Search Results (61)

Atrial fibrillation (AF) is increasingly understood as the electrical expression of a systemic and atrial cardiometabolic disease rather than an isolated disorder of pulmonary-vein triggers. Obesity, insulin resistance, hypertension, sleep-disordered breathing, heart failure with preserved ejection fraction, and visceral adiposity promote atrial stretch, inflammation, fibrosis, autonomic imbalance, and conduction heterogeneity. Epicardial adipose tissue (EAT), particularly the peri-left-atrial depot, may provide a local mechanistic bridge between systemic metabolic dysfunction and atrial cardiomyopathy through paracrine, inflammatory, fibrotic, and infiltrative pathways. This framework has direct therapeutic implications. Structured weight loss, cardiorespiratory fitness, alcohol reduction, and comprehensive risk-factor management can reduce AF burden and improve rhythm-control outcomes, although the magnitude of benefit varies across populations and trial designs. Incretin-based therapies have introduced a potentially important pharmacologic route to substrate modification. Semaglutide and tirzepatide produce substantial weight loss and favorable cardiovascular and heart-failure effects, while emerging observational and prospective data suggest lower AF incidence and post-ablation recurrence. However, evidence for reduced post-ablation recurrence remains predominantly non-randomized and is susceptible to residual confounding, treatment-selection effects, and healthy-user bias. Causality, weight-independent antiarrhythmic effects, optimal timing relative to ablation, and durability after treatment withdrawal remain unresolved. Observational sodium-glucose cotransporter-2 (SGLT2) inhibitor data support further investigation of cardiometabolic approaches to rhythm control, although randomized evidence has not consistently demonstrated benefit. Our review integrates mechanistic, imaging, lifestyle, pharmacologic, and electrophysiological evidence and proposes a practical model in which catheter ablation and cardiometabolic substrate modification are complementary strategies. Full article

Atrial fibrillation (AF) is the most commonly encountered arrhythmia, with a rapidly growing prevalence and significant cost to the global healthcare system. Left untreated, AF progresses over time from paroxysmal AF to persistent AF (perAF) and long-standing persistent AF (LS-perAF). AF is associated with significant mortality and morbidity by increasing the risk of developing cardiomyopathy, heart failure, dementia, stroke and systemic embolization. Endocardial catheter ablation (CA) targeting pulmonary vein isolation (PVI) alone is the most commonly employed treatment strategy for patients undergoing invasive treatment for all forms of AF. Despite technological improvements such as pulsed field ablation (PFA), procedural success rates in preventing AF recurrences in patients with perAF and LS-perAF remain suboptimal. A lack of lesion transmurality gives rise to epicardial–endocardial dissociation, which may contribute to AF recurrences. Hybrid ablation (HA) combines epicardial surgical ablation with endocardial CA. HA leads to greater freedom from AF in advanced AF compared to CA, and while existing data support the safety of HA, HA inherently is more invasive, requires a multidisciplinary approach, and has a 5–7.8% risk of major adverse events. HA is reasonable in patients with symptomatic, drug-refractory perAF or LS-perAF. Future directions include evaluating the role of novel operative technologies in HA. Full article

Background: Catheter ablation (CA) with pulmonary vein isolation is an established treatment for atrial fibrillation (AF). Epicardial adipose tissue (EAT) has been implicated in AF pathophysiology, but data on periatrial EAT and cardiac structural changes after CA in patients with heart failure with preserved ejection fraction (HFpEF) remain limited. Methods: We prospectively included 43 patients with paroxysmal AF and HFpEF undergoing radiofrequency CA. Cardiac magnetic resonance (CMR) was performed before ablation and after 6 months to quantify periatrial EAT volume and left ventricular mass (LVM) as prespecified primary endpoints, alongside secondary exploratory structural and functional parameters. Results: The study included 43 patients (74.4% male; mean age 60.5 ± 10.4 years). At 6-month follow-up, both primary endpoints improved significantly: periatrial EAT volume decreased from 28.8 ± 6.3 to 20.3 ± 5.9 mL (p < 0.001), and LVM decreased from 102 (95–115) to 97 (89–104) g/m² (p = 0.003). Exploratory analyses demonstrated favorable reverse cardiac remodeling, including reductions in left atrial area (LAA), left ventricular end-diastolic and end-systolic volumes, right ventricular end-systolic volume, and an increase in left ventricular stroke volume. Greater reduction in periatrial EAT volume correlated with more pronounced reverse cardiac remodeling, particularly with reductions in LVM (ρ = 0.48; p < 0.001) and LAA (ρ = 0.44; p = 0.003), with similar associations observed across other left ventricular remodeling parameters. Conclusions: In patients with paroxysmal AF and HFpEF, CA was associated with significant reductions in periatrial EAT volume and LVM, accompanied by favorable structural changes on CMR. These findings are consistent with reverse cardiac remodeling following CA and support further investigation of its structural effects in this patient population. Full article

Background: Obesity is a major independent risk factor for atrial fibrillation (AF), contributing to adverse outcomes and complicating rhythm control. While lifestyle modification is recommended, catheter ablation remains central to management. Conventional thermal ablation techniques often yield suboptimal results in obese patients due to anatomical and biophysical challenges. Pulsed field ablation (PFA), a novel non-thermal modality, may overcome these limitations. Methods: A systematic search of PubMed, Scopus, and Embase identified observational cohort studies (2017–2026) evaluating PFA outcomes in obese AF patients or across BMI categories. Four cohort studies met the inclusion criteria. Results: Findings on AF recurrence were heterogeneous. Recurrence rates appeared lower with PFA compared to radiofrequency ablation (RFA), though differences were not statistically significant. In a PFA-only study, freedom from arrhythmia recurrence did not vary across BMI categories. Compared with cryoballoon ablation (CBA), one matched-cohort study demonstrated significantly higher one-year freedom from AF with PFA-PVI, whereas another reported no difference. Left atrial epicardial adipose tissue (LA EAT) emerged as the only independent predictor of recurrence in PFA patients, suggesting electrical field perturbation by fat tissue. Radiation exposure was lower with PFA than CBA, while fluoroscopy time and periprocedural complications were comparable across groups. Conclusions: Current observational evidence suggests that PFA may be a feasible and safe option for AF ablation in overweight and obese patients, with outcomes comparable to conventional ablation techniques. However, comparative efficacy and long-term safety remain uncertain. Obesity-related adipose hypertrophy, systemic inflammation, and atrial remodeling may alter electric field distribution, contributing to variable recurrence outcomes. Larger prospective and randomized trials are warranted to define the long-term role of PFA in this high-risk population. Full article

Background: Current ablation strategies for the treatment of cardiac arrhythmias remain suboptimal. Treating cardiac arrhythmias using epicardial pulsed field ablation (PFA) selectively targets ganglionated plexi (GPs) within epicardial fat, offering a promising alternative to thermal ablation. Previous computational studies lacked physiological realism, excluding catheter geometry, fluid flow and post-PFA thermal latency. This study aimed to develop a realistic 3D epicardial PFA model integrating a clinical catheter, clinical PFA parameters and a sequentially coupled electro-thermal-fluid dynamics model, including thermal latency, to assess electrical and thermal collateral effects near stented coronary arteries. Methods: The model included epicardial fat, myocardium, blood, and the left circumflex artery containing a metallic stent positioned 0.25 mm beneath the catheter electrodes. Pulses of 1000, 2000, and 2500 V (60 pulses × 100 µs, 1 Hz) were simulated to analyze electric field distribution, PFA-induced lesion volume, temperature evolution, and Arrhenius-based thermal damage, including a 90 s post-pulse period to account for thermal latency. The PFA-threshold of 1000 V/cm was considered. Results: The artery reduced PFA-induced lesion size mainly by occupying fat tissue volume, while the stent shielded the lumen without altering fat lesion volume. The presence of a stent produced localized electric field enhancement at the arterial wall, with up to 3.83% of the arterial wall volume affected by PFA in the worst-case configuration. At clinical settings (1000 V), temperature remained below 40 °C and no collateral damage occurred. Voltages > 2000 V increased arterial wall heating, with thermal damage expanding up to five-fold during latency in the epicardial fat. Myocardium remained unaffected in all cases. Conclusions: The computational model developed in this study indicates that clinically relevant PFA parameters (1000 V) produce localized electric field enhancement at the stent–artery interface, resulting in limited collateral electrical effects in the arterial wall, while avoiding collateral thermal effects and preserving the myocardium. However, the use of higher pulse voltages can lead to delayed thermal damage within the epicardial fat. Full article

Background: Epicardial mapping and ablation of ventricular tachycardia (VT) are used in different clinical situations but pericardial adhesions following prior cardiac surgery or previous epicardial procedures may limit a percutaneous approach. The objective of this case series is to evaluate the safety and feasibility of a hybrid approach with surgical epicardial access as a valid alternative when pericardial space is not accessible percutaneously. Methods: After a complete preprocedural evaluation, four patients with prior cardiac surgery underwent hybrid VT ablation under general anesthesia. Surgical subxiphoid access was performed in three cases and one patient was subjected to median resternotomy for concomitant open-heart surgery. Epicardial electroanatomic voltage maps were acquired using the CARTO 3 system (Biosense Webster) or NavX (St. Jude Medical) and VT ablations with irrigated catheters were performed. The procedural endpoint was VT non-inducibility and/or LAVA/LP abolition. Results: No serious periprocedural complications occurred after hybrid VT ablation. Three patients had no complex ventricular arrhythmias after a median follow-up of 43 months. A symptomatic sustained VT relapsed in one patient, without requiring a redo ablation procedure but responded to escalation of antiarrhythmic therapy. Conclusions: A carefully planned hybrid VT ablation with surgical epicardial access is a safe and feasible procedure in patients with epicardial scar-related re-entry circuits and pericardial adhesions that limit a percutaneous approach. Full article

Background and Objectives: Atrial fibrillation (AF) is the most common cardiac arrhythmia, present in up to 14–20% of patients undergoing cardiac surgery, with the number of patients expected to double within the next decade. Despite a Class I recommendation for concomitant surgical ablation and a Class I-B recommendation for left atrial appendage (LAA) occlusion in patients with AF undergoing cardiac surgery (Class IIa for endoscopic or hybrid AF ablation), both procedures remain substantially underutilized in clinical practice. The design of the Mapping atrial fibrillation after Epicardial Surgical Ablation plus AtriClip to Guide Endocardial ablation (MESAGE) prospective study is presented. Materials and Methods: A narrative literature review was conducted using PubMed through March 2025. Randomized controlled trials, multicenter registries, meta-analyses and current clinical guidelines were prioritized. The MESAGE study protocol is presented in accordance with the SPIRIT recommendations. Results: Randomized evidence demonstrates that hybrid ablation achieves 32–48% greater arrhythmia freedom than catheter ablation (CA) alone in persistent and long-standing persistent AF, with comparable safety and significantly fewer interventions at two-year follow-up. Epicardial LAA occlusion with the AtriClip device achieves complete occlusion in all patients with an 87.5% relative reduction in ischemic stroke risk in anticoagulation-free follow-up. Continuous implantable loop recorder (ILR)-based monitoring reveals AF recurrence in substantially more patients than conventional monitoring, with AF burden emerging as a more meaningful endpoint than arrhythmia freedom. The MESAGE study enrolls 40 patients undergoing cardiac surgery who have pre-existing AF, pre-randomized 1:1 to pulmonary vein isolation (PVI) alone versus PVI-BOX, with mandatory pre-operative ILR implantation, intra-operative AtriClip LAA exclusion, and systematic Day-60 endocardial mapping and supplementary ablation using the Affera dual-energy system. Conclusions: Hybrid epicardial–endocardial ablation combined with LAA exclusion and continuous ILR monitoring represents a comprehensive, mechanistically rational and evidence-informed approach to AF management in patients undergoing cardiac surgery, although current evidence remains heterogeneous, and the benefits depend on the AF phenotype and monitoring strategy. The MESAGE pilot study will generate hypothesis-generating prospective comparative data on epicardial PVI versus PVI-BOX in the concomitant surgical setting, assessed through systematic post-surgical endocardial mapping and continuous rhythm monitoring. Full article

Background/Objectives: Persistent and long-standing persistent atrial fibrillation (AF) presents a therapeutic clinical challenge balancing complex rhythm management with a heightened stroke risk. The left atrial appendage (LAA) is the primary source of thromboembolisms in these patients. This study evaluated the safety and efficacy of combining LAA exclusion with Convergent Hybrid Ablation for stroke prevention and rhythm control in a refractory patient cohort. Methods: A single-center observational cohort study was conducted including 28 patients with symptomatic persistent or long-standing persistent AF. The cohort was highly refractory, with 82.1% having failed at least one endocardial catheter ablation. The hybrid procedure consisted of sub-xiphoid epicardial ablation, thoracoscopic LAA exclusion (AtriClip), and endocardial catheter ablation. Safety and efficacy were assessed at 3 months and 12 months. Results: LAA exclusion was successfully performed in 96.4% of patients. The peri-operative safety profile was acceptable, with zero procedure-related strokes or deaths. At the 12-month follow-up, the rate of stroke or any other major adverse events was at 0.0%. Freedom from AF was 75.0%, shown by a 12-lead electrocardiography (ECG). Freedom from any atrial arrhythmia off anti-arrhythmic drugs (AADs) was achieved in 50.0% of patients. A total of 32.1% of the cohort required catheter ablation within 12 months to maintain sinus rhythm as part of the hybrid treatment. Conclusions: Concomitant LAA exclusion during Convergent Hybrid Ablation is a safe procedure with a high clinical success rate in maintaining sinus rhythm in a highly complex AF patient group. While no thromboembolic events were observed at 12 months, larger studies with longer follow-up are needed to confirm the potential for long-term stroke risk reduction. The findings suggest that for many patients, the hybrid procedure should be viewed as part of a multi-step strategy often requiring endocardial “touch-up” ablation. Full article

Background: Visceral adipose tissue (VAT) and epicardial adipose tissue (EAT) are increasingly recognized as relevant contributors to cardiometabolic alterations and subclinical myocardial dysfunction, independently of overall obesity. Their pathogenic role extends beyond simple fat accumulation, encompassing inflammatory activation, lipotoxicity, and altered myocardial metabolism. Objective: This narrative review synthesizes current evidence on the relationships between VAT/EAT and myocardial strain parameters, with emphasis on subclinical cardiovascular risk detection and nutritional interventions. Methods: We conducted a comprehensive review of studies published between 2003–2025, focusing on imaging-based assessments of adipose tissue distribution and strain parameters using echocardiography, computed tomography, and cardiac magnetic resonance. Results: Increased EAT and, to a lesser extent, VAT showed significant associations with impaired global longitudinal strain (GLS) across imaging-based studies. In patients with type 2 diabetes, VAT mediated a substantial proportion of the association between insulin resistance and left ventricular dysfunction. Mediterranean diet adherence was associated with lower epicardial adipose tissue burden, while higher EAT was associated with persistent atrial fibrillation among patients with atrial fibrillation undergoing catheter ablation. Speckle-tracking echocardiography consistently showed superior prognostic value compared to ejection fraction for detecting subclinical dysfunction. Conclusions: VAT and EAT represent important mechanistic links between body composition and early myocardial dysfunction, identifiable through advanced strain imaging before clinical disease becomes apparent. These findings support the integration of multimodal cardiac imaging and nutritional interventions into cardiovascular prevention strategies, providing novel opportunities for early risk stratification and personalized treatment approaches. Full article

Background: Atrial fibrillation (AF) is a prevalent arrhythmia closely associated with cardiometabolic disorders and systemic inflammation. Epicardial adipose tissue (EAT), located in direct contact with the atrial myocardium, has emerged as a biologically active tissue involved in atrial remodeling through inflammatory, fibrotic, and electrophysiological mechanisms. The objective of this review is to summarize current translational and clinical evidence on the role of EAT in AF pathophysiology and to discuss its implications for diagnostic assessment, interventional management, and cardiometabolic therapeutic strategies. Methods: A narrative, structured review of experimental, translational, and clinical studies was conducted using major biomedical databases. The literature was evaluated with a focus on mechanisms linking EAT to atrial remodeling, noninvasive imaging techniques for EAT characterization, echocardiographic and electroanatomical markers of atrial disease, outcomes of catheter ablation strategies, and pharmacological interventions targeting metabolic and inflammatory pathways. Results: The available evidence indicates that increased EAT volume and altered inflammatory activity are associated with atrial fibrosis, conduction abnormalities, and impaired atrial function, contributing to AF initiation and persistence. Multimodality imaging, including cardiac computed tomography and cardiac magnetic resonance, enables quantitative and qualitative assessment of EAT and supports clinical phenotyping. Clinical studies report an association between higher EAT burden and increased AF recurrence after pulmonary vein isolation, particularly in patients with persistent AF. Emerging cardiometabolic therapies, such as glucagon-like peptide-1 receptor agonists and dual GIP/GLP-1 agonists, have been shown to reduce EAT volume and inflammatory markers, although direct evidence linking these interventions to improved AF outcomes remains limited. Conclusions: EAT represents a relevant pathophysiological interface between metabolic disease and AF with potential clinical implications. Incorporating EAT assessment into routine evaluation may enhance risk stratification and support personalized AF management. Further prospective studies are required to define its role as a therapeutic target in clinical practice. Full article

Background/Objectives: Accessing intramural or epicardial arrhythmogenic substrates is limited in endocardial ablation, and in these circumstances, epicardial ablation may overcome these limitations. Because epicardial access may be associated with severe complications, intentional distal coronary vein exit and carbon dioxide (CO₂) insufflation have emerged as techniques to facilitate safer access. Methods: We conducted a single-centre retrospective observational analysis of all patients who underwent epicardial ablation using the CO₂ insufflation technique between September 2021 and October 2024. Results: Among 21 patients selected for the procedure, successful pericardial access was achieved in 19 (90.5%). The main indication for ablation was ventricular tachycardia (14 patients, 66.7%), and 16 patients (76.2%) had previously undergone endocardial ablation for the same arrhythmia. Most patients had non-ischemic cardiomyopathy (17 patients, 81.0%). Three intra-procedural complications occurred: one (5.3%) was access-related, and two (10.5%) were ablation-related. Early post-procedural complications occurred in three patients (15.8%). Acute procedural success was achieved in 16 of 17 patients (94.1%) who underwent ablation. In-hospital mortality occurred in three cases (15.8%), including one procedure-related death (5.3%). Conclusions: Intentional coronary vein exit and CO₂ insufflation provide a safe and reproducible technique to obtain subxiphoid pericardial access for epicardial ablation. Full article

Background/Objectives: Surgical ablation for atrial fibrillation (AF) during cardiac surgery decreases perioperative morbidity and mortality and improves long-term patient outcomes. Because of these benefits, it has been designated a Class I surgical society recommendation. As surgical ablation techniques have evolved, so too have ablation tools such as radiofrequency and cryothermal devices. In this study, we evaluated real-world evidence (RWE) of concomitant surgical ablation featuring an epicardial left atrial encircling lesion created by a novel bipolar radiofrequency clamp. Methods: Thirteen centers in the observational Tracking Results of Ablation to Combat AF (TRAC-AF) Registry (NCT05111015) contributed data used in this analysis. Included patients had AF and received the epicardial encircling lesion during cardiac surgery. Additional ablation and follow-up were per institutional standard of care. Freedom from AF/atrial tachycardia (AT)/atrial flutter (AFL) and survival were evaluated using the Kaplan–Meier method. Safety was evaluated within 30 days of the procedure. Results: Among 327 patients, 70% were male with a median age of 69 years. Sixty-nine percent had paroxysmal AF. Median left atrial diameter was 4.1 cm, and CHA₂DS₂-VASc score was 3. Isolated coronary artery bypass graft and aortic valve surgery were performed in 51% and 11% of patients, respectively. One- and two-year survival rates were 95.3% (95% CI, 91.7–97.3%) and 88.1% (95% CI, 81.5–92.5%). Through 12- and 24-months freedom from AF/AT/AFL was 87.4% (95% CI, 81.3–91.6%) and 79.9% (95% CI 72.0–85.8%). Mortality within 30 days of the index procedure was 1.5%. No serious adverse events were related to the epicardial cardiac ablation procedure or device. Conclusions: RWE from the TRAC-AF Registry demonstrates surgical ablation including an epicardial left atrial encircling lesion made by a novel bipolar RF clamp was safe and resulted in favorable long-term rhythm outcomes. Full article

Catheter ablation (CA) has become a validated technique for treating patients with symptomatic or paroxysmal atrial fibrillation (AF), as recommended by the latest 2024 European society of cardiology (ESC) guidelines, class II level A. The procedure is also recommended for patients with persistent AF without major risk factors for AF recurrence, as an alternative to antiarrhythmic medications class I or III. However, CA carries the risk of AF recurrence in 30–35% of patients, sometimes after the procedure. Multiple factors impact the onset, maintenance, and recurrence of AF after CA, including clinical, biohumoral, echocardiographic, genetic, and lifestyle factors. Beyond traditional predictors, emerging factors such as obstructive sleep apnea syndrome, chronic renal failure, chronic lung disease, physical activity patterns, gut microbiota composition, and epicardial fat thickness significantly influence outcomes. Therefore, optimizing patient’s selection for CA is an important strategy to minimize the risk of AF recurrence. Many echocardiographic parameters emerged as predictors of AF recurrence post-CA, but none stood out as a potential single factor. These factors include traditional markers such as left atrial size by 2D echocardiography, LV ejection fraction, LV diastolic function parameters as well as myocardial deformation addressed by the recently developed speckle tracking analysis. Additionally, the duration and type of AF represent fundamental risk factors, with longstanding persistent AF showing significantly higher recurrence rates compared to paroxysmal forms. Novel biomarkers including MR-proANP, caspase-8, hsa-miR-206, and neurotrophin-3 show promise in enhancing risk prediction capabilities. The aim of this review is to explore the most relevant echocardiographic parameters, including myocardial deformation, that could accurately predict recurrence of AF after CA, while also examining the role of emerging clinical and biochemical predictors in comprehensive patient selection strategies. Full article

Background: Despite advances in ablation strategies, a substantial proportion of patients with atrial fibrillation (AF) experience arrhythmia recurrence, highlighting the need for improved preprocedural risk stratification. One of the emerging factors associated with arrhythmogenic remodeling is epicardial adipose tissue (EAT), particularly in the proximity of the left atrium (LA), due to its metabolic and inflammatory activity. Methods: This study investigated whether preprocedural assessment of EAT parameters on computed tomography (CT), including volume, mean attenuation, and attenuation dispersion, could predict AF recurrence following ablation. Seventy patients with AF underwent either pulsed field or cryoballoon ablation and were followed for 18 months. Results: Recurrence of AF occurred in 26 (37.1%) patients. Both higher LA-EAT attenuation (OR 1.09; 95% CI: 1.02–1.17) and greater total-EAT volume (OR 2.41; 95% CI: 1.16–4.99) were independently associated with arrhythmia recurrence. Subgroup analysis revealed that LA-EAT volume was highly predictive of recurrence in patients with persistent AF (AUC = 0.91), whereas LA-EAT attenuation demonstrated greater prognostic value in those with paroxysmal AF (AUC = 0.80). Conclusions: These findings suggest that quantitative evaluation of EAT using routine cardiac CT may enhance risk stratification before ablation. Full article

Ventricular arrhythmias (VAs) are common and clinically important complications in patients supported by left ventricular assist devices (LVADs), occurring in up to 50% of cases within the first year after implantation. Despite the hemodynamic support provided by LVADs, VAs are linked to increased morbidity and mortality, primarily through recurrent implantable cardioverter defibrillator (ICD) shocks and right ventricular failure. The underlying mechanisms of VAs in this population are multifactorial, involving structural myocardial remodeling, device-related factors, and pre-existing arrhythmic substrates. Catheter ablation has become a valuable treatment option when antiarrhythmic drug therapy and device reprogramming are inadequate, though procedural timing (pre-, intra-, or post-implantation) and approaches remain under discussion. Epicardial access during LVAD surgery may provide advantages for selected patients, while ablation after implantation poses technical challenges due to altered anatomy and electromagnetic interference. This review offers a comprehensive overview of the epidemiology, pathophysiology, risk stratification, and management of VAs in LVAD recipients, emphasizing technical considerations, procedural safety, and clinical outcomes of catheter ablation. A multidisciplinary approach remains essential in guiding personalized treatment and optimizing outcomes for this complex population. Undergoing studies will provide more insight into optimal management of arrhythmias, particularly regarding the optimal timing of catheter ablation. The impact of new technologies such as non-invasive mapping alongside pre-procedural imaging needs also to be further evaluated. Full article