Search Results (77)

Percutaneous coronary intervention (PCI) is a widely performed revascularisation procedure for coronary artery disease. Although effective, its reliance on fluoroscopy and iodinated contrast exposes patients and operators to risks of radiation and nephrotoxicity. As PCI techniques have become more complex, interest has grown in imaging methods that reduce dependence on fluoroscopy and contrast. Electro-anatomical mapping systems (EAMS), developed for catheter navigation in electrophysiology, enable real-time three-dimensional visualisation without the need for fluoroscopy or contrast. By adapting coronary guidewires as electrodes, EAMS can reconstruct vessel anatomy and track interventional tools in real time. EAMS have demonstrated feasibility and safety in device implantation, and early studies suggest their applicability to PCI, where they may mitigate radiation and contrast exposure by providing an alternative method for guidewire and stent visualisation. This review provides a narrative overview of current evidence, outlining the technical principles, applications in device implantation, and the emerging role of EAMS in coronary intervention. Full article

Background/Objectives: For many years, catheter ablation (CA) has been a cornerstone in atrial fibrillation (AF) rhythm control therapy; however, recurrence remains common. Multiple parameters have been proposed to quantify AF arrhythmogenic substrate, yet reliable predictors of long-term outcomes are lacking. To assess the value of non-invasive amplified P-wave duration (PWD), echocardiographic parameters, biomarkers, and electroanatomical mapping (EAM) were used in predicting left atrial (LA) fibrosis and arrhythmia recurrence after CA. Methods: We included 196 patients undergoing first CA for paroxysmal or persistent AF. Amplified 12-lead ECG PWD parameters [Pmax, Pmin and left atrial P-wave (LAP)], echocardiographic parameters, and biomarkers were assessed pre-procedure. We measured low-voltage areas (LVA, 0.2–0.5 mV) on high-density voltage EAM during sinus rhythm as a surrogate of fibrosis. Freedom from arrhythmia was evaluated at 6 and 12 months. Results: Patients with LVA on EAM had prolonged Pmax (148 vs. 135 ms, p < 0.0001), Pmin (111 vs. 101.5 ms, p = 0.0001), LAP (73.5 vs. 55.5 ms, p < 0.0001), larger LA diameter (p = 0.0002), area (p = 0.0365) and volume (p = 0.004), higher E/E’ (p = 0.0007) and E/A ratios (p = 0.037), more mitral regurgitation (p = 0.0315), and higher pro-BNP levels (p = 0.0094). Univariate analysis showed 12-month recurrence rates higher with greater Pmax, Pmin, LAP, LVA presence and extent; however, in multivariate analysis, only P-wave parameters remained independently associated with recurrence. Conclusions: Prolonged PWD parameters strongly reflect LA substrate (Pmax, Pmin) and independently predict post-ablation AF recurrence (Pmax, Pmin, and LAP). LA size, diastolic dysfunction, and mitral regurgitation were associated with LA fibrosis, while pro-BNP was associated with both fibrosis and arrhythmia recurrence. Integrating these simple, non-invasive markers into a multimodal assessment alongside EAM could improve pre-procedural risk stratification and guide individualized ablation strategies. Full article

Background: Left ventricular (LV) summit is an important origin for ventricular arrhythmias (VAs). However, the complex electroanatomic structure of LV summit and the surrounding anatomic sites makes ablation of this arrhythmia challenging. Aim: In this paper, we review the main strategies to mapping and ablation of LV summit VAs and summarize our experience in this challenging ablation. Methods: To summarize our experience, we included all consecutive patients with outflow VAs referred to our institute for ablation between 2019 and 2024 who were eventually diagnosed with LV summit origin based on electroanatomical mapping and ablation result using stepwise and sequential ablation approach. Results: A total of 38 patients were found to have VAs from LV summit origin. Overall five patients had history of at least one failed ablation. V1 transition was seen in 15 patients, V2 transition in 12 patients, and V3 transition in 11 patients. Four patients had R wave pattern break in lead V2. Ablation was performed from the earliest activation or from one of the adjacent sites using stepwise and sequential approach. Acute suppression of VAs occurred in 35 patients without complications, except one case of pseudoaneurysm of femoral artery. Conclusions: Stepwise and sequential ablation approach can suppress VAs originating from LV summit in most patients. Full article

Introduction: The radiofrequency catheter ablation (RFCA) of ventricular arrhythmias (VAs) originating from the right ventricular outflow tract (RVOT) is a well-established therapy. Traditionally, RFCA is guided using electroanatomical 3D mapping systems involving manual catheter navigation within cardiac chambers. While effective, this approach may be time-consuming, and it carries a potential risk of cardiac wall perforation. Although the risk is low, it cannot be underestimated. Therefore, alternative mapping methods are sought to reduce procedural times and improve the overall efficiency of RVOT-VAs ablation. Aim: To evaluate the safety, feasibility, and efficacy of a universal RVOT 3D model implementation for the ablation of idiopathic RVOT-VAs. Methods: Consecutive patients undergoing VA ablation supported with a universal RVOT 3D model (3D-MODEL group) were included in the study. The RVOT universal model in this group was created by processing DICOM images for the improved segmentation of anatomical structures, followed by production using 3D printing technology. Patients who underwent classic endocardial electroanatomical mapping served as controls (EAM group). Results: A total of 228 patients were included in the study (143 women, age 50 ± 17 years): 149 in the 3D-MODEL group and 79 in the EAM group. The acute complete elimination of clinical VAs was achieved for 133 (89%) of patients in the 3D-MODEL group vs. 65 (82%) in the EAM group (p = 0.14). The procedural time was significantly shorter in the 3D-MODEL group compared to the EAM group (38 ± 14 min vs. 80 ± 39 min, p < 0.001). A significant difference was also observed in the radiofrequency time between the 3D-MODEL and EAM groups (251 ± 176 s vs. 503 ± 425 s, p < 0.001). No significant difference in fluoroscopy time was found between the groups (284 ± 167 s vs. 260 ± 327 s, p = 0.49). Two cases of cardiac tamponade occurred, both in patients from the EAM group. During follow-up, lasting 14 ± 10 months, 87% of patients in the 3D-MODEL group and 75% in the EAM group remained arrhythmia-free (p = 0.45). Conclusions: The use of universal RVOT 3D modeling is a feasible, safe, and effective alternative to classic electroanatomical mapping in the ablation of idiopathic RVOT-VAs. Full article

Ventricular tachycardia (VT) remains a major cause of morbidity and mortality in patients with structural heart disease. While catheter ablation has become a cornerstone in VT management, recurrence rates remain substantial due to limitations in electroanatomic mapping (EAM), particularly in cases of deep or heterogeneous arrhythmogenic substrates. Cardiac imaging, especially when multimodal and integrated with mapping systems, has emerged as a critical adjunct to enhance procedural efficacy, safety, and individualized strategy. This comprehensive review explores the evolving role of various imaging modalities, including echocardiography, cardiac magnetic resonance (CMR), computed tomography (CT), positron emission tomography (PET), and intracardiac echocardiography (ICE), in the preprocedural and intraprocedural phases of VT ablation. We highlight their respective strengths in substrate identification, anatomical delineation, and real-time guidance. While limitations persist, including costs, availability, artifacts in device carriers, and lack of standardization, future advances are likely to redefine procedural workflows. Full article

Background: Atrial fibrosis is a key contributor to atrial cardiomyopathy and can be assessed invasively using mean left atrial voltage (MLAV) from electroanatomical mapping. However, the invasive nature of this procedure limits its clinical applicability. Machine learning (ML), particularly regression tree-based models, may offer a non-invasive approach for predicting MLAV using clinical and echocardiographic data, improving non-invasive atrial fibrosis characterisation beyond current dichotomous classifications. Methods: We prospectively included and followed 113 patients with paroxysmal or persistent atrial fibrillation (AF) undergoing pulmonary vein isolation (PVI) with ultra-high-density voltage mapping (uHDvM), from whom MLAV was estimated. Standardised two-dimensional transthoracic echocardiography was performed before ablation, and clinical and echocardiographic variables were analysed. A regression tree model was constructed using the Classification and Regression Trees—CART-algorithm to identify key predictors of MLAV. Results: The regression tree model exhibited moderate predictive accuracy (R² = 0.63; 95% CI: 0.55–0.71; root mean squared error = 0.90; 95% CI: 0.82–0.98), with indexed minimum LA volume and passive emptying fraction emerging as the most influential variables. No significant differences in AF recurrence-free survival were found among MLAV tertiles or model-based generated groups (log-rank p = 0.319 and p = 0.126, respectively). Conclusions: We present a novel ML-based regression tree model for non-invasive prediction of MLAV, identifying minimum LA volume and passive emptying fraction as the most significant predictors. This model offers an accessible, non-invasive tool for refining atrial cardiomyopathy characterisation by reflecting the fibrotic substrate as a continuum, a crucial advancement over existing dichotomous approaches to guide tailored therapeutic strategies. Full article

Background: The influence of the initial ablation modality on pulmonary vein (PV) reconnection and substrate characteristics in redo procedures for recurrent atrial fibrillation (AF) remains unclear. We assessed how different thermal strategies—ablation index (AI)-guided radiofrequency (RF) versus cryoballoon (CB) ablation—affect remapping findings during redo pulmonary vein isolation (PVI). Methods: We included patients undergoing redo ablation between 2015 and 2024 with high-density electroanatomic mapping. Initial PVI modalities were retrospectively classified as low-power, long-duration (LPLD) RF; high-power, short-duration (HPSD) RF; or second-/third-generation CB. Reconnection sites were mapped using multielectrode catheters. Redo PVI was performed using AI-guided RF. Segments showing PV reconnection were reisolated; if all PVs remained isolated and AF persisted, posterior wall isolation was performed. Results: Among 195 patients (LPLD: 63; HPSD: 30; CB: 102), complete PVI at redo was observed in 0% (LPLD), 23.3% (HPSD), and 10.1% (CB) (p < 0.01 for LPLD vs. HPSD). Reconnection patterns varied by technique; LPLD primarily affected the right carina, while HPSD and CB showed reconnections at the LSPV ridge. Organized atrial tachycardia was least frequent after CB (12.7%, p < 0.002). Conclusion: Initial ablation strategy significantly influences PV reconnection and post-PVI arrhythmia patterns, with implications for redo procedure planning. Full article

Background: Atypical atrial flutter (AFL) is a complex clinical challenge, particularly in patients with prior atrial fibrillation (AF) treated with pulmonary vein isolation (PVI). Arrhythmias involving the vein of Marshall (VOM) often require extensive lesion sets, including ethanol infusion, to effectively target the epicardial substrate. To minimize tissue damage, an alternative strategy has been proposed, emphasizing advanced electroanatomical mapping, entrainment maneuvers, and highly targeted ablation techniques. Case Presentation: We describe a 72-year-old woman with recurrent atrial arrhythmias following pulmonary vein isolation (PVI), who presented with palpitations as her primary symptom. After ineffective pharmacological therapy, she underwent a catheter ablation procedure. Electroanatomical mapping revealed significant left atrial scarring and suggested a macroreentrant circuit involving the VOM. Entrainment maneuvers confirmed the VOM’s involvement. A single targeted endocardial ablation guided by the ablation index terminated the arrhythmia within 12 s, without the need for ethanol infusion or extensive lesion sets. Discussion: This case underscores the VOM’s role in sustaining atypical AFL post-PVI and highlights the effectiveness of precise electroanatomical mapping combined with targeted endocardial ablation. Unlike broader ablation or ethanol infusion strategies, a focused lesion at the critical isthmus achieved arrhythmia termination with minimal tissue damage. Conclusions: Endocardial ablation at the site of entrainment can safely and effectively treat VOM-related AFL, offering symptom relief and restoration of sinus rhythm. This approach may reduce procedural risks and expand the feasibility of VOM-related arrhythmia management in centers without access to ethanol infusion. Full article

Brugada syndrome (BrS) has been traditionally considered a pure electrical disorder without an underlying structural substrate. However, early ECG studies showed the presence of depolarization abnormalities in this condition, while many studies based on advanced imaging have suggested the presence of subtle structural alterations. On the other hand, electrophysiological study (EPS) and electroanatomic mapping (EAM) techniques have provided important data regarding right ventricular functional and structural arrhythmic substrate. More recently, histology and immunology shed light on the possible role of fibrotic and inflammatory substrates in BrS. Notably, a significant overlap between electro anatomical and structural features in BrS and arrhythmogenic cardiomyopathy has been proposed. In this review, we summarized the physio pathological pathways and substrate underlying BrS. A deeper knowledge of the structural abnormalities involved in the pathogenesis of this disease could improve our diagnostic and prognostic approach, while novel findings regarding the role of inflammation and immune activation could potentially lead to new therapeutic strategies for BrS. Full article

Atrial fibrillation (AF) is increasingly recognized as the clinical manifestation of an underlying atrial disease process rather than a purely electrical disorder. This evolving paradigm has given rise to the concept of atrial cardiomyopathy (AtCM), encompassing structural, electrical, contractile, and molecular remodeling of the atrial myocardium that contributes to AF initiation, maintenance, and progression. Although consensus definitions of AtCM now exist, its integration into clinical practice remains limited, with AF management still largely guided by arrhythmic patterns rather than substrate characterization. This review synthesizes current diagnostic strategies for AtCM within the context of AF, emphasizing a multimodal approach. We outline advances in cardiac imaging—including echocardiography, cardiac magnetic resonance, and computed tomography—for detailed assessment of atrial morphology, function, and fibrosis. Electroanatomic mapping is discussed as a key invasive tool for substrate localization, while electrocardiographic indices such as P-wave morphology and dispersion serve as accessible surrogates of electrical remodeling. In parallel, we examine the role of circulating biomarkers and emerging genomic, transcriptomic, and epigenomic markers in refining disease phenotyping. Despite promising progress, significant challenges remain. Standardization of imaging protocols, validation of biomarker thresholds, and integration of artificial intelligence tools are needed to enhance clinical utility. A diagnostic framework informed by atrial substrate assessment may support more tailored therapeutic decision-making in AF. Future research should prioritize the harmonization of diagnostic criteria and explore how substrate profiling in AF may refine risk stratification and improve clinical outcomes. Full article

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia, associated with significant morbidity, mortality, and healthcare burden. Despite advances in AF management, challenges persist in early detection, risk stratification, and treatment optimization, necessitating innovative solutions. Artificial intelligence (AI) has emerged as a transformative tool in AF care, leveraging machine learning and deep learning algorithms to enhance diagnostic accuracy, improve risk prediction, and guide therapeutic interventions. AI-powered electrocardiographic screening has demonstrated the ability to detect asymptomatic AF, while wearable photoplethysmography-based technologies have expanded real-time rhythm monitoring beyond clinical settings. AI-driven predictive models integrate electronic health records and multimodal physiological data to refine AF risk stratification, stroke prediction, and anticoagulation decision making. In the realm of treatment, AI is revolutionizing individualized therapy and optimizing anticoagulation management and catheter ablation strategies. Notably, AI-enhanced electroanatomic mapping and real-time procedural guidance hold promise for improving ablation success rates and reducing AF recurrence. Despite these advancements, the clinical integration of AI in AF management remains an evolving field. Future research should focus on large-scale validation, model interpretability, and regulatory frameworks to ensure widespread adoption. This review explores the current and emerging applications of AI in AF, highlighting its potential to enhance precision medicine and patient outcomes. Full article

(1) Objective: To examine the efficiency and efficacy of using endovascular mapping and pulsed field ablation in the setting of a hybrid video-assisted thoracoscopic atrial fibrillation (AF) ablation procedure. (2) Methods: Eleven consecutive patients underwent hybrid video-assisted thoracoscopic epicardial ablation and left atrial appendage exclusion followed by endocardial ablation using pulsed field ablation energy. The completeness of epicardial and endocardial lesion sets were assessed using 3D electro-anatomical mapping. (3) Results: Left atrial appendage (LAA) exclusion and durable pulmonary vein isolation (PVI) and posterior wall isolation (PWI) were achieved in all patients. The endovascular part of the necessary lesion set using PFA energy was successful in 100% of the patients. All patients remained in SR during the 12-month follow-up period. (4) Conclusions: Our study confirms the feasibility of using endovascular pulsed field ablation to complete previously performed epicardial lesion sets during the hybrid AF ablation procedures, without extending the procedure time or increasing the risk of complications. Full article

The cornerstone of ablative therapy for atrial fibrillation (AF) is pulmonary vein isolation (PVI). Whether PVI should be added with additional lesions in persistent atrial fibrillation (PerAF) or for any post-ablative recurrent AF is a matter of debate. Whatever the ablative strategy, it must determine the choice of energy source to achieve the most durable lesion sets with the least likelihood of complications. Radiofrequency (RF) is the most studied thermal ablation technique. It can be combined with high-density electroanatomic mapping and can be used for both pulmonary and extrapulmonary atrial ablation. Cryoenergy is at least as effective as radiofrequency for PVI; it is rapid, relatively safe, and has a steep learning curve. Therefore, it has been proposed as a first-line approach for PVI-only procedures. More recently, a non-thermal technique based on the application of pulsed direct current (Pulsed Field Ablation—PFA) has been introduced. PFA causes cell death by opening cell membrane pores (electroporation) without a significant increase in tissue temperature. It is fast and does not alter the extracellular matrix as thermal techniques do, although it ends up causing long-lasting, transmural lesions. Most importantly, it is relatively selective on cardiac myocytes and therefore potentially safer than thermal techniques. Some PFA systems can be combined with electroanatomic mapping systems. However, as of now, it appears that these ablation technologies should be considered complementary rather than alternative for a number of practical and theoretical reasons. Full article

Background/Objectives: Fluoroscopy has traditionally supported three-dimensional (3D) electroanatomical mapping (EAM)-guided left atrial (LA) electrophysiological procedures (EPs), but the associated ionizing radiation poses long-term health risks for patients and healthcare professionals. Advances in 3D EAM systems now enable nearly or entirely radiation-free ablations. Imaging techniques such as transesophageal echocardiography (TEE) are increasingly used for precise and safe LA access. This study evaluates the safety and efficacy of TEE-guided, zero-fluoroscopy/near-zero-fluoroscopy LA EPs in routine clinical practice. Methods: 142 consecutive patients undergoing LA EAM-guided radiofrequency ablation at the Ulm University Heart Center between October 2023 and November 2024 were analyzed. In total, 73 patients underwent zero-fluoroscopy/near-zero-fluoroscopy ablation guided solely by TEE, while another 69 patients received fluoroscopy-guided ablation using TEE and fluoroscopy guidance. Results: Of the 142 patients, 58.0 (40.8%) were female, and the median age was 73.0 (64.0; 79.0) years. A total of 53 (37.3%) underwent zero-fluoroscopy EP, 20 (14.1%) underwent near-zero-fluoroscopy EP, and 69 (48.6%) underwent fluoroscopy-guided EP. Procedure duration was without significantly relevant difference between both groups (132.0 vs. 133.0 min; p = 0.52). Median radiation exposure in the zero-fluoroscopy/near-zero-fluoroscopy group was 0 (0.0; 0.0) minutes, compared to significantly higher values in the fluoroscopy group (9.7 (5.9; 15.3) minutes; p < 0.001). No significant differences in complications were observed (p = 0.09). Conclusions: TEE-guided, radiation-free LA EP offers a safe and effective approach, significantly reducing radiation exposure and its associated risks while maintaining high procedural efficacy without increasing the risk of complications. Full article

Background: Age is a relevant risk factor for the development of atrial arrhythmias and an independent predictor of adverse cardiovascular outcomes. The incidence of atrial tachycardia (AT) is known to increase with aging, but so far, there are no data on elderly patients with AT. Therefore, we sought to assess the safety and outcomes of AT ablation in patients ≥75 years compared to those <75 years. Methods: A total of 420 consecutive patients undergoing AT ablation after previous cardiac interventions (mean 2.1 ± 0.1 prior ablation procedures) were analyzed. Safety, as well as acute and mid-term outcomes of AT ablation were compared between 140 patients ≥75 years (mean age 78.1 ± 0.2 years, 22.9% aged ≥80 years (range 80–86 years)) and 280 patients <75 years (mean age 62.2 ± 0.6 years). Results: Patients ≥75 years were more often female (54.3% vs. 38.2%; p = 0.0024) and presented with more cardiac comorbidities, including arterial hypertension (85.0% vs. 64.3%; p < 0.0001) and coronary artery disease (33.6% vs. 18.2%; p = 0.0006). Acute success of AT ablation was reached in 96.4% vs. 97.9% of patients (p = 0.5173). Major complications (1.4% vs. 0.7%; p = 0.6035) and duration of hospital stay (2 (IQR 2–4) days vs. 2 (IQR 2–3) days; p = 0.9125) did not differ significantly between groups. During a follow-up of 364 (IQR 183–729.5) days, arrhythmia recurrences occurred in 45.0% vs. 49.3% (p = 0.4684), whereas repeat ablation was less frequently performed in patients ≥75 years (25.7% vs. 36.1%; p = 0.0361). Conclusions: AT ablation in patients ≥75 years after previous cardiac interventions in tertiary arrhythmia centers is safe and effective. Therefore, AT ablation should not be ruled out in elderly patients due to age alone, but should be considered based on arrhythmia burden, symptom severity and concomitant clinical and procedural risk factors. Full article