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Recent studies showed that an early strategy for ventricular tachycardia (VT) ablation resulted in reduction of VT episodes or mortality. Cardiac magnetic resonance (CMR)-derived border zone channel (BZC) mass has proved to be a strong non-invasive predictor of VT in post-myocardial infarction (MI). CMR-guided VT substrate ablation proved to be safe and effective for reducing sudden cardiac death (SCD) and VA occurrence.PREVENT-VT is a prospective, randomized, multicenter, and controlled trial designed to evaluate the safety and efficacy of prophylactic CMR-guided VT substrate ablation in chronic post-MI patients with CMR-derived arrhythmogenic scar characteristics. Chronic post-MI patients with late gadolinium enhancement (LGE) CMR will be evaluated. CMR images will be post-processed and the BZC mass measured: patients with a BZC mass 5.15 g will be eligible. Consecutive patients will be enrolled at 3 centers and randomized on a 1:1 basis to undergo a VT substrate ablation (ABLATE arm) or optimal medical treatment (OMT arm). Primary prevention ICD will be implanted following guideline recommendations, while non-ICD candidates will be implanted with an implantable cardiac monitor (ICM). The primary endpoint is a composite outcome of sudden cardiac death (SCD) or sustained monomorphic VT, either treated by an ICD or documented with ICM. Secondary endpoints are procedural safety and efficiency outcomes of CMR-guided ablation.In some patients, the first VA episode causes SCD or severe neurological damage. The aim of the PREVENT-VT is to evaluate whether primary preventive substrate ablation may be a safe and effective prophylactic therapy for reducing SCD and VA occurrence in patients with previous MI and high-risk scar characteristics based on CMR.ClinicalTrials.gov, NCT04675073, registered on January 1, 2021.

Atrial fibrillation (AF) is the most common sustained arrhythmia encountered in clinical practice. The aim of this review was to evaluate the progress made in the management of AF over the two last decades.Clinical classification of AF is usually based on the presence of symptoms, the duration of AF episodes and their possible recurrence over time, although incidental diagnosis is not uncommon. The majority of patients with AF have associated cardiovascular diseases and more recently the recognition of modifiable risk factors both cardiovascular and non-cardiovascular which should be considered in its management. Among AF-related complications, stroke and transient ischaemic accidents (TIAs) carry considerable morbidity and mortality risk. The use of implantable devices such as pacemakers and defibrillators, wearable garments and subcutaneous cardiac monitors with recording capabilities has enabled to access the burden of "subclinical AF". The recent introduction of non-vitamin K antagonists has led to improve the prevention of stroke and peripheral embolism. Agents capable of reversing non-vitamin K antagonists have also become available in case of clinically relevant major bleeding. Transcatheter closure of left atrial appendage represents an option for patients unable to take oral anticoagulation. When treating patients with AF, clinicians need to select the most suitable strategy, i.e. control of heart rate and/or restoration and maintenance of sinus rhythm. The studies comparing these two strategies have not shown differences in terms of mortality. If an AF episode is poorly tolerated from a haemodynamic standpoint, electrical cardioversion is indicated. Otherwise, restoration of sinus rhythm can be obtained using intravenous pharmacological cardioversion and oral class I or class III antiarrhythmic is used to prevent recurrences. During the last two decades after its introduction in daily practice, catheter ablation has gained considerable escalation in popularity. Progress has also been made in AF associated with heart failure with reduced or preserved ejection fraction.Significant progress has been made within the past 2 decades both in the pharmacological and non-pharmacological managements of this cardiac arrhythmia.

Aims Pulmonary vein (PV) antrum isolation proved to be effective for treating persistent atrial fibrillation (PeAF). We sought to investigate the results of a personalized approach aimed at adapting the ablation index (AI) to the local left atrial wall thickness (LAWT) in a cohort of consecutive patients with PeAF. Methods and results Consecutive patients referred for PeAF first ablation were prospectively enrolled. The LAWT three-dimensional maps were obtained from pre-procedure multidetector computed tomography and integrated into the navigation system. Ablation index was titrated according to the local LAWT, and the ablation line was personalized to avoid the thickest regions while encircling the PV antrum. A total of 121 patients (69.4% male, age 64.5 ± 9.5 years) were included. Procedure time was 57 min (IQR 50–67), fluoroscopy time was 43 s (IQR 20–71), and radiofrequency (RF) time was 16.5 min (IQR 14.3–18.4). The median AI tailored to the local LAWT was 387 (IQR 360–410) for the anterior wall and 335 (IQR 300–375) for the posterior wall. First-pass PV antrum isolation was obtained in 103 (85%) of the right PVs and 103 (85%) of the left PVs. Median LAWT values were higher for PVs without first-pass isolation as compared to the whole cohort (P = 0.02 for left PVs and P = 0.03 for right PVs). Recurrence-free survival was 79% at 12 month follow-up. Conclusion In this prospective study, LAWT-guided PV antrum isolation for PeAF was effective and efficient, requiring low procedure, fluoroscopy, and RF time. A randomized trial comparing the LAWT-guided ablation with the standard of practice is in progress (ClinicalTrials.gov, NCT05396534).

Aims To non-invasively characterize, by means of late gadolinium enhancement cardiac magnetic resonance (LGE-CMR), scar differences, and potential variables associated with ventricular tachycardia (VT) occurrence in chronic post-myocardial infarction (MI) patients. Methods and results A case–control study was designed through retrospective LGE-CMR data analysis of chronic post-MI patients (i) consecutively referred for VT substrate ablation after a first VT episode (n = 66) and (ii) from a control group (n = 84) with no arrhythmia evidence. The myocardium was characterized differentiating core, border zone (BZ), and BZ channels (BZCs) using the ADAS 3D post-processing imaging platform. Clinical and scar characteristics, including a novel parameter, the BZC mass, were compared between both groups. One hundred and fifty post-MI patients were included. Four multivariable Cox proportional hazards regression models were created for total scar mass, BZ mass, core mass, and BZC mass, adjusting them by age, sex, and left ventricular ejection fraction (LVEF). A cut-off of 5.15 g of BZC mass identified the cases with 92.4% sensitivity and 86.9% specificity [area under the ROC curve (AUC) 0.93 (0.89–0.97); P Conclusions The mass of BZC is the strongest independent variable associated with the occurrence of sustained monomorphic ventricular tachycardia in post-MI patients after adjustment for age, sex, and LVEF. Border zone channel mass measurement could permit a more accurate VT risk stratification than LVEF in chronic post-MI patients.

There is growing interest in performing fluoroless radiofrequency ablation (RFA) for atrial fibrillation (AF) due to the increasing awareness of risk associated with radiation exposure of patients and professional staff. The present study aimed to evaluate the feasibility, safety, and efficacy of a stepwise transesophageal echocardiography (TEE)–guided zero-fluoroscopy approach (ZFA) for RFA. Consecutive patients (n = 111) referred for AF-ablation were prospectively enrolled with intention to RFA with ZFA. Procedural outcomes were compared with historical controls (HCs) after 1:1 propensity score matching. ZFA success was considered when no X-ray was utilized to perform the whole procedure. ZFA success was achieved in 80 (72%) procedures. BMI > 35 kg/m2 resulted in the only independent predictor of ZFA failure (OR = 6.10, 95% CI 1.15–46.49, p = 0.04). In comparison to HCs, a significant reduction in radiation exposure was observed in the ZFA group: fluoroscopy time (3 vs. 63 s, p

Pulmonary vein isolation is the standard for atrial fibrillation ablation. Although the most commonly applied energy source is radiofrequency (RF), cryoablation has rapidly evolved as a powerful one-shot tool, particularly after the introduction of the second-generation catheter, gaining widespread use in recent years. The efficacy in maintaining sinus rhythm after a first ablative procedure is ∼70–80%, and the randomization studies comparing cryoablation to RF have not been able to reveal significant differences up to now. Although different baseline characteristics may influence the efficacy of cryoablation, we are not yet able to distinguish which patients may benefit from a personalized choice of ablative source. Regarding safety, cryoballoon ablation appears to be associated with a lower rate of pericardial effusion and cardiac tamponade, mainly due to the lack of risk of overheating. The other side of the coin is a higher incidence of phrenic nerve damage, which occurs in 1–2% of procedures. In conclusion, we do not yet have definitive data to affirm the superiority of the RF technique over that of cryoablation. The choice of energy source currently depends on the availability of the centre and on the experience of the operator.

Background Pacemapping (PM) is a useful maneuver for aiding premature ventricular complex (PVC) ablation. Its standalone clinical value is still to be defined. Objectives The purpose of this study was to analyze the efficacy of a predefined PM protocol for low-burden PVC ablation, regardless of their site of origin (SOO) and the presence of structural heart disease. Methods This was a prospective, nonrandomized, multicenter study. The PM protocol was performed when 94% correlation, and 3 radiofreqency (RF) applications were delivered. Results Of 185 patients, 105 (57%) underwent activation mapping, 60 (32%) were PM-guided, and 20 (11%) were canceled due to absence of PVCs. Baseline QRS, PVC burden, and outflow tract origin were independent predictors of PM-guided ablation. A higher proportion of right ventricular outflow tract SOO in the PM group (52% vs 40%; P = .03) was observed. Mean target area was 0.6 ± 0.9 cm2. Mean 10-ms isochronal area in local activation time (LAT)-guided procedures was higher (1.7 ± 2.3 cm2; P Conclusion When LAT mapping is precluded, application of a PM-guided ablation protocol directed to >94% matching correlation target area is a more efficient alternative with comparable clinical results.

Aims To determine if adapting the ablation index (AI) to the left atrial wall thickness (LAWT), which is a determinant of lesion transmurality, is feasible, effective, and safe during paroxysmal atrial fibrillation (PAF) ablation. Methods and results Consecutive patients referred for PAF first ablation. Left atrial wall thickness three-dimensional maps were obtained from multidetector computed tomography and integrated into the CARTO navigation system. Left atrial wall thickness was categorized into 1 mm layers and AI was titrated to the LAWT. The ablation line was personalized to avoid thicker regions. Primary endpoints were acute efficacy and safety, and freedom from atrial fibrillation (AF) recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter. Ninety patients [60 (67%) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins with first-pass in 87 (97%). Procedure time was 59 min (49–66); radiofrequency (RF) time 14 min (12.5–16); and fluoroscopy time 0.7 min (0.5–1.4). No major complication occurred. Eighty-four out of 90 (93.3%) patients were free of recurrence after a mean FU of 16 ± 4 months. Conclusion Personalized AF ablation, adapting the AI to LAWT allowed pulmonary vein isolation with low RF delivery, fluoroscopy, and procedure time while obtaining a high rate of first-pass isolation, in this patient population. Freedom from AF recurrences was as high as in more demanding ablation protocols. A multicentre trial is ongoing to evaluate reproducibility of these results.

A 38-year-old woman with a structurally normal heart was referred for catheter ablation due to symptomatic, monomorphic, high burden (12%) premature ventricular complexes (PVC) refractory to medical therapy. The PVC's ECG morphology suggested an origin in the proximal left anterior fascicle (LAF). During procedure PVCs were mechanically suppressed. Consequently, selection of the ablation target site was based on pace-mapping. This case illustrates how ablation from the right coronary cusp (RCC) for PVC arising from the proximal LAF could be accurately guided by pace-mapping. At this location, pacing can result in both a selective and a non-selective capture of the proximal LAF.

Pulmonary vein isolation (PVI) implies unavoidable ablation lesions to the left atrial posterior wall, which is closely related to the esophagus, leading to several potential complications. This study evaluates the usefulness of the esophageal fingerprint in avoiding temperature rises during paroxysmal atrial fibrillation (PAF) ablation.Isodistance maps of the atrio-esophageal relationship (esophageal fingerprint) were derived from the preprocedural computerized tomography. Patients were randomized (1:1) into two groups: (1) PRINT group, the PVI line was modified according to the esophageal fingerprint; (2) CONTROL group, standard PVI with operator blinded to the fingerprint. The primary endpoint was temperature rise detected by intraluminal esophageal temperature probe monitoring. Ablation settings were as specified on the Ablate BY-LAW study protocol.Sixty consecutive patients referred for paroxysmal AF ablation were randomized (42 (70%) men, mean age 60 ± 11 years). Temperature rise ( 39.1 °C) occurred in 5 (16%) patients in the PRINT group vs. 17 (56%) in the CONTROL group (p 0.01). Three AF recurrences were documented at a mean follow-up of 12 ± 3 months (one (3%) in the PRINT group and 2 (6.6%) in the CONTROL group, p = 0.4).The esophageal fingerprint allows for a reliable identification of the esophageal position and its use for PVI line deployment results in less frequent esophageal temperature rises when compared to the standard approach. Further studies are needed to evaluate the impact of PVI line modification to avoid esophageal heating on long-term outcomes. The development of new imaging-derived tools could ultimately improve patient safety (NCT04394923).

BACKGROUND Left atrial wall thickness (LAWT) has been related to pulmonary vein (PV) reconnections after atrial fibrillation (AF) ablation. The aim was to integrate 3D-LAWT maps in the navigation system and analyze the relationship with local reconnection sites during AF-redo procedures. METHODS Consecutive patients referred for AF-redo ablation were included. Procedure was performed using a single catheter technique. LAWT maps obtained from multidetector computerized tomography (MDCT) were imported into the navigation system. LAWT of the circumferential PV line, the reconnected segment and the reconnected point, were analyzed. RESULTS Sixty patients [44 (73%) male, age 61 ± 10 years] were included. All reconnected veins were isolated using a single catheter technique with 55 min (IQR 47-67) procedure time and 75 s (IQR 50-120) fluoroscopy time. Mean LAWT of the circumferential PV line was 1.46 ± 0.22 mm. The reconnected segment was thicker than the rest of segments of the circumferential PV line (2.05 + 0.86 vs. 1.47 + 0.76, p

Late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) and multidetector cardiac computed tomography (MDCT) have emerged as novel, fascinating imaging tools for arrhythmogenic substrate identification and characterization. The role of these techniques for aiding and guiding the catheter ablation of ventricular tachycardia, either as a complement or a surrogate of the electroanatomic map, has been rising in recent years. Integrating pixel signal intensity maps or wall thickness maps delivered from LGE-CMR or MDCT, respectively, into the navigation system has become a cornerstone for VT ablation procedures in a few centers of excellence around the world. The pre-procedure scar characterization offers some advantages, helping decide for the best procedure planning and approach; complete substrate identification and characterization, helping to focus electroanatomical mapping in regions of interest and also has a positive impact in procedure efficiency and outcomes. In the present article, we perform a review of the most practical aspects for using LGE-CMR or MDCT when a VT ablation procedure is planned, from the image acquisition to the integration into the navigation system, analyzing the current role of the LGE-CMR and MDCT for arrhythmogenic substrate characterization as well as for guiding VT ablation.

Aims Air entrapment (AE) has been reported as a potential cause of early inappropriate shocks (ISs) following subcutaneous implantable cardioverter defibrillator (S-ICD) implantation, but a cause–effect relationship is not always evident. This systematic review aims to analyse this phenomenon concerning implantation techniques, electrogram (EGM) features, radiologic findings, and patient management. Methods and results A systematic search was conducted using PubMed, Embase, and Google Scholar databases following the PRISMA guidelines to obtain all available literature data since 2010 on S-ICD malfunctions possibly due to AE. The final analysis included 54 patients with AE as a potential cause of S-ICD malfunction. Overall, the aggregate incidence of this condition was 1.2%. Of ICD malfunctions possibly due to AE, 93% were ISs, and 95% were recorded within the first week following implantation. Radiologic diagnosis of AE was confirmed in 28% of the entire study cohort and in 68% of patients in whom this diagnostic examination was reported. At the time of device malfunction, EGMs showed artefacts, baseline drift, and QRS voltage reduction in 95, 76, and 67% of episodes, respectively. Management included ICD reprogramming or testing, no action (observation), and invasive implant revision in 57, 33, and 10% of patients, respectively. No recurrences occurred during follow-up, irrespective of management performed. Conclusions Device malfunction possibly due to AE may occur in ∼1% of S-ICD recipients. Diagnosis is strongly suggested by early occurrence, characteristic EGM features, and radiologic findings. Non-invasive management, principally device reprogramming, appears to be effective in most patients.

Objectives This study sought to analyze safety and outcomes of ventricular tachycardia (VT) substrate ablation during sinus rhythm (SR), without baseline VT induction. Background Safety and outcomes after scar-related VT ablation during SR are not well known. Hemodynamic instability and need for electrical cardioversion can compromise safety of VT ablation procedures. Methods Four hundred twelve consecutive patients with structural heart disease undergoing VT ablation were included in a prospective multicenter registry. Substrate ablation during SR, without baseline VT induction, was the first step of the ablation procedure and the standard protocol. Scar dechanneling was the substrate ablation technique used. VT inducibility was tested after substrate ablation. Results VT induction protocol was negative after substrate ablation in 289 patients (70.1%), completing the procedure in SR. Procedure-related complication rate was 6.5%, including 1 death (0.2%). Thirty-day mortality after first VT ablation procedure was 1.7%. Overall survival was 95.8% and 88.6% at 1 and 3 years of follow-up, respectively. In a multivariable proportional hazards regression model, age ≥70 years (hazard ratio [HR]: 4.95 [2.59 to 9.47]; p Conclusions Substrate ablation during SR avoiding multiple VT induction has low procedure-related complications and low early mortality. Age, chronic obstructive pulmonary disease, and reduced left ventricular ejection fraction, but also incomplete substrate elimination, are predictors of mortality.

[Background]: Ventricular tachycardia substrate ablation (VTSA) incorporating hidden slow conduction (HSC) analysis allows further arrhythmic substrate identification., [Objective]: The purpose of this study was to analyze whether the elimination of HSC electrograms (HSC-EGMs) during VTSA results in better short- and long-term outcomes., [Methods]: Consecutive patients (N = 70; 63% ischemic; mean age 64 ± 14.6 years) undergoing VTSA were prospectively included. Bipolar EGMs with >3 deflections and duration, [Results]: A total of 5076 EGMs were analyzed; 1029 (20.2%) qualified as potential HSC-EGMs, and 475 of them were tagged as HSC-EGMs. Scars in patients with HSC-EGMs (n = 43 [61.4%]) were smaller (32.2 [17–58] cm2 vs 85 [41–92.4] cm2; P = .006) and more heterogeneous (core/scar area ratio 0.15 [0.05–0.44] vs 0.44 [0.33–0.57]; P = .017); 32.4% of HSC-EGMs were located in normal voltage tissue. Patients undergoing VTSA incorporating HSC analysis required less radiofrequency time (15.6 [8–23.1] vs 23.9 [14.9–30.8]; P < .001) and had a lower rate of VT inducibility after VTSA (28.6% vs 52.9%; P = .003) than did the historical controls. Patients undergoing VTSA incorporating HSC analysis showed a higher 2-year VT/ventricular fibrillation–free survival (75.7% vs 58.8%; log-rank, P = .046) after VTSA., [Conclusion]: VTSA incorporating HSC analysis allowed further arrhythmic substrate identification (especially in the border zone and normal voltage areas) and was associated with increased VTSA efficiency and better short- and long-term outcomes.

Objectives This study aimed to characterize the long-term scar remodeling process after an acute myocardial infarction (AMI) and the underlying scar-related arrhythmogenic substrate using serial late gadolinium enhancement cardiac magnetic resonance (LGE-CMR). Background Little is known about the time course needed for completion of the scar healing process after an AMI, which can be assessed by noninvasive cardiac imaging techniques such as LGE-CMR. Methods Fifty-six patients with revascularized ST-segment elevation AMI (STEMI) were consecutively included. LGE-CMR (3-T) was obtained at 7 days, 6 months, and 4 years after STEMI. The myocardium was segmented into 10 layers from the endocardium to epicardium, characterizing the core, border zone (BZ), and BZ channels (BZCs) using a dedicated post-processing software. Results Mean age of the patients was 57 ± 11 years; 77% were men. Left ventricular ejection fraction improved at 6 months from 47% to 51% (p Conclusions CMR data post-processing permitted a dynamic assessment of quantitative and qualitative post-AMI scar characteristics. Scar size and number of BZCs steadily decreased 4 years after AMI. BZC distribution was significantly modified during this time. These dynamic parameters could be reliably assessed with CMR; their evaluation might be of prognostic value.

To investigate the role of classical (CLM, CD14++CD16−), intermediate (INTM, CD14++CD16+), and non-classical (Non-CLM, CD14+CD16++) monocytes in scar formation after ST-elevation myocardial infarction (STEMI), evaluated with cardiac magnetic resonance (CMR). One hundred two patients with a first STEMI had serial blood analyses after 1, 3, and 7 days. A CMR was performed at 7 days and 6 months, depicting scar core (CO), border zone (BZ), and the presence of BZ channels. CLM and INTM levels progressively decreased, correlated with the scar mass, CO, and BZ at 7 days and 6 months (p

Frequent premature ventricular contractions (PVCs) associated left ventricular systolic dysfunction (LVSD) is a well-known clinical scenario and numerous predictors for cardiomyopathy (CMP) development have been already thoroughly described. It may present as a "pure" form of dissynchrony-induced cardiomyopathy or it may be an aggravating component of a multifactorial structural heart disease. However, the precise risk to develop PVC-induced CMP (which would allow for tailored-patient monitoring and/or early treatment) and the degree of CMP reversibility after PVC suppression/elimination (which may permit appropriate candidate selection for therapy) are unclear. Moreover, there is limited data regarding the time course of CMP development and resolution after arrhythmia suppression. Even less known are the other components of PVC-induced CMP, such as right ventricular (RV) and atrial myopathies. This review targets to synthetize the most recent information in this regard and bring a deeper understanding of this heart failure scenario. The mechanisms, time course (both in experimental models and clinical experiences) and predictors of reverse-remodelling after arrhythmia suppression are described. The novel experience hereby presented may aid everyday clinical practice, promoting a new paradigm involving more complex, multi-level and multi-modality evaluation and possible earlier intervention at least in some patient subsets.

Atrial fibrillation (AF) and hypertrophic cardiomyopathy (HCM) are two very common clinical entities, which often occur simultaneously, giving a hard time to both patients and cardiologists. Myocyte hypertrophy, myocyte disarray and interstitial fibrosis in the left atrium (LA) predisposes to atrial arrhythmias due to modifications of the substrate that promote re-entry. AF is usually poorly tolerated due to the shortening of the diastolic time with rapid heart rates and the lack of the atrial contribution to the diastolic filling in patients who often have a previous diastolic dysfunction. AF onset frequently results in exercise intolerance and recurrent heart failure admissions and also has prognostic implications. Early maintenance of sinus rhythm appears as a worthy approach in these patients, especially when started early in the course of the disease. However, treatment with antiarrhythmic (AA) agents in HCM patients is less effective than in patients without the disease, and concerns regarding safety frequently limit the long-term adherence. Catheter ablation has limited efficacy in patients with persistent AF but can play an important role in patients with paroxysmal AF, emphasizing the importance of an accurate patient selection. The aim of this review is to provide an overview of the pathophysiology of combined HCM and AF and the principal pharmacological and non-pharmacological treatments recommended in this complex clinical scenario.