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Introduction: Posterior wall isolation (PWI) combined with pulmonary vein isolation (PVI) has proven effective for persistent atrial fibrillation (AF). However, when performing PWI, creating transmural lesions with subendocardial ablation is sometimes difficult. Endocardial unipolar voltage amplitude had a higher sensitivity than bipolar voltage mapping for identifying intramural viable myocardium in the atria. In this study, we aimed to retrospectively investigate the correlation between the residual potential in the posterior wall (PW) following PWI for persistent AF and atrial arrhythmia recurrence using endocardial unipolar voltage. Methods: This was a single‐center observational study. Patients who underwent PVI and PWI for persistent AF in the first procedure between March 2018 and December 2021 at the Tokyo Metropolitan Hiroo Hospital were included in this study. The patients were divided into two groups based on the presence of residual unipolar PW potentials after PWI with a cutoff of 1.08 mV and the recurrence of atrial arrhythmias was compared. Results: In total, 109 patients were included in the analysis. Forty‐three patients had residual unipolar potentials after PWI and 66 patients had no residual unipolar potentials. The atrial arrhythmia recurrence rate was significantly higher in the group with residual unipolar potential (41.8% vs. 17.9%, p = 0.003). The residual unipolar potential was an independent predictor of recurrence (odds ratio: 4.53; confidence interval: 1.67–12.3, p = 0.003). Conclusion: Residual unipolar potential after PWI for persistent AF is associated with recurrent atrial arrhythmias. [ABSTRACT FROM AUTHOR]

Although it is common for bi‐atrial tachycardia (AT) circuits to include the Bachmann bundle, there are few reports of its role in left AT circuits. A 77‐year‐old man was admitted for recurrent AT with a cycle length of 425 ms. The endocardial and epicardial activation map revealed an AT circuit located in the left atrial anterior wall and transverse pericardial sinus, showing a centrifugal pattern stemming from the left atrial appendage. After radiofrequency ablation, AT was no longer induced. This case suggests that the Bachmann bundle may be part of the left AT circuit. [ABSTRACT FROM AUTHOR]

Introduction: In patients with coronary artery disease, a high coronary artery calcium score (CACS) correlates with atrial fibrillation (AF); however, the association between left atrial (LA) remodeling progression and coronary arteriosclerosis is unclear. This study aimed to evaluate the relationship between LA remodeling progression and the CACS. Methods: This retrospective study enrolled 148 patients with AF (paroxysmal AF, n = 94) who underwent catheter ablation. Voltage mapping for the left atrium and coronary computed tomography for CACS calculations were performed. The ratio of the LA low‐voltage area (LA‐LVA), defined by values less than 0.5 mV divided by the total LA surface without pulmonary veins, was calculated. Patients with LA‐LVA (<0.5 mV) >5% and ≤5% were classified as the LVA (n = 30) and non‐LVA (n = 118) groups, respectively. Patient characteristics and CACS values were compared between the two groups. Results: LA volume, age, CHA2DS2VASc score, and percentage of female patients were significantly higher, and the estimated glomerular filtration rate was lower in the LVA group than in the non‐LVA group. The CACS was significantly higher in the LVA group (248.4 vs. 13.2; p =.001). Multivariate analysis identified the LA volume index and CACS as independent predictors of LA‐LVA (<0.5 mV) greater than 5%. The areas under the receiver operating characteristic curves for predicting LA‐LVA (<0.5 mV) greater than 5% with CACS were 0.695 in the entire population, 0.782 in men, and 0.587 in women. Conclusion: Progression of LA remodeling and coronary artery calcification may occur in parallel. A high CACS may indicate advanced LA remodeling, especially in men. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to compare touch‐up ablation (TUA) rates and pulmonary vein isolation (PVI) durability of hot balloon ablation (HBA) and cryoballoon ablation (CBA) in paroxysmal atrial fibrillation (PAF) patients. Methods: In total, 137 PAF patients were enrolled in the study. Among them, 59 underwent two HBA procedures at 6‐month intervals and 78 patients underwent two CBA sessions, both regardless of atrial fibrillation recurrence. Propensity score matching was performed to estimate similar patient characteristics between the HBA and CBA groups. Results: Each group comprised of 46 matched patients for comparison. The TUA rate at the first session was higher for HBA (49 of 184 PVs) than for CBA (20 PVs) (P =.01), with the highest incidence at the left superior pulmonary vein (LSPV). The rates of PVI durability at the second session performed 7 months later were similar between HBA (168 of 184 PVs) and CBA (162 PVs) groups. The PVI durability rate at the TUA sites of the first session was higher for HBA than for CBA (41 of 49 PVs vs 10 PVs, respectively; P =.01). Fifty percent of the patients underwent HBA at 73°C for the LSPV. HBA performed at 73°C yielded a lower TUA rate than that at 70°C (16 of 23 PVs vs 7 of 23 PVs; P =.008). Conclusions: While PVI durability was similar between HBA and CBA, the TUA rate was higher for HBA than for CBA, especially on the LSPV. For LSPV, HBA at a balloon temperature of 73°C may reduce the TUA rate. [ABSTRACT FROM AUTHOR]

Introduction: In patients with prior atrial septal defect (ASD) closure and atrial tachyarrhythmias, transseptal puncture can be challenging. Methods and Results: This case report discusses a 65‐year‐old man who had previously undergone pulmonary vein isolation (PVI) and cavo‐tricuspid isthmus ablation for atrial fibrillation before ASD closure, respectively. He developed atrial tachycardia (AT) and underwent catheter ablation. AT was diagnosed as peri‐mitral flutter and the mitral isthmus (MI) linear ablation via a trans‐aortic approach successfully terminated it. Conclusion: This case demonstrates the feasibility and safety of transaortic MI linear ablation in patients with ASD closure devices or anatomical challenges when transseptal puncture is difficult. [ABSTRACT FROM AUTHOR]

Introduction: Local impedance (LI) parameters of IntellaNav STABLEPOINT for successful pulmonary vein isolation (PVI) of atrial fibrillation (AF) remain unclear. The purpose of this study was to seek LI data achieving successful PVI. Methods: Consecutive AF patients who underwent catheter ablation with STABLEPOINT were prospectively enrolled in two centers. PVI was performed under a constant 35‐or 40‐watt power, 20‐s duration, and >5‐g contact force. The operators were blinded to the LI data. The characteristics of all ablation points with/without conduction gaps (Unsuccess or Success tags) after the first‐attempt PVI were evaluated for the right/left PVs and anterior/posterior wall (RPV/LPV and AW/PW, respectively), and cutoff values of LI data were calculated for successful lesion formation. Results: A total of 5257 ablation points in 102 patients (65 [58–72] years old, 65.7% male) were evaluated. The LI drop values were higher in the Success tags than Unsuccess tags on the LPV‐AW and RPV‐AW/PW (p <.001), except for the LPV‐PW (p =.105). The %LI drop values (LI drop/initial LI) were higher for the Success tags in all areas (15.8 [12.2%–19.6%] vs. 11.6 [9.7%–15.6%] in LPV‐AW: p <.001, 15.0 [11.5%–19.3%] vs. 11.4 [8.7%–17.3%] in LPV‐PW: p =.035, 15.3 [11.5%–19.4%] vs. 9.9 [8.1%–13.7%] in RPV‐AW: p <.001, and 13.3 [10.1%–17.4%] vs. 8.1 [6.3%–9.5%] in RPV‐PW, p <.001). The LI drop and %LI drop cutoff values were 20.0 ohms and 11.6%, respectively. Conclusions: An insufficient LI drop with STABLEPOINT was associated with a gap formation during PVI, and the best cutoff values for the LI drop and %LI drop were 20.0 ohms and 11.6%, respectively. [ABSTRACT FROM AUTHOR]

Introduction: It is important to consider recurrent arrhythmia after catheter ablation for persistent atrial fibrillation (AF) for planning an ablation strategy. However, the studies are limited to pulmonary vein isolation (PVI) plus posterior wall isolation (PWI), which were reported to improve procedural outcomes. The objective of this study is to evaluate the effect of PWI on recurrent arrhythmia. Methods: This is an observational study on patients with persistent AF comparing PVI plus PWI and PVI only strategies. In PVI plus PWI group, linear ablation of the left atrium roofline and bottom line were performed to achieve PWI after PVI. Some patients with AF recurrence underwent the second procedure. The presence of recurrent arrhythmia and results of the second procedures were evaluated. Results: A total of 181 patients (mean age, 66.9 ± 10.2 years; male, 76.8%) were included. PVI plus PWI group and PVI only group consisted of 90 and 91 patients, respectively. AF recurrence was observed in 28 of 90 (31.1%) patients with PVI plus PWI and in 43 of 91 (47.3%) with PVI only, and log‐rank test did not show any significant difference (p =.35). The occurrence of recurrent persistent AF was significantly lower in PVI plus PWI group than in PVI only group (5/90; 5.6% vs. 18/91; 20.9%, p =.002). There was no significant difference between the two groups in recurrent paroxysmal AF and atrial tachycardia (AT). Conclusion: PWI, in addition to PVI, for persistent AF was significantly related to fewer episodes of recurrent persistent AF, and it did not increase recurrent AT. [ABSTRACT FROM AUTHOR]

Introduction: Successful pulmonary vein isolation (PVI) can improve the quality of life (QOL) of patients with atrial fibrillation (AF). However, the role of durable PVI for such QOL improvement is not known. The aim of this study was to clarify the effectiveness of durable PVI in improving the QOL of patients with AF. Methods and Results: We assessed 119 patients who underwent PVI (age 66.4 ± 9.6 years, 104 paroxysmal AF). A scheduled electrophysiological study was performed 6 months after the first PVI session—regardless of recurrence of AF—to assess the durability of PVI and to identify and re‐isolate reconnected pulmonary veins. QOL scores were evaluated by an AF‐specific QOL questionnaire and checked at baseline, 6 months, and 1 year after the first session. In patients without AF recurrence (nonrecurrence group, n = 93), the scores at 6 months improved compared with those at baseline; conversely, the scores did not improve in patients with AF recurrence (n = 26). Nevertheless, the scores at 1 year improved compared with those at 6 months in both groups. Within the nonrecurrence group, the score difference between 6 months and baseline was higher in the durable PVI group (n = 58) than that in the nondurable PVI group (n = 35). Conclusions: The QOL of AF patients improved by the resumption of sinus rhythm following PVI. Patients with durable PVI had increased QOL scores compared with those with nondurable PVI. The durability of PVI may achieve further improvements in the QOL of patients with AF. [ABSTRACT FROM AUTHOR]

The Accufix bipolar active fixation atrial pacing lead (Model 330‐801; Telectronics) can have mechanical complications due to a fracture of its J retention wire. An 80‐year‐old man had the Accufix atrial pacing lead implanted 29 years prior, and surgical removal was required because a part of the lead was perforating the apex of the right ventricle. Regular follow‐up examinations are recommended to eliminate the possibility of protrusion and detachment of the J retention wire, even if the clinical course after implantation is stable for a prolonged period. [ABSTRACT FROM AUTHOR]

Introduction: While characteristic waveforms of 12‐lead electrocardiograms have been reported to predict the epicardial origin of ventricular tachycardia (VT), it has not been fully examined whether ventricular intracardiac electrograms (VEGMs) recorded from the implantable cardioverter defibrillator (ICD) via telemetry can determine the origin of VT or not. The aim of this study was to investigate the VEGM characteristics of VT originating from the epicardia. Method and Results: Intracardiac VEGMs of the induced VTs, with detected sites of origin during the VT study, were recorded in 15 (23 VTs) of the 46 patients. The characteristics of the 23 VTs were evaluated using far‐field and near‐field VEGMs recorded via telemetry. Five of 23 VTs were found to be focused on the epicardial site (epi group) and 18 VTs were focused on the endocardium (endo group). VTs of the epi group had longer VEGM duration in far‐field EGM than those of the endo group (epi group: 240 ± 49 ms vs endo group: 153 ± 45 ms; P = 0.002) and the duration from the onset to the peak of VEGM was also longer than that of the endo group (epi group: 153 ± 53 ms vs endo group: 63 ± 28 ms; P < 0.001). There was no difference in the V wave duration in tip‐ring EGM between both groups (epi group: 122 ± 52 ms vs endo group: 98 ± 6 ms; P = 0.377). Conclusion: Evaluation of intracardiac VEGM before VT ablation may be helpful to predict the epicardial origin of VT in patients with an ICD. [ABSTRACT FROM AUTHOR]

Abstract: Background: During epicardial mapping, determination of appropriate ablation sites in low voltage areas (LVA) is challenging because of large epicardial areas covered by adipose tissue. Objective: To evaluate the impedance difference between epicardial fat and the epicardial LVA using multiple detector computed tomography (MDCT). Methods: We enrolled patients who underwent ventricular tachycardia (VT) ablation via the epicardial approach after endocardial ablation failure. After the procedure, MDCT‐derived images of epicardial fat were loaded to the mapping system. Then, all points acquired during sinus rhythm were retrospectively superimposed and analyzed. Results: This study included data from 7 patients (62.5 ± 3.9 years old) who underwent eight epicardial VT ablation procedures. After the procedure, MDCT‐derived images of epicardial fat were registered in eight procedures. Retrospective analysis of 1,595 mapping and 236 ablation points was performed. Of the 1,595 mapping points on the merged electroanatomical and epicardial fat maps, normal voltage area (NVA) and low voltage area (LVA) without fat had lower impedance than those with fat (NVA without fat 182 ± 46 Ω vs. NVA with fat 321 ± 164.0 Ω, P  =  0.001, LVA without fat 164 ± 69 Ω vs. LVA with fat 248 ± 89 Ω, P  =  0.002). Of the 236 ablation points, initial impedance before ablation was higher on epicardial fat than on epicardial LVA without fat (134 ± 16 Ω vs. 156 ± 28 Ω, P  =  0.01). Conclusions: Real time epicardial impedance evaluation may be useful to determine effective epicardial ablation sites and avoid adipose tissue. However, the number of patients in the present study is limited. Further investigation with a large number of patients is needed to confirm our result. [ABSTRACT FROM AUTHOR]

Scar-Related Left Atrial Anterior Wall Reentry. Introduction: Macroreentrant atrial tachycardia (MRAT) has been described most frequently in patients with prior cardiac surgery. Left atrial tachycardia and flutter are common in patients who undergo atrial fibrillation ablation; however, few reports describe left atrial MRAT involving the regions of spontaneous scarring. Here, we describe left atrial MRAT in patients without prior cardiac surgery or catheter ablation (CA) and discuss the clinical and electrophysiological characteristics of tachycardia and outcome of CA. Methods and Results: An electrophysiological study and CA were performed in 6 patients (3 men; age 76 ± 6 years) with MRAT originating from the left atrial anterior wall (LAAW). No patient had a history of cardiac surgery or CA in the left atrium. Spontaneous scars (areas with bipolar voltage ≤ 0.05 mV) were observed in all patients. The activation map showed a figure-eight circuit with loops around the mitral annulus (4 counterclockwise and 2 clockwise) and a low-voltage area with LAAW scarring. The mean tachycardia cycle length was 303 ± 49 milliseconds. The conduction velocity was significantly slower in the isthmus between the scar in the LAAW and the mitral annulus than in the lateral mitral annulus (0.17 ± 0.05 m/s vs 0.94 ± 0.35 m/s; P = 0.003). Successful ablation of the isthmus caused interruption of the tachycardia and rendered it noninducible in all patients. Conclusion: Spontaneous LAAW scarring is an unusual cause of MRAT, showing activation patterns with a figure-eight configuration. Radiofrequency CA is a feasible and effective treatment in such cases. (J Cardiovasc Electrophysiol, Vol. 24, pp. 404-412, April 2013) [ABSTRACT FROM AUTHOR]

A 79‐year‐old woman with a history of pulmonary vein isolation for persistent atrial fibrillation was admitted for recurrence of atrial tachycardia, with a tachycardia cycle length of 236 milliseconds. The ultra–high‐resolution mapping system revealed that tachycardia circuit detouring the epicardium at the anterior wall scar and breaking through to the endocardium below the left atrial appendage. Radiofrequency energy was applied to this site, which successfully terminated the tachycardia. This case suggests that epicardial conduction could occur even at the left atrial anterior wall and identifies a variation in epicardial conduction around the left atrium, which could be a tachycardia circuit. [ABSTRACT FROM AUTHOR]

The cover image is based on the EP Image Macroreentrant atrial tachycardia detouring the epicardium at the anterior wall of the left atrium by Satoshi Miyazawa et al., https://doi.org/10.1111/jce.13766. [ABSTRACT FROM AUTHOR]