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Atrial fibrillation (AF) is one of the most prevalent cardiac arrhythmias in the world. Patients with AF also suffer from heart failure (HF). The relationship between AF and HF is often considered bidirectional and both share very similar risk factors. The mechanism of AF-induced cardiomyopathy lies in 3 distinct components: tachycardia-related cardiac dysfunction, heart rhythm irregularity, and AF-induced atrial myopathy. These components are mediated by calcium mishandling, neurohormonal activation, oxidative stress, myocardial supply-demand mismatch, and irreversible fibrosis and remodeling. Managing AF-induced cardiomyopathy should focus on early rhythm control to mitigate the development of irreversible remodeling and atrial myopathy., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Biosense Webster, Stereoataxis and Rhythm Management, and has received speaker honoraria/travel from Biosense Webster, St. Jude Medical (now Abbott), Boston Scientific, Medtronic, Biotronik, Atricure, Baylis, and Zoll. The other authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

The left atrial appendage (LAA) is now recognized as a significant contributor to arrhythmia and thromboembolism in patients with a history of atrial fibrillation. Thoracoscopic exclusion of the LAA is made possible with the AtriClip device. In this report, we describe the case of a 65-year-old man with history of multiple left atrial ablation procedures and LAA clipping. He developed a microreentrant atrial tachycardia originating from the anterior base of the LAA stump, underwent complete isolation of the LAA, and had subsequent resolution of arrhythmogenic activity from the residual LAA stump., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Prolonged use of fluoroscopy during catheter ablation (CA) of arrhythmias is associated with a significant exposure to ionizing radiation and risk of orthopedic injuries given the need for heavy protective equipment. CA of ventricular arrhythmias (VAs) arising from the left ventricular (LV) summit is challenging, requiring a vast knowledge of the intricate cardiac anatomy of this area and careful imaging delineation of the different anatomical structures, which is frequently performed using fluoroscopic guidance. Certain techniques, including pericardial mapping and ablation, use of intracoronary wires, and mapping and ablation inside the coronary venous system have been proposed, further prolonging fluoroscopy time. Fluoroless CA procedures are feasible with currently available technology and appear to have similar safety and efficacy outcomes compared with conventional techniques. To successfully perform fluoroless CA of LV summit arrhythmias, it is important to be fully acquainted with intracardiac echocardiography (ICE) imaging and electroanatomic mapping (EAM). We will describe our approach to perform fluoroless CA in LV summit VAs., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, Abbott Medical, and has received speaker honoraria/travel from Medtronic, Atricure, Bristol Meyers Squibb, Pfizer, and Biotronik. Dr A. Natale is a consultant for Biosense Webster, Stereotaxis, Abbott, and has received speaker honoraria/travel from Medtronic, Atricure, Biotronik, and Janssen. The remaining authors report no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Idiopathic ventricular arrhythmias (VA), particularly left ventricular outflow tract (LVOT) VA accounts for up to 10% of all VAs referred for ablative therapy. In addition to being infrequent, its intricate anatomy and its pathophysiology make catheter ablation (CA) of these arrhythmias a challenge even for experts. In this scenario, detailed right ventricular outflow tract as well as LVOT electroanatomic mapping including epicardial mapping are essential. In this article, we will emphasize our approach toward the CA technique used for LVOT VA, particularly IVS and/or LVS VA originating from intramural foci, along with its acute and long-term efficacy and safety., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, Abbott Medical and has received speaker honoraria/travel from Medtronic, Atricure, Bristol Meyers Squibb, Pfizer, and Biotronik. Dr A. Natale is a consultant for Biosense Webster, Stereotaxis, Abbott and has received speaker honoraria/travel from Medtronic, Atricure, Biotronik, and Janssen. The remaining authors report no conflict of interest., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Numerous systemic manifestations, including cardiac involvement in the form of myocardial infarction, myocarditis, and electrocardiographic changes, have been associated with COVID-19..In this review, the authors describe the electrocardiographic features that have been reported to date in patients affected by this disease and their possible underlying mechanisms., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, and Abbott Medical and has received speaker honoraria/travel support from Medtronic, Atricure, Bristol Meyers Squibb, Pfizer, and Biotronik. Dr A. Natale is a consultant for Biosense Webster, Stereotaxis, and Abbott and has received speaker honoraria/travel support from Medtronic, Atricure, Biotronik, and Janssen. Remaining authors report no conflict of interest., (Copyright © 2021 Elsevier Inc. All rights reserved.)

We review the current data on epidemiology, the clinical significance, the pathophysiologic mechanisms, and the treatment of VAs in the setting of COVID-19. VAs prevail in 0.15% to 8% of hospitalized patients, but only sustained and rapid tachyarrhythmias are purportedly associated with a significant increase in mortality. Multiple factors can elicit VAs, which are ultimately deemed to be a marker of severe systemic disease rather than a distinct cardiac condition. Even though the electrophysiologist plays a determinant role in the secondary prevention of VAs, a multidisciplinary approach is indispensable for primary prophylaxis and acute management., Competing Interests: Disclosure Dr A. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. Dr L. Di Biase is a consultant for Biosense Webster, RMG, Stereotaxis, Boston Scientific, and Abbott. Dr L. Di Biase received speaker honoraria/travel from Medtronic, Atricure, and Biotronik. All other authors have reported that they have no relationships relevant to the contents of this article to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

COVID-19 mainly affects the respiratory system but has been correlated with cardiovascular manifestations such as myocarditis, heart failure, acute coronary syndromes, and arrhythmias. Cardiac arrhythmias are the second most frequent complication affecting about 30% of patients. Several mechanisms may lead to an increased risk of cardiac arrhythmias during COVID-19 infection, ranging from direct myocardial damage to extracardiac involvement. The aim of this review is to describe the role of COVID-19 in the pathogenesis of cardiac arrhythmias and provide a comprehensive guidance for their monitoring and management., Competing Interests: Disclosure Dr J.D. Burkhardt is a consultant for Biosense Webster and Stereotaxis. Dr L. Di Biase is a consultant for Biosense Webster, Boston Scientific, Stereotaxis, and St. Jude Medical; and has received speaker honoraria from Medtronic, Atricure, EPiEP, and Biotronik. Dr A. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this article to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Intracardiac echocardiography (ICE) is a valuable tool and should be standard of care in any modern electrophysiology laboratory. Through real-time imaging of cardiac anatomy, ICE is used to guide electrophysiology procedures and monitor for complications. This article is a short overview of the application of real-time ICE imaging during atrial fibrillation ablation procedures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Accessory pathways are abnormal electrical conductions between the atrial and ventricular myocardium, bypassing the atrioventricular node and as such are an important substrate for arrhythmias. Ablation is a curative treatment and should always be offered to symptomatic patients and asymptomatic patients with high risk professions. Adequate knowledge and understanding of different mapping and ablation techniques is pivotal to achieve successful outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The percutaneous epicardial approach has become an adjunctive tool for electrophysiologists to treat disparate cardiac arrhythmias, including accessory pathways, atrial tachycardia, and particularly ventricular tachycardia. This novel technique prompted a strong impulse to perform epicardial access as an alternative strategy for pacing and defibrillation, left atrial appendage exclusion, heart failure with preserved ejection fraction, and genetically engineered tissue delivery. However, because of the incremental risk of major complications compared with stand-alone endocardial ablation, it is still practiced in a limited number of highly experienced centers across the world., Competing Interests: Conflicts of interest Dr J.D. Burkhardt is a consultant for Biosense Webster and Stereotaxis. Dr A. Natale has received speaker honoraria from Boston Scientific, Biosense Webster, St. Jude Medical, Biotronik, and Medtronic; and is a consultant for Biosense Webster, St. Jude Medical, and Janssen. All other authors have reported that they have no relationships relevant to the contents of this article to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Fluoroscopy continues to be considered an indispensable part of atrial fibrillation (AF) ablation worldwide. Deleterious effects of radiation exposure to patients, physicians, and catheter laboratory personnel are gaining increased consideration. Safety and efficacy of a fluoroless approach for AF ablation is comparable with outcomes achieved with fluoroscopy use. This article focuses on AF ablation with zero fluoroscopy use as well as current evidence on efficacy and safety of this technique. In contrast, minimal fluoroscopy is an alternative. Relying on intracardiac echocardiography for transseptal access and electroanatomic mapping for catheter manipulation can help implement this approach on a wider scale., Competing Interests: Disclosure The authors have no disclosures related to this article., (Copyright © 2020 Elsevier Inc. All rights reserved.)

When patients have symptomatic recurrent atrial tachyarrhythmias after 2 months following pulmonary vein antral isolation, a repeat ablation should be considered. Patients might present with isolated pulmonary veins posterior wall. In these patients, posterior wall isolation is extended, and non-pulmonary vein triggers are actively sought and ablated. Moreover, in those with non-paroxysmal atrial fibrillation or a known higher prevalence of non-pulmonary vein triggers, empirical isolation of the superior vena cava, coronary sinus, and/or left atrial appendage might be performed. In this review, we will focus on ablation of non-pulmonary vein triggers, summarizing our current approach for their mapping and ablation., Competing Interests: Disclosure No relevant conflicts of interest to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The optimal ablation strategy for non-paroxysmal atrial fibrillation remains controversial. Non-PV triggers have been shown to have a major arrhythmogenic role in these patients. Common sources of non-PV triggers are: posterior wall, left atrial appendage, superior vena cava, coronary sinus, vein of Marshall, interatrial septum, crista terminalis/Eustachian ridge, and mitral and tricuspid valve annuli. These sites are targeted empirically in selected cases or if significant ectopy is noted (with or without a drug challenge), to improve outcomes in patients with non-paroxysmal atrial fibrillation. This article focuses on summarizing the current evidence and the approach to mapping and ablation of these frequent non-PV trigger sites., Competing Interests: Disclosure Dr L. Di Biase is a consultant for Stereotaxis, Biosense Webster, Boston Scientific, and Abbott Medical; and received speaker honoraria/travel support from Medtronic, Pfizer, Bristol Meyers Squibb, and Biotronik. The other authors have no disclosures., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Left atrial appendage (LAA) is the dominant source of systemic thromboembolic (TE) events in patients with nonvalvular atrial fibrillation (AF). In patients with significant bleeding risk, various LAA exclusion strategies have been developed as an alternative to pharmacologic TE prophylaxis. Nevertheless, in a relatively small percentage of patients, incomplete LAA closure can be documented, either at the time of procedure or during follow-up. This persistent patency can potentially jeopardize an effective stroke prophylaxis. Hereby, we report an update on the current clinical implications of LAA leaks and how to manage them., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Atrial fibrillation catheter ablation has emerged as the most effective strategy to restore and maintain sinus rhythm. The cornerstone of atrial fibrillation ablation is elimination of triggers from the pulmonary veins by pulmonary vein isolation. Nevertheless, some patients may experience atrial tachyarrhythmia recurrences even with permanent pulmonary vein antral isolation. Whether and in which patients pulmonary vein antral isolation should be considered as the only ablation strategy remains a matter of debate. This review aims to summarize the rationale and effectiveness of different ablation approaches and identify key points for a uniform atrial fibrillation ablation strategy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Owing to the rapid development of new electrophysiologic techniques, our understanding of arrhythmias and their underlying mechanisms has reached unprecedented levels. In some cases, baseline ECG alterations can be identified before arrhythmia development; early recognition of these alterations is of utmost importance to start appropriate preventive therapies and stratify the risk according to patients' outcomes. Hereby, we report a systematic revision of main baseline ECG abnormalities and their implications on clinical outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The surface ECG is a valuable mapping tool in patients with idiopathic and scar-related ventricular arrhythmias (VAs). A detailed analysis of 12-lead ECG can provide useful information in localizing the VA site of origin. This might help tailoring the ablation strategy to optimize procedural duration, increase the probability of success, and prevent complications. The aim of this article is to review the ECG features of both idiopathic and scar-related VAs and discuss their potential implications for optimizing the ablation strategy., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Leadless pacemaker therapy is a new technology that aims at avoiding lead- and pocket-related complications of conventional transvenous and epicardial pacing. To date, 2 self-contained leadless pacemakers for right ventricular pacing have been clinically available: the Nanostim Leadless Pacemaker System and the Micra Transcatheter Pacing System. Additionally, a new multicomponent leadless pacemaker for endocardial left ventricular pacing has been proposed as an alternative choice for cardiac resynchronization therapy. In this review, we describe the state of the art of leadless pacing and compare the currently available devices with traditional transvenous leadless pacemakers., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The atrioventricular junction has a central role in electrophysiology, responsible for reentrant and automatic forms of supraventricular tachycardia. During atrioventricular nodal reentry tachycardia, the circuit involves 2 electrophysiologically separate pathways located in the vicinity of the atrioventricular node. Atrioventricular reentry tachycardia is caused by the presence of an accessory pathway located almost anywhere along the atrioventricular groove; the macroreentrant circuit involves the atrioventricular node, the accessory pathway and necessarily portions of atria and ventricles. Junctional tachycardia is a rare form of nonparoxysmal supraventricular tachycardia, secondary to enhanced automaticity or triggered activity. By analyzing a 12-lead electrocardiogram during sinus rhythm and tachycardia, it is possible to accurately diagnose the specific type of supraventricular tachycardia., (Copyright © 2017 Elsevier Inc. All rights reserved.)

The atrioventricular junction is a pivotal component of the cardiac conduction system, a key electrical relay site between the atria and the ventricles. The sophisticated functions carried out by the atrioventricular junction are possible for the presence of a complex apparatus made of specialized anatomic structures, cells with specific ion-channel expression, a well-organized spatial distribution of intercellular junctions (connexins), cells with intrinsic automatism, and a rich autonomic innervation. This article reviews the main anatomic and electrophysiologic features of the atrioventricular junction, with a focus on cardiac preexcitation., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Ventricular arrhythmias are a frequent cause of mortality in patients with ischemic cardiomyopathy and nonischemic cardiomyopathy. Scar-related reentry represents the most common arrhythmia substrate in patients with recurrent episodes of sustained ventricular tachycardia (VT). Initial mapping of scar-related VT circuits is focused on identifying arrhythmogenic tissue. The substrate-based strategies include targeting late potentials, scar dechanneling, local abnormal ventricular activities, core isolation, and homogenization of the scar. Even though substrate-based strategies for VT ablation have shown promising outcomes for patients with structural heart disease related to ischemic cardiomyopathy, the data are scarce for patients with nonischemic substrates., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Ventricular tachycardia (VT) ablation is usually performed with an ablation catheter that delivers unipolar radiofrequency (RF) energy to eliminate the re-entry circuit responsible for VT. However, there are some instances when unipolar RF ablation fails, notably in VTs with a deep intramural origin, or cases in which epicardial access is not attainable due to prior cardiac surgery. To overcome these limitations, several alternative approaches have been used in clinical practice, including alcohol ablation or coil embolization, simultaneous unipolar or bipolar RF ablation, surgical ablation, or noninvasive ablation with stereotactic radiosurgery. This review article describes some of these alternative techniques., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Although cardiac resynchronization therapy (CRT) is an important treatment of symptomatic heart failure patients in sinus rhythm with low left ventricular ejection fraction and ventricular dyssynchrony, its role is not well defined in patients with atrial fibrillation (AF). CRT is not as effective in patients with AF because of inadequate biventricular capture and loss of atrioventricular synchrony. Both can be addressed with catheter ablation of AF. It is still unclear if these therapies offer additive benefits in patients with ventricular dyssynchrony. This article discusses the role and techniques of catheter ablation of AF in patients with heart failure, and its application in CRT recipients., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Transcatheter treatment of atrial fibrillation (AF) is a complex intervention performed in patients who are at inherently increased risk of a thromboembolic complication, including stroke. It is therefore not surprising that cerebrovascular accidents have been among the most feared complications since the inception of AF ablation. While improvements have been made to limit the incidence of thromboembolic events during catheter ablation of AF, the optimal strategy to minimize such complications has yet to be determined. It is hoped that larger trials using periprocedural anticoagulation strategies can be undertaken to definitively address these important concerns., (Copyright © 2014 Elsevier Inc. All rights reserved.)

This article reviews the role of cardiac imaging in stroke prevention, defining how imaging tools can be useful in this field. Cardioembolic sources during atrial fibrillation are discussed. New closure devices can be implanted in the left atrial appendage and routinely monitored with imaging modalities. Acute and chronic left ventricular dysfunction is reviewed, identifying the possible mechanism of thrombus formation and its early detection. Valvular evaluation of native heart disease and possible implications for stroke risk are defined., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Sosa and colleagues first described a percutaneous approach (via the subxiphoid area) to access the pericardial space in 1996. Epicardial mapping and ablation is increasingly used for the treatment of supraventricular and ventricular arrhythmias and represents an adjunctive approach for challenging arrhythmias to improve procedural success rates. Epicardial ablation should be considered not only after the failure of an endocardial ablation but often as a first-line approach. Complications may occur during percutaneous access and epicardial ablation, and these might be reduced or avoided by improved operator skills and experience. New tools to access the epicardial space are being evaluated., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This article addresses the use of catheter ablation (CA) as first-line therapy for atrial fibrillation (AF). CA increases long-term freedom from AF, reduces hospitalizations, and improves quality of life compared with antiarrhythmic drug (AAD) therapy in patients with symptomatic AF who have already failed one AAD. The role of CA as first-line therapy for AF, however, is still controversial. Evidence from randomized controlled trials shows that CA is definitely superior to AADs as first-line therapy for relatively young patients with paroxysmal AF, with comparable complication rates and results consistently reproducible across different institutions, operators, and types of ablation approaches., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Permanent pulmonary vein isolation constitutes the main procedural goal of current approaches to atrial fibrillation (AF) catheter ablation, with established effectiveness as a stand-alone procedure in most patients with paroxysmal AF. In patients with AF of longer duration, however, the definition of the optimal procedural end point is still controversial. Based on analysis of data from 16 studies that have assessed the value of AF termination in predicting long-term procedural success, it is concluded that AF termination clearly represents an unreliable procedural end point during ablation of nonparoxysmal AF., (Copyright © 2012 Elsevier Inc. All rights reserved.)

This article reviews the published evidence on stroke prevention with percutaneous closure of the left atrial appendage and provides comparative insight into the various left atrial appendage closure devices currently in development., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Mapping and ablation in the pericardial space has been shown to be beneficial for the treatment of different supraventricular and ventricular arrhythmias. The percutaneous subxiphoid approach is the most frequently used approach to access the pericardial space. Mapping and ablation in this space may be challenging because it is an open space without obstacles where catheters can move freely, making some locations difficult to reach. Remote magnetic navigation is a modern way to overcome many of the limitations the electrophysiologist encounters during mapping and ablation of arrhythmias in the pericardial space. This article recounts the authors' experiences and reviews the limited data on this topic., (Copyright © 2010. Published by Elsevier Inc.)

This article discusses how ventricular tachycardia ablation should be used, discusses which patients may derive benefit from this treatment, and highlights the best means of implementing it., (Copyright © 2009. Published by Elsevier Inc.)