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Although pulmonary vein (PV) isolation (PVI) is the cornerstone for atrial fibrillation (AF) ablation, no data exist comparing PV anatomy between AF subtypes directly. We aimed to compare PV anatomic characteristics between paroxysmal (PAF) and persistent AF (PeAF) in a matched population using cardiac computed tomography (CCT). Fifty-eight PeAF patients (with CCT prior first AF ablation procedure, absence of valvular disease/previous cardiac intervention), and 58 age-, sex-, body surface area-matched PAF patients were evaluated for left atrial (LA) and PV anatomy: ostial area, ovality index (OVI), transverse/frontal angles. In PeAF vs PAF group, beside higher LA volume index (LAVI), PVs' ostial areas were significantly larger (between 64 - 101 mm 2 , P < 0.001 for all PVs; remaining valid after LAVI adjustment for left superior [LS], left inferior [LI], and right inferior [RI]PV); left PVs were less oval (0.7 - 0.11 OVI decrease, P =0.039 for LSPV; P = 0.012 for LIPV); LSPV (P = 0.019), LIPV (P < 0.001), RIPV (P = 0.029) were more posteriorly directed; whereas LSPV (P = 0.002), and right superior PV (P = 0.043) were more superiorly directed. Incidence of anatomic variations or early branching was not different. This study showed significant anatomical PV differences between patients with PeAF and PAF, in terms of PV orientation, ostial size and ovality. Anticipating such anatomical differences may aid in choosing the adequate catheter design and technology for PeAF ablation., Competing Interests: Declaration of Competing Interest Dr. de Asmundis reports speaker fees for Medtronic, Biotronik, Biosense Webster, Abbott, and Boston Scientific; teaching honoraria from Medtronic, Biotronik, Abbott, and Boston Scientific; proctoring honoraria from Medtronic, Abbott, and Biotronik. Dr. Chierchia reports speaker fees for Medtronic, Biotronik, Biosense Webster, and Abbott; teaching honoraria from Medtronic and Biotronik; proctoring honoraria from Medtronic. Dr. Brugada reports consulting fees and speaker honoraria from Medtronic. Dr. Miraglia has received an educational grant from the “Foundation Enrico and Enrica Sovena.” The remaining authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The purpose of this review is to determine the causal mechanisms and treatment of inappropriate sinoatrial tachycardia (IST), defined as a non-physiological elevation in resting heart rate. IST is defined as a resting daytime sinus rate >100 beats/minute and an average 24-hour heart rate >90 beats/minute. Potential causal mechanisms include sympathetic receptor hypersensitivity, blunted parasympathetic tone, or enhanced intrinsic automaticity within the sinoatrial node (SAN) pacemaker-conduction complex. These anomalies may coexist in the same patient. Recent ex-vivo near-infrared transmural optical imaging of the SAN in human and animal hearts provides important insights into the functional and molecular features of this complex structure. In particular, it reveals the existence of preferential sinoatrial conduction pathways that ensure robust SAN activation with electrical conduction. The mechanism of IST is debated because even high-resolution electroanatomical mapping approaches cannot reveal intramural conduction in the 3-dimensional SAN complex. It may be secondary to enhanced automaticity, intranodal re-entry, or sinoatrial conduction pathway re-entry. Different pharmacological approaches can target these mechanisms. Long-acting β blockers in IST can act on both primarily increased automaticity and dysregulated autonomic system. Ivabradine targets sources of increased SAN automaticity. Conventional or hybrid ablation may target all the described abnormalities. This review provides a state-of-the-art overview of putative IST mechanisms. In conclusion, based on current knowledge, pharmacological and ablation approaches for IST, including the novel hybrid SAN sparing ablation, are discussed., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Management of ventricular arrhythmias (VAs) beyond implantable cardioverter-defibrillator positioning in patients with arrhythmogenic right ventricular cardiomyopathy (ARVC) is challenging. Catheter ablation of the ventricular substrate often requires a combination of endocardial and epicardial approaches, with disappointing outcomes due to the progressive nature of the disease. We report the Universitair Ziekenhuis Brussel experience through a case series of 16 patients with drug-refractory ARVC, who have undergone endocardial and/or epicardial catheter ablation of VAs with a thoracoscopic hybrid-approach. After a mean follow-up time of 5.16 years (SD 2.9 years) from the first hybrid-approach ablation, VA recurrence was observed in 5 patients (31.25%): among these, patients 4 patients (80%) received a previous ablation and 1 of 11 patients (9.09%) who had a hybrid ablation as first approach had a VA recurrence (80% vs 9.09%; log-rank p = 0.04). Despite the recurrence rate of arrhythmic events, all patients had a significant reduction in the arrhythmic burden after ablation, with a mean of 4.65 years (SD 2.9 years) of freedom from clinically significant arrhythmias, defined as symptomatic VAs or implantable cardioverter-defibrillator-delivered therapies. In conclusion, our case series confirms that management of VAs in patients with ARVC is difficult because patients do not always respond to antiarrhythmic medications and can require multiple invasive procedures. A multidisciplinary approach involving cardiologists, cardiac surgeons, and cardiac electrophysiologists, together with recent cardiac mapping techniques and ablation tools, might mitigate these difficulties and improve outcomes., Competing Interests: Disclosures Dr. de Asmundis receives research grants on behalf of the center from Biotronik, Medtronic, Abbott, LivaNova, Boston Scientific, AtriCure, Philips, and Acutus and has received compensation for teaching purposes and proctoring from Medtronic, Abbott, Biotronik, Livanova, Boston Scientific, AtriCure, and Daiichi Sankyo. Dr. Chierchia has received compensation for teaching purposes and proctoring from AF Solutions, Medtronic,Abbott, and Biotronik. Dr. La Meir is a consultant for AtriCure. Dr. Bisignani is consultant for Biotronik. Dr. Miraglia has received an educational grant from the "Foundation Enrico and Enrica Sovena". Dr. Brugada has received compensation for teaching purposes from Medtronic and Biotronik., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Brugada syndrome (BrS) diagnosis requires the presence of a typical type 1 ECG pattern. Owing to the spontaneous ECG variability, the real BrS prevalence in the general population remains unclear. The aim of the present study was to evaluate the prevalence of positive ajmaline challenge for BrS in a cohort of consecutive patients who underwent electrophysiological evaluation for different clinical reasons. All consecutive patients from 2008 to 2019 who underwent ajmaline testing were prospectively included. A total of 2,456 patients underwent ajmaline testing, 742 (30.2%) in the context of familial screening for BrS. In non-familial screening group (1,714) ajmaline testing resulted positive in 186 (10.9%). Indications for ajmaline testing were: suspicious BrS ECG in 23 cases (12.4%), palpitations in 27 (14.5%), syncope in 71 (38.2%), presyncope in 7 (3.8%), family history of sudden cardiac death in 18 (9.7%), documented ventricular arrhythmias in 12 (6.5%), unexplained cardiac arrest in 4 (2.2%), atrial fibrillation in 16 (8.5%), brady-arrhythmias in 1 (0.5%), and cerebrovascular accidents in 7 (3.7%). Compared with the overall population, ajmaline testing positive patients were younger (42.8 ± 15.5 vs 48.9 ± 20.4; p <0.001) and more frequently male (65.1% vs 56.3%; p = 0.023). Implantable cardioverter defibrillator was implanted in 84 patients (45.2%). During a median follow-up of 42.4 months, 12 appropriate shocks and 13 implantable cardioverter defibrillator related complications were reported. In conclusion, the BrS was diagnosed in an unexpected high proportion of patients that underwent ajmaline testing for a variety of cardiovascular symptoms. This can lead to an adequate counseling and clinical management in BrS patients., (Copyright © 2020 Elsevier Inc. All rights reserved.)