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Aims: Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via a pentaspline pulsed field ablation (PFA) catheter in persistent AF sustained beyond 6 months (PerAF > 6 m) and long-standing persistent AF (LSPAF)., Methods and Results: The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia regionalization and ablation (Stage 3). Seventy-two [age:68 ± 10years, 61.1%males; AF history: 25 (18-45) months] patients with PerAF > 6 m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The PFA catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit. Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112 ± 25 min and 59 ± 22 min, respectively. Major complications occurred in 2 (2.8%) patients. Single-procedure success rate was 74.6% after 14.9 ± 2.7 months of follow-up; AF-free survival was 89.2%., Conclusion: In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favourable clinical outcomes were observed during >1 year of follow-up., Competing Interests: Conflict of interest: M.L.M. is a consultant for AtriCure. A.N. serves as a consultant for Abbott, Biosense Webster, Biotronik, Boston Scientific, and iRhythm. C.d.A. receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips and Acutus and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical and Daiichi Sankyo. G.B.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Competing Interests: Dr de Asmundis received research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical, and Daiichi Sankyo. Dr Chierchia received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. Dr Sarkozy is a consultant for Biosense Webster, Medtronic, Biotronik, and MicroPort. The other authors report no conflicts.

Background: Pulsed field ablation (PFA) is selective for the myocardium. However, vagal responses and reversible effects on ganglionated plexi (GP) are observed during pulmonary vein isolation (PVI). Anterior-right GP ablation has been proven to effectively prevent vagal responses during radiofrequency-based PVI., Objective: The purpose of this study was to test the hypothesis that PFA-induced transient anterior-right GP modulation when targeting the right superior pulmonary vein (RSPV) before any other pulmonary veins (PVs) may effectively prevent intraprocedural vagal responses., Methods: Eighty consecutive paroxysmal atrial fibrillation patients undergoing PVI with PFA were prospectively included. In the first 40 patients, PVI was performed first targeting the left superior pulmonary vein (LSPV-first group). In the last 40 patients, RSPV was targeted first, followed by left PVs and right inferior PV (RSPV-first group). Heart rate (HR) and extracardiac vagal stimulation (ECVS) were evaluated at baseline, during PVI, and postablation to assess GP modulation., Results: Vagal responses occurred in 31 patients (78%) in the LSPV-first group and 5 (13%) in the RSPV-first group (P <.001). Temporary pacing was needed in 14 patients (35%) in the LSPV-first group and 3 (8%) in the RSPV-first group (P = .003). RSPV isolation was associated with similar acute HR increase in the 2 groups (13 ± 11 bpm vs 15 ± 12 bpm; P = .3). No significant residual changes in HR or ECVS response were documented in both groups at the end of the procedure compared to baseline (all P >.05)., Conclusion: PVI with PFA frequently induced vagal responses when initiated from the LSPV. Nevertheless, an RSPV-first approach promoted transient HR increase and reduced vagal response occurrence., Competing Interests: Disclosures Dr Sarkozy is a consultant for Biosense Webster, Medtronic, Biotronik, and MicroPort. Dr de Asmundis received research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus; and compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, LivaNova, Boston Scientific, AtriCure, Acutus Medical, and Daiichi Sankyo. Dr Chierchia received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. All other authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Posterior wall (PW) isolation is an important adjunctive ablation target in patients with non-paroxysmal atrial fibrillation (AF). Traditionally performed with point-by-point radiofrequency (RF) ablation, PW isolation has also been performed with different cryoballoon technologies. We aimed at assessing the feasibility of PW isolation with the novel RF balloon catheter Heliostar™ (Biosense Webster, CA, USA)., Methods: We prospectively enrolled 32 consecutive patients with persistent AF scheduled for first-time ablation with the Heliostar™ device. Procedural data were compared with those from 96 consecutive persistent AF patients undergoing pulmonary vein (PV) plus PW isolation with a cryoballoon device. The ratio RF balloon/cryoballoon was 1:3 for each operator involved in the study, aiming at avoiding any imbalance related to different experience., Results: Single-shot PV isolation was documented in a significantly higher number of cases with the RF balloon technology compared to cryoballoon ablation (89.8% vs. 81.0%; p = 0.02, respectively). PW isolation was achieved with a similar number of balloon applications between the two groups (11 ± 4 with the RF balloon versus 11 ± 2 with the cryoballoon; p = 0.16), but in a significantly shorter time among RF balloon patients (228 ± 72 s versus 1274 ± 277 s with cryoballoon; p < 0.001). Primary safety endpoint occurred in none of the RF balloon patients versus 5 (5.2%) patients in the cryoballoon group (p = 0.33). Primary efficacy endpoint was achieved in all (100%) RF balloon patients versus 93 (96.9%) cryoballoon ones (p = 0.57). Oesophageal endoscopy did not show any signs of thermal lesions in RF balloon patients with luminal temperature rise., Conclusions: RF balloon-based PW isolation was safe and promoted shorter procedure times compared to similar cryoballoon-based ablation procedures., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: A novel sinus node (SN) sparing hybrid ablation for inappropriate sinus node tachycardia (IST)/postural orthostatic tachycardia syndrome (POTS) has been demonstrated to be an effective and safe therapeutic option in patients with symptomatic drug-resistant IST/POTS. The aim of this study was to evaluate the long-term rate of redo procedures after hybrid IST ablation and procedural strategy, outcomes and safety of redo procedures., Methods and Results: All consecutive patients from 2015 to 2023 were prospectively enrolled in the UZ Brussel monocentric IST/POTS registry. They were analysed if the following inclusion criteria were fulfilled: 1) diagnosis of IST or POTS, 2) symptomatic IST/POTS refractory or intolerant to drugs, and 3) hybrid SN sparing ablation performed. The primary endpoint was redo procedure. The primary safety endpoint was pacemaker (PM) implantation. A total of 220 patients undergone to hybrid IST ablation were included, 185 patients (84.1%) were treated for IST and 61 patients (27.7%) for POTS.After a follow-up of 73.3 ± 16.2 months, 34 patients (15.4%) underwent a redo. A total of 23 patients (67.6%) had a redo for IST recurrence and 11 patients (32.4%) for other arrhythmias. Pacemaker implantation was performed in 21 patients (9.5%). Nine patients (4.1%) had no redo procedure and experienced sick sinus syndrome requiring a PM. Twelve patients (5.4%) received a PM as a shared therapeutic choice combined with SN ablation procedure., Conclusion: In a large cohort of patients the long-term free survival from redo procedure after hybrid IST ablation was 84.6% with a low PM implantation rate., Competing Interests: Conflict of interest: C.d.A receives research grants on behalf of the centre from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus; C.d.A. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, AtriCure, and Acutus Medical Daiichi Sankyo. A.S. received research grants from Daiichi Sankyo and Bayer; he has received speaker fees from Menarini and Bayer. PB received compensation for teaching purposes from Biotronik. G.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, and Acutus Medical. MLM is consultant for AtriCure. The remaining authors have nothing to disclose., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: The influence of divergent anesthesia types during ablation of premature ventricular complexes (PVCs) is not known. While previously performed under general anesthesia (GA) at our institution, these procedures were exclusively performed under local anesthesia (LA) ± minimal sedation during the COVID-19 outbreak for logistic reasons., Methods: One hundred and eight consecutive patients (82 GA versus 26 LA) undergoing PVC ablation at our center were evaluated. Intraprocedural PVC burden (over 3 min) pre-ablation was measured twice: (1) at the start (before GA induction) and (2) before catheter insertion (after GA induction). Upon cessation of ablation and after a waiting period of ≥ 15 min, acute ablation success (AAS) was defined as absence of PVCs until the end of the recording period., Results: Intraprocedural PVC burden was not significantly different between LA versus GA group: (1) 17.8 ± 3% vs 12.7 ± 2%, P = 0.17 and (2) 10.0 ± 3% vs 7.4 ± 1%, P = 0.43, respectively. Activation mapping-based ablation was performed significantly more in the LA vs GA group (77% vs 26% of patients, P < 0.001, respectively). AAS was significantly higher in LA vs GA group: 22/26 (85%) vs 41/82 (50%), respectively, P < 0.01. After multivariable analysis, LA was the only independent predictor for AAS (OR 13, 95% CI 1.57-107.4, P = 0.017)., Conclusion: Ablation of PVC under LA presented significantly higher AAS rate compared to GA. The procedure under GA might be complicated by PVC inhibition (after catheter insertion/during mapping) and PVC disinhibition post-extubation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose of Review: Imaging plays a crucial role in the therapy of ventricular tachycardia (VT). We offer an overview of the different methods and provide information on their use in a clinical setting., Recent Findings: The use of imaging in VT has progressed recently. Intracardiac echography facilitates catheter navigation and the targeting of moving intracardiac structures. Integration of pre-procedural CT or MRI allows for targeting the VT substrate, with major expected impact on VT ablation efficacy and efficiency. Advances in computational modeling may further enhance the performance of imaging, giving access to pre-operative simulation of VT. These advances in non-invasive diagnosis are increasingly being coupled with non-invasive approaches for therapy delivery. This review highlights the latest research on the use of imaging in VT procedures. Image-based strategies are progressively shifting from using images as an adjunct tool to electrophysiological techniques, to an integration of imaging as a central element of the treatment strategy., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: The multielectrode radiofrequency balloon catheter (RFB) has been developed to achieve safe and effective pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation. This single-centre study aimed to evaluate the midterm clinical outcome and predictors of single-shot PVI with the novel RFB., Methods and Results: All consecutive patients with symptomatic paroxysmal or persistent AF undergoing first-time PVI with the RFB were prospectively included. Clinical and procedural parameters were systematically collected. The primary safety endpoint was defined as any major periprocedural complications. The primary efficacy endpoint consisted of freedom from any atrial tachyarrhythmias (ATas) lasting >30 s during the follow-up after a 3-month blanking period. Persistent single-shot PVI was defined as PVI achieved with a single RFB application without acute reconnection. A total of 104 consecutive patients (mean age 64.3 ± 11.4 years, 56.7% males) were included. 15 patients (14.4%) presented with persistent AF. The procedure time was 59.0 min with a dwell time of 20.0 min. One major complication occurred in one patient. At a mean follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. ATas occurred in 14 patients, 11/69 patients (15.9%) with paroxysmal AF and 3/13 (23.1%) with persistent AF. The best cut-offs to predict persistent single-shot PVI were impedance drop >19.2 Ω [area under the receiver operator characteristic curve (AUC) 0.74] and temperature rise >11.1° C (AUC 0.77)., Conclusion: In a large cohort of patients undergoing PVI with the RFB, the complication rate was 1%. At a mid-term follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. Specific cut-offs of impedance drop and temperature rise may be useful to predict persistent single-shot isolation., Competing Interests: Conflict of interest: A.B. is a consultant for Biotronik. A.S. received research grants from Daiichi Sankyo and Bayer; he has received speaker fees from Menarini and Bayer. P.B. received compensation for teaching purposes from Biotronik. M.L.M. is a consultant for Atricure. G.-B.C. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Boston Scientific, Acutus Medical. C.d.A. receives research grants on behalf of the centre from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus; C.d.A. received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, Atricure, Acutus Medical, Daiichi Sankyo. All remaining authors have declared no conflicts of interest., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Management of ventricular arrhythmias (VAs) beyond implantable cardioverter-defibrillator positioning in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging. Catheter ablation of the ventricular substrate often requires a combination of endocardial and epicardial approaches, with disappointing outcomes due to the progressive nature of the disease. We report the Universitair Ziekenhuis Brussel experience through a case series of 16 patients with drug-refractory ARVC, who have undergone endocardial and/or epicardial catheter ablation of VAs with a thoracoscopic hybrid-approach. After a mean follow-up time of 5.16 years (SD 2.9 years) from the first hybrid-approach ablation, VA recurrence was observed in 5 patients (31.25%): among these, patients 4 patients (80%) received a previous ablation and 1 of 11 patients (9.09%) who had a hybrid ablation as first approach had a VA recurrence (80% vs 9.09%; log-rank p = 0.04). Despite the recurrence rate of arrhythmic events, all patients had a significant reduction in the arrhythmic burden after ablation, with a mean of 4.65 years (SD 2.9 years) of freedom from clinically significant arrhythmias, defined as symptomatic VAs or implantable cardioverter-defibrillator-delivered therapies. In conclusion, our case series confirms that management of VAs in patients with ARVC is difficult because patients do not always respond to antiarrhythmic medications and can require multiple invasive procedures. A multidisciplinary approach involving cardiologists, cardiac surgeons, and cardiac electrophysiologists, together with recent cardiac mapping techniques and ablation tools, might mitigate these difficulties and improve outcomes., Competing Interests: Disclosures Dr. de Asmundis receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus and has received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, AtriCure, and Daiichi Sankyo. Dr. Chierchia has received compensation for teaching purposes and proctoring from AF Solutions, Medtronic,Abbott, and Biotronik. Dr. La Meir is a consultant for AtriCure. Dr. Bisignani is consultant for Biotronik. Dr. Miraglia has received an educational grant from the "Foundation Enrico and Enrica Sovena". Dr. Brugada has received compensation for teaching purposes from Medtronic and Biotronik., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Purpose: Radiofrequency (RF) catheter ablation is widely accepted as a first-line therapy for cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL). The novel DiamondTemp (DT) catheter with temperature feedback during RF ablation has been released recently on the market. The purpose of this study was to evaluate the impact of DiamondTemp (DT) technology on ablation efficiency during AFL., Methods: In this single-center study, 30 consecutive patients with typical AFL indicated to ablation of CTI were included. The first 15 patients underwent CTI ablation using 8-mm tip catheter, and the following 15 patients underwent temperature-controlled RF ablation using DT catheter. The endpoints were number and mean total duration of RF applications, mean temperature reached in the setting of CTI, procedural times, and fluoroscopy times., Results: There were no significant differences between the two groups concerning baseline characteristics. Mean duration of the each application (71.5 s ± 30.6 vs 12.4 s ± 13.2, p value < 0.001), mean total duration of RF applications (517,73 s ± 377,96 vs 112,8 s ± 43,58; p value < 0.001), procedural times (51.6 min ± 24.2 vs 38.6 ± 8.2; p = 0.03), and fluoroscopy times (16.2 min ± 10.2 vs 8 min ± 4.24; p = 0.005) were longer in the 8-mm ablation catheter group. Mean temperature measurements (51.9 °C ± 3.59 vs 56.7 °C ± 3.34, p value < 0.003) were as well lower in the 8-mm ablation catheter group., Conclusions: Catheter ablation of CTI-dependent AFL by means of DT resulted in a significant reduction of total and single application RF delivery time, procedure, and fluoroscopy times., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background Pharmacological treatment of atrial fibrillation (AF) in the setting of Brugada syndrome (BrS) is challenging. In addition, patients with BrS with an implantable cardioverter-defibrillator (ICD) might experience inappropriate shocks for fast AF. Long-term outcome of pulmonary vein isolation in BrS has not been well established yet, and it is still unclear whether pulmonary vein triggers are the only pathophysiological mechanism of AF in BrS. The aim of the study is to assess the long-term outcomes in patients with BrS undergoing pulmonary vein isolation for paroxysmal AF compared with a matched cohort of patients without BrS. Methods and Results Sixty patients with BrS undergoing pulmonary vein isolation with cryoballoon catheter ablation for paroxysmal AF were matched with 60 patients without BrS, who underwent the same procedure. After a mean follow-up of 58.2±31.7 months, freedom from atrial tachyarrhythmias was achieved in 61.7% in the BrS group and in 78.3% in the non-BrS group (log-rank P =0.047). In particular, freedom from AF was 76.7% in the first group and in 83.3% in the second ( P =0.27), while freedom from atrial tachycardia/atrial flutter was 85% and 95% ( P =0.057). In the BrS group, 29 patients (48.3%) had an ICD and 8 (27.6%) had a previous ICD-inappropriate shock for fast AF. In the BrS cohort, ICD-inappropriate interventions for AF were significantly reduced after ablation (3.4% versus 27.6%; P =0.01). Conclusions Pulmonary vein isolation in patients with BrS was associated with higher rate of arrhythmic recurrence. Despite this, catheter ablation significantly reduced inappropriate ICD interventions in BrS patients and can be considered a therapeutic strategy to prevent inappropriate device therapies.

Background: Catheter ablation for persistent atrial fibrillation (persAF) is associated with less favorable outcomes than for paroxysmal AF. To improve success rates, left atrial (LA) substrate modification is frequently performed in addition to pulmonary vein isolation (PVI). The purpose of the study was to compare 4 different ablation approaches using radiofrequency catheter ablation (RFCA) or cryoballoon ablation (CB-A) for persAF and to evaluate the respective outcomes on a midterm follow-up of 12 months., Methods: We did a propensity score-matched comparison of 30 patients undergoing PVI + LA posterior wall isolation (LAPWI) with CB-A, 30 patients who underwent PVI + linear ablation (roof and mitral lines) using RFCA, 60 patients with PVI alone using CB-A, and 60 patients who had PVI alone using RFCA. The endpoint was recurrence of documented atrial tachyarrhythmias (ATas) > 30 s at 1-year follow-up., Results: After 12 months, freedom from ATas after a single procedure was 83.3% in the PVI + LAPWI group, 46.7% in the PVI + linear ablation group, 58.3% in the PVI-alone CB-A group, and 61.6% PVI-alone RFCA (p = 0.03). Moreover, freedom from ATas was significantly higher comparing the PVI + LAPWI group with each of the other groups., Conclusions: In this propensity-matched comparison of strategies for persAF, LAPW ablation in addition to PVI with CB-A seems to improve 1-year outcome in comparison to PVI + linear ablation using RFCA and to PVI alone using RFCA or CB-A. Randomized comparisons are eagerly awaited., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Left atrial posterior wall isolation (LAPWI) is often performed in addition to pulmonary vein isolation (PVI) in the setting of persistent atrial fibrillation (AF) ablation. The aim of this study was to evaluate the feasibility and safety of a new cryoballoon ablation system in achieving PVI + LAPWI isolation., Methods: The study was a prospective, non-randomized, single center study. Forty consecutive patients, undergoing PVI + LAPWI with the novel POLARx™, were compared to 40 consecutive patients who underwent the same procedure with the established Arctic Front Advance PRO™., Results: Acute isolation was achieved in all PVs in both groups and left posterior wall isolation (LAPWI) was achieved in 38 patients (95%) in the POLARx group and in 36 patients (90%) in Arctic Front group. Procedural outcomes were similar between both groups, except for lower temperatures during cryoenergy in the POLARx group, for both pulmonary vein isolation (PVI) and LAPWI., Conclusion: LAPWI + PVI with the novel POLARx™ Cryoballoon is feasible and safe; the results are comparable with the Arctic Front Advance PRO™ system., (© 2022 The Authors. Pacing and Clinical Electrophysiology published by Wiley Periodicals LLC.)

Achieving the goal management of some arrhythmic syndromes can be challenging; medical treatment for inappropriate sinus tachycardia (IST) and postural orthostatic tachycardia syndrome (POTS) may be ineffective, necessitating multidisciplinary team treatment. Implantable defibrillator devices (ICDs), along with anti-arrhythmic drugs (AADs), remain the first-line treatment for primary electrical diseases that pose a risk of sudden cardiac death (SCD). Ablation of the arrhythmogenic substrate is not always suggested in patients with these pathologies, but it may be a valuable support for reducing arrhythmic burden, improving quality of life, and treating pathologies that are resistant to pharmacological treatment; however, this option is not often considered due to the potential risks associated with an invasive approach. Minimally invasive hybrid ablation in these syndromes, such as a hybrid thoracoscopic approach and the use of non-invasive mapping systems, reduces post-surgery complications and ensures the best possible outcome for the patient., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Purpose: The purpose of the study was to evaluate the impact of left atrial posterior wall isolation (LAPWI) in addition to pulmonary vein isolation (PVI) vs PVI alone, performed using CB-A, in patients with PAF on a midterm follow-up of 12 months., Methods: Eighty consecutive patients indicated to index cryoballoon ablation (CB-A) for the treatment of drug resistant PAF were included. The first 50 (62.5%) underwent PVI only, and the following 30 patients (37.5%) underwent LAPWI + PVI., Results: Acute isolation was achieved in all PVs in both groups. The LAPW was successfully isolated in 29 out of 30 (97%) patients; in the remaining patient, adjunct radiofrequency ablation was required. The total procedure time and the mean fluoroscopy time were significantly shorter in patients who underwent PV isolation only (p < 0.001). The freedom from atrial fibrillation (AF) at 12 months was not significantly different between the 2 groups (LAPW + PVI = 90% vs PVI = 88%) (log-rank p = 0.816)., Conclusion: LAPW ablation in addition to PVI by the means of CB-A does not seem to reduce the risk of AF recurrence if compared with the standard PVI on a midterm follow-up of 12 months., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Purpose: The purpose of this study was to evaluate the safety and feasibility of the new high-resolution mapping algorithm SuperMap (Acutus Medical, CA, USA) in identifying and guiding ablation in the setting of regular atrial tachycardias following index atrial fibrillation (AF) ablation., Methods: Seven consecutive patients who underwent a radiofrequency catheter ablation guided by the novel noncontact charge density (CD) SuperMap for atrial tachycardia were prospectively enrolled in our study., Results: Arrhythmogenic substrate was identified in all seven patients. Mean number of EGM per map was 5859.7 ± 4348.5 points. Three patients (43%) exhibited focal tachycardia mechanisms in the left atrium, alternating from anteroseptal right superior pulmonary vein (RSPV), posterior in proximity of left inferior pulmonary vein (LIPV), and interarial septum in proximity of fossa ovalis, respectively. Four patients exhibited macroreentrant mechanism. In 3 of these patients, SuperMap detected mitral isthmus-dependent flutters with tachycardia cycle lengths of 240, 270 and 420 ms, respectively. In one patient, the mechanism was a macroreentrant tachycardia with the critical isthmus located between the crista terminalis and atriotomy. The mean ablation time (min) was 18.2 ± 12.5 and the mean procedural duration time was 56.4 ± 12.1 min. No minor or major complications occurred., Conclusion: The novel high-resolution mapping algorithm SuperMap proved to be safe, fast, and feasible in identifying and guiding ablation in the setting of regular atrial tachycardias following index AF ablation.

Currently, pulmonary vein isolation (PVI) is the gold standard in catheter ablation for atrial fibrillation (AF). However, PVI alone may be insufficient in the management of persistent AF, and complementary methods are being explored. One such method takes an anatomical approach—improving both its success rate and lesion durability may lead to improved treatment outcomes. An additional approach complementary to the anatomical one is also attracting attention, one that focuses on epicardial conduction. This involves ethanol ablation of the vein of Marshall (VOM) and can be very effective in blocking epicardial conduction related to Marshall structure; it is becoming incorporated into standard treatment. However, the pitfall of this "Marshall-PLAN", a method that combines an anatomical approach with ethanol infusion within the VOM (Et-VOM), is that Et-VOM and other line creations are not always successfully completed. This has led to cases of AF and/or atrial tachycardia (AT) recurrence even after completing this lesion set. Investigating effective adjunctive methods will enable us to complete the lesion set with the aim to lower the rates of recurrence of AF and/or AT in the future. [ABSTRACT FROM AUTHOR]

Omnipolar technology (OT) was recently proposed to generate electroanatomic voltage maps with orientation-independent electrograms. We describe the first cohort of patients undergoing ventricular tachycardia (VT) ablation guided by OT. The purpose of this study was to compare omnipolar and bipolar high-density maps with regard to voltage amplitude, late potential (LP) annotation, and isochronal late activation mapping distribution. A total of 24 patients (16 [66%] ischemic cardiomyopathy and 12 [50%] redo cases) underwent VT ablation under OT guidance. Twenty-seven sinus rhythm substrate maps and 10 VT activation maps were analyzed. Omnipolar and bipolar (HD Wave Solution algorithm, Abbott, Abbott Park, IL) voltages were compared. Areas of LPs were correlated with the VT isthmus areas, and late electrogram misannotation was evaluated. Deceleration zones based on isochronal late activation maps were analyzed by 2 blinded operators and compared to the VT isthmuses. OT maps had higher point density (13.8 points/cm2 vs 8.0 points/cm2). Omnipolar points had 7.1% higher voltages than bipolar points within areas of dense scar and border zone. The number of misannotated points was significantly lower for OT maps (6.8% vs 21.9%; P =.01), showing comparable sensitivity (53% vs 59%) but higher specificity (79% vs 63%). The sensitivity and specificity of detection of the VT isthmus in the deceleration zones were, respectively, 75% and 65% for OT and 35% and 55% for bipolar mapping. At 8.4 months, 71% freedom from VT recurrence was achieved. OT is a valuable tool for guiding VT ablation, providing more accurate identification of LPs and isochronal crowding due to slightly higher voltages. [Display omitted] [ABSTRACT FROM AUTHOR]

Aims Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure. Methods and results All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence. Conclusion In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo. [ABSTRACT FROM AUTHOR]

Aims The multielectrode radiofrequency balloon catheter (RFB) has been developed to achieve safe and effective pulmonary vein isolation (PVI) for atrial fibrillation (AF) ablation. This single-centre study aimed to evaluate the midterm clinical outcome and predictors of single-shot PVI with the novel RFB. Methods and results All consecutive patients with symptomatic paroxysmal or persistent AF undergoing first-time PVI with the RFB were prospectively included. Clinical and procedural parameters were systematically collected. The primary safety endpoint was defined as any major periprocedural complications. The primary efficacy endpoint consisted of freedom from any atrial tachyarrhythmias (ATas) lasting >30 s during the follow-up after a 3-month blanking period. Persistent single-shot PVI was defined as PVI achieved with a single RFB application without acute reconnection. A total of 104 consecutive patients (mean age 64.3 ± 11.4 years, 56.7% males) were included. 15 patients (14.4%) presented with persistent AF. The procedure time was 59.0 min with a dwell time of 20.0 min. One major complication occurred in one patient. At a mean follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. ATas occurred in 14 patients, 11/69 patients (15.9%) with paroxysmal AF and 3/13 (23.1%) with persistent AF. The best cut-offs to predict persistent single-shot PVI were impedance drop >19.2 Ω [area under the receiver operator characteristic curve (AUC) 0.74] and temperature rise >11.1° C (AUC 0.77). Conclusion In a large cohort of patients undergoing PVI with the RFB, the complication rate was 1%. At a mid-term follow-up of 10.1 ± 5.3 months, freedom from ATas was 82.9%. Specific cut-offs of impedance drop and temperature rise may be useful to predict persistent single-shot isolation. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) and heart failure (HF) often coexist and synergistically contribute to an increased risk of hospitalization, stroke, and mortality. Objective: To compare the efficacy of catheter ablation (CA) versus medical therapy (MT) in HF patients with AF. Methods: Electronic databases were queried for randomized controlled trials (RCTs) of CA versus MT of AF in patients with HF. Risk ratios (RRs), mean differences (MDs), and 95% confidence intervals (CIs) were measured using the Mantel–Haenszel method. Results: A total of nine RCTs enrolling 2155 patients met the inclusion criteria. Compared to MT, CA led to a significant reduction in the composite of all-cause mortality and HF hospitalization (24.6% vs. 37.1%; RR: 0.65 (95% CI: 0.53–0.80); p < 0.0001), all-cause mortality (8.8% vs. 13.6%; RR: 0.65 (95% CI: 0.51–0.82); p = 0.0005), HF hospitalization (15.4% vs. 22.4%; (RR: 0.67 (95% CI: 0.54–0.82); p = 0.0001), AF recurrence (31.8% vs. 77.0%; RR: 0.36 (95% CI: 0.24–0.54); p < 0.0001), and cardiovascular (CV) death (4.9% vs. 8.4%; RR: 0.58 (95% CI: 0.39–0.86); p = 0.007). CA improved the left ventricular ejection fraction (MD:4.76% (95% CI: 2.35–7.18); p = 0.0001), 6 min walk test (MD: 20.48 m (95% CI: 10.83–30.14); p < 0.0001), peak oxygen consumption (MD: 3.1 2mL/kg/min (95% CI: 1.01–5.22); p = 0.004), Minnesota Living with Heart Failure Questionnaire score (MD: −6.98 (95% CI: −12–03, −1.93); p = 0.007), and brain natriuretic peptide levels (MD:−133.94 pg/mL (95% CI: −197.33, −70.55); p < 0.0001). Conclusions: In HF patients, AF catheter ablation was superior to MT in reducing CV and all-cause mortality. Further significant benefits occurred within the ablation group in terms of HF hospitalizations, AF recurrences, the systolic function, exercise capacity, and quality of life. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein (PV) isolation is an established treatment for paroxysmal drug‐refractory atrial fibrillation (AF). High parasympathetic tone and reconnection of PVs have demonstrated to be possible culprits of AF recurrence after ablation. Our aim was to investigate the association between parasympathetic tone and reconnected PVs in patients with paroxysmal AF. Methods: Consecutive patients who underwent a redo catheter ablation procedure for atrial tachyarrhythmia recurrence by means of 3D electroanatomic mapping with documentation of presence or absence of PVs reconnection following an initial procedure of cryoballoon (CB) ablation for symptomatic drug‐refractory paroxysmal AF were screened for the study. Results: A total of 92 patients were included, of whom 50 (54.35%) were males. Reconnected PVs were found in 64 (69%) patients. PVs reconnection could be predicted by DC (C‐statistic =.770), by SDNNI (C‐statistic =.714) and by absolute VLF power (C‐statistic =.722), while right‐sided PVs reconnection could be better predicted by DC (C‐statistic =.848) and by SDNNI (C‐statistic =.761). In multivariate binary logistic regression analysis, a DC value ≥6.45 ms and an absolute VLF power value ≥160 ms2 were associated with three times and five times higher odds of PVs reconnection, respectively. On a vein‐per‐vein analysis, absolute VLF power ≥160 ms2 was associated with three times higher odds, while reaching of −40°C within 60 s was associated with three times lower odds of PVs reconnection. Conclusion: High parasympathetic tonus accurately predicts PVs reconnection. On a vein‐per‐vein analysis, parasympathetic markers along with biophysical parameters predicted PVs reconnection. On a case‐by‐case analysis, parasympathetic markers were the only predictors of PVs reconnection, thus being a robust PVs reconnection prediction tool. [ABSTRACT FROM AUTHOR]