Search Results (36)

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

(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

Background: The present study aims to investigate the influence of systematic radiological screening for silent vertebral fractures (VFs) on osteoporosis diagnosis, treatment decisions, and long-term clinical outcomes compared to standard care without routine screening in elderly patients hospitalised primarily for fractures requiring surgical treatment at sites other than the spine. Material/Methods: In a level 1 trauma centre, patients with fractures requiring surgical treatment after low-energy trauma were prospectively examined over a period of 12 months. Using radiographs of the thoracic and lumbar spine in two planes, previously unknown VFs were identified and categorised according to the classification for osteoporotic fractures (OFs) of the thoracolumbar spine. Results: A total of 106 patients with a mean age of 79.4 years participated in this study, and 112 previously unknown vertebral compression fractures were diagnosed in 57% (60/106) of the patients. In this group, lumbar vertebra 2 was the most frequently affected, and the majority of these VFs were classified as OF 2, which corresponds to an isolated endplate fracture with minimal involvement of the posterior wall. Furthermore, 26% (28/106) of the patients in the evaluation showed VFs at multiple levels. This study revealed no statistically significant difference in the prevalence of silent VFs between male and female patients (p = 0.055). Additionally, the analysis revealed that nearly 75% of patients exhibited vitamin D insufficiency. Conclusions: The high prevalence of silent VFs in elderly patients emphasises the necessity for systematic radiological investigations, irrespective of gender. Full article

Background: Pulsed field ablation [PFA] is a novel ablation technique for pulmonary vein isolation [PVI] in patients with paroxysmal and persistent atrial fibrillation. However, data for the efficacy and safety of PFA for left atrial substrate modification using a single shot PFA system, in patients with long-standing persistent atrial fibrillation [AF] and left atrial macro- as well as micro-reentrant atrial tachycardia [LAMRT], are scarce. Here, we provide a small, single-center case series regarding the efficacy and safety of left atrial substrate modification using a single-shot PFA system. Methods: Nine patients with long-standing persistent AF and LAMRT underwent redo-PVI and left atrial substrate modification using a single-shot PFA system. Patients were subsequently followed up for 1 year. Results: The median age was 64 years [IQR 55.5–75], with 44% of the participants being female. The median time since the first diagnosis of AF was 7 years [IQR 4–15.5]. After re-PVI, posterior wall isolation was performed in five patients, roof isolation in six patients, and anterior wall ablation between the superior mitral annulus and the right superior pulmonary vein [RSPV] in five patients. In two patients, cavotricuspid isthmus ablation was additionally performed to treat typical atrial flutter. The acute procedural success rate was 100%, with all LAMRTs and typical flutters successfully terminating by ablation. At 1-year follow-up, four patients [44%] experienced a recurrence of any atrial arrhythmia. Median time to recurrence was 164 days [138–212.8]. Importantly, no acute or chronic complications were observed. Conclusions: In this small, single-center case series, left atrial substrate modification for long-standing persistent AF and AT using a single-shot PFA system was safe and showed an excellent acute success rate. Full article

Atrial fibrillation is the most common sustained cardiac arrhythmia with a significant impact on quality of life in terms of symptoms and reduction of functional status. Also, it is associated with an increased risk of mortality, stroke, and peripheral embolism. Catheter ablation for atrial fibrillation has become a well-established treatment, improving arrhythmia outcomes without increasing the risk of serious adverse events compared to antiarrhythmic drug therapy. The field has undergone significant advancements in recent years, yet pulmonary vein isolation continues to be the cornerstone of any atrial fibrillation ablation procedure. The purpose of this review is to provide an overview of the current techniques, emerging technologies, and future directions. Full article

Background/Objectives: Isolated defects of the posterior hypopharyngeal/upper esophageal wall are rare, typically arising after cancer resection or complications following cervical spine osteosynthesis. Various local and free flaps are available for reconstruction, but we opted for a double-island anterolateral thigh (ALT) flap in this case. Methods: A scoping review was conducted (June 2024) following PRISMAScR 2018 guidelines in order to examine the coverage options available in the literature for posterior hypopharyngeal/upper esophagus wall defects while also presenting a case where such a defect was covered with a double-island anterolateral thigh (ALT) flap. Eligibility criteria: Human studies describing defect coverage of the posterior hypopharyngeal/upper esophagus wall were included. Sources of evidence: A literature search was conducted in PubMed, Cochrane Library, and Google Scholar, following PRISMAScR guidelines. Charting methods: Data on surgical techniques, outcomes, and complications were extracted and analyzed by two independent reviewers. Case report: A 57-year-old female developed a chronic posterior wall perforation following Zenker’s diverticulum treatment and C5/6 cage osteosynthesis. Reconstruction was performed using a free fasciocutaneous ALT flap with two skin paddles: one (2 × 2 cm) for the esophageal mucosa and an additional vascularized fascia layer (4 × 8 cm) to separate the cage from the hypopharyngeal defect. To enable flap monitoring in the otherwise hidden defect, a second skin island was externalized cervically. Results: Postoperative recovery was uneventful, with a continuous viable flap signal. A Gastrografin swallow test confirmed an intact esophagus without leaks or dehiscences. Oral intake resumed after 10 days. The literature review highlighted 239 cases with multiple reconstructive techniques, each with advantages and limitations. Conclusions: The double-paddle free fasciocutaneous ALT flap is a viable option for posterior hypopharyngeal/upper esophageal wall reconstruction, allowing effective postoperative monitoring. This approach offers a valuable modification for complex cases requiring enhanced structural integrity and flap assessment. Full article

Background and Aims: Various pulsed field ablation (PFA) systems are currently being developed. Recently, a novel CE-approved circular array PFA catheter (PulseSelect™ PFA System, Medtronic, Minneapolis, MN, USA) was introduced. Data on this commercially available system are sparse. The aim was to elucidate real-world data assessing the feasibility, safety, and acute efficacy of pulmonary vein isolation (PVI) and ablation beyond PVI with this novel ablation system. Methods: Consecutive patients with paroxysmal and persistent atrial fibrillation (AF) undergoing first-time ablation with the circular PFA catheter were enrolled in this study. In patients with persistent AF and left atrial (LA) enlargement (LA area > 20 cm²), additional left atrial roof ablation (LARA) was performed. Those with concomitant typical atrial flutter received adjunctive cavo-tricuspid isthmus (CTI) ablation. Results: A total of 100 AF patients were included (29% female, 50% persistent AF). Of these, 33 patients (33%) underwent adjunctive LARA, 1 patient (1%) received posterior wall isolation, and 6 patients (6%) required additional CTI ablation. The skin-to-skin procedural time averaged 66.3 ± 13.8 min, while the fluoroscopy time and dose area product were 13.7 ± 4.7 min and 6.8 ± 4.9 Gycm², respectively. Acute PVI was achieved in 100% of pulmonary veins. A bidirectional conduction block of the LARA and CTI lines was confirmed in all patients, and no major adverse events were reported. Conclusions: These real-world data demonstrate the feasibility, safety, and acute efficacy of PVI and ablation beyond PVI using a novel circular array PFA catheter in patients with atrial fibrillation and flutter. The system can easily be integrated with standard PVI workflows. Further and larger studies are warranted to assess the clinical long-term effectiveness and safety of this PFA system. Full article

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p < 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p > 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3–97.3] and 82.8% [95% CI, 68.1–97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications. Full article

Background: Pulmonary vein isolation (PVI) is a foundational treatment for persistent atrial fibrillation (PeAF), but the effectiveness of adding posterior wall isolation (PWI) and selective complex fractionated atrial electrogram (CFAE) ablation in the roof and anterior wall remains debated. The potential of these additional ablation techniques to improve long-term outcomes for PeAF patients is still uncertain. Methods: This retrospective study included 151 PeAF patients who underwent first-time catheter ablation at our center. The choice of ablation strategy was based on the operator’s clinical judgment, taking into account the patient’s specific condition and anatomical features. Patients were divided into two groups: the PVI group, which received PVI alone, and the modified PWI (MPWI) group, which received PVI along with additional PWI and selective CFAEs ablation in the roof and anterior wall. The primary endpoint was the absence of atrial arrhythmia lasting more than 30 s, without antiarrhythmic drugs, at 12 months. Results: At the 12-month follow-up, 77.3% of the patients in the MPWI group and 52.1% of the patients in the PVI group remained in sinus rhythm without an atrial arrhythmia recurrence (p = 0.001). The BIC-based Cox regression analysis identified the ablation strategy and atrial fibrillation (AF) duration as independent predictors of recurrence across the cohort. It was found that MPWI significantly reduced the risk of recurrence, while a longer AF duration increased it. In the MPWI group, AF duration, left ventricular internal diameter in systole (LVIDs), and moderate or greater tricuspid regurgitation were independent predictors of recurrence. In the PVI group, only the left atrial low voltage area (LVA) index was a significant predictor. Conclusion: The addition of PWI and selective CFAE ablation to PVI significantly improves 12-month arrhythmia-free survival compared to PVI alone, demonstrating the superiority of this combined approach in improving long-term outcomes for patients with persistent AF. Full article

Background: The TactiFlex™ ablation catheter, Sensor Enabled™ (Abbott, Minneapolis, MN, USA), is an open-irrigation radiofrequency (RF) ablation catheter with flexible tip technology. This catheter delivers high-power short-duration (HPSD) RF ablations and has been adopted for atrial fibrillation (AF) ablation. HPSD is well-established not only in pulmonary vein isolation (PVI) but also when targeting extra-pulmonary vein (PV) targets. This study aims to determine the safety, effectiveness, and acute outcomes of PVI plus posterior wall isolation (PWI) in patients with persistent atrial fibrillation (Pe-AF) using HPSD and the TactiFlex™ ablation catheter. Methods: Consecutive patients who underwent the ablation of Pe-AF in our centre between February 2023 and February 2024 were prospectively enrolled in the study. All patients underwent PVI plus PWI using TactiFlex™ and the HPSD strategy. The RF parameters were 50 W on all the PV segments and the roof, and within the posterior wall (PW). Left atrial mapping was performed with the EnSite X mapping system and the high-density multipolar Advisor HD Grid, Sensor Enabled™ mapping catheter. We compared the procedural data using HPSD with TactiFlex™ (n = 52) vs. a historical cohort of patients who underwent PVI plus PWI using HPSD settings and the TactiCath ablation catheter (n = 84). Results: Fifty-two consecutive patients were included in the study. PVI and PWI were achieved in all patients in the TactiFlex™ group. First-pass PVI was achieved in 97.9% of PVs (n = 195/199). PWI was obtained in all cases by delivering extensive RF lesions within the PW. There were no significant differences compared to the TactiCath group: first-pass PVI was achieved in 96.3% of PVs (n = 319/331). Adenosine administration revealed PV reconnection in 5.7% of patients, and two reconnections of the PW were documented. Procedure and RF time were significantly shorter in the TactiFlex™ group compared to the TactiCath group, 73.1 ± 12.6 vs. 98.5 ± 16.3 min, and 11.3 ± 1.5 vs. 23.5 ± 3.6 min, respectively, p < 0.001. The fluoroscopy time was comparable between both groups. No intraprocedural and periprocedural complications related to the ablation catheter were observed. Patients had an implantable loop recorder before discharge. At the 6-month follow-up, 76.8% of patients remained free from atrial arrhythmia, with no significant differences between groups. Conclusions: HPSD PVI plus PWI using the TactiFlex™ ablation catheter is effective and safe. Compared to a control group, the use of TactiFlex™ to perform HPSD PVI plus PWI is associated with a similar effectiveness but with a significantly shorter procedural and RF time. Full article

Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions. Full article

Background: POP (pelvic organ prolapse) involves the descent of one or more pelvic organs downwards with or without protrusion from the vaginal opening, caused by the relaxation and weakening of ligaments, connective tissue, and pelvic muscles. Such an outcome negatively impacts the quality of life. The gold standard procedure for repairing apical compartment prolapse is colposacropexy (CS) to secure the anterior and posterior walls of the vagina to the anterior longitudinal sacral ligament, located anteriorly to the sacral promontory, using a mesh. Several surgical approaches are feasible. Laparotomic or minimally invasive methods, including laparoscopic or robotic ones, can restore the horizontal axis of the vagina and typically involve concomitant hysterectomy. Methods: This study is based on 80 patients who underwent CS at Palermo’s Ospedali Riuniti Villa Sofia-Cervello from 2019 to 2023. Women aged 35–85 at the time of surgery were divided into two groups: 40 patients underwent mini-laparoscopic surgery, and 40 patients underwent robotic surgery. The following parameters were accounted for: demographic data (initials of name and surname, age), preoperative clinical diagnosis, date of surgery, surgical procedure performed, estimated intraoperative blood loss, duration of surgical intervention, length of hospital stay, postoperative pain assessed at 24 h using the VAS scale, and any complications occurring in the postoperative period. Mini-laparoscopic CS (Minilap) and robotic CS (Rob) were then compared in terms of outcomes. Results: In the Minilap group, 11 patients out of 40 had a preoperative diagnosis of vaginal vault prolapse. The average age in this group was 61.6. Five of these patients had isolated cystocele, while the rest presented vaginal stump prolapse linked to cystocele, rectocele, or both. The remaining 29 patients in the Minilap group had a preoperative diagnosis of uterovaginal prolapse, also associated with cystocele, rectocele, or both, or isolated in nine cases. In the Rob group (average age: 60.1), 13 patients were diagnosed with vaginal prolapse (isolated or associated with cystocele), while the remaining 27 had a diagnosis of uterovaginal prolapse. In the Minilap group, the average procedure duration was 123.3 min, shorter than the Rob group (160.1 min). Conclusions: The data collected throughout this prospective study point to the mini-laparoscopic approach as being preferable over the robotic one in terms of surgical procedure length, intraoperative blood loss, postoperative pain, and aesthetic outcome. Hospital stay duration and post operative complication rates were similar for both groups. The innovative and ever-progressing nature of such procedures calls for novel standards prioritizing patient care as well as medicolegal viability. Full article

Background: Pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) is a standard-of-care treatment in the rhythm control strategy of symptomatic atrial fibrillation (AF). Ablation protocols, varying in the power and duration of energy delivery, have changed rapidly in recent years. Very high-power very short-duration ablation (vHPvSD) is expected to shorten procedural times compared to conventional ablation approaches. However, the existing data suggest that this might come at the cost of lower first-pass isolation rates, a predictor of poor ablation long-term outcomes. This study aims to compare a vHPvSD protocol to a hybrid strategy, in which the power and duration of the energy transfer are adapted depending on the anatomical location. Methods: We retrospectively analyzed procedural and outcome data from 93 patients (55 vHPvSD vs. 38 hybrid) scheduled for de novo pulmonary vein isolation. A vHPvSD ablation protocol (90 Watt (W), 4 s) was compared to a hybrid protocol using vHPvSD on the posterior wall and 50 W HPSD (high-power short-duration) ablation guided by the Ablation Index along the remaining spots. Results: Ablation times were significantly shorter in the vHPvSD cohort (5.4 min. vs. 14.2 min, p < 0.001), thus resulting in a significant reduction in the overall procedural duration (91 min vs. 106 min, p = 0.003). The non-significant slightly higher first-pass isolation rates in the vHPvSD cohort (85% vs. 76%, p = 0.262) did not affect freedom from AF 6 months after the procedure (83% vs. 87%, p = 0.622). Conclusions: vHPvSD helps in shortening the PVI procedural duration, thus neither affecting first-pass isolation rates nor freedom from atrial tachyarrhythmia recurrence at 6 months after the index procedure. Full article

Study Design: Retrospective cohort study. Objective: Frontal sinus fractures (FSFs) can lead to a range of clinical challenges, including facial deformity, impaired facial sensation, cerebrospinal fluid (CSF) leakage, sinus drainage impairment, chronic sinus pain and mucocele formation. The optimal management approach, whether surgical or conservative, remains a topic of ongoing discussion. The aim of this study was to evaluate and compare the functional and esthetic outcomes of patients with surgically and conservatively treated FSFs. Methods: In this retrospective study, patients treated for FSFs at the Karolinska university hospital 2004 to 2020 were identified in hospital records and invited to participate in a long-term follow-up. Sequelae and satisfaction with the esthetic result were assessed trough questionnaires and physical examinations. Results: A total of 93 patients were included in the study, with 49 presenting isolated anterior wall fractures and 44 presenting combined anterior and posterior wall fractures. Surgical intervention was performed in 45 cases, while 48 were managed conservatively. Among patients with moderate anterior wall fractures (4–6 mm dislocation), 80% of surgically treated patients compared to 100% of conservatively treated patients expressed satisfactionwith their cosmetic outcomes at follow-up (p = 0.03). In conservatively treated patients with a forehead impression, the anterior wall fracture dislocation ranged from 5.3 to 6.0 mm (p < 0.0001). Approximately 50% of surgically treated patients vs 15% of conservatively treated patients developed impaired forehead sensation at follow-up (p = 0.03). Thirty-six percent of surgically treated patients reported dissatisfaction with surgery-related scarring, particularly those who underwent surgery via laceration or bicoronal incision. Conclusions: This study suggests that anterior FSFs with a dislocation of 5 mm or less can be effectively managed conservatively with high patient satisfaction, low risk of long-term forehead sensation impairment and without potential development of forehead impression. Bicoronal incision or incision via a laceration may be associated with esthetic dissatisfaction and late sequelae such as alopecia. Full article

Background and Objectives: The combination of aortic valve stenosis (AS) and ischemic heart disease (IHD) is quite common and is associated with myocardial fibrosis (MF). The purpose of this study was to evaluate the association between the histologically verified left ventricular (LV) MF and its geometry and function in isolated AS and AS within IHD groups. Materials and Methods: In a single-center, prospective trial, 116 patients underwent aortic valve replacement (AVR) with/without concomitant surgery. The study population was divided into groups of isolated AS with/without IHD. Echocardiography was used, and LV measurements and aortic valve parameters were obtained from all patients. Myocardial tissue was procured from all study patients undergoing elective surgery. Results: There were no statistical differences between isolated AS and AS+IHD groups in LV parameters or systolic and diastolic functions during the study periods. The collagen volume fraction was significantly different between the isolated AS and AS+IHD groups and was 7.3 ± 5.6 and 8.3 ± 6.4, respectively. Correlations between MF and left ventricular end-diastolic diameter (LVEDD) (r = 0.59, p = < 0.001), left ventricular mass (LVM) (r = 0.42, p = 0.011), left ventricular ejection fraction (LVEF) (r = −0.67, p < 0.001) and an efficient orifice area (EOA) (r = 0.371, p = 0.028) were detected in isolated AS during the preoperative period; the same was observed for LVEDD (r = 0.45, p = 0.002), LVM (r = 0.36, p = 0.026), LVEF (r = −0.35, p = 0.026) and aortic annulus (r = 0.43, p = 0.018) in the early postoperative period; and LVEDD (r = 0.35, p ≤ 0.05), LVM (r = 0.43, p = 0.007) and EOA (r = 0.496, p = 0.003) in the follow-up period. In the group of AS and IHD, correlations were found only with LV posterior wall thickness (r = 0.322, p = 0.022) in the follow-up period. Conclusions: Histological MF in AS was correlated with LVM and LVEDD in all study periods. No correlations between MF and LV parameters were found in aortic stenosis in the ischemic heart disease group across all study periods. Full article