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Aims Ablation of outflow tract ventricular arrhythmias may be limited by a deep intramural location of the arrhythmogenic source. This study evaluates the acute and long-term outcomes of patients undergoing ablation of intramural outflow tract premature ventricular complexes (PVCs). Methods and results This multicenter series included patients with structurally normal heart or nonischemic cardiomyopathy and intramural outflow tract PVCs defined by: (a) ≥ 2 of the following criteria: (1) earliest endocardial or epicardial activation < 20ms pre-QRS; (2) Similar activation in different chambers; (3) no/transient PVC suppression with ablation at earliest endocardial/epicardial site; or (b) earliest ventricular activation recorded in a septal coronary vein. Ninety-two patients were included, with a mean PVC burden of 21.5±10.9%. Twenty-six patients had had previous ablations. All PVCs had inferior axis, with LBBB pattern in 68%. In 29 patients (32%) direct mapping of the intramural septum was performed using an insulated wire or multielectrode catheter, and in 13 of these cases the earliest activation was recorded within a septal vein. Most patients required special ablation techniques (one or more), including sequential unipolar ablation in 73%, low-ionic irrigation in 26%, bipolar ablation in 15% and ethanol ablation in 1%. Acute PVC suppression was achieved in 75% of patients. Following the procedure, the PVC burden was reduced to 5.8±8.4%. The mean follow-up was 15±14 months and 16 patients underwent a repeat ablation. Conclusion Ablation of intramural PVCs is challenging; acute arrhythmia elimination is achieved in 3/4 patients, and non-conventional approaches are often necessary for success.

We compared the efficacy and safety of cardioneuroablation (CNA) vs. permanent pacing (PM) for recurrent cardioinhibitory vasovagal syncope (CI-VVS).One hundred sixty-two patients (CNA = 61, PM = 101), age 36 + 11 years) with syncope frequency of 6.7 ± 3.9/year were included in this multicenter study. All patients with CNA were provided by a single center, while patients with PM were provided by 4 other centers. In the CNA arm, an electroanatomic mapping guided approach was used to detect and ablate ganglionated plexus sites. Dual chamber rate drop response (RDR) or close loop stimulation (CLS) transvenous and leadless pacemakers were implanted using standard technique. The primary endpoint was freedom from syncope.Of 101 patients in the PM group, 39 received dual-chamber pacemaker implants with the CLS algorithm, 38 received dual-chamber pacemakers with the RDR algorithm, and 24 received a leadless pacemaker. At 1-year follow-up, 97% and 89% in the CNA and PM group met the primary endpoint (adjusted HR = 0.27, 95% CI 0.06-1.24, p = 0.09). No significant differences in adverse events were noted between groups. There was no significant association between age (HR:1.01, 95% CI 0.96-1.06, p = 0.655), sex (HR:1.15, 95% CI 0.38-3.51, p = 0.809), and syncope frequency in the past year (HR:1.10, 95% CI 0.97-1.25, p = 0.122) and the primary outcome in univariable analyses.After adjustment for patient characteristics, the medium-term syncope recurrence risk of CI-VVS patients who underwent CNA was similar to that of a population of patients undergoing pacemaker implantation with a similar safety profile.

Aims Catheter ablation (CA) is recommended for patients with atrial fibrillation (AF) after failure of antiarrhythmic drugs (AADs). The role of CA as ‘initial therapy’ for AF is to be determined. Methods and results Following PRISMA guideline an up-to-date pooled analysis of randomized data comparing ablation vs. AADs as first-line therapy for symptomatic AF was performed. The primary outcome was recurrence of atrial tachyarrhythmia. The secondary outcomes were improvement in quality-of-life (QoL) and major adverse events. A total of 997 patients from five randomized trials were enrolled (mean age 57.4 years, 68.6% male patients, 98% paroxysmal AF, mean follow-up 1.4 years). The baseline characteristics were similar between the ablation and AADs group. Overall pooled analysis showed that, as compared with AADs, CA as first-line therapy was associated with significantly higher freedom from arrhythmia recurrence (69% vs. 48%, odds ratio: 0.36, 95% confidence interval: 0.27–0.48, P Conclusions Catheter ablation as ‘initial therapy’ was superior to AADs in maintenance of sinus rhythm and improving QoL for patients with symptomatic paroxysmal AF, without increasing risk of serious adverse events.

The impact of cardioneuroablation (CNA) on ventricular repolarization by using corrected QT interval (QTc) measurements has been recently demonstrated. The effects of cardiac pacing (CP) on ventricular repolarization have not been studied in patients with vasovagal syncope (VVS). We sought to compare ventricular repolarization effects of CNA (group 1) with CP (group 2) in patients with VVS.We enrolled 69 patients with age 38 ± 13 years (53.6% male), n = 47 in group 1 and n = 22 in group 2. Clinical diagnosis of cardioinhibitory type was supported by cardiac monitoring or tilt testing. QTc was calculated at baseline (time-1), at 24 h after ablation (time-2), and at 9-12 months (time-3) in the follow-up.In the group 1, from time-1 to time-2, a significant shortening in QTcFredericia (from 403 ± 27 to 382 ± 27 ms, p0.0001), QTcFramingham (from 402 ± 27 to 384 ± 27 ms, p0.0001), and QTcHodges (from 405 ± 26 to 388 ± 24 ms, p0.0001) was observed which remained lower than baseline in time-3 (373 ± 29, 376 ± 27, and 378 ± 27 ms, respectively). Although the difference between measurements in time-1 and time-2 was not statistically significant for QTcBazett, a significant shortening was detected between time-1 and time-3 (from 408 ± 30 to 394 ± 33, p = 0.005). In the group 2, there was no time-based changes on QTc measurements. In the linear mixed model analysis, the longitudinal reduction tendency in the QTcFredericia and QTcFramingham was more pronounced in group 1.Our results demonstrate that CNA reduces QTc levels through neuromodulation effect whereas CP has no effect on ventricular repolarization in patients with VVS.

Aims Anticoagulation for atrial fibrillation patients with liver disease represents a clinical dilemma. We sought to evaluate the efficacy/safety of different anticoagulation, i.e. vitamin K antagonist (VKA) and non-VKA oral anticoagulants (NOACs) in such patient group. Methods and results This was a pooled-analysis enrolling up-to-date clinical data. Two subsets: subset A (VKA vs. Non-Anticoagulation) and subset B (NOACs vs. VKA) were pre-specified. The study outcomes were ischaemic stroke (IS)/thromboembolism (TE), major bleeding (MB), intracranial bleeding (ICB), gastrointestinal bleeding (GIB), and all-cause mortality. A total of 20 042 patients’ data were analysed (subset A: N = 10 275, subset B: N = 9767). Overall mean age: 71 ± 11 years, mean CHA2DS2-VASc score: 4.0 ± 1.8, mean HAS-BLED score: 3.6 ± 1.2. The majority of the patients had Child-Pugh category (A-B). As compared with Non-Anticoagulation, VKA seemed to reduce the risk of IS/TE [odds ratio (OR): 0.60, P = 0.05], but heighten the risk of all-bleeding events including MB (OR: 2.81, P = 0.01), ICB (OR: 1.60, P = 0.01), and GIB (OR: 3.32, P = 0.01). When compared with VKA, NOACs had similar efficacy in reducing the risk of IS/TE (OR: 0.82, P = 0.64), significantly lower risk of MB (OR: 0.54, P = 0.0003) and ICB (OR: 0.35, P Conclusions VKA appears to reduce the risk of IS/TE but increase all-bleeding events. NOACs have similar effect in reducing the risk of IS/TE and have significantly lower risk of MB and ICB as compared with VKA. NOACs seem to be associated with better clinical outcome than VKA in patients with mild–moderate liver disease.

Background Radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) arising from the inaccessible basal region of the left ventricular summit (LVS) is challenging due to proximity to coronary vessels, epicardial fat, and poor radiofrequency (RF) delivery within the distal coronary venous system. Objective The purpose of this study was to describe the outcomes of an anatomic approach to inaccessible LVS-VAs using bipolar radiofrequency (Bi-RFCA) delivered from the anatomically adjacent left pulmonic cusp (LPC) to the opposite left ventricular outflow tract (LVOT). Methods Patients from 3 centers who had undergone Bi-RFCA for inaccessible LVS-VAs refractory to conventional RFCA using an anatomic approach targeting the adjacent LPC (reversed U approach) with catheter tip pointing inferiorly within the LPC and LVOT were reviewed. Results Seven patients (age 59 ± 12 years; 3 women) underwent Bi-RF from the LPC to the LVOT for LVS-VAs after ≥1 failed conventional RFCA. Bi-RFCA (power 36 ± 7 W; duration 333 ± 107 seconds) resulted in VA suppression in 5 of 7 patients. In 2 cases, Bi-RFCA was successfully performed using dextrose 5% in water. No complications occurred. After mean follow-up of 14 ± 6 months, no recurrent VT was documented in 2 of 2 patients with baseline VT. Mean 84% reduction in premature ventricular contraction (PVC) burden (31% ± 13% vs 4% ± 5% PVCs per day; P = .0027) was documented in the other patients. Conclusion In patients with LVS-VAs arising from the inaccessible region and refractory to conventional RFCA, an anatomic approach using Bi-RFCA from the LPC and opposite LVOT is an effective alternative approach.

Background: Predictors of long‑term outcomes and an optimal catheter set for ablation of the cavotricuspid isthmus in patients with atrial flutter (AFL) are not well known. Aims: This study aimed to identify predictors of clinical events following ablation. Methods: We studied 741 patients (mean [SD] age, 62.2 [10.8] years; 248 women) who were followed for a mean (SD) time of 4.4 (2.7) years. The 2- versus 3‑electrode approach and clinical predictors ofclinical events during follow‑up were analyzed. Results: The 2‑electrode approach was faster (mean [SD] time, 62.5 [30.3] vs 101.4 [51] min; P < 0.001), associated with shorter fluoroscopy time (13.1 [9.3] vs 20.3 [12.4] min; P < 0.001), cost‑effective (8.29 [2.82] vs 11.89 [2.51] units; P < 0.001), and more effective (92.1% vs 86.1%; P = 0.012). The independent predictors of AFL recurrence were: calcium blocker use (hazard ratio [HR], 3.24; 95% CI, 1.64–6.4), mitral valve disease (HR, 1.82; 95% CI, 1.12–2.95), previous stroke and/ or TIA (HR, 2.38; 95% CI, 1.21–4.65), pulmonary artery dilatation (HR, 3.94; 95% CI, 1.22–12.73), and previous pulmonary embolism (HR, 3.77; 95% CI, 1.14–12.43); of atrial fibrillation (AF): previous AF (HR, 6.054; 95% CI, 4.58–8), left atrial enlargement (HR, 1.43; 95% CI, 1.12–1.81), number of antiarrhythmic drugs used (HR, 1.16; 95% CI, 1.05–1.28), and mitral valve disease (HR, 1.28; 95% CI, 1.04–1.58); of pacemaker implantation: tachycardia‑bradycardia syndrome (HR, 6.17; 95% CI, 3.16–12.05), previous second-/third‑degree atrioventricular block (HR, 29.4; 95% CI, 7.37–117.28), centrally acting hypotensive drugs (HR, 29.55; 95% CI, 6.14–142.25), aortic dilatation or aneurysm (HR, 2.58; 95% CI, 1.06–6.3), a labile international normalized ratio (HR, 3.45; 95% CI, 1.72–6.93), left bundle branch block (HR, 4.7; 95% CI, 1.49–14.82), the shortest R‑R interval during AFL (HR, 1.003; 95% CI, 1.001–1.005), previous cardiac surgery (HR, 2.69; 95% CI, 1.27–5.7), and aortic valve disease (HR, 2.22; 95% CI, 1.08–4.59). Conclusion: Ablation of cavotricuspid isthmus with a minimal number of electrodes is safe and effective. Specific predictors of clinical events during long‑term follow-up can be determined.

Background: Data on the feasibility of an ultrasound‑guided venous access (USGVA) for catheter ablation (CA) and electrophysiological studies (EPS) in large cohorts are scarce. The impact of the Valsalva maneuver (VM), which can increase the diameter of the femoral vein (FV), on the USGVA is unknown. Aims: The study aimed to determine the impact of the VM on FV diameters during establishing the USGVA and overall safety and effectiveness profile of the USGVA in a large cohort. Methods: Consecutive patients undergoing CA and/ or EPS with the USGVA were included, and those with anatomical landmark–guided VA were recruited as controls. In a subgroup of USGVA patients, a VM‑ ‑facilitated FV puncture was performed. The measurements obtained before and during the VM were used to calculate the estimated access area (EAA) of the FV. Results: A total of 1564 ultrasound-guided FV accesses in 876 patients and 172 FV accesses in 105 patients in the anatomical‑VA group were performed. We observed no major complications associated with the USGVA. Minor adverse events related with VA were less common in the USGVA group than in controls (1.5% vs 6.7%, respectively; P = 0.001), resulting in a 4‑fold decrease in VA‑related complications. In 204 consecutive patients who underwent the VM‑facilitated USGVA, the FV diameters increased during VM in both vertical (mean [SD], 10.1 [3] mm vs 14.4 [3.2] mm; P < 0.001) and horizontal axes (10.6 [2.9] mm vs 14.5 [3.2] mm; P < 0.001). This led to the mean (SD) increase in EAA of 38%: from 0.8 (0.2)cm2 at baseline to 1.1 (0.2) cm2 during VM (P < 0.001). Conclusions: The USGVA for EPS and/ or CA is feasible. Complication rates for the USGVA are low and result in minor events. The Valsalva maneuver is a simple way to remarkably increase the femoral vein EAA and it can be helpful in performing the USGVA in difficult cases.

Catheter Ablation (CA) is an effective therapeutic option in treating atrial fibrillation (AF). Importantly, recent data show that CA as a rhythm control strategy not only significantly reduces AF burden, but also substantially improves clinical hard endpoints. Since AF is a progressive disease, the time of Diagnosis-to-Intervention appears crucial. Recent evidence shows that earlier rhythm control is associated with a lower risk of adverse cardiovascular outcomes in patients with early AF. Particularly, CA as an initial first line rhythm control strategy is associated with significant reduction of arrhythmia recurrence and rehospitalization in patients with paroxysmal AF. CA is shown to significantly lower the risk of progression from paroxysmal AF to persistent AF. When treating persistent AF, the overall clinical success after ablation remains unsatisfactory, however the ablation outcome in patients with “early” persistent AF appears better than those with “late” persistent AF. “Adjunctive” ablation on top of pulmonary vein isolation (PVI), e.g., ablation of atrial low voltage area, left atrial posterior wall, vein of Marshall, left atrial appendage, etc., may further reduce arrhythmia recurrence in selected patient group. New ablation concepts or new ablation technologies have been developing to optimize therapeutic effects or safety profile and may ultimately improve the clinical outcome.

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This study evaluated the role of adjunctive left atrium posterior wall isolation (PWI) in preventing atrial fibrillation (AF) recurrence.The left atrium posterior wall is an arrhythmogenic substrate that contributes to the development of AF.This was an updated pooled analysis that included clinical data regarding PWI plus pulmonary vein isolation (PVI) in treating AF. The primary outcome was recurrence of atrial tachyarrhythmias.A total of 26 studies with 3,287 patients with AF (age 61.7 ± 10.8 years) were included. Mean follow-up was 15.2 ± 8.4 months. Procedural success to achieve PWI was 92.8%. In paroxysmal AF, adjunctive PWI did not reduce the recurrence of all atrial arrhythmias (P = 0.21) or AF (P = 0.37); however, in persistent AF, adjunctive PWI was associated with substantially lower recurrence of all atrial arrhythmias (risk ratio: 0.74; P 0.001) and AF (risk ratio: 0.67; P = 0.01), particularly when randomized data were included. Subgroup analyses based on meta-regression demonstrated that patients with older age, a larger left atrial diameter, and persistent AF benefited more significantly from the adjunctive PWI. Adjunctive PWI using either radiofrequency or a cryoballoon reduced AF recurrence, whereas using radiofrequency seemed to be associated with higher recurrence rate of atrial tachycardias and/or atrial flutter. Non-BOX adjunctive PWI rather than BOX PWI was associated with significantly lower recurrence of AF. The incidence of procedural adverse events between the PVI+PWI (3.2%) and PVI (2.8%) groups was low and similar. PVI+PWI needed longer ablation and/or procedural time but had similar fluoroscopy time.Adjunctive PWI can be achieved in most patients without compromising safety. Patients with persistent AF appear to benefit from this approach. The ablation technology and/or approach may affect the clinical outcome of PWI.

Purpose of Review The COVID-19 pandemic has significantly impacted the delivery of education for all specialties, including cardiac electrophysiology. This review will provide an overview of the COVID-19 spurred digital transformation of electrophysiology education for practicing clinicians and trainees in electrophysiology and cover the use of social media in these educational efforts. Recent Findings Major international, national, and local meetings and electrophysiology fellowship–specific educational sessions have transitioned rapidly to virtual and distanced learning, enhanced by social media. This has allowed for participation in educational activities by electrophysiologists on a wider, more global scale. Social media has also allowed rapid dissemination of new advances, techniques, and research findings in real time and to a global audience, but caution must be exercised as pitfalls also exist. Summary The digital and social media transformation of cardiac electrophysiology education has arrived and revolutionized the way education is delivered and consumed. Continued hybrid in-person and virtual modalities will provide electrophysiologists the flexibility to choose the best option to suit their individual needs and preferences for continuing education.

Radiofrequency catheter ablation (RFCA) of premature ventricular complexes (PVC) and ventricular tachycardia (VT) can be an effective method of treatment. However, when arrhythmia originates from the left ventricular summit (LVS), an ablation performed with conventional unipolar energy sources can be challenging and may require alternative approaches. Bipolar RFCA from coronary veins and an adjacent endocardium in cases of refractory PVC/VT has not yet been studied. We retrospectively analysed cases of consecutive patients who underwent bipolar ablation in whom conventional unipolar ablation of LVS PVC/VT and antiarrhythmic drugs failed to abolish arrhythmia. Bipolar RFCA was delivered from the earliest PVC/VT activation located in the coronary venous circulation and opposite LV endocardial sites. A total number of 4 patients (1 female, age 55 ± 10 years) underwent bipolar ablation of LVS from coronary veins and an adjacent endocardium. Bipolar RFCA led to acute elimination of PVC/VT in all patients. A mean bipolar RFCA time was 244 ± 15 s. There were no complications during procedures and all antiarrhythmic drugs were discontinued. A follow-up lasted 15 ± 4 months; there was no VT recurrence and the mean 83 ± 27 % PVC burden reduction (24250 ± 1372 vs. 3000 ± 3600 PVC/d; p = 0.0228) was achieved. All patients remained symptom-free. Bipolar RFCA from coronary veins and an opposite endocardium can be used for safe and successful treatment of PVC/VT originating from a deep LV summit.

Funding Acknowledgements Type of funding sources: None. Introduction Ablation for atrial fibrillation (AF) carries a significant risk of esophageal injury. Current methods of esophageal protection are invasive, expensive and their cost-effectiveness can be questioned. Standard placement of dispersive patch (DP) at patient’s back exposes esophagus to radio-frequency (RF) current-mediated thermal injury and such complications as esophageal wall ulceration, peri-esophageal injury or life-threatening atrio-esophageal fistula. Redirecting RF current by DP repositioning to anterior chest can theoretically protect oesophagus from thermal injury, however, such an approach has not yet been investigated. Aim To determine feasibility of anterior DP position for treatment of AF using RF catheter ablation (RFCA)-based system. Methods We retrospectively analysed consecutive patients undergoing RFCA-based pulmonary vein isolation (PVI) using multi-electrode PVAC catheter with DP located either in anterior or traditional-posterior position. Two additional patients underwent point-by-point RFCA and mapping of PV ostia with impedance measurements during RFCA performed using anterior and posterior DP positioning. Results 62 patients (25 females, age 60 ± 12 years) underwent PVI using PVAC: 40 patients in posterior and 22 in anterior DP group. There were no major complications during procedures. There was no significant difference in AF recurrence rate between anterior and posterior DP groups during one-year follow up (log rank p = 0.065). In two additional consecutive patients (1 female, age 74 ± 2 years) undergoing point-by-point RFCA a total number of 30 measurements around PV ostia were performed. There was a significant difference between impedance values in anterior vs posterior DP positions (134 ± 7 Ω vs 122 ± 8 Ω, p = 0.0004). Conclusions Anterior position of dispersive electrode for PV isolation using RFCA-based systems is safe, feasible, atraumatic and is not associated with any additional cost. Apart from redirecting RF current away from the esophagus, anterior dispersive patch placement is associated with higher impedance values which can act as an additional protection. Possible prevention of esophageal complications using anterior dispersive patch positioning needs to be determined in prospective studies. Abstract Figure. AF-free survival and impedance

Funding Acknowledgements Type of funding sources: None. OnBehalf The NIPS-ICD Investigators Background Implantable cardioverter-defibrillator (ICD) offers an opportunity to examine vulnerability to ventricular tachycardia (VT) or ventricular fibrillation (VF) by performing non-invasive programmed ventricular stimulation (NIPS). Whether NIPS can predict mortality in patients with primary prevention ICD, has not yet been examined. Purpose To examine a long-term predictive value of NIPS for identification of patients at increased risk of death during follow up. Methods The study group consisted of consecutive 41 patients with ICD implanted for primary prevention of sudden cardiac death, included in the prospective NIPS-ICD study (ClinicalTrials ID: NCT02373306) (34 males, age 64 ± 11 years). The patients underwent NIPS using the protocol up to three premature extrastimuli at 600, 500 and 400ms drive cycle lengths. The end-point of NIPS was induction of sustained VT or VF or completion of the protocol. Results At baseline NIPS, VT/VF was induced in 8 (20%) patients. After 5 year follow up mortality rate was significantly higher in patients who had VT/VF induced at NIPS vs no VT/VF at NIPS (38% vs 12%, p = 0.04). The difference in mortality was most remarkable at 3 (38% vs 3%, p = 0.001) and 4 years (38% vs 6%, p = 0.007). The NIPS-induced VT/VF had a sensitivity of 37.5%, specificity of 88%, positive predictive value of 43% and negative predictive value of 85% for occurrence of death during follow up. An occurrence of secondary composite endpoint consisting of VT/VF recurrence or death was also most frequent in NIPS-inducible group (75% vs 24%, p = 0.037). In a multivariate Cox-Proportional Hazard model induction of VT/VF at NIPS along with age≥65, and treatment with amiodarone was an independent predictor of the composite endpoint during follow-up Conclusions Inducibility of VF/VF during NIPS in patients with primary prevention ICD is associated with higher mortality and higher incidence of composite endpoint consisting of death or VT/VF during a long term observation. Abstract Figure. Kaplan-Meier survival curves

Funding Acknowledgements Type of funding sources: None. Background Pulmonary vein isolation (PVI) is a cornerstone for catheter ablation (CA) of atrial fibrillation (AF), however, long-term efficacy of PVI is frequently below expectations. PVI is invasive, expensive and may be associated with devastating complications. It has been postulated that vagally-mediated AF can be treated by attenuation of parasympathetic drive to the heart using cardioneuroablation by means of radiofrequency CA (RFCA) of the right anterior ganglionated plexus (RAGP), however, data in literature and guidelines are lacking. Purpose To examine the efficacy of RFCA targeting RAGP without PVI in management of vagal AF. Methods We included consecutive 9 male patients with vagal AF who underwent RFCA of RAGP without PVI. RAGP was targeted anatomically from the right atrium (RA) at the postero-septal area below superior vena cava (SVC) and from the left atrium (LA) if needed. The aim was to achieve >30% increase in heart rate (HR) . The follow up consisted of regular visits and Holter ECG conducted every 3 months. Results A total number of 9 patients (age 52 ± 13) with vagally-mediated AF underwent RFCA of RAGP (mean RAGP RF time 147 ± 85, max power 34 ± 8W). The mean procedure time was 60 ± 29min. HR increase >30% was achieved in 8 (89%) patients (pre-RF vs post-RF: 58 ± 8bpm vs 87 ± 12bpm, p = 0.00002) . Transseptal to reach RAGP also from the LA was needed in 2 (22%) patients. There were no major complications during the procedures. The follow up lasted 6 ± 2 months. Antiarrhythmic drugs were discontinued in 8 (89%) patients. There was 1 (11%) AF recurrence in the patient in whom targeted HR acceleration during RFCA was not achieved. B-blockers were administered in 6 (67%) patients due to increased HR and such treatment was well tolerated by all. Conclusions Catheter ablation of RAGP without performing PVI is feasible and can be effective in majority of patients with vagally-mediated AF. Increased HR after such cardioneuroablation can be well controlled using b-blockers and is usually associated with mild symptoms. The role of cardioneuroablation for treatment of vagally-mediated AF needs to be determined in prospective trials. Abstract Figure. Cardioneuroablation in vagal AF

Introduction Biophysics of bipolar radiofrequency catheter ablation (Bi-RFCA) suggest more condensed and selective lesion formation when compared to conventional-unipolar approach. Whether more selective Bi-RFCA can result in safe and effective ablation of arrhythmic substrates in close proximity of His bundle has not been investigated so far. Purpose To determine feasibility and effectiveness of Bi-RFCA in His bundle area. Methods Consecutive patients after failed unipolar ablation for symptomatic premature ventricular complexes (PVC) or ventricular tachycardia (VT) originating from the vincity of His bundle underwent Bi-RFCA. Results We ultimately enrolled 8 patients (2 females, age 60 ± 15 years) to undergo Bi-RFCA of PVC/VT. Previous pharmacological treatment consisting of at least one antiarrhythmic drug and conventional catheter ablation failed in all. Bi-RFCA using open-irrigated and non-irrigated ablation catheters (AC) was delivered from two earliest PVC/VT activation sites located in the vincity of His bundle (Figure, panels A-B). A total number of 93 bipolar applications were delivered (mean bipolar RF time 508 ± 565s, mean power 35 ± 13W, mean impedance 163 ± 18Ω). Transient conduction disturbances occurred in 2 patients and were associated with mechanical compression of conduction system. No persistent conduction disturbances occurred. Bipolar RFCA led to acute elimination of PVC/VT in 6 (75%) patients. Follow up lasted 11 ± 5 months: two patients underwent repeat procedure using dual-irrigated Bi-RFCA, there was no VT recurrence and 72% PVC burden reduction was achieved (16200 ± 11600 pre-ablation vs 4500 ± 6200 post-ablation PVC/day, p = 0,035) (Figure, panel C). Conclusion Bi-RFCA performed in proximity of His bundle can be safe and effective in majority of patients. Abstract Figure. Bipolar ablation of parahisian PVC/VT

Background Data on occurrence, management and outcomes of iatrogenic aortic dissections (IAD) as a complication of catheter ablation (CA) do not exist. Purpose To evaluate multicenter data on occurrence, management and outcomes of IAD as a complication of CA. Methods Data on occurrence, management and outcomes of documented vascular dissections from 10 centers were evaluated. Results IADs occurred in 7 patients (2 females, age 63 ± 8 years). Indications for CA were frequent premature ventricular complexes (PVC)/ventricular tachycardia (VT) in 6 patients (86%) and left-sided accessory pathway in the remaining one (14%). Hypertension was most frequent comorbidity (4 pts, 57%). All IADs occurred during retrograde advancement of ablation catheter. In the vast majority of patients creation of IAD during catheter advancement was not associated with any symptoms (6 pts, 86%). IAD was initially detected using trans-luminal angiogram in 5 (71%) and further confirmed using computed tomography (CT) (5 pts, 71%), conventional angiography (2 pts, 28%) and ultrasound (2 pts, 28%). One IAD was detected during CT scan performed for other indication after CA. There was one IAD-related death and IAD was evaluated post-mortem. Follow-up lasted 10 ± 19 months. Four patients were treated conservatively, one patient underwent descending aorta stenting and one femoral artery stenting. Conclusions IAD during CA is a rare but can be devastating. Early recognition can be difficult. Conservative management of IAD is an option of treatment.

Respiratory cycle-dependent atrial tachycardia (RCAT) is rare. RCAT can be associated with severe symptoms and trigger atrial fibrillation. Focal radiofrequency ablation of RCAT can be a successful method of treatment. In the presented case RCAT originated from the roof of the left atrium - the site not previously reported in the literature. Ablation led to complete elimination of arrhythmia with no recurrence during follow up.

When arrhythmia originates from the His bundle (HB) area conventional radiofrequency catheter ablation (RFCA) is associated with increased risk of atrioventricular block (AVB). Biophysics of bipola...

INTRODUCTION Radiofrequency (RF) catheter ablation (RFCA) of ventricular tachycardia (VT) is an effective method of treatment. However, when arrhythmia has ischemic etiology and originates from the posterosuperior process (PSP) of the left ventricular (LV) base, ablation performed with conventional unipolar energy sources may be challenging or impossible. METHOD AND RESULT A 67-year-old male after six unsuccessful RFCA for highly symptomatic VT originating from PSP of LV base underwent successful RFCA using multiple bipolar RF applications delivered between two electrodes located at LV endocardium and adjacent right atrial sites. CONCLUSION This case report shows that bipolar RFCA can be used for safe and successful treatment of VT originating from deep PSP of LV base.

Intramural origin of ventricular arrhythmias is one of the reasons for failure of catheter ablation, especially in nonischemic substrates. Conventional unipolar ablation has limited efficacy for the creation of deep transmural lesions in the ventricular myocardium, and alternative ablation strategies have been developed to overcome this problem. These novel approaches include simultaneous unipolar ablation, bipolar ablation, use of low-ionic irrigant solution, needle ablation, and ethanol ablation. This review provides an overview of each one of these techniques, including their main advantages and limitations.

Background Catheter ablation has been considered an effective strategy for the treatment of ventricular arrhythmias (VAs) originating from the left ventricular summit (LVS). However, the inherent complexity of the anatomy of the LVS may result in failed ablation or recurrence of VA. Objective The purpose of this multicenter study was investigate the procedural outcomes of ablation of LVS VA. Methods A total of 238 patients (54.6% men; mean age 53.2 ± 15.0 years) undergoing catheter ablation of LVS VA were included. Baseline characteristics, procedural parameters, and clinical outcomes were analyzed. Results Acute procedural success was achieved in 199 patients (83.6%). Initial epicardial ablation via the coronary venous system (93.8% [91/97]) or percutaneous transpericardial approach (6.2% [6/97]) achieved successful ablation in 40 of 97 patients (41.2%), and VA was eliminated by initial approaches from the aortic sinus of Valsalva or subvalvular endocardium in 68 of 139 patients (48.9%; P = .29). Multisite ablations were performed in the process of acute VA elimination in 105 patients (51.8%), and 7 complications occurred. During median follow-up of 26 (1–87) months, 82.2% of patients with acute success were free from VA recurrences, and the overall long-term success rate was 68.1%. Multisite ablation was the only independent predictor of VA recurrences. Conclusion Acute elimination of VA originating from the LVS could be achieved in 83.6% of patients, with 82.2% having no VA recurrences. Despite acute elimination of VA with multisite ablation, the incidence of VA recurrence still was high.

INTRODUCTION Bipolar radiofrequency catheter ablation (Bi-RFCA) emerged as an option for treatment of arrhythmias resistant to the conventional approach. Data on safety issues of Bi-RFCA, including temperature values of intracardiac return electrode (IRE) are lacking. OBJECTIVE To determine the safety profile of Bi-RFCA regarding temperature measurements obtained from nonirrigated IRE of different sizes. METHODS The study group consisted of consecutive patients after failed conventional RFCA who underwent Bi-RFCA. RESULTS Out of 1510 RFCA performed in our center, 19 patients underwent Bi-RFCA due to refractory to previous RFCA ventricular arrhythmias (15 patients) or typical atrial flutter (four patients). Nonirrigated small (4 mm) and large (8 mm) tip catheters were used as IRE in 14 (including three cross-overs to 8 mm IRE) and five patients, respectively. A total number of 164 bipolar applications were performed (128 for 4 mm and 36 for 8 mm IRE). Maximal temperatures of 4 mm IRE were significantly higher than those of 8 mm IRE (63°C ± 16°C vs 43°C ± 4°C; P = .027). A significant rise of temperature and steam-pops, preventing further Bi-RFCA, occurred in seven patients treated with 4 mm IRE. Bi-RFCA using 4 mm IRE operated at significantly higher impedance values (211 ± 83 vs 143 ± 38; P = .04) and lower power values (mean 20 W ± 6 W vs 32 W ± 7 W, P = .0005; max 29 W ± 9 W vs 39 W ± 10 W, P = .027). CONCLUSION The use of 8 mm IRE for Bi-RFCA is associated with lower temperatures of the catheter used as ground and lower incidence of steam-pops which may suggest a better safety profile than 4 mm IRE. Determination of safety/efficacy balance requires further studies.

Salbutamol is a selective beta2 adrenoreceptor agonist causing bronchodilation. It is commonly used for the treatment of acute bronchoconstriction episodes such as acute asthmatic crisis or status asthmaticus. It is also used for treatment of chronic obstructive pulmonary disease. As a β2 selective agonist, intravenous salbutamol may also serve as a pharmacologic agent for the induction of arrhythmias during electrophysiological study (EPS). Infusion of salbutamol significantly shortens sinus node cycle length and sinus node recovery time. It also shortens effective refractory period of the AV node, significantly shortens AH interval and the Wenckebach point (WP), and decreases atrial and ventricular effective refractory periods. Doses used in the setting of EPS differ from those used during acute asthmatic crisis. A recommended single bolus dose for use in the EP lab equals 0.125 mg of salbutamol.

Digital and social media are transforming society and Medicine. In this review, we discuss how social media speeds the translation of medical evidence, disrupts peer review, changes the path to leadership, improves lifelong learning, connects colleagues and may even transform cardiovascular research. Despite some downsides, we make the case that social media will be a net positive for Medicine.