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Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: 25 June 2025 | Viewed by 14934

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Special Issue Editors

Dr. Hussam Ali

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Guest Editor

Arrhythmia and EP Research Center, IRCCS MultiMedica, Sesto San Giovanni, 20099 Milan, Italy
Interests: catheter ablation; cardiac mapping; pacing maneuvers; subcutaneous ICD; atrial fibrillation; WPW; sudden cardiac death

Dr. Antonio Frontera

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Guest Editor

Cardiac Arrhythmia Department, Great Metropolitan Hospital Niguarda, Milan, Italy
Interests: catheter ablation; sudden cardiac death; atrial fibrillation; substrates mapping; novel ablation and pacing technologies

Special Issue Information

Dear Colleagues,

The catheter ablation of cardiac arrhythmias has evolved over the past few decades, using different techniques and energies, and has proven to be superior to pharmacological therapy in various clinical settings. Understanding the underlying electrophysiological mechanisms and correlated anatomical substrates remains crucial to guide successful ablation and improve clinical outcomes. Despite massive advances in catheter ablation safety and efficacy, many challenging arrhythmias and conditions require further studies and research to optimize arrhythmic patient care.

The scope of this Special Issue, “Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias”, focuses on cardiac arrhythmias management, including, but not limited to, diagnosis, intracardiac mapping, and catheter ablation.

Original or review articles addressing novel ablation technologies or energies, state-of-the-art reviews, gaps in the current knowledge, and challenging arrhythmic conditions are welcome.

Dr. Hussam Ali
Dr. Antonio Frontera
Guest Editors

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Keywords

cardiac electrophysiology
cardiac arrhythmias
atrial fibrillation
catheter ablation

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Published Papers (10 papers)

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Research

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13 pages, 641 KiB

Open AccessArticle

Spontaneous Resolution of Ventricular Pre-Excitation During Childhood: A Retrospective Study

by Antonio Sanzo, Alessandro Seganti, Andrea Demarchi, Riccardo Simone Fino, Irene Raso, Alessia Claudia Codazzi, Barbara Petracci, Andrea Bongiorno, Roberto Rordorf and Savina Mannarino

J. Clin. Med. 2025, 14(7), 2367; https://doi.org/10.3390/jcm14072367 - 29 Mar 2025

Viewed by 418

Abstract

Background/Objectives: Ventricular pre-excitation (VP) increases the risk of sudden cardiac death among children. While transcatheter ablation could potentially be therapeutic, it is not without risk, especially in smaller children. Accessory pathways (APs) may spontaneously lose anterograde conduction properties over time, making invasive treatment unnecessary. We aim to investigate the probability of spontaneous loss of VP during childhood, as well as the potential factors that may be associated with VP resolution. Methods: We conducted a retrospective study of patients with VP diagnosed before 12 years of age and referred to two Northern Italian tertiary care hospitals between 1993 and 2021. Patients with complex congenital heart disease were excluded. Our primary objective was to determine the likelihood of spontaneous resolution of VP. Results: Overall, 153 patients were included, with a median age at first diagnosis of 4.9 years (25th–75th percentile: 75 days–8.4 years) and a median follow-up of 4.9 years (25th–75th percentile: 1.8–8 years). Through left truncated Kaplan–Meier analysis, we estimated that anterograde conduction would persist in 53% and 33.8% of patients at the age of 1 and 16 years, respectively. Our findings revealed that the absence of symptoms and intermittent VP were associated with a higher likelihood of VP resolution. It is noteworthy that no major arrhythmic events were reported. Conclusions: Our study strongly supports the implementation of a conservative strategy in younger children with VP. Our findings indicate that a significant proportion of pediatric patients may experience spontaneous resolution of VP in the early years of their lives, making any invasive treatment unnecessary. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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12 pages, 1748 KiB

Open AccessArticle

Prediction of Ablation Index and Lesion Size Index for Local Impedance Drop-Guided Ablation

by Lukas Sprenger, Fabian Moser, Vera Maslova, Adrian Zaman, Marc Nonnenmacher, Sven Willert, Derk Frank and Evgeny Lian

J. Clin. Med. 2025, 14(3), 832; https://doi.org/10.3390/jcm14030832 - 27 Jan 2025

Viewed by 738

Abstract

(1) Background: The effectiveness of RF ablation for PVI depends on the lesion location and size to achieve continuous and durable lesion lines. AI and LSI are widely accepted lesion metrics for guiding the ablation procedure. LI dynamics is another parameter that guides PVI and does not rely on input variables. Limited data are available on a direct comparison between lesion metrics. Our study aims to compare RF application durations and influencing factors during index-guided (AI and LSI) and LI-guided approaches by predicting lesion metrics using machine learning. (2) Methods: While the coefficients in AI and LSI formulas are not disclosed, we trained custom machine-learning models based on Random Forest and Gradient Boosting Regressors to predict AI and LSI metrics for LI-guided ablations. (3) Results: The median RF application durations differed significantly between the lesion metrics, with 7.32, 19.91, and 11.92 s for AI-, LSI-, and LI-guided procedures, respectively. Mean CF was found to be an important predictor of RF application duration for the AI- and LSI-guided approaches. (4) Conclusions: Depending on the metric used, the significant differences in RF application durations suggest that an AI-guide approach may allow for shorter RF application durations, followed by LSI-guided and LI-guided procedures. Further studies are needed to evaluate the safety and efficacy of these results in a clinical setting. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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16 pages, 2548 KiB

Open AccessArticle

Electrographic Flow Mapping Provides Prognosis for AF Ablation Outcomes Across Two Independent Prospective Patient Cohorts

by Kent R. Nilsson, Amitesh Anerao, Melissa H. Kong, Pawel Derejko, Tamás Szili-Török, Sandeep Goyal, Mohit Turagam, Atul Verma and Steven Castellano

J. Clin. Med. 2025, 14(3), 693; https://doi.org/10.3390/jcm14030693 - 22 Jan 2025

Viewed by 833

Abstract

Background/Objectives: Electrographic flow (EGF) mapping allows for the visualization and quantification of atrial fibrillation (AF) wavefront propagation patterns. EGF-identified sources were shown in the randomized controlled FLOW-AF trial to significantly increase the likelihood of AF recurrence within 1 year if left unablated. Electrographic flow consistency (EGFC) additionally measures the stability of observed wavefront patterns, such that patients with more organization have a healthier substrate and lower recurrence. Source presence and EGFC can be used collectively to assign mechanistic phenotypes to AF patients. Methods: The patient phenotypes, treatment modalities, and outcomes in FLOW-AF were compared with those of patients in the ensuing AF-FLOW Global Registry, which was conducted by separate physicians at discrete clinical centers. Results: Patients with low EGFC (≤0.62) had a 12-month freedom from AF (FFAF) of 46%, while those with a high mean EGFC (>0.62) had a FFAF of 81%. Right atrial EGFC was correlated with left atrial EGFC, and the highest recurrence occurred in those with biatrial low EGFC. Source presence also affected the recurrence rates in both trials, such that the presence of EGF-identified sources in PVI-only patients lowered the FFAF from 65% to 36%, but the elimination of sources produced a 30% absolute increase in FFAF from 36% to 66%. Conclusions: Patient outcomes by EGF-based AF phenotype were consistent across two cohorts of patients from separate clinical trials at distinct centers. Patients with a high EGFC and no sources post-procedure had the best outcomes. EGF mapping provides insights into underlying disease pathophysiology and may be employed prospectively to predict recurrence. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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11 pages, 1063 KiB

Open AccessArticle

LA PULSE: Evaluating Left Atrial Function Pre- and Post-Atrial Fibrillation Ablation Using PULSEd Field Ablation

by Noha Mahrous, Florian Blaschke, Doreen Schöppenthau, Gerhard Hindricks, Leif-Hendrik Boldt and Abdul Shokor Parwani

J. Clin. Med. 2025, 14(1), 68; https://doi.org/10.3390/jcm14010068 - 26 Dec 2024

Viewed by 965

Abstract

Background: Atrial fibrillation (AF) is a common cardiac arrhythmia associated with left atrial dysfunction. The impact of pulmonary vein isolation (PVI) using pulsed field ablation (PFA) on left atrial function has not been previously quantified. This study aims to evaluate the effects of PVI using PFA on left atrial function in patients with AF. Methods: Thirty-four patients undergoing PVI with PFA between July 2022 and November 2023 were included. The left atrial function was assessed using echocardiography pre-procedure and at 6 months post-procedure. Results: The mean age of the patients was 66.5 ± 9.76 years, with 70.6% being male. The cohort included 44% of patients with paroxysmal AF. PVI was successfully achieved in all patients, with a significant improvement in all aspects of left atrial strain at an average of six-month follow-up. The left atrial strain reservoir (LASr) increased from 12.5 ± 5.8% to 21.7 ± 8.1% (p < 0.001). Notably, patients with paroxysmal AF exhibited a greater increase in LASr compared to those with persistent AF. Additionally, pre-procedural sinus rhythm was a significant predictor of better LASr outcomes. Conclusions: PFA is associated with significant improvement in left atrial reservoir strain, suggesting a positive impact on atrial function. These findings have important implications for the therapeutic management of AF and warrant further research. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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12 pages, 656 KiB

Open AccessArticle

Early versus Late Radiofrequency Catheter Ablation in Atrial Fibrillation: Timing Matters

by Ahmad A. A. Farghaly, Hussam Ali, Pierpaolo Lupo, Sara Foresti, Guido De Ambroggi, Salah Atta, Ahmed Abdel-Galeel, Aly Tohamy and Riccardo Cappato

J. Clin. Med. 2024, 13(16), 4643; https://doi.org/10.3390/jcm13164643 - 8 Aug 2024

Cited by 3 | Viewed by 1503

Abstract

Background: Despite the progressive course of atrial fibrillation (AF), the optimal timing of radiofrequency catheter ablation (RFCA) during disease course is still unknown. We aimed to investigate the impact of early RFCA within a year after AF diagnosis on procedural outcomes. Methods: A single-center retrospective study was conducted on symptomatic AF patients (n = 130) referred for RFCA with a 16-month median follow-up. Patients were stratified based on the diagnosis-to-ablation time (DAT) into early (≤1 year) and late (>1 year) RFCA groups. Atrial arrhythmia recurrence after single RFCA was the primary outcome. Secondary outcomes included cardiovascular hospitalizations, AF progression, and antiarrhythmic drug (AAD) use. Results: Within a year of AF diagnosis, 33 patients (25.4%) underwent RFCA. In the early-RFCA group, 84.4% of patients did not have recurrent atrial arrhythmia, in contrast to 60.8% in the late-RFCA group (p = 0.039). Late RFCA (HR = 2.74, 95% CI = 1.062–7.052, p = 0.037) and AF recurrence during the blanking period (HR = 4.57, 95% CI = 2.38–8.57, p < 0.0001) were independent predictors of atrial arrhythmia recurrence on multivariate analysis. Compared to the late-RFCA group, the early-RFCA group had significantly lower rates of cardiovascular hospitalizations (18% vs. 42%, p = 0.023), AF progression (0.0% vs. 11.3%, p = 0.044), and AAD use (45.4% vs. 81.4%, p < 0.001). Conclusions: Early RFCA within a year of AF diagnosis is associated with less atrial arrhythmia recurrence, fewer cardiovascular hospitalizations, less AF progression, and less AAD use. DAT of more than one year and AF recurrence during the blanking period are independent predictors of atrial arrhythmia recurrence after single RFCA. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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12 pages, 4481 KiB

Open AccessArticle

Anatomical and Electrophysiological Characteristics of Dual-Loop Re-Entry in Atypical Atrial Flutter: Implications for Mapping and Catheter Ablation

by Nicolas Johner, Mehdi Namdar and Dipen C. Shah

J. Clin. Med. 2024, 13(10), 2847; https://doi.org/10.3390/jcm13102847 - 12 May 2024

Cited by 2 | Viewed by 1557

Abstract

Background: Atypical atrial flutter (AFL) can be challenging to ablate, especially when involving dual-loop re-entry. We sought to assess the electroanatomical characteristics of single- and dual-loop AFLs in patients undergoing catheter ablation. Methods: We analyzed 25 non-cavotricuspid isthmus-dependent macro-re-entrant AFL in 19 consecutive patients. Three-dimensional high-density activation mapping was performed, and active re-entry loops were confirmed by entrainment mapping. Results: Of 25 AFLs (24 left, 1 right atrial), 13 (52%) exhibited dual-loop re-entry. The most common circuits included, in 6/13 (46% of dual loops), a perimitral re-entry with a second loop around the right/left pulmonary veins (PV) and, in 6/13 (46%), involved a right PV ostium with a second loop around either a functional conduction block or another PV. Ablation at the common isthmus of dual-loop AFLs and at the critical isthmus of single-loop AFLs terminated the arrhythmia more frequently than ablation at a secondary isthmus of dual-loop AFLs (5/6 (83%) and 8/11 (73%) versus 1/8 (13%), respectively, p = 0.013). Conclusions: More than half of AFLs exhibited a dual-loop re-entrant mechanism. Most critical isthmuses were found at the mitral isthmus, the left atrial roof or right PV ostia. Ablation targeting the common isthmus resulted in a higher termination rate. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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11 pages, 1242 KiB

Open AccessArticle

Real World Data from Catheter Ablation of Ventricular Tachycardias and Premature Ventricular Complexes in a Tertiary Care Center

by Christian Schlatzer, Jan Berg, Firat Duru, Corinna Brunckhorst, Ardan M. Saguner and Laurent M. Haegeli

J. Clin. Med. 2024, 13(8), 2310; https://doi.org/10.3390/jcm13082310 - 17 Apr 2024

Cited by 1 | Viewed by 1547

Abstract

Background: Catheter ablation in patients with ventricular arrhythmias (VA), such as ventricular tachycardias (VT) or frequent premature ventricular complexes (PVC), is increasingly considered an effective and safe therapy when performed in experienced centers. This study sought to determine acute success rates and complication rates of ablation procedures for patients with VA in a Swiss tertiary care center. Methods: All patients who underwent ablation therapy for VT and PVC at the University Heart Center in Zurich, Switzerland, between March 2012 and April 2017 were included in this analysis. Results: A total of 120 patients underwent catheter ablation for VT and PVC (69 and 51, respectively). Seventy percent of patients were male, and the mean age was 55.3 years. The most common indication for ablation was high PVC burden (47.5%), followed by paroxysmal VT (38.3%), ICD shocks (23.3%), incessant VT (12.5%), electrical storm (7.5%), and syncope (3.3%). Acute success rates for VT and PVC ablations were 94.2% and 92.2%, respectively. Rates for complications (including major and minor) for VT and PVC were 10.1% and 7.8%, respectively. Complications occurred only in patients with structural heart disease; no complications were noted in structurally normal hearts. Conclusions: Our results suggest that catheter ablation for VT and PVC has high acute success rates with a reasonable risk for complications in the setting of tertiary care centers, comparable to those reported in other studies. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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Review

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19 pages, 1727 KiB

Open AccessReview

Substrates of Sudden Cardiac Death in Hypertrophic Cardiomyopathy

by Matteo Sclafani, Giulio Falasconi, Giacomo Tini, Beatrice Musumeci, Diego Penela, Andrea Saglietto, Luca Arcari, Chiara Bucciarelli-Ducci, Emanuele Barbato, Antonio Berruezo and Pietro Francia

J. Clin. Med. 2025, 14(4), 1331; https://doi.org/10.3390/jcm14041331 - 17 Feb 2025

Viewed by 984

Abstract

Sudden cardiac death (SCD), the most devastating complication of hypertrophic cardiomyopathy (HCM), is primarily triggered by ventricular tachycardia or fibrillation. Despite advances in knowledge, the mechanisms driving ventricular arrhythmia in HCM remain incompletely understood, stemming from an interplay of multiple pro-arrhythmic factors. Myocyte disarray and myocardial fibrosis form a structural substrate favorable to re-entrant arrhythmias by altering myocardial electrophysiological properties, while cellular abnormalities predominate in patients without evident structural remodeling. Traditional SCD risk prediction models rely on clinical risk factors and regression-based risk estimation, often overlooking specific arrhythmic substrates. Emerging techniques now allow for the direct assessment of these substrates, providing deeper insights into the arrhythmogenic mechanisms and paving the way for more personalized SCD risk stratification. This review explores the contribution of cellular, structural, and electrophysiological substrates to arrhythmic risk in HCM, emphasizing their distinct roles. Furthermore, it highlights the potential of substrate-based approaches to refining SCD prevention strategies and improving outcomes for patients with HCM. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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18 pages, 2423 KiB

Open AccessFeature PaperReview

High-Density and Resolution Epicardial Mapping of the Atria: Translational Research with Clinical Impact

by Ziliang Ye, Yifan Jia, Mathijs S. van Schie, Paul Knops, Vehpi Yildirim, Yannick J. H. J. Taverne and Natasja M. S. de Groot

J. Clin. Med. 2024, 13(21), 6386; https://doi.org/10.3390/jcm13216386 - 25 Oct 2024

Viewed by 1345

Abstract

The electrical arrhythmogenic substrate underlying the most common cardiac arrhythmia atrial fibrillation (AF) may consist of conduction disorders, low-voltage areas, or fractionated potentials. High-density and resolution epicardial mapping (HDREM) approaches have been introduced to quantify and visualize electrophysiological properties of the atria. These approaches are essential for obtaining innovative insights into arrhythmogenic substrates and identifying novel targets for therapy. The aim of this review is to summarize and discuss the (1) contribution of HDREM studies to the knowledge on atrial arrhythmogenesis and (2) future applications of HDREM of atria in daily clinical practice. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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16 pages, 1072 KiB

Open AccessReview

Anti-Arrhythmic Effects of Heart Failure Guideline-Directed Medical Therapy and Their Role in the Prevention of Sudden Cardiac Death: From Beta-Blockers to Sodium-Glucose Cotransporter 2 Inhibitors and Beyond

by Wael Zaher, Domenico Giovanni Della Rocca, Luigi Pannone, Serge Boveda, Carlo de Asmundis, Gian-Battista Chierchia and Antonio Sorgente

J. Clin. Med. 2024, 13(5), 1316; https://doi.org/10.3390/jcm13051316 - 26 Feb 2024

Cited by 4 | Viewed by 3786

Abstract

Sudden cardiac death (SCD) accounts for a substantial proportion of mortality in heart failure with reduced ejection fraction (HFrEF), frequently triggered by ventricular arrhythmias (VA). This review aims to analyze the pathophysiological mechanisms underlying VA and SCD in HFrEF and evaluate the effectiveness of guideline-directed medical therapy (GDMT) in reducing SCD. Beta-blockers, angiotensin receptor–neprilysin inhibitors, and mineralocorticoid receptor antagonists have shown significant efficacy in reducing SCD risk. While angiotensin-converting enzyme inhibitors and angiotensin receptor blockers exert beneficial impacts on the renin-angiotensin-aldosterone system, their direct role in SCD prevention remains less clear. Emerging treatments like sodium-glucose cotransporter 2 inhibitors show promise but necessitate further research for conclusive evidence. The favorable outcomes of those molecules on VA are notably attributable to sympathetic nervous system modulation, structural remodeling attenuation, and ion channel stabilization. A multidimensional pharmacological approach targeting those pathophysiological mechanisms offers a complete and synergy approach to reducing SCD risk, thereby highlighting the importance of optimizing GDMT for HFrEF. The current landscape of HFrEF pharmacotherapy is evolving, with ongoing research needed to clarify the full extent of the anti-arrhythmic benefits offered by both existing and new treatments. Full article

(This article belongs to the Special Issue Cardiac Electrophysiology and Catheter Ablation of Different Arrhythmias)

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