, the mean age was mean age was 70.1 ± 14.3 years, 24 (44%) were women, and the most frequent primary pacing indication was complete heart block in 24 (44%). The median RV pacing burden was 45.4 (interquartile range [IQR] 3.5-97.0). On echocardiogram performed 8.9 months (IQR 4.5-14.5) after implant, there was no change in the average severity of tricuspid regurgitation (mean change 0.07 ± 1.15, p = .64) from pre-procedure echocardiogram. We observed a decrease in the average left ventricular ejection fraction (LVEF) (52.3 ± 9.3 to 47.9 ± 12.1, p = .0019) and tricuspid annular plane systolic excursion (TAPSE) (1.8 ± 0.6 to 1.6 ± 0.4, p = .0437). Thirteen patients (24%) had absolute drop in LVEF of ≥10%.<br /><b>Conclusion</b><br />We did not observe short term worsening valvular function in patients with leadless pacemakers. However, consistent with the pathophysiologic impact of RV pacing, leadless pacing was associated with a reduction in biventricular function.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 13 Sep 2023; epub ahead of print</small></div>

<div><h4>The impact of age on ablation outcomes in AF-mediated cardiomyopathy.</h4><i>Segan L, Chieng D, Sugumar H, Voskoboinik A, ... Kistler PM, Prabhu S</i><br /><b>Introduction</b><br />The absence of ventricular scar in patients with atrial fibrillation (AF) and systolic heart failure (HF) predicts left ventricular (LV) recovery following AF ablation. It is unknown whether age impacts the degree of LV recovery, reverse remodeling, or AF recurrence following catheter ablation (CA) among this population.<br /><b>Objectives</b><br />To evaluate the impact of age on LV recovery and AF recurrence in a population with AF and systolic HF without fibrosis (termed AF-mediated cardiomyopathy) following CA.<br /><b>Methods</b><br />Consecutive patients undergoing CA between 2013 and 2021 with LV ejection fraction (LVEF) < 45% and absence of cardiac magnetic resonance imaging (CMR) detected LV myocardial fibrosis were stratified by age (<65 vs. ≥65 years). Following CA, participants underwent remote rhythm monitoring for 12 months with repeat CMR for HF surveillance.<br /><b>Results</b><br />The study population consisted of 70 patients (10% female, mean LVEF 33 ± 9%), stratified into younger (age < 65 years, 63%) and older (age ≥ 65 years, 37%) cohorts. Baseline comorbidities, LVEF (34 ± 9 vs. 33 ± 8 ≥65 years, p = .686), atrial and ventricular dimensions (left atrial volume index: 55 ± 21 vs. 56 ± 14 mL/m<sup>2</sup> age ≥ 65, p = .834; indexed left ventricular end-diastolic volume: 108 ± 40 vs. 104 ± 28 mL/m<sup>2</sup> age ≥ 65, p = .681), pharmacotherapy and ablation strategy (pulmonary vein isolation in all; posterior wall isolation in 27% vs. 19% age ≥ 65, p = .448; cavotricuspid isthmus in 9% vs. 11.5% age ≥ 65) were comparable (all p > .05) albeit a higher CHADS<sub>2</sub> VASc score in the older cohort (2.7 ± 0.9 vs. 1.6 ± 0.6 age < 65, p < .001).   Freedom from AF was comparable (hazard ratio: 0.65, 95% confidence interval: 0.38-1.48, LogRank p = .283) as was AF burden [0% (interquartile range, IQR: 0.0-2.1) vs. age ≥ 65: [0% (IQR 0.0-1.7), p = .516], irrespective of age. There was a significant improvement in LV systolic function in both groups (ΔLVEF + 21 ± 14% vs. +21 ± 12% age ≥ 65, p = .913), with LV recovery in the vast majority (73% vs. 69%, respectively, p = .759) at 13 (IQR: 12-16) months. This was accompanied by comparable improvements in functional status (New York Heart Association class p = .851; 6-min walk distance 50 ± 61 vs. 93 ± 134 m in age ≥ 65, p = .066), biomarkers (ΔN-terminal-pro brain natriuretic peptide -139 ± 246 vs. -168 ± 181 age ≥ 65,p = .629) and HF symptoms (Short Form-36 survey Δphysical component summary p = .483/Δmental component summary, p = .841).<br /><b>Conclusion</b><br />In patients undergoing CA for AF with systolic HF in the absence of ventricular scar, comparable improvements in ventricular function, symptoms, and freedom from AF are achieved irrespective of age.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Observations of interventricular septal behavior during left bundle branch pacing.</h4><i>Ponnusamy SS, Ganesan V, Anand V, Vadivelu R, ... Murugan S, Vijayaraman P</i><br /><b>Introduction</b><br />Left bundle branch pacing (LBBP) involves the deployment of the lead deep inside the septum. Penetration of the septum by the lead depends on the texture of the septum, rapidity of rotations, operator experience, and implantation tools.<br /><b>Objectives</b><br />The aim of our study was to assess the behavior of the lumenless lead during rapid rotations and the physiological property of the interventricular septum(IVS) during LBBP.<br /><b>Methods</b><br />Patients undergoing LBBP between January 2021 and December 2022 were retrospectively included in the study.<br /><b>Results</b><br />Among 255 attempted patients, 20 (7.9%) had procedural failure(no LBB capture-four, inability to penetrate septum-seven, and dislodgements after sheath removal-nine). Septal penetration achieved in 248/255 patients (97.2%). Lead movement inside the IVS was assessed by lead traverse time. Based on the behavior of the IVS (n = 255), three different responses were noted. Type-I response(normal/firm septum) in 93.7% (n = 239) characterized by constant and progressive movement of lead. Neither perforation nor further change in premature-ventricular-complex morphology beyond M-beat were observed despite additional few unintentional rotations indicating the protective mechanism of LV-endocardium. Type-II response(soft/cheesy septum) in 3.5% (n = 9) characterized by hyper-movement of lead without resistance due to altered texture of septum and poor LV subendocardial barrier resulting in perforation. No patients in this group had LV dysfunction or associated coronary artery disease. In type-III response, seen in 2.8% (n = 7), lead could not be penetrated due to scar in IVS.<br /><b>Conclusion</b><br />Three different patterns of responses were observed during LBBP. The most distinct type-ll response was associated with soft/cheesy septum with hyper-movement of the lead predisposing for future dislodgments in patients without structural heart disease.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Guiding ablation strategies for ventricular tachycardia in patients with structural heart disease by analyzing links and conversion patterns of traceable abnormal late potential zone.</h4><i>Song X, Que D, Zhu Y, Yu W, ... Cai Y, Yang P</i><br /><b>Background</b><br />Substrate-based ablation can treat uninducible or hemodynamically instability scar-related ventricular tachycardia (VT). However, whether a correlation exists between the critical VT isthmus and late activation zone (LAZ) during sinus rhythm (SR) is unknown.<br /><b>Objective</b><br />To demonstrate the structural and functional properties of abnormal substrates and analyze the link between the VT circuit and abnormal activity during SR.<br /><b>Methods</b><br />Thirty-six patients with scar-related VT (age, 50.0 ± 13.7 years and 86.1% men) who underwent VT ablation were reviewed. The automatic rhythmia ultrahigh resolution mapping system was used for electroanatomic substrate mapping. The clinical characteristics and mapping findings, particularly the LAZ characteristics during SR and VT, were analyzed. To determine the association between the LAZ during the SR and VT circuits, the LAZ was defined as five activation patterns: entrance, exit, core, blind alley, and conduction barrier.<br /><b>Results</b><br />Forty-five VTs were induced in 36 patients, 91.1% of which were monomorphic. The LAZ of all patients was mapped during the SR and VT circuits, and the consistency of the anatomical locations of the LAZ and VT circuits was analyzed. Using the ultrahigh resolution mapping system, interconversion patterns, including the bridge, T, puzzle, maze, and multilayer types, were identified. VT ablation enabled precise ablation of abnormal late potential conduction channels.<br /><b>Conclusion</b><br />Five interconversion patterns of the LAZ during the SR and VT circuits were summarized. These findings may help formulate more precise substrate-based ablation strategies for scar-related VT and shorter procedure times.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 11 Sep 2023; epub ahead of print</small></div>

<div><h4>Impact of intracardiac echocardiography usage on the safety of cryoballoon atrial fibrillation ablation: Subanalysis of the prospective FREEZE cluster cohort study.</h4><i>Pongratz J, Kuniss M, Wu L, Tebbenjohanns J, ... Straube F, FREEZE Cohort Study Investigators</i><br /><b>Introduction</b><br />Cryoballoon ablation (CBA) aiming at pulmonary vein isolation (PVI) became a standardized atrial fibrillation (AF) ablation procedure. Life-threatening complications like cardiac tamponade exist. Intracardiac echocardiography (ICE) usage is associated with superior safety in radiofrequency ablation. It is unclear if ICE has an impact on safety of CBA.<br /><b>Methods</b><br />The FREEZE Cohort (NCT01360008) subanalysis included patients undergoing \"PVI only\" CBA. Patients with intraprocedural transesophageal echocardiography were excluded. Group A comprises conventional, group B ICE-guided CBA. Periprocedural results were compared.<br /><b>Results</b><br />From 2011 to 2016, a total of 4189 patients were enrolled, and 1906 (45.5%) were included in this subanalysis, split up in two groups (A: 1066 [55.9%], B: 840 [44.1%]). Group A was younger (60.6 ± 10.8 vs. 62.4 ± 10.5 years, p < .001), with smaller left atria (41 vs. 43 mm, p < .001), and less persistent AF (23.1 vs. 38.1%, p < .001). Procedure, left atrial, and fluoroscopy times were shorter in group A as compared to group B. Dose area product was significantly higher in group A (2911 vs. 2072 cGyxcm<sup>2</sup> , p < .001). In-hospital major adverse cerebrovascular and cardiac event rates including two deaths in group A were not different between groups (0.5% vs. 0.1%, p = .18). The rate of total procedural (10.4% vs. 5.1%, p < .001) and major complications (3.2% vs. 1.3%, p < .001) was significantly higher in group A. Cardiac tamponade occurred significantly more frequently in group A (8 [0.8%] vs. 1 [0.1%], p = .046). Independent predictors for major complications were female sex (odds ratio [OR] 2.03, p = .03) and non-ICE usage (OR 2.38, p = .02). No differences were observed for persistent phrenic nerve palsy, nor for groin complications.<br /><b>Conclusion</b><br />CBA was significantly safer and required less radiation if ICE was used, although the procedures were more complex. The risk of groin complications was not increased with ICE usage. Non-ICE usage was the only modifiable independent predictor of major complications.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Comparison of pulsed field ablation and cryoballoon ablation for pulmonary vein isolation.</h4><i>Schipper JH, Steven D, Lüker J, Wörmann J, ... Pavel F, Sultan A</i><br /><b>Introduction</b><br />Pulmonary vein isolation (PVI) remains the cornerstone in the treatment of atrial fibrillation (AF). PVI using cryoballoon (CB) technology has emerged as a standard procedure in many centers. Recently, pulsed field ablation (PFA) has been introduced and used to achieve PVI. First data show high acute and favorable long-term outcomes. So far, data comparing these new \"single shot\" devices are sparse. We sought to compare procedural and outcome data for first time PFA users versus CB in patients undergoing de novo PVI. Furthermore, potentially postprocedural discomfort and affection of autonomic ganglia were assessed.<br /><b>Methods and results</b><br />A retrospective analysis and comparison of all de novo PVIs with PFA and CB was performed. Furthermore, PFA PVI learning curve was evaluated. During follow-up, repeat outpatient visits and Holter electrocardiogram were performed to analyze arrhythmia-free survival. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI. Potential changes in heart rate (HR) between baseline and at 3-month follow-up were evaluated. A total of 108 patients (54 PFA and 54 CB; PFA; 33 (30%) female) with paroxysmal and persistent AF were analyzed. Type of AF was comparable (Patients suffering from PAF: PFA: 16 (30%), CB: 17 (31%), p = 1.0). In 107 (99%) patients, successful PVI was achieved. Transient phrenic palsy omitted complete PVI in one CB patient. A trend for a shorter overall procedure duration was observed in the PFA group (PFA: 64.5 ± 17.5 min; CB: 73.0 ± 24.8 min; p = 0.07). Excluding LA mapping time (first 14 cases), procedure time was significantly shorter using PFA (PFA: 58.0 ± 12.5 min, CB: 73.0 ± 24.8 min, p = 0.0001). Fluoroscopy time was significantly longer for PFA (PFA: 15.3 ± 4.7 min, CB: 12.3 ± 5.3 min; p = 0.001), but significantly less contrast medium was used (PFA: 12 ± 6 mL; CB: 51 ± 29 mL, p < 0.0001). Subgroup analysis of the PFA group revealed a significant shortening of procedure duration over time (first tertile: 72.7 ± 13.5 min, second tertile: 67.3 ± 21.7 min, third tertile: 53.4 ± 9.8 min, first vs. third tertile p < 0.0001). Two cardiac tamponades occurred in the PFA group (p = 0.495), of which one was most likely related to complex transseptal puncture. In the first 48 h after PVI, the number of prescribed analgesics due to postprocedural pain was equal between both groups (PFA: 7 (13%) patients, CB: 10 (19%) patients, p = 0.598). After a FU of 273 ± 129 days, 35 of 47 patients (74%) after PFA and 36 of 50 patients (72%) after CB PVI were free of any atrial arrhythmia (HR: 0.98, p = 0.88). Only in the PFA group, a significant increase in HR 3 months after PVI was observed (pre-PVI: 61 ± 8 beats/min, post-PVI: 65 ± 9 beats/min, p = 0.008).<br /><b>Conclusion</b><br />The new PFA technology is equally effective and safe as compared to CB for complete PVI with potentially shorter procedure time and significantly less contrast medium. However, AF recurrence rates after PFA PVI seem to be comparable to CB PVI.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Improved cerebral blood flow and hippocampal blood flow in stroke-free patients after catheter ablation of atrial fibrillation.</h4><i>Hashimoto N, Arimoto T, Koyama K, Kutsuzawa D, ... Watanabe T, Watanabe M</i><br /><b>Introduction</b><br />Atrial fibrillation (AF) is a risk factor for reduced cerebral blood flow (CBF) and cognitive dysfunction, even in stroke-free patients. We aimed to test the hypothesis that CBF and hippocampal blood flow (HBF), measured with arterial spin labeling magnetic resonance imaging (MRI), improve after catheter ablation of AF to achieve sinus rhythm (SR).<br /><b>Methods</b><br />A total of 84 stroke-free patients (63.1 ± 9.1 years; paroxysmal AF, n = 50; non-paroxysmal AF, n = 34) undergoing AF catheter ablation were included. MRI studies were done before, 3 months, and 12 months after the procedure with CBF and HBF measurements.<br /><b>Results</b><br />Baseline CBF and HBF values in 50 paroxysmal AF patients were used as controls. Baseline CBF was higher in patients with paroxysmal AF than with non-paroxysmal AF (100 ± 32% vs. 86 ± 28%, p = .04). Patients with non-paroxysmal AF had increased CBF 3 months after AF ablation (86 ± 28% to 99 ± 34%, p = .03). Differences in CBF and HBF were greater in the group with AF restored to SR (p < .01). Both CBF and HBF levels at 12 months were unchanged from the 3 months level. Successful rhythm control by catheter ablation was an independent predictor of an increase in CBF > 17.5%. The Mini-Mental State Examination score improved after ablation (p = .02).<br /><b>Conclusion</b><br />SR restoration with catheter ablation was associated with improved CBF and HBF at 3 months, maintenance of blood flow, and improved cognitive function at 12 months.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Myocardial scarring and recurrence of ventricular arrhythmia in patients surviving an out-of-hospital cardiac arrest.</h4><i>Thomsen AF, Winkel BG, Golvano LCC, Porta-Sánchez A, ... Roca-Luque I, Jacobsen PK</i><br /><b>Introduction</b><br />Prediction of recurrent ventricular arrhythmia (VA) in survivors of an out-of-hospital cardiac arrest (OHCA) is important, but currently difficult. Risk of recurrence may be related to presence of myocardial scarring assessed with late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Our study aims to characterize myocardial scarring as defined by LGE-CMR in survivors of a VA-OHCA and investigate its potential role in the risk of new VA events.<br /><b>Methods</b><br />Between 2015 and 2022, a total of 230 VA-OHCA patients without ST-segment elevation myocardial infarction had CMR before implantable cardioverter-defibrillator implantation for secondary prevention at Copenhagen University Hospital, Rigshospitalet, and Hospital Clínic, University of Barcelona, of which n = 170 patients had a conventional (no LGE protocol) CMR and n = 60 patients had LGE-CMR (including LGE protocol). Scar tissue including core, border zone (BZ) and BZ channels were automatically detected by specialized investigational software in patients with LGE-CMR. The primary endpoint was recurrent VA.<br /><b>Results</b><br />After exclusion, n = 52 VA-OHCA patients with LGE-CMR and a mean left ventricular ejection fraction of 49 ± 16% were included, of which 18 (32%) patients reached the primary endpoint of VA. Patients with recurrent VA in exhibited greater scar mass, core mass, BZ mass, and presence of BZ channels compared with patients without recurrent VA. The presence of BZ channels identified patients with recurrent VA with 67% sensitivity and 85% specificity (area under the ROC curve (AUC) 0.76; 95% CI: 0.63-0.89; p < .001) and was the strongest predictor of the primary endpoint.<br /><b>Conclusions</b><br />The presence of BZ channels was the strongest predictor of recurrent VA in patients with an out of-hospital cardiac arrest and LGE-CMR.<br /><br />© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Limits of the spatial ventricular gradient and QRST angles in patients with normal electrocardiograms and no known cardiovascular disease stratified by age, sex, and race.</h4><i>Stabenau HF, Sau A, Kramer DB, Peters NS, Ng FS, Waks JW</i><br /><b>Introduction</b><br />Measurement of the spatial ventricular gradient (SVG), spatial QRST angles, and other vectorcardiographic measures of myocardial electrical heterogeneity have emerged as novel risk stratification methods for sudden cardiac death and other adverse cardiovascular events. Prior studies of normal limits of these measurements included primarily young, healthy, White volunteers, but normal limits in older patients are unknown. The influence of race and body mass index (BMI) on these measurements is also unclear.<br /><b>Methods</b><br />Normal 12-lead electrocardiograms (ECGs) from a single center were identified. Patients with abnormal cardiovascular, pulmonary, or renal history (assessed by International Classification of Disease [ICD-9/ICD-10] codes) or abnormal cardiovascular imaging were excluded. The SVG and QRST angles were measured and stratified by age, sex, and race. Multivariable linear regression was used to assess the influence of age, BMI, and heart rate (HR) on these measurements.<br /><b>Results</b><br />Among 3292 patients, observed ranges of SVG and QRST angles (peak and mean) differed significantly based on sex, age, and race. Sex differences attenuated with increasing age. Men tended to have larger SVG magnitude (60.4 [46.1-77.8] vs. 52.5 [41.3-65.8] mv*ms, p < .0001) and elevation, and more anterior/negative SVG azimuth (-14.8 [-25.1 to -4.3] vs. 1.3 [-9.8 to 10.5] deg, p < .0001) compared to women. Men also had wider QRST angles. Observed ranges varied significantly with BMI and HR. SVG and QRST angle measurements were robust to different filtering bandwidths and moderate fiducial point annotation errors, but were heavily affected by changes in baseline correction.<br /><b>Conclusions</b><br />Age, sex, race, BMI, and HR significantly affect the range of SVG and QRST angles in patients with normal ECGs and no known cardiovascular disease, and should be accounted for in future studies. An online calculator for prediction of these \"normal limits\" given demographics is provided at https://bivectors.github.io/gehcalc/.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 08 Sep 2023; epub ahead of print</small></div>

<div><h4>Adverse events associated with amplatzer left atrial appendage occlusion delivery system: A Food and Drug Administration MAUDE database study.</h4><i>Kewcharoen J, Shah K, Bhardwaj R, Contractor T, ... Lakkireddy D, Garg J</i><br /><b>Background</b><br />Dual occlusive closure mechanism (disc and lobe type), Amulet device (Abbott; a second-generation device that has replaced Amplatzer Cardiac Plug) was approved by the Food and Drug Administration (FDA) in August 2021 for percutaneous left atrial appendage occlusion (LAAO). However, real-world safety data on the delivery system (Amplatzer Cardiac Plug and Amplatzer Amulet device) are lacking.<br /><b>Objective</b><br />We sought to assess the type of adverse events associated with the Amplatzer LAAO delivery system using the FDA Manufacturer and User Facility Device Experience (MAUDE) database.<br /><b>Methods</b><br />A MAUDE database search was conducted on March 31, 2023, for reports received between February 2013 and March 2023 to capture all adverse events.<br /><b>Results</b><br />A total of 59 adverse events were reported, of which 58 were sheath-related events, and one was a wire-related event. The most commonly encountered issue was air embolism (19%, 11 events), followed by sheath thrombosis (13.8%, eight events, two of which were also associated with device thrombosis), kinked sheath (10.3%, six events), and sheath deformation (8.6%, five events). Patient-related adverse events included pericardial effusion requiring pericardiocentesis (22.4%, 13 events), vascular complications (20.7%, 12 events), and device dislodgement (5.2%, three events).<br /><b>Conclusion</b><br />LAAO-related adverse events are increasingly being reported using the Amplatzer LAAO delivery sheath. It is anticipated that improvements in device technology, the advent of steerable sheaths, and operator experience will minimize these complications.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>Are antiarrhythmic agents indicated in premature ventricular complex-induced cardiomyopathy and when?</h4><i>Kantharia BK, Shah AN</i><br /><b>Introduction</b><br />Premature ventricular complexes (PVCs) are the most common ventricular arrhythmia that are encountered in the clinical practice. Recent data suggests that high PVC burden may lead to the development of PVC-induced cardiomyopathy (PVC-CM) even in patients without structural heart disease. Treatment for effective suppression of PVCs, can reverse PVC-CM. Both antiarrhythmic drugs (AADs) and catheter ablation (CA) are recognized treatment modalities for any cardiac arrhythmias. However, with increasing preference of CA, the role of AADs needs further defining regarding their efficacy, safety, indications and patient selection to treat PVC-CM.<br /><b>Methods</b><br />To ascertain the role of AADs to treat PVC-CM; whether they are indicated to treat PVC-CM, and if so, when, we interrogated PubMed and other search engines for English language publications with key words premature ventricular complexes (PVCs), cardiomyopathy, anti-arrhythmic drugs, catheter ablation, and pharmacological agents. All publications were carefully reviewed and scrutinized by the authors for their inclusion in the review paper. For illustration of cases, ethical standard was observed as per the 1975 Declaration of Helsinki, and the patient was treated as per the prevailing standard of care. Informed consent was obtained from the patient for conducting the ablation procedure.<br /><b>Results</b><br />Our literature search specifically the pharmacological treatment of PVC-CM with AADs revealed significant paradigm shift in treatment approach for PVCs and PVC-induced cardiomyopathy. No major large, randomized control trials of AADs versus CA for PVC-CM were found. We found that beta-blockers and calcium channel blockers are particularly effective in the treatment of PVCs originating from right ventricular outflow tract. For Class Ic AADs - flecainide and propafenone, small clinical studies showed Class Ic AADs to be effective in PVC suppression, but their usage was not recommended in patients with significant coronary artery disease. Mexiletine was found to have modest effect on PVC suppression. Studies showed sotalol to significantly reduce PVCs frequency in patients receiving both low and high doses. Studies also showed amiodarone to have higher successful PVC suppression, but not recommended as a first-line treatment for patients with idiopathic PVCs in the absence of symptoms and left ventricular dysfunction. For dronedarone, no major clinical data were available.<br /><b>Conclusions</b><br />Based on the available data in the literature, we conclude that AADs play important role in the treatment of PVC-induced cardiomyopathy. However, appropriate patient selection criteria are vitally important, and in general terms AADs are indicated or polymorphic PVCs, epicardial PVCs; and when CA procedure is contraindicated, or not feasible or failed.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 07 Sep 2023; epub ahead of print</small></div>

<div><h4>Athletes and suspected catecholaminergic polymorphic ventricular tachycardia: Awareness and current knowledge.</h4><i>Mascia G, Brugada J, Arbelo E, Porto I</i><br /><b>Introduction</b><br />Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a cardiac inherited arrhythmogenic disease potentially leading to sudden cardiac death that is determined by electrical instability exacerbated by acute adrenergic tone.<br /><b>Methods and results</b><br />Despite its life-threatening nature, CPVT remains potentially unnoticed since diagnosis may be difficult especially in apparently healthy athletes. This review summarizes current knowledge and shortcomings of CPVT, focusing on genetics, arrhythmic mechanisms, sport preparticipation screening, and current recommendations.<br /><b>Conclusions</b><br />The paper captures the importance of CPVT athletes regarding the necessity of risk stratification, as well as the importance of maintaining a healthy lifestyle.<br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Sep 2023; epub ahead of print</small></div>

<div><h4>Catheter-induced right bundle branch block: Practical implications for the cardiac electrophysiologist.</h4><i>Ali H, Lupo P, Foresti S, De Ambroggi G, ... Cristiano E, Cappato R</i><br /><AbstractText>The right bundle branch (RBB), due to its endocardial course, is susceptible to traumatic block caused by \"bumping\" during right-heart catheterization. In the era of cardiac electrophysiology, catheter-induced RBB block (CI-RBBB) has become a common phenomenon observed during electrophysiological studies and catheter ablation procedures. While typically transient, it may persist for the entire procedure time. Compared to pre-existing RBBB, the transient nature of CI-RBBB allows for comparative analysis relative to the baseline rhythm. Furthermore, unlike functional RBBB, it occurs at similar heart rates, making the comparison of conduction intervals more reliable. While CI-RBBB can provide valuable diagnostic information in various conditions, it is often overlooked by cardiac electrophysiologists. Though it is usually a benign and self-limiting conduction defect, it may occasionally lead to diagnostic difficulties, pitfalls, or undesired consequences. Avoidance of CI-RBBB is advised in the presence of baseline complete left bundle branch block and when approaching arrhythmic substrates linked to the right His-Purkinje-System, such as fasciculo-ventricular pathways, bundle branch reentry, and right-Purkinje focal ventricular arrhythmias. This article aims to provide a comprehensive practical review of the electrophysiological phenomena related to CI-RBBB and its impact on the intrinsic conduction system and various arrhythmic substrates.</AbstractText><br /><br />© 2023 Wiley Periodicals LLC.<br /><br /><small>J Cardiovasc Electrophysiol: 01 Sep 2023; epub ahead of print</small></div>