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Background In patients with non-valvular atrial fibrillation (AF), at high stroke risk, and who are ineligible for long-term oral anticoagulation, the left atrial appendage closure (LAAC) could be an alternative to anticoagulation. Pulsed field ablation (PFA) is a new non-thermal method for cardiac ablation modality based on high-voltage electrical energy for irreversible electroporation. We first report a case of a concomitant PFA pulmonary vein isolation (PVI) and LAAC. Case summary A 74-year-old female patient was referred to our department for PVI for persistent AF (CHA2DS2-VASc score 5). A concomitant percutaneous LAAC was proposed because of a history of previous cerebellar transient ischaemic attack despite continuous oral anticoagulation therapy. Pulmonary vein isolation was achieved with a pentaspline PFA catheter, and LAAC was performed with a WATCHMAN FLX™ device (Boston Scientific, Plymouth, MN, USA). After PVI, a swelling of the left atrial ridge was observed, yet a 27 mm LAAC device was successfully implanted. The follow-up transesophageal echo (TEE) after 6 weeks showed complete resolution of the oedema, no device-related thrombus, but a slight proximal tilting of the LAAC device without leakage could be observed. The 6-month follow-up demonstrated a stable sinus rhythm, no stroke, or bleeding events were recorded. Discussion In this case of synchronous PFA-PVI procedure in AF and WATCHMAN FLX™ device implantation, the electroporation created an acute oedema at the ridge level which at the TEE follow-up after 6 weeks was resolved. This resulted in a slightly tilted WATCHMAN device position which was nevertheless stable and showed no leakage. [ABSTRACT FROM AUTHOR]

Background: Laser balloon (LB) pulmonary vein isolation (PVI) is an established ablation technique for atrial fibrillation (AF). We report long‐term follow‐up and procedural data of LB‐PVI and we compare the first and second LB generation. Methods: Patients undergoing LB ablation with first‐ (LB1) or second‐generation LB (LB2) for AF were retrospectively enrolled and divided into two groups. Procedural endpoint was complete PVI. Clinical success was defined as no recurrence of AF/atrial tachycardia after a 90 days blanking period. Results: 538 patients were included (age 66 ± 10 years, 58% paroxysmal AF), 427 in LB1 and 111 in LB2. 2079 PVs were targeted and 2073 (99.7%) were successfully isolated; 2027 (97.5%) using solely the LB. Additional touch‐up ablation was limited (46 PVs; 2.2%) with no difference between the groups. Procedural (LB1: 120 ± 33 minutes vs. LB2: 99 ± 22 min; p <.001) and fluoroscopy time (LB1: 11.2 ± 5 min vs. LB2: 8.5 ± 3 min; p <.001) were shorter with LB2. The complication rate was 8.9% (LB1: 10.1% vs. LB2: 4.5%; p =.067) with most complications resulting from the access site (21/48). Overall freedom from AF after 1‐year was 73.7% (paroxysmal AF: 76.9%; persistent AF: 69.3%; p <.001) with no difference between the groups (LB1: 73.4% vs. LB2: 74.7%; p =.491). Conclusion: LB showed a high efficacy and acceptable safety, with numerically lower complication rates with the second‐generation LB. Procedure and fluoroscopy times were shorter with LB2. Overall, 73.7% of patients were free from AF at 1‐year, with comparable results among both generations. [ABSTRACT FROM AUTHOR]

Background: Management of atrial fibrillation (AF) in very severe obese patients is challenging. Cryoballoon ablation (CBA) represents an effective rhythm control strategy. However, data in this patient group were limited. Methods: Highly symptomatic AF patients with body mass index (BMI) ≥ 40 kg/m2 who had failed antiarrhythmic drug therapy and electrocardioversion and failure to achieve targeted body‐weight‐reduction underwent CBA. Results: Data of 72 very severe obese AF patients (Group A) and 129 AF patients with normal BMI (Group B, BMI < 25 kg/m2) were consecutively collected. Group A had significantly younger age (60.6 ± 10.4 vs. 69.2 ± 11.2 years), higher BMI (44.3 ± 4.3 vs. 22.5 ± 1.6 kg/m2). Procedural pulmonary vein isolation (PVI) was successful in all patients (2 touch‐up ablation in Group A). Compared to Group B, Group A had similar procedural (61.3 ± 22.6 vs. 57.5 ± 19 min), similar fluoroscopy time (10.1 ± 5.5 vs. 9.2 ± 4.8 min) but significantly higher radiation dose (2852 ± 2095 vs. 884 ± 732 µGym2). We observed similar rates of real‐time‐isolation (78.6% vs. 78.5%), single‐shot‐isolation (86.5% vs. 88.8%), but significantly longer time‐to‐sustained‐isolation (53.5 ± 33 vs. 43.2 ± 25 s). There was significantly higher rate of puncture‐site‐complication (6.9% vs. 1.6%) in Group A. One‐year clinical success in paroxysmal AF was (Group A: 69.4% vs. Group B: 80.2%; p <.001), in persistent AF was (Group A: 58.1% vs. Group B: 62.8%; p =.889). In Re‐Do procedures Group A had a numerically lower PVI durability (75.0% vs. 83.6%, p =.089). Conclusion: For very severe obese AF patients, CBA appears feasible, leads to relatively good clinical outcome. [ABSTRACT FROM AUTHOR]

Aims Technological advancements have contributed to the enhanced precision and lesion flexibility in pulsed-field ablation (PFA) by integrating a three-dimensional mapping system combined with a point-by-point ablation strategy. Data regarding the feasibility of this technology remain limited to some clinical trials. This study aims to elucidate initial real-world data on catheter ablation utilizing a lattice-tip focal PFA/radiofrequency ablation (RFA) catheter in patients with persistent atrial fibrillation (AF). Methods and results Consecutive patients who underwent catheter ablation for persistent AF via the lattice-tip PFA/RFA catheter were enrolled. We evaluated acute procedural data including periprocedural data as well as the clinical follow-up within a 90-day blanking period. In total, 28 patients with persistent AF underwent AF ablation either under general anaesthesia (n = 6) or deep sedation (n = 22). In all patients, pulmonary vein isolation was successfully achieved. Additional linear ablations were conducted in 21 patients (78%) with a combination of successful anterior line (n = 13, 46%) and roof line (n = 19, 68%). The median procedural and fluoroscopic times were 97 (interquartile range, IQR: 80–114) min and 8.5 (IQR: 7.2–9.5) min, respectively. A total of 27 patients (96%) were interviewed during the follow-up within the blanking period, and early recurrent AF was documented in four patients (15%) including one case of recurrent AF during the hospital stay. Neither major nor minor procedural complication occurred. Conclusion In terms of real-world data, our data confirmed AF ablation feasibility utilizing the lattice-tip focal PFA/RFA catheter in patients with persistent AF. [ABSTRACT FROM AUTHOR]

Introduction: 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. Methods: 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. Results: 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. Conclusions: 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. [ABSTRACT FROM AUTHOR]

Catheter ablation is an effective rhythm control strategy in treating atrial fibrillation (AF) [[1]-[5]]. The PFA ablation catheter can be progressively configured into different poses: from a baseline linear shape for introducing the PFA catheter into the steerable sheath, to a semi-deployed ball or basket pose, and to a fully deployed flower configuration. The 12-F PFA ablation catheter (Farawave) contains 5 splines, each containing 4 electrodes to deliver pulsed field ablation energy. The PFA system The PFA system consists of (1) a generator which delivers pulsed electrical waveforms over multiple channels (Farastar, Farapulse Inc., Menlo Park, California), (2) a 13-F steerable delivery sheath (Faradrive), and (3) a PFA ablation catheter (Farawave). [Extracted from the article]

Aims A novel irrigated radiofrequency (RF) balloon (RFB) for pulmonary vein (PV) isolation (PVI) was released in selected centres. We pooled the procedural data on efficacy and safety of RFB-PVI from two high volume German centres. Methods and results Consecutive patients with RFB procedures were enrolled. A 3D electroanatomical left atrial map guided the RFB navigation. Every RF delivery lasted 60 s, and duration was automatically reduced to 20 s for electrodes facing the posterior wall. Procedural data and post-procedural endoscopy data (<48 h) were analysed. Data from 140 patients were collected (57% male, 67 ± 11 years, 57% paroxysmal atrial fibrillation). There were 547 PVs identified, and 99.1% could be isolated using solely the RFB. Single-shot PVI was recorded in 330/547 (60%) PVs. Median time to isolation during the first application was 10 s (IQR 8–13). A total of 2.1 ± 1.8 applications per PV were delivered, with the left superior PV requiring more application compared to other PVs. Median procedure and fluoroscopy time were 77 min (61–99) and 13 min (10–17), respectively. Major safety events were recorded only in the first 25 cases at each centre and included 1/140(0.7%) cardiac tamponade, 1/140(0.7%) phrenic nerve palsy, and 2/140 strokes (1.4%). An oesophageal temperature rise was recorded in 81/547 (15%) PVs, and endoscopy detected oesophageal lesions in 7/85 (8%) patients undergoing endoscopy. Conclusion The RFB showed a high efficacy allowing for fast PVI procedures, and 60% of PVs could be isolated at the first application. Most safety events were recorded during the learning phase. An oesophageal temperature monitoring is suggested: oesophageal lesions were detected in 8% of patients. [ABSTRACT FROM AUTHOR]

Pulsed field ablation (PFA) using high‐voltage electrical energy is a novel and powerful ablation modality. However, PFA as a first‐line rhythm control in atrial fibrillation (AF) has been rarely described; whether PFA interacts with the pacemaker (PM) has been seldom reported. We reported PFA of AF in a patient with PM who needed effective rhythm control. Pulmonary vein isolation (PVI) was successfully performed without complication, and the procedure was extremely fast (skin‐to‐skin 25 min.) with short fluoroscopic time (3.9 min). PFA had no influence on the PM function. Six months' follow‐up showed good clinical outcome and significantly decreased AF burden. [ABSTRACT FROM AUTHOR]

The 12-F PFA ablation catheter (Farawave) contains 5 splines, each containing 4 electrodes to deliver pulsed field ablation energy. Pulsed field ablation (PFA) is a novel nonthermal ablation technology to treat atrial fibrillation (AF). When considering catheter ablation, using traditional point-by-point radiofrequency ablation or cryoballoon ablation can still be challenging in view of the obesity and significantly dilated LA. [Extracted from the article]

We present the case of a 60-year-old male patient who was admitted to our hospital after experiencing a syncopal episode. First ECGs showed sinus rhythm with polymorphic premature ventricular complexes and later ventricular tachycardia with a left bundle branch block morphology were recorded. Imaging with TEE and MRI revealed a space-occupying lesion in the left ventricle, which was ultimately identified as a rare cardiac metastasis of renal cell carcinoma. Treatment was initiated with monoclonal antibodies resulting in lesion regression. This case highlights the importance of comprehensive diagnostic in patients with history of malignancy. [ABSTRACT FROM AUTHOR]

Aims: Pulsed-field ablation (PFA) can offer a novel perspective for atrial fibrillation (AF) ablation. We aimed to characterize the incidence of pulmonary vein (PV) reconnection, types of recurrent atrial tachyarrhythmia (ATa) and lesion quality after PFA-guided PV isolation (PVI).Methods and Results: Patients undergoing second ablation for recurrent ATa following the initial PVI using the pentaspline PFA catheter were investigated. The rate of PV reconnection, the features of recurrent ATa, and the amount of isolated posterior wall (PW) surface area (ISAPW%) (ratio of the isolated- to total surface area on PW) were analyzed.Results: Among 360 patients treated with PFA, 25 patients (paroxysmal AF, n = 19) with 99 PVs underwent a second procedure 6.1 ± 4.0 months after the initial procedure. The rate of PV reconnection was 9.1% (9 PVs). Patients presented with atrial tachycardia (AT) (n = 16), AF (n = 8) and typical atrial flutter (n = 1). The mechanism of all but one AT was macro-reentry. The critical isthmus was found to be linked to the initial lesion set at the left atrial (LA) PW in eight patients and linked to pre-existing substrate at the LA anterior wall in four patients. One AT had a focal origin at the septum. In three patients, AT were unmappable. Mean ISAPW% was 72.7 ± 19.0%.Conclusion: We revealed a remarkable low reconnection rate with a large antral lesion at the PW after pentaspline PFA catheter-guided PVI. However, macro-reentrant AT with a critical isthmus at the LAPW linked to the PVI lesion set was commonly observed. [ABSTRACT FROM AUTHOR]

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Background Pulsed field ablation (PFA) is a new feasible and safe method for the ablative treatment of cardiac arrhythmias, such as atrial fibrillation (AF). Through the use of electric fields, it causes pore-like openings in the cell's wall, leading to cell death. The most appealing characteristic of this new technique is its selectivity for cardiomyocytes and consequently its low risk of collateral damage to extracardiac tissues. We present three cases of a PFA-induced transient phrenic nerve (PN) injury documented during pulmonary vein isolation (PVI). Case summaries Three patients aged 55–81 years underwent PFA for symptomatic AF. Cases 1 and 3 were affected by paroxysmal AF without evidence of structural heart disease. Case 2 had persistent AF and ischaemic cardiomyopathy with preserved ejection fraction. We observed a transient right hemidiaphragm palsy during the delivery of impulses in the right superior pulmonary vein (Cases 1 and 2) and in the right inferior pulmonary vein (Case 3). The palsy lasted <1 min and was followed by spontaneous full recovery in all cases. Discussion Transient PN dysfunction can be observed following PFA in AF ablation. According to our initial experience, a full recovery of the PN function can be expected within seconds. We hypothesize a hyperpolarization of neuronal cells or a depletion of acetylcholine in the motoric endplate to explain this event. Further studies are required to understand the exact pathophysiological mechanism. [ABSTRACT FROM AUTHOR]

Background: The iCLAS ultra‐low temperature cryoablation (ULTC) system has recently been brought to the market. A combination of a newly exploited cryogen and interchangeable stylet enables flexible and continuous lesion creation in atrial fibrillation (AF) ablation. The use of an esophageal warming balloon is recommended when using the system to reduce the potential for collateral esophageal injury. Objective: To describe the initial clinical experience when using ULTC in the AF treatment without general anesthesia (GA). Methods: Consecutive patients undergoing AF ablation using ULTC under deep sedation without GA were enrolled. We assessed the procedural data focusing on "single‐shot isolation" defined as successful pulmonary vein (PV) isolation after the first application. Esophagogastroduodenoscopy was systematically performed the day after ablation. Results: A total of 27 AF patients (67% paroxysmal AF) were analyzed. Onehundred four out of 106 PVs (98.1%) were isolated solely using ULTC. The mean procedure time was 79 ± 30 min. The mean number of applications per PV was 2.6 ± 1.0. Single‐shot isolation was achieved in 57 PVs (54%) varying across PVs from left superior to inferior PVs (40%–64%). The single procedure 6‐month recurrence‐free rate was 84%. No major complication (cerebrovascular event, pericardial effusion/tamponade, esophageal damage on esophagogastroduodenoscopy) occurred. A single transient phrenic nerve palsy occurred during the right superior PV ablation, which had recovered by the 3‐month follow‐up appointment. Conclusions: AF ablation using the novel ULTC system seemed feasible without GA and enabled a >50% single‐shot isolation rate. The promising safety profile has to be confirmed in large‐scale studies. [ABSTRACT FROM AUTHOR]

Background: Left atrial appendage (LAA) isolation (LAAI) has been described as an adjunctive ablation strategy for patients with recurrent atrial tachyarrhythmia (ATa). Objectives: We compared the clinical impact of persistent durable LAAI between radiofrequency (RF)‐guided wide‐area LAAI and cryoballoon (CB)‐guided ostial LAAI. Methods: Consecutive patients who underwent RF‐ or CB‐guided LAAI were retrospectively analyzed. RF‐guided LAAI was performed by combining linear ablation. CB‐guided LAAI was performed by LAA ostial ablation. Following LAAI, the patients underwent an invasive remapping study. LAA closure was conducted if persistent durability was confirmed. The procedural data, LAAI durability, and ATa recurrence were assessed. Results: A total of 260 patients (RF: n = 201; CB: n = 59) undergoing LAAI were identified. The acute rate of procedural LAAI was higher in the CB group (CB:94.9% vs. RF:82.6%, p =.02) with a lower pericardial effusion incidence (CB:0% vs. RF:7.5%, p =.03). The 6‐week durable LAAI was similar between the two groups (RF:78.3% vs. CB:66.0%, p =.103). During follow‐up, one gastrointestinal bleeding and four stroke events including one subsequent intracranial bleeding leading to death occurred in the RF group, while one gastrointestinal bleeding occurred in the CB group. The 1‐year ATa recurrence‐free rate was higher in patients with durable LAAI following RF‐guided LAAI (RF:76.3% vs. CB:56.7%, p =.0017). Multivariate analysis revealed RF‐guided LAAI as a predictor of freedom from ATa recurrence (HR: 0.478, 95%CI: 0.336–0.823, p =.017). Conclusions: LAAI can be more readily and safely achieved by CB‐guided ostial ablation. In patients with confirmed LAAI, however, the freedom from ATa recurrence was higher after RF‐guided wide‐area isolation. [ABSTRACT FROM AUTHOR]

Introduction: Ablation of atrial fibrillation in the context of obesity can be challenging. We sought to evaluate the role of cryoballoon pulmonary vein isolation (CB‐PVI) in obese patients with symptomatic atrial fibrillation (AF). Methods: Patients with a BMI ≥ 25 kg/m2 and symptomatic AF who underwent CB‐PVI were retrospectively enrolled. Three groups were defined (G1: BMI of 25–29 kg/m2; G2: BMI of 30–34 kg/m2; G3: BMI ≥ 35 kg/m2). Results: 600 patients were included (59% male; 66 ± 11 years old); 337, 149, and 114 were assigned to G1, G2, and G3, respectively. Acute procedural success was recorded in 99.7% of patients. Procedural and fluoroscopy time were comparable but the radiation dose was significantly higher in G3. Procedural complications were 3% in G1, 5.4% in G2, and 8.8% in G3 (p =.01). The overall freedom from AF after 1‐year was 77%. G3 had a significantly worse 1‐year success rate compared to G1 and G2 (G3: 66.5% vs. G1: 78.4%; p =.015 and vs. G2: 82.5%; p =.008) with reduced 1‐year success in paroxysmal AF (G1: 84.0%; G2: 86.3%; and G3: 69.6%) but not in persistent AF (G1: 68.7%; G2: 77.4%; and G3: 62.1%). G3 showed similar success rates irrespective of AF form (PAF: 69.6% vs. persAF 62.1%; p =.501). Conclusion: Cryoballoon ablation in obese patients can be effective with an acceptable safety profile, 77% of patients were in stable SR at 1 year. Severe obese patients (BMI ≥ 35) showed reduced procedural safety and 1‐year success rate. In association with life style modification, CB ablation may represent a strategy to enhance rhythm control in the context of obesity. [ABSTRACT FROM AUTHOR]

Background: The endoscopic ablation system (EAS) is an established ablation device for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). The novel X3 EAS is now equipped with a contiguous circumferential ablation mode (RAPID mode). Aim: To determine the feasibility of single‐shot fashioned ablation using X3. Methods: Consecutive patients who underwent AF ablation using X3 were enrolled. We assessed the acute procedural data focusing on "Single‐sweep PVI" defined as successful PVI with a single RAPID mode energy application, and on "first‐pass isolation" defined as successful PVI after initial circular lesion set. Results: One hundred AF patients (56% male, age: 68 ± 10 years, 66% paroxysmal AF) were analyzed. A total of 379 of 383 PVs (99%) were isolated with X3. Single‐sweep PVI and first‐pass‐isolation were achieved in 214 PVs (56%) and in 362 PVs (95%), respectively. Single‐sweep PVI rates varied across PVs with higher rates at the superior PVs (61.2% vs. inferior PVs: 49.5%, p =.0239) and at PVs with maximal ostial diameter <24 mm (57.6% vs. >24 mm: 36.8%, p =.0151). The mean total procedure and fluoroscopy times were 43.0 ± 10 and 4.0 ± 2 min, respectively. In none of the patients an acute thromboembolic event (stroke or transient ischemic attack) or a pericardial effusion/tamponade occurred. A single transient phrenic nerve palsy was observed. Conclusion: The new X3 EAS allows for single‐shot fashioned ablation in terms of single‐sweep PVI in half or more of PVs. The new RAPID ablation mode leads to an improved rate of first‐pass isolation associated with very short procedure times without compromising safety. [ABSTRACT FROM AUTHOR]

• This study revealed the data following pulmonary vein isolation with the successor laser balloon catheters. • The continuous robotic motor driven ablation led to higher index lesion durability. • Right superior pulmonary vein was the most common reconnected vein irrespective of generations. • The need for focal energy reduction was a predictor of pulmonary vein reconnection. The second- and third-generation endoscopic ablation systems (EAS2 and EAS3) have been launched in recent years. We aimed to assess the lesion durability as well as gap localization using the multigenerational novel technologies in patients with recurrent atrial fibrillation (AF). Consecutive patients who underwent second ablation for recurrent AF following the initial pulmonary vein isolation (PVI) with EAS2 or EAS3 were retrospectively investigated. The persistent durability of PVI, gap localization at the second procedure, and procedural/anatomical features of durable PVI were analyzed. Among 225 patients treated with EAS3 (N = 125) and EAS2 (N = 100), 34 patients (EAS3: 13 patients, 50 PVs, EAS2: 21 patients, 82 PVs) underwent a second procedure because of recurrent AF mean 11.9 ± 9.3 months after the initial procedure. Persistent isolation of all four PVs was recorded in 6 (46.2%) patients in EAS3 group and 4 (19.1%) patients in EAS2 group (p = 0.130). Ninety-one out of 132 (68.9%) PVs were persistently isolated with a higher rate in EAS3 group (82.0% vs. EAS2 group: 61.0%, p = 0.0113). A total of 45 gaps were recorded in 41 PVs. Right superior PV (RSPV) was the predominantly common reconnected vein (15 gaps, 14 PVs) irrespective of generations (EAS3: 4 gaps in 3 PVs and EAS2: 12 gaps in 11 PVs). Logistic multivariate regression analysis revealed ablation without reduced energy dose (5.5–7 W) as an independent predictor of durable PVI [adjusted OR: 3.70, 95% CI (1.408–10.003)], p = 0.008]. The technical innovation resulted in a higher lesion durability in EAS3-guided PVI in patients with recurrent AF. The most common gap location was found at RSPV in successor EASs. Ablation without reduced energy was a predictor of durable PVI in successor EASs. [Display omitted] [ABSTRACT FROM AUTHOR]

Visually guided laser balloon (LB) catheter has been an established modality dedicated for pulmonary vein (PV) isolation in patients with atrial fibrillation. The newly updated version of this novel device has technically evolved recent years. This review will summarize the contemporary technical evolution of LB catheter. Available efficacy outcomes and the historical change of ablation style will be evaluated. Furthermore, the future perspectives for clinical practice are discussed. The initial LB ablation system provided comparable clinical results in PV isolation with other technologies, but with a unique strategical concept enabling the direct visualization of the tissue to cauterize. With multigenerational development, the LB catheter has been equipped with more compliant balloon for favorable PV occlusion and a robotically motor driven continuous ablation mode (RAPID mode). These technical innovations changed the concept of the ablation strategy using LB catheter as 'point-by-point' into 'single-shot' fashion. The remaining tasks are further improvements such as equipping with real-time recording system of intracardiac electrogram, durable structured balloon and the instrument for visualizing the cauterization area in a 360-degree panoramic view, which includes potential possibilities to develop this novel device to the more optimal device for PV isolation. [ABSTRACT FROM AUTHOR]

Background: Recently a double 120 s freeze cryoballoon (CB) pulmonary vein isolation (PVI) protocol proved to be non inferior to a double 240 s freeze protocol in terms of atrial fibrillation (AF) recurrences. We hypothesized that this approach could also result in an increased procedure safety. Methods: Eighty consecutive patients treated with a double 120 s freeze protocol (Group CB120) were compared with 80 previous consecutive patients treated with a single 240 s freeze protocol (Group CB240). Procedures were performed with a temperature probe to monitor the luminal esophageal temperature (LET), using a cut off for cryoenergy interruption of 15°C. During ablation at the septal pulmonary veins (PVs), the phrenic nerve (PN) function was monitored by pacing. Results: In CB120 and CB240 the rate of single shot isolation was similar in all PVs. Time to isolation was not different between the two groups. Mean minimal esophageal temperature was lower in LSPV and LIPV of the CB240 group. A total of 4/80 patients (5%) of the CB120 group experienced a PN injury, but no persistent form was recorded; 11/80 patients (14%) of the CB240 group experienced a PN injury, three in a persistent form (p =.10). A LET <15°C was recorded in 3/80 patients (4%) in the CB120 group and in 16/80 patients (20%) in the CB240 group (p <.01). Composite rate of energy‐related safety events (LET <15°C and PN injury) was significantly lower in the CB120 (34% vs. 9%, p <.01). Conclusions: Safety of second generation CB PVI can be increased using a double 120 s freeze protocol. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate the feasibility, procedural data, and lesion characteristics of the anterior line (AL) and roofline (RL) ablation by using ablation index (AI)‐guided high power (50 W) among patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT) after pulmonary vein isolation (PVI). Methods: Data from 35 consecutive patients with macro‐reentrant left atrial tachycardia or substrate at the left atrium anterior wall or roof after previous PVI were collected. Ablation power was set to 50 W, targeting AI 500 for AL and 400 for RL. The first‐pass conduction block (FPB) was evaluated. The AL was arbitrarily divided into three (caudal, middle, and cranial) segments to analyze the location of conduction gaps in non‐FPB patients. Results: A total of 32 AL and 17 RL were deployed and FPB was achieved in 24 (75%) and 14 (82%) of them, respectively. In the non‐FPB group, the most frequent gap location along the AL was the middle third. The final block of AL was achieved in 97%, and the block of RL was achieved in 100%. The radiofrequency (RF) ablation time was short (2.9 ± 0.8 min for AL and 46.2 ± 15.6 s for RL). For AL, the female gender was significantly more frequent in FPB than in non‐FPB patients (p =.028); patients with non‐FPB were associated with significantly longer RF time as compared to patients with FPB (204 ± 47 s vs. 161 ± 41 s; p =.02). No procedural complications occurred. Conclusion: AI‐guided high‐power (50 W) ablation appears to be a feasible, effective, and fast technique for AL and RL ablation. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency (RF) high‐power ablation appears to be a novel concept in treating atrial fibrillation (AF). The ablation‐index (AI) has been linked with the durability of pulmonary vein isolation (PVI). To report the midterm clinical results of a new ablation strategy using AI‐guided high‐power (50 W) ablation (AI‐HP). Methods and Results: Symptomatic AF patients were included and underwent wide‐area circumferential PVI. Contact‐force catheters were used, RF power was set to 50 W targeting AI values (550/400 for anterior/posterior) and interlesion distance 6 mm. Luminal esophageal temperature (LET) was monitored during the procedure; patients with LET ≥39°C underwent post‐ablation esophageal‐endoscopy. Seventy‐two‐hour‐Holter ECGs were scheduled during follow‐up. Procedural PVI was achieved in all (N = 122; mean age, 68.2 years; male, 71.3%) patients, rate of first‐pass PVI was 96.7% per patient. Procedural mean RF time was 11.5 min, and mean RF time during posterior wall segment was 3.1 min. Per RF‐lesion, the mean contact force, RF duration, AI, and impedance‐drop at anterior/posterior wall were 26 ± 14 g/23 ± 12 g, 16.2 ± 7.5 s/8.8 ± 3.6 s, 552 ± 53/438 ± 47, and 13 ± 6 Ω/9 ± 5 Ω, respectively. Mean PVI procedural‐time, 55.8 min; mean procedural fluoroscopic time, 5.6 min. Three (2.5%) patients had asymptomatic endoscopic small erosion/erythema esophageal lesions, no serious adverse events were observed. During a 15‐month follow‐up, overall single‐procedure freedom from clinical recurrence of AF/atrial tachycardia (AT) off antiarrhythmic drug after blanking period was 85.2% (89.4% for paroxysmal AF, 80.4% for persistent AF). Conclusion: The AI‐HP (50 W) appears as an efficient ablation technique in treating AF and leads to a high single‐procedure arrhythmia‐free survival at 15 months. [ABSTRACT FROM AUTHOR]

Background: The role of nonpulmonary vein (PV) triggers ablation in persistent atrial fibrillation (PEAF) was suggested but it is still under debate. Objectives: We aimed to assess the effectiveness of non‐PV trigger‐targeted ablation for patients with PEAF. Methods: Consecutive patients with PEAF undergoing catheter ablation (CA) between January 2015 and April 2017 were enrolled. Isoproterenol plus adenosine challenge was performed to provoke non‐PV triggers. Non‐PV triggers were defined as the trigger beats inducing AF (non‐PV AF triggers) and/or frequent premature contractions (non‐PV PACs) from other than PVs. Three groups were defined: Group 1 (n = 186) without non‐PV triggers; Group 2 (n = 65) with non‐PV triggers that could be completely eliminated with CA; Group 3 (n = 49) with non‐PV triggers still inducible after CA. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence. Results: A total of 300 patients (230 males, age 64 ± 10) were enrolled. The mean follow‐up period was 27 ± 10 months. Freedom from ATa recurrence at 1 and 2 years were significantly lower in Group 3 compared to the other two groups (Group 1; 74.7%, 67.2% vs. Group 2; 75.8%, 68.3% vs. Group 3: 52.1%, 38.6%, p =.0005), irrespective of the type of non‐PV triggers (non‐PV AF triggers vs. non‐PV PACs). On multivariate analysis, unsuccessful elimination of non‐PV triggers was an independent predictor for ATa recurrence (hazard ratio = 1.80, 95% confidence interval = 1.07–2.95, p =.026). Conclusion: Successful non‐PV triggers elimination can improve the ATa recurrence rate in PEAF ablation. ATa recurrence rate is higher, if non‐PV AF triggers or even non‐PV PACs remain in patients with PEAF. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) represents the cornerstone in atrial fibrillation ablation. Cryoballoon and laserballoon catheters have emerged as promising devices but lack randomized comparisons. Therefore, we sought to compare efficacy and safety comparing both balloons in patients with persistent and paroxysmal atrial fibrillation (AF).Methods: Symptomatic AF patients (n=200) were prospectively randomized (1:1) to receive either cryoballoon or laserballoon PVI (cryoballoon: n=100: 50 paroxysmal atrial fibrillation + 50 persistent AF versus laserballoon: n=100: 50 paroxysmal atrial fibrillation + 50 persistent AF). All antiarrhythmic drugs were stopped after ablation. Follow-up included 3-day Holter-ECG recordings and office visits at 3, 6, and 12 months. Primary efficacy end point was defined as freedom from atrial tachyarrhythmia between 90 and 365 days after a single ablation. Secondary end points included procedural parameters and periprocedural complications.Results: Patient baseline parameters were not different between both groups. In all (n=200) complete PVI was obtained and the entire follow-up accomplished. Balloon only PVI was obtained in 98% (cryoballoon) versus 95% (laserballoon) requiring focal touch-up in 2 and 5 patients, respectively. Procedure but not fluoroscopy time was significantly shorter in the cryoballoon group (50.9±21.0 versus 96.0±20.4 minutes; P<0.0001 and 7.4±4.4 versus 8.4±3.2 minutes, P=0.083). Overall, the primary end point of no atrial tachyarrhythmia recurrence was met in 79% (cryoballoon: 80.0% versus laserballoon: 78.0%, P=ns). No death, atrio-esophageal fistula, tamponade, or vascular laceration requiring surgery occurred. In the cryoballoon group, 8 transient but no persistent phrenic nerve palsy were noted compared with 2 persistent phrenic nerve palsy and one transient ischemic attack in the laserballoon group.Conclusions: Both balloon technologies represent highly effective and safe tools for PVI resulting in similar favorable rhythm outcome after 12 months. Use of the cryoballoon is associated with significantly shorter procedure but not fluoroscopy time. [ABSTRACT FROM AUTHOR]

Objective: Epicardial access is sometimes required to effectively treat ventricular arrhythmias, but it can be associated with increased risk of procedural complications needing surgical intervention. The present study aimed to evaluate the feasibility and safety of epicardial mapping/ablation in experienced center without onsite cardiac surgery. Methods: Patients who had drug-refractory, recurrent ventricular arrhythmias were scheduled for catheter ablation. All operators (SC, JC, SB, BS) had at least fifty pericardial puncture experiences. Epicardial puncture and perioperative anticoagulation were carried out based on institutional protocol. Phrenic nerve was mapped by 3-D mapping system. Coronary anatomy was delineated by coronary angiography. Results: A total of 44 patients (63.3 years, male 86.4%) received epicardial access. Of them 7 (15.9%) were scheduled for PVC ablation, 37 (84.1%) for VT ablation (ICM: 25%, NICM: 59.1%). Mean LVEF was 41.3%. Acute ablation success rate was 35 (79.5%). Procedural adverse events included: pericardial effusion occurred in 3 (6.8%) patients who all well treated with pericardial drainage; and pericardial tamponade in 1 (2.3%) patient requiring transfer to surgical intervention. No death, stroke, phrenic nerves palsy, or coronary artery injury were observed. Median hospitalization was 4 (3-6) days. Univariable analysis and ROC curve showed that patients' age was a significant predictor of epicardial procedural complication (area under curve (AUC): 0.813, P D0:041). Conclusions: Guided by a tailored procedural protocol, the majority of the epicardial access related complications can be treated conservatively without needing onsite surgery. Older age is a risk factor associated with epicardial access related complications. [ABSTRACT FROM AUTHOR]

Maze‐like linear substrate modification in atrial fibrillation patients nonresponders to pulmonary vein isolation represents a feasible technique to gain left atrial appendage electrical isolation even in the presence of a Watchman occluder device. [ABSTRACT FROM AUTHOR]

Aims: Systematic data on phrenic nerve palsy (PNP) associated with contemporary balloon ablation techniques (cryoballoon [CBA] vs laser balloon [LBA]) are sparse. We aimed to investigate the incidence, characteristics, and clinical recovery course in patients with PNP who underwent CBA or LBA. Methods and Results: A total of 2433 consecutive patients who underwent balloon‐based pulmonary vein isolation (CBA: n = 1720 and LBA: n = 713) were retrospectively identified. PNP was classified into (a) transient (recovery before discharge) or (b) persistent (within 6 months, 6‐12 months, and >12 months) according to clinical recovery course. In general, PNP occurred significantly more often in CBA 71/1720 (4.2%) than LBA 11/713 (1.5%) (P =.003). The rate of transient PNP was significantly higher in CBA (3.0%, n = 45) than LBA (0.1%, n = 1, P =.004). The rate of persistent PNP did not significantly differ between two groups (CBA: 1.2% vs LBA: 1.4%, P =.89). The rate of persistent PNP which recovered within 6 months was similar (CBA: 17.4% vs LBA 18.2%, P = 1.000). However, the rates of persistent PNP which recovered within 6 to 12 months (CBA: 2.9% vs LBA 27.3%, P =.0171) and more than 12 months (CBA: 7.3% vs LBA 45.5%, P =.0034) were significantly higher in LBA. Conclusion: PNP occurred more often in CBA than LBA, however, the majority of PNP in CBA was transient whereas the majority of PNP in LBA was persistent. Either balloon technology is not superior in terms of long‐term PNP. [ABSTRACT FROM AUTHOR]

Background: Time‐to‐isolation (TTI) guided second‐generation cryoballoon (CB2) ablation has been shown to be effective for pulmonary vein isolation (PVI). Objective: The objective of this paper is to compare the safety and clinical outcome of CB2 PVI using the TTI guided 4 minutes vs 3 minutes freeze protocol. Methods: This was a propensity‐matched study based on an institutional database. Symptomatic atrial fibrillation (AF) patients who underwent CB2 PVI and systematic follow‐up were consecutively included. Results: A total of 573 patients were identified, of them 214 (107 matched‐pairs) symptomatic AF (paroxysmal AF: 61%, persistent AF: 39%) patients (age: 67.7 ± 11.2 years) were analyzed. The baseline characteristics were comparable between the two groups. Procedural time was significantly longer in the 4 minutes group compared to 3 minutes group (67.2 ± 21.8 vs 55.9 ± 16.9 minutes, P <.0001). During a mean follow‐up of 2 years, the 4 minutes group was associated with a significantly higher rate of freedom from arrhythmia recurrence compared with the 3 minutes group (66.4% vs 56.1%, P =.009), which was mainly driven by patients with persistent AF. The multivariate regression showed that the 4 minutes freeze was the independent predictor of freedom from arrhythmia recurrence. During the repeat procedure, the 4 minutes group was associated with a significantly higher rate of durable PVI. There was no difference regarding procedural adverse events between the two groups. Conclusion: As compared with the 3 minutes freeze, the TTI guided 4 minutes freeze is associated with a significantly higher rate of arrhythmia‐free and durable PVI without compromising the safety profile, patients with persistent AF may benefit from the TTI guided 4 minutes freeze more pronouncedly. [ABSTRACT FROM AUTHOR]

Background: Cryoballoon ablation is an established procedure for atrial fibrillation (AF). Patient with vena cava filter undergoing pulmonary vein isolation (PVI) were seldom reported. Case presentation: We describe an AF ablation technique using the second generation cryoballoon in a patient after vena cava filter implantation. All pulmonary veins were successfully isolated without complication. Conclusions: For AF patient with previously implanted vena cava filter, cryoballoon based PVI appears feasible and safe. [ABSTRACT FROM AUTHOR]

Background: Patients with a left atrial appendage thrombus (LAAT) despite oral anticoagulation (OAC) are at high risk of thromboembolism (TE) and a relevant proportion of LAAT do not resolve under continued OAC. Left atrial appendage closure (LAAC) in the presence of LAAT was anecdotally described as a therapeutic option to prevent TE in the patients. Objective: To describe the feasibility of LAAC despite LAAT in consecutive patients. Methods: We searched the LAAC database of our center to identify patients in whom a LAAC was performed despite evidence of a thrombus in the LAA. All procedures were performed under transesophageal echocardiography guidance, no angiographies were performed to avoid LAAT dislocation. An Amulet Occluder device was preferred to allow proximal implantation and sealing of the LAA. Results: Nine patients were identified. The mean age was 68.1 ± 10.7 years, four were female, mean CHADSVASC and HASBLED were 3.6 ± 1.7 and 3.0 ± 1.0. Eight of nine patients were on OAC, one patient was under lone aspirin therapy because of bleeding. The mean distance between the LAAT and the estimated landing zone was 18 ± 6 mm, the minimal distance was 11 mm. The mean landing zone was 21 ± 3 mm, devices with a mean size of 25 ± 4 mm were chosen for implantation. All implantation succeeded, only two patients required an intraprocedural replacement. No procedural complication nor short term thromboembolic complication during a follow up of 138 ± 149 days were recorded. Conclusion: In the presented series a percutaneous LAAC despite a LAAT resulted to be feasible and safe. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency high‐power ablation appears to be a novel concept for atrial fibrillation (AF). The ablation index (AI) value has been associated with durability of pulmonary vein isolation (PVI). Objectives: This study aimed to report the procedural data and initial results of a combined ablation technique using AI‐guided high‐power (AI‐HP; 50 W) ablation for PVI. Methods: Symptomatic AF patients were consecutively enrolled and underwent wide‐area contiguous circumferential PVI. Contact‐force catheters were used, ablation power was set to 50 W targeting AI values (550 anterior and 400 posterior). Esophageal temperature was monitored during procedure, all patients underwent postablation esophageal endoscopy. Results: PVI was achieved in all (n = 50, mean age: 68 ± 9 years, female: 60%) patients, rate of first‐round PVI was 92%. A total of N = 2105 AI‐guided ablation lesions were analyzed. Comparing left anterior wall vs left posterior wall and right anterior wall vs right posterior wall, mean ablation time (s) per lesion was 20.5 ± 8 vs 8.6 ± 3 and 12.2 ± 4 vs 9.3 ± 3; mean contact force (g): 17.1 ± 12 vs 25.4 ± 14 and 33.7 ± 13 vs 21.0 ± 11; mean AI: 547 ± 48 vs 445 ± 55 and 555 ± 56 vs 440 ± 47 (all P < .0001). Procedure and fluoroscopy time (minute) were 55.6 ± 6.6 and 6 ± 1.7, respectively. Only one (2%) patient had a minimal esophageal lesion. During In‐hospital and 1‐month follow‐up no major complications such as death, stroke, tamponade, or atriaesophageal fistula (AE) occurred. Preliminary 6‐month follow‐up showed 48 of 50 (96%) patients were free from clinical AF/atrial tachycardia recurrence. Conclusion: AI‐HP (50 W) ablation appears to be a feasible, safe, fast, and effective ablation technique for PVI. [ABSTRACT FROM AUTHOR]

An 89‐year‐old woman underwent left atrial appendage (LAA) closure (LAAC) in our hospital because of recurrent gastrointestinal bleedings. The first transesophageal echocardiography (TEE) follow‐up at six weeks revealed a complete sealing of the LAA and no device related thrombus. In a TEE follow‐up at one year after the LAA closure, a large device related thrombus (6 × 3 cm) was found. Treated with oral anticoagulation (apixaban) the thrombus showed a partial resolution one year later. [ABSTRACT FROM AUTHOR]

The article presents a case study of an 81 year old female patient with history of atrial fibrillation (AF) was referred to our clinic for transesophageal echocardiography (TEE) examination as institutional routine 6‐week follow up after left atrial appendage electrical isolation (LAAI). The patient had undergone multiple catheter ablation of symptomatic recurrent persistent AF including pulmonary vein isolation (PVI).

We describe a case of radiofrequency ablation of ventricular premature contraction (VPC) originating from the left ventricular outflow tract after transcatheter aortic valve replacement. The VPC origin was the native aortic valve annulus between the left and right coronary cusps. Radiofrequency ablation was successfully performed by manipulating the ablation catheter from the gap between the sinotubular junction and implanted valve. [ABSTRACT FROM AUTHOR]

Background: Pulsed field ablation represents an energy source specific for ablation of cardiac arrhythmias including atrial fibrillation. The aim of the study was to describe the adoption and the process of streamlining procedures with a new ablation technology.Methods: All-comer atrial fibrillation patients (n=191; mean age 69±12 years) underwent catheter ablation with a pulsed field ablation ablation device exclusively using analog-sedation. In the validation phase (n=25), device electrogram quality was compared with a circular mapping catheter to assess pulmonary vein isolation and esophageal temperature monitoring was used. In the streamline phase (n=166), a single-catheter approach was implemented. Postprocedural cerebral magnetic resonance imaging was performed in 53 patients. In 52 patients, esophageal endoscopy was performed at day 1 after the procedure. Follow-up was performed using 72 hours Holter ECGs.Results: On a pulmonary vein basis, pulmonary vein isolation rate was 100% including a single shot isolation rate of 99.5%. The electrogram information of the pulsed field ablation catheter and the circular mapping catheter were 100% congruent. Neither esophageal temperature rises nor esophageal thermal injury were observed. Two minor strokes occurred, presumable due to air embolism during catheter exchanges through the large bore sheath (13.8 F ID). In the streamline phase, reduced procedure times (46±14 versus 38±13 minutes, P=0.004), no further strokes and a low incidence of silent cerebral injury (10/53 patients; 19%) were noted. During short-term follow-up, 17/191 patients (9%) had a atrial tachyarrhythmia recurrence.Conclusions: The pulsed field ablation device allows for simple and safe simple single shot pulmonary vein isolation using standard sedation protocols. Procedural speed and efficacy are remarkable and streamlining measures have added safety. [ABSTRACT FROM AUTHOR]