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Even for a basic study, the electrophysiologist needs to have a clear mental picture of cardiac anatomy when positioning the diagnostic catheters. This review highlights some of the features of the four cardiac chambers relevant for translating anatomic knowledge into an understanding of fluoroscopy images and electrograms. Integration of images from real cardiac anatomy into three-dimensional mapping based on electrograms and "virtual" anatomy is crucial for the success and safety of diagnostic and therapeutic electrophysiological procedures., (© 2022. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

AV conduction abnormalities are observed in 15-30% of patients with hypertrophic cardiomyopathy but are usually not severe enough to require permanent pacemaker implant. Both septal myectomy and alcohol septal ablation are effective options to relieve symptoms due to left ventricular outflow tract gradient in patients with hypertrophic cardiomyopathy but have procedure-specific effects on AV conduction and the His Purkinje system. Septal myectomy is associated with the development of LBBB in 50-100% of patients, while alcohol septal ablation is associated with RBBB in 37-70% of patients. Baseline abnormalities in the contralateral bundles and the presence of conduction disease have an important impact on the likelihood of the development of AV block for both of these therapies. AV block requiring permanent pacing occurs in approximately 2-3% of patients after septal myectomy and 10-15% of patients after alcohol septal ablation. Permanent pacemaker implant after alcohol septal ablation is more common in older patients (> 55 years old 13 vs. < 55 years old 5%; p = 0.06). Improved outcomes for septal myectomy and alcohol septal ablation are observed in experienced centers. Septal reduction therapies should be performed at medical centers with a dedicated hypertrophic cardiomyopathy program using a multidisciplinary approach.

Background: Persistent and long-standing persistent atrial fibrillation (AF) often requires extensive and/or repeat radiofrequency (RF) ablation procedures., Objective: The Tailored Treatment of Persistent Atrial Fibrillation (TTOP-AF) study assessed the effectiveness and safety of the phased RF system in a randomized controlled comparison of medical therapy against phased RF ablation for the management of persistent and long-standing persistent AF., Methods: Patients who had failed at least 1 antiarrhythmic drug (AAD) were randomized (2:1) to ablation management (AM) or medical management (MM). AM patients were allowed up to 2 ablations. Index and retreatment procedures consisted of pulmonary vein isolation and ablation of complex fractionated atrial electrograms. MM patients received AAD changes and/or cardioversion. The primary end points of the TTOP-AF study included chronic effectiveness and safety at 6 months and acute safety within 7 days of ablation., Results: At 6 months, a greater proportion of AM patients achieved effectiveness off AAD (77 of 138 [55.8%]) compared to MM patients (19 of 72 [26.4%]) (P < .0001). Acutely, 92.8% (128/138) of the procedures were successful while 12.3% (17/138) experienced a serious procedure and/or device-related adverse event. The predefined acute safety end point was not met. The proportion of patients with chronic safety events did not differ significantly between groups., Conclusions: Catheter ablation of persistent/long-standing persistent AF with the phased RF ablation system is effective with greater reduction of AF compared with MM. More intense anticoagulation strategies, careful attention to catheter placement relative to the pulmonary vein ostia, and elimination of electrode interaction are expected to reduce the risk of stroke, pulmonary vein stenosis, and asymptomatic cerebral emboli., (© 2014 Heart Rhythm Society Published by Heart Rhythm Society All rights reserved.)

Introduction: Although warfarin has traditionally been used for reducing risk of stroke in patients with atrial fibrillation, over the past year, the direct thrombin inhibitor dabigatran has become an accepted alternative. No study has conclusively investigated bleeding risks of patients treated with dabigatran immediately following radiofrequency catheter ablation (RFCA) procedures., Methods: We evaluated 156 consecutive patients referred for RFCA of atrial arrhythmias: 31 patients were on dabigatran and 125 patients were on warfarin. The incidence of bleeding complications during the first 48 h and the first week following ablation were recorded and comparisons made using Fisher's exact test. Major complications were defined as hemorrhage requiring blood products or the need for vascular intervention. Minor complications were defined as prolonged bleeding from the catheter insertion site, hematoma formation, or development of ecchymosis. Our study also took into account the intraprocedure activated clotting time (ACT) levels in an effort to describe any differences between both patient groups., Results: There were no differences in age, gender, procedure type, or level of intraprocedural anticoagulation between the warfarin and dabigatran groups. No major bleeding complications were observed in either patient group at either 48 h or 1 week postprocedure. Six of the 31 dabigatran patients and 21 of the 125 warfarin patients had minor bleeding complications. There was no statistically significant difference between the incidence of minor bleeding complications between the two groups (p = 0.7384), although rebleeding was more commonly observed in patients on dabigatran. In regard to the intraprocedure ACT levels, there was more variability in the dabigatran patient group, and it was more difficult to achieve the goal ACT level, yet these results did not affect overall bleeding complications., Conclusion: In our cohort, bleeding-related complications 48 h and 1 week post-ablation were similar for warfarin and dabigatran. Dabigatran is associated with more intraprocedural variability in ACT than warfarin.

Introduction: Catheter ablation (CA) of atrial fibrillation (AF) has become a treatment option for younger patients with drug refractory AF. It is not known whether pulmonary veins (PV) have an important mechanistic role in elderly patients with AF or whether CA is an effective treatment for the elderly., Methods: We evaluated 240 consecutive patients that were referred to the electrophysiology laboratory for CA for AF using a PV antral isolation approach. Linear ablations were not routinely performed. Clinical outcomes and healthcare resource utilization was evaluated during the 12 months after CA in patients <65 years old (Group 1; 91 patients), 65-75 years old (Group II; 88 patients), and >75 years old (Group III; 61 patients)., Results: Older patients were more likely to have persistent atrial fibrillation (I: 24%, II: 34%, III: 66%). Major complication rates (I: 1%; II: 1%; III: 0%; p=ns) and minor complication rates (I: 4%; II: 5%; III: 5%; p=ns) were similar for all three groups. At 12 month follow-up younger patients were more likely to be in sinus rhythm without prolonged episodes of atrial fibrillation without antiarrhythmic drug therapy (AARx) (I: 94%, II: 84%, III: 61%). However in Group III, effective treatment (AF <1 h/mo +/- AARx) was achieved in 82% of patients. After radiofrequency catheter ablation, hospitalizations, emergency room and nonroutine clinic visits decreased significantly for all three groups during the 12 months after RFA (I: pre 22; post: 3; Group II: pre 26; post 4; III: pre 20; post 2)., Conclusions: CA can be effective for treating AF in selected older patients as stand-alone therapy or as hybrid therapy with AARx. PVs appear to be an important arrhythmogenic structure regardless of age. CA is associated with decreased healthcare resource utilization in all age groups.

Objective: We evaluated the prevalence, trends, outcomes and the general experience of physicians performing atrial fibrillation ablation (AF-ABL) in the United States (US)., Background: AF-ABL is a non-pharmacological and potentially curative therapy for AF. Success rates for AF-ABL have been reported to be between 80 and 90%. Although there are numerous clinical trial addressing this therapy little is known about the general status of AF-ABL in clinical practice., Methods: We administered a mailed survey to the physician members of a professional arrhythmia society (Heart Rhythm Society, formerly known as the North American Society of Pacing and Electrophysiology) who practiced in the US (n = 1843)., Results: There were 304 responses, 66% (n = 204) performed ABL and 30% (n = 92) performed AF-ABL. The study group performed a total of 5,592 AF-ABL from 2000 to 2003, out of 72,575 total ABL procedures during the same time period. There was a four-fold increase in the number of AF-ABL between 2000 and 2003 (2000: 628 vs. 2003: 2,575). In the same period, the self-reported short and long-term success rates of AF-ABL improved an average of 18 +/- 4% (p < or = 0.001). In 2003 the average self-reported one-month, one-year, and two-year success rates were: 71 +/- 4%, 66 +/- 5%, 63 +/- 6% respectively. The predicted five-year success was 60 +/- 4%. The average procedure took 4.5 +/- 0.4 hours. Physicians reported that approximately 29 +/- 4% of their patents were potential candidates for AF-ABL., Conclusions: AF-ABL is becoming a much more common procedure in the US. Over the last four years the perceived short and long term success rates of AF-ABL have improved. Success rates in this survey are 10 to 20% lower than those reported in the recent clinical trials.

A patient with D-transposition of the great arteries developed drug refractory atrial tachycardia 12 years after a Senning operation. Electrophysiological study confirmed the presence of atrial baffle-tricuspid valve isthmus dependent reentrant intraatrial tachycardia. Intracardiac echocardiography facilitated initial identification of structures, catheter positioning, and identification of the atrial baffle-tricuspid valve isthmus.

In some patients, rapid activation from one or several foci can lead to atrial fibrillation. This study evaluated long-term changes in quality of life and healthcare resource utilization in patients with atrial fibrillation treated by ablation of focal triggers. Thirty-three patients underwent ablation for paroxysmal atrial fibrillation. Health surveys (SF-36) were obtained at baseline, and after 1 year and 3 years of follow-up. Health care costs were measured for the 3 years before and after ablation. Ablation was successful in 82%, partially successful in 12% (no sustained episodes but on antiarrhythmic drug therapy), and unsuccessful in 6% of patients. The average number of ablation procedures was 1.6 +/- 0.6 per patient. After ablation, patients reported significantly improved quality of life in all SF-36 categories except bodily pain. Healthcare resource utilization was significantly reduced after ablation (Clinic visits: 7.4 +/- 2.5 per year vs. 1.1 +/- 0.6 per year, p < 0.05; Emergency room visits: 1.7 +/- 0.90 per year vs. 0.03 +/- 0.17 per year, p < 0.05; Hospitalization: 1.6 +/- 0.81 vs. 0, p < 0.05). Cost of healthcare (not including procedural costs) was significantly reduced after ablation (Pre-ablation: 1,920 +/- 889 dollars/year vs. post-ablation: 87 +/- 68 dollars/year; p < 0.01). Procedural cost of ablation was 17,173 +/- 2,466 dollars/patient. Ablation of focal triggers of atrial fibrillation is associated with a sustained improvement in quality of life. Although the initial cost of ablation is high, after ablation, utilization of healthcare resources is significantly reduced.

A patient with a surgically repaired double outlet right ventricle developed AF 6 months after successful RF catheter ablation of typical atrial flutter. Guided by a 64-electrode basket catheter, the patient's AF was found to be dependent on an atypical atrial flutter circuit rotating around the fossa ovalis. Successful RF catheter ablation was performed by creating a line of conduction block from the superior vena cava to the fossa ovalis.

AIM: The 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS: A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE: Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation and the 2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

The article discusses a study on patients reported with esophageal injury after atrial fibrillation (AF) ablation. The first presented with dysphagia and odnophagia a day after the procedure. The second presented with dysphagia a day after ablation and had esophageal ulceration in 2 locations and the third patient developed atrio-esophageal fistula 17 days after the procedure. It suggests the use of endoscopic ultrasonography (EUS) to identify patients at highest risk for injury.

Background: Atypical atrial flutter (AAFL) prevalence is increasing due to the escalating atrial fibrillation (AF) ablations and cardiac surgeries. We wanted to explore the outcome of the AAFL ablation, considering the recent changes in mapping and ablation. Methods: This study was approved by the Institutional Review Board (IRB) of Mayo Clinic hospital. We retrospectively studied 419 patients who had undergone AAFL ablation at Mayo Clinic from January 2017 to June 2022. Thirteen patients declined research authorization, and 19 patients were lost to follow-up during the 90-day blanking period, resulting in a sample size of 387. The median follow-up time for patients was 25.7 months (95% CI 23.7, 32.3). Results: Recurrent symptoms with documentation of atrial arrhythmia occurred in 226/387 (58.4%) patients, of which 151/226 (66.8%) occurred within the first year. The median time to recurrence was 8.5 months (max 57.8 months). Eleven patients died during the study period, nine of whom experienced recurrence prior to death. Overall, the median recurrence-free survival (RFS) time was 16.6 months (95% CI 13.2, 20.0) with a one-year RFS rate of 57.2% (95% CI 52.2, 62.7%). Acute termination occurred 324/387 (83.7%) during the ablation. The one-year RFS rate was 58.9% (95% CI 53.5%, 64.9%) for patients with acute termination and 49.0% (95% CI 37.9%, 63.4%) for those without acute termination. The rate was not significantly different based on acute termination status (p = 0.11). Conclusions: Our study underscores the challenge of managing AAFL, with a one-year recurrence-free survival rate of 57.2%, even when acute termination is achieved in most cases (83.7%). This outcome underscores the complex nature of substrate abnormalities in AAFL, necessitating further investigation and refinement of ablation strategies. [ABSTRACT FROM AUTHOR]

In a survey of 140 electrophysiologic laboratories in the USA, 49% reuse catheters to some extent. Catheter reuse is associated with significant reductions in cost but is not conducted in a standardized fashion. [ABSTRACT FROM AUTHOR]

We prospectively compared the impact on quality of life and cost effectiveness between ablation and medication as an initial strategy for patients with paroxysmal supraventricular tachycardia (SVT). Seventy-nine consecutive patients with newly documented paroxysmal SVT were treated with either ablation or medication. Health surveys (SF-36 and disease-specific questions) were obtained at baseline and after 12 months of follow up. Cost of health care utilization for the 6 months before and after treatment were measured. Both medication and ablation improved quality of life. However, ablation improved quality of life in more general health categories than medication. At follow up, ablation was associated with significantly improved quality of life in the bodily pain (63+/-24 vs 81+/-20, p <0.005), general health (69+/-21 vs 79+/-21, p <0.05), vitality (55+/-21 vs 66+/-22, p <0.05), and role emotion (78+/-36 vs 94+/-17, p <0.05) categories when compared with medication. Although both medication and ablation decreased frequency of disease-specific symptoms, ablation resulted in complete amelioration of symptoms in more patients (33% vs 74%). Potential long-term costs were similar for medication and ablation. In conclusion, ablation improves health-related quality of life to a greater extent, and in more aspects of general and disease-specific health than medication. [ABSTRACT FROM AUTHOR]