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Preamble: Robotic magnetic navigation (RMN)-guided catheter ablation (CA) technology has been used for the treatment of cardiac arrhythmias for almost 20 years. Various studies reported that RMN allows for high catheter stability, improved lesion formation and a superior safety profile. So far, no guidelines or recommendations on RMN-guided CA have been published., Purpose: The aim of this consensus paper was to summarize knowledge and provide recommendations on management of arrhythmias using RMN-guided CA as treatment of atrial fibrillation (AF) and ventricular arrhythmias (VA)., Methodology: An expert writing group, performed a detailed review of available literature, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Recommendations on RMN-guided CA are presented in a guideline format with three levels of recommendations to serve as a reference for best practices in RMN procedures. Each recommendation is accompanied by supportive text and references. The various sections cover the practical spectrum from system and patient set-up, EP laboratory staffing, combination of RMN with fluoroscopy and mapping systems, use of automation features and ablation settings and targets, for different cardiac arrhythmias., Conclusion: This manuscript, presenting the combined experience of expert robotic users and knowledge from the available literature, offers a unique resource for providers interested in the use of RMN in the treatment of cardiac arrhythmias., Competing Interests: The Erasmus MC has received research grants from Acutus Medical, Biosense Webster and Stereotaxis. TS-T has received an educational grant from Abbott, a contract for education and advisory activities with Biotronik and consultancy contract with Acutus Medical and Ablacon. SW has received honoraria from Biotronik en Daiichi Sankyo. S-CY has received a research grant from Medtronic and honoraria from Medtronic and Boston Scientific. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Noten, Szili-Torok, Ernst, Burkhardt, Cavaco, Chen, Cheung, de Chillou, Crystal, Cooper, Gasparini, Geczy, Goehl, Hügl, Jin, Kampus, Kazemian, Khan, Kongstad, Magga, Peress, Raatikainen, Romanov, Rossvoll, Singh, Vatasescu, Wijchers, Yamashiro, Yap and Weiss.)

Introduction: 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., Methods: 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., Results: 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)., Conclusion: 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., (© 2023 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: Catheter ablation (CA) has become a well-established first-line therapy for a broad spectrum of arrhythmias, including atrial tachycardias (ATs). In this study we aimed to assess the performance of the integrated novel high-resolution new generation noncontact mapping system (AcQMap) with robotic magnetic navigation (RMN) system in CA procedures for patients with ATs including comparing patient subgroups based on the utilized mapping modality, arrhythmia mechanism, localization and type of procedure., Methods: All patients undergoing CA for AT using the AcQMap-RMN system were included. Procedural safety and efficacy were characterized by intra- and post-procedural complications. Acute procedural success and the long-term outcome were assessed in the overall group and in the subgroups., Results: A total number of 70 patients were referred for CA with atrial arrhythmias including 67 AT/AFL (mean age 57.1 ± 14.4 years), and 3 additional patients with inappropriate sinus tachycardia. Thirty-eight patients had de novo AT, 24 had post-PVI AT including 2 patients with perinodal AT, and 5 had post-MAZE AT. Two patients (2.9%) suffered post-procedural complications including 1 patient with groin hematoma and 1 patient with a transient ischemic attack. Acute success was achieved in 63/67 (94.0%) procedures. Thirteen patients (19.4%) had documented recurrence at the end of the 12-months follow-up period. The performance of AcQMap was equally good in focal vs. reentry mechanisms (p = 0.61, acute success), in the left and right atrium (p = 0.21)., Conclusions: AcQMap-RMN integration might improve success rates in CA of ATs with low number of complications., (© 2023. The Author(s).)

Background: Short runs of atrial tachycardias (ATs) and infrequent premature atrial contractions (PACs) are difficult to map and ablate using sequential electrophysiology mapping techniques. The AcQMap mapping system allows for highly accurate mapping of a single atrial activation., Objectives: We aimed to test the value of a novel dipole charge density-based high-resolution mapping technique (AcQMap) in the treatment of brief episodes of ATs and PACs., Methods: Data of all patients undergoing catheter ablation (CA) using the AcQMap mapping system were reviewed., Results: Thirty-one out of 219 patients (male n = 8; female n = 23) had short runs of ATs (n = 23) and PACs (n = 8). The mean procedural time was 155.3 ± 46.6 min, with a mean radiation dose of 92.0 (IQR 37.0-121.0) mGy. Total radiofrequency application duration 504.0 (271.0-906.0) s. Left atrial localization of ATs and PACs was identified in 45.1% of the cases, right atrium localization in 45.1%, and septal origins in 9.8% of the cases. Acute success was achieved in 30/31 (96.8%), and recurrence during the follow-up developed in six patients (19.4%), including four patients with PACs and two patients with short-lived ATs. One patient presented procedure-related groin hematoma as minor complication., Conclusion: Brief episodes of highly symptomatic ATs and infrequent PACs can be mapped using charge density mapping and successfully ablated with high acute and long-term success rates., (© 2022. The Author(s).)

Catheter ablation (CA) is an important treatment option for ventricular arrhythmias (VA) in pediatric cardiology. Currently, various CA techniques are available, including remote magnetic navigation (RMN)-guided radiofrequency (RF) ablation. However, no studies evaluate RMN-guided ablative therapy outcomes in children with VA yet. This study aimed to compare procedural and long-term outcomes between RMN-guided and manual (MAN)-guided VA ablation in children. This single-center, retrospective study included all CA procedures for VA performed in children with or without structural heart disease from 2008 until 2020. Two study groups were defined by CA technique: RMN or MAN. Primary outcome was recurrence of VA. Baseline clinical, procedural and safety data were also evaluated. This study included 22 patients, who underwent 30 procedures, with a median age of 15 (IQR 14-17; range 1-17) years and a mean weight of 57 ± 20 kg. In total, 14 procedures were performed using RMN and 16 using MAN (22 first and 8 redo procedures). Regarding first procedures, recurrence rates were significantly lower in RMN compared to MAN (20% versus 67%, P = 0.029), at a mean follow-up of 5.2 ± 3.0 years. Moreover, fluoroscopy dosages were significantly lower in RMN compared to MAN [20 (IQR 14-54) versus 48 (IQR 38-62) mGy, P = 0.043]. In total, 20 patients (91%) were free of VA following their final ablation procedure. This is the first study to investigate the use of RMN in pediatric VA ablation. RMN showed improved outcomes compared to MAN, resulting in lower VA recurrence and reduced fluoroscopy exposure., (© 2022. The Author(s).)

Aims: Robotic magnetic navigation (RMN) provides increased catheter precision and stability. Formerly, only the CARTO 3 mapping system was integrated with the RMN system (CARTO-RMN). Recently, a novel high-resolution non-contact mapping system (AcQMap) has been integrated with the RMN system (AcQMap-RMN) for the treatment of atrial fibrillation (AF) and atrial tachycardias (AT). We aim to compare the safety, efficiency, and efficacy of AcQMap-RMN with CARTO-RMN guided catheter ablation (CA) procedures., Material and Methods: In this prospective registry, procedural safety efficiency and outcome data from total of 238 consecutive patients (147 AcQMap-RMN and 91 CARTO-RMN patients) were compared., Results: AcQMap-RMN is non-inferior in the primary endpoint of safety as compared to CARTO-RMN across the whole group (overall procedural complications in 5 (3.4%) vs. 3 (3.3%) patients, p = 1.0). Overall procedure durations were longer and associated with more fluoroscopy use with AcQMap-RMN (172.5 vs. 129.6 min, p < 0.01; 181.0 vs. 131.0 mGy, p = 0.02, respectively). Procedure duration and fluoroscopy use decreased significantly between the first 30 and the last 30 AcQMap-RMN procedures. The AcQMap-RMN system had fewer recurrences after persistent AF ablations and was non-inferior in paroxysmal AF patients compared to CARTO-RMN at 12 months (36.6% vs. 75.0%, p = 0.04, PAF 6.6% vs. 12.5%, p = 0.58; respectively). CA of AT outcomes were better using the AcQMap-RMN system (1 year recurrence 17.1% vs. 38.7%, p < 0.05)., Conclusion: AcQMap-RMN integration has no negative impact on the excellent safety profile of RMN guided ablations. It improves outcomes of CA procedures for persAF and AT but requires longer procedure times and higher fluoroscopy use during the initial learning phase., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Catheter ablation (CA) is the first-choice treatment for tachyarrhythmia in children. Currently available CA techniques differ in mechanism of catheter navigation and energy sources. There are no large studies comparing long-term outcomes between available CA techniques in a pediatric population with atrioventricular reentry tachycardia (AVRT) or atrioventricular nodal reentry tachycardia (AVNRT) mechanisms., Objective: This study aimed to compare procedural and long-term outcomes of remote magnetic navigation-guided radiofrequency (RF) ablation (RMN), manual-guided RF ablation (MAN) and manual-guided cryoablation (CRYO)., Methods: This single-center, retrospective study included all first consecutive CA procedures for AVRT or AVNRT performed in children without structural heart disease from 2008 to 2019. Three study groups were defined by the ablation technique used: RMN, MAN or CRYO. Primary outcome was long-term recurrence of tachyarrhythmia., Results: In total, we included 223 patients, aged 14 (IQR 12-16) years; weighting 56 (IQR 47-65) kilograms. In total, 108 procedures were performed using RMN, 76 using MAN and 39 using CRYO. RMN had significantly lower recurrence rates compared to MAN and CRYO at mean follow-up of 5.5 ± 2.9 years (AVRT: 4.3% versus 15.6% versus 54.5%, P < 0.001; AVNRT: 7.7% versus 8.3% versus 35.7%, P = 0.008; for RMN versus MAN versus CRYO respectively). In AVNRT ablation, RMN had significantly lower fluoroscopy doses compared to CRYO [30 (IQR 20-41) versus 45 (IQR 29-65) mGy, P = 0.040)., Conclusion: In pediatric patients without structural heart disease who underwent their first AV(N)RT ablation, RMN has superior long-term outcomes compared to MAN and CRYO, in addition to favorable fluoroscopy doses., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors.)

Pulmonary vein isolation (PVI) using cryoballoon causes acute tissue edema of the osteal region of the pulmonary veins and the left atrium. In two cases combining PVI with an implantation of a left atrial appendage closure device led to malsizing of the device, device shouldering, and a paraprosthetic residual flow. ( Level of Difficulty: Advanced. )., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2021 The Authors.)

Introduction: Remote magnetic navigation (RMN)-guided catheter ablation (CA) is a feasible treatment option for patients presenting with ischemic ventricular tachycardia (VT). Catheter-tissue contact feedback, enhances lesion formation and may consequently improve CA outcomes. Until recently, contact feedback was unavailable for RMN-guided CA. The novel e-Contact Module (ECM) was developed to continuously monitor and ensure catheter-tissue contact during RMN-guided CA., Objective: The present study aims to evaluate the effect of ECM implementation on acute and long-term outcomes in RMN-guided ischemic VT ablation., Method: This retrospective, two-center study included consecutive ischemic VT patients undergoing RMN-guided CA from 2010 to 2017. Baseline clinical data, procedural data, including radiation times, and acute success rates were compared between CA procedures performed with ECM (ECM+) and without ECM (ECM-). One-year VT-free survival was analyzed using Cox-proportional hazards models, adjusting for potential confounders: age, left ventricular function, VT inducibility at baseline and substrate based ablation strategy., Results: The current study included 145 patients (ECM+ N = 25, ECM- N = 120). Significantly lower fluoroscopy times were observed in the ECM+ group (9.5 (IQR 5.3-13.5) versus 12.5 min (IQR 8.0-18.0), P = 0.025). Non-inducibility of the clinical VT at the end of procedure was observed in 92% ECM+ versus 72% ECM- patients (P = 0.19). ECM guidance was associated with significantly lower VT-recurrence rates during 1-year follow-up (16% ECM+ versus 40% ECM-; multivariable HR 0.29, 95%-CI 0.10-0.69, P = 0.021, reference group: ECM-)., Conclusion: Contact feedback by the ECM further decreases fluoroscopy exposure and improves VT-free survival in RMN-guided ischemic VT ablation., Competing Interests: Declaration of competing interest None., (Copyright © 2020 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: The quality of catheter-tissue contact is one of the most important determinants of catheter ablation (CA) success. The absence of catheter-tissue contact feedback has been regarded a major limitation of remote magnetic navigation (RMN)-guided CA. The e-Contact module (ECM) is a novel feature designed for RMN that measures the quality of catheter-tissue contact., Objective: The purpose of this study was to describe the first clinical experience with this feature and to test its effect on procedural parameters and interference with other ablation equipment during CA procedures as well as its safety., Methods: This was a prospective, single-center, 2-phase study investigating ECM use during complex RMN procedures in 30 patients. Impact of ECM on procedural parameters was evaluated in the feasibility phase (FP), and its interference with other equipment was tested in the interference phase (IP) using pacing maneuvers at 3 randomly selected right atrial sites. Intracardiac electrograms were evaluated for disturbances by 2 independent electrophysiologists., Results: For FP, mean procedural time was 162 ± 66 minutes, fluoroscopy time 21 ± 9 minutes, and ablation time 34 ± 21 minutes. For IP, no significant differences in pacing capture or thresholds were found (ECM- vs ECM+: site 1: 2.05 vs 2.21 mA; P = .320; site 2: 2.15 vs 2.12 mA; P = .873; site 3: 2.51 vs 2.50 mA; P = .976). Electrogram disturbances did not significantly differ between ECM- and ECM+. No adverse events were reported., Conclusion: The ECM is a novel catheter-tissue contact technology designed for RMN-guided CA. Our study suggests that this feature is feasible and does not interfere with other electrophysiology equipment while maintaining an excellent safety profile., (© 2020 Heart Rhythm Society. Published by Elsevier Inc.)

We present a unique case of a left-sided phrenic nerve injury (PNI) long after a previous contralateral PNI following pulmonary vein isolation (PVI) procedures. Firstly, right-sided PNI after cryoballoon ablation, and secondly a left-sided PNI was observed following a redo PVI extended with box-lesion and left atrial appendage isolation (LAAI)., Competing Interests: None of the authors.