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Aims Pulmonary vein isolation (PVI) for catheter ablation of atrial fibrillation (AF) is a time-demanding procedure. High-power short-duration (HPSD) ablation protocols and high-density mapping catheters have recently been introduced to clinical practice. We investigated the impact of high-density mapping and HPSD ablation protocols on procedural timing, efficacy, and safety by comparing different standardized set-ups. Methods and results Three electrophysiology (EP) laboratory set-ups were analysed: (i) circular catheter for mapping and HPSD ablation with 30/35 W guided by an ablation index (AI); (ii) pentaspline catheter for mapping an HPSD ablation with 50 W guided by an AI; and (iii) pentaspline catheter for mapping and HPSD ablation with 90 W over 4 s using a novel ablation catheter. All patients underwent PVI without additional left atrial ablation strategies. Procedural data and operating intervals in the EP laboratory were systematically analysed. Three hundred seven patients were analysed (30/35 W AI: n = 102, 50 W AI: n = 102, 90 W/4 s: n = 103). Skin-to-skin times [105.3 ± 22.7 (30/35 W AI) vs. 81.4 ± 21.3 (50 W AI) vs. 69.5 ± 12.2 (90 W/4 s) min, P ≤ 0.001] and total laboratory times (132.8 ± 42.1 vs. 107.4 ± 25.7 vs. 95.2 ± 14.0 min, P < 0.001) significantly differed among the study groups. Laboratory interval analysis revealed significant shortening of mapping and ablation times. Arrhythmia-free survival after 12 months was not different among the study groups (log-rank P = 0.96). Conclusion The integration of high-density mapping and HPSD protocols into an institutional AF ablation process resulted in reduced procedure times without compromising safety or efficacy. [ABSTRACT FROM AUTHOR]

Background Catheter ablation is one of the most effective treatment options for patients with drug-refractory, scar-related monomorphic ventricular tachycardia (VT). In selected cases, catheter ablation also plays an important role in treatment of polymorphic VT (PMVT) and/or ventricular fibrillation (VF). Rarely, premature ventricular contractions (PVCs) originating from the Purkinje network can induce PMVT/VF. Ablation and elimination of these PVCs can prevent VF recurrences. Case summary A 41-year-old patient with a history of orthotopic heart transplantation (HTX) 8 years before admission and newly diagnosed SARS-CoV-2 pneumonia was referred to our centre after experiencing several episodes of drug-refractory VF. An electrophysiological study showed ectopy-triggered VF originating from the anterior and posterior fascicles of the left bundle branch (LBB). Ablation of these PVCs from the LBB led to complete elimination of VF. A subcutaneous implantable cardioverter defibrillator was implanted as secondary prophylaxis. During the observation period of 6 months, no VF recurrence was observed. Conclusion Identifying and eliminating the trigger (PVCs) can be life-saving and prevent VF in the specific cohort of HTX patients. High-density mapping using multipolar catheters with microelectrodes contributes significantly to our understanding of tachycardia mechanisms. [ABSTRACT FROM AUTHOR]

The article focuses on the management of recurrent electrical storms in an 82-year-old patient with end-stage heart failure and ischaemic cardiomyopathy. Topics include the use of catheter ablation for left ventricular substrate modification and pulmonary vein isolation, the role of mechanical circulatory support with an Impella device during the procedure, and the challenge of managing electrical storms triggered by ventricular arrhythmias and atrial fibrillation.

Aims Accessory pathway (AP) ablation is a standard procedure for the treatment of Wolff-Parkinson-White syndrome (WPW). Twelve-lead electrocardiogram (ECG)-based delta wave analysis is essential for predicting ablation sites. Previous algorithms have shown to be complex, time-consuming, and unprecise. We aimed to retrospectively develop and prospectively validate a new, simple ECG-based algorithm considering the patients' heart axis allowing for exact localization of APs in patients undergoing ablation for WPW. Methods and results Our multicentre study included 211 patients undergoing ablation of a single manifest AP due to WPW between 2013 and 2021. The algorithm was developed retrospectively and validated prospectively by comparing its efficacy to two established ones (Pambrun and Arruda). All patients (32 ± 19 years old, 47% female) underwent successful pathway ablation. Prediction of AP-localization was correct in 197 patients (93%) (sensitivity 92%, specificity 99%, PPV 96%, and NPV 99%). Our algorithm was particularly useful in correctly localizing antero-septal/-lateral (sensitivity and specificity 100%) and posteroseptal (sensitivity 98%, specificity 92%) AP in proximity to the tricuspid valve. The accuracy of EASY-WPW was superior compared to the Pambrun (93% vs. 84%, P = 0.003*) and the Arruda algorithm (94% vs. 75%, P < 0.001*). A subgroup analysis of children (n = 58, 12 ± 4 years old, 55% female) revealed superiority to the Arruda algorithm (P < 0.001*). The reproducibility of our algorithm was excellent (ϰ>0.8; P < 0.001*). Conclusion The novel EASY-WPW algorithm provides reliable and accurate pre-interventional ablation site determination in WPW patients. Only two steps are necessary to locate left-sided AP, and three steps to determine right-sided AP. [ABSTRACT FROM AUTHOR]

Background Despite substantial technical improvements in long-term mechanical circulatory support, ventricular tachycardia (VT) remains a major challenge in left ventricular assist device (LVAD) patients. Recurrent VTs in LVAD patients are not only associated with limited quality of life, but also increased mortality. Although LVAD therapy improves VT tolerance of the left ventricle, haemodynamical deterioration of the right ventricle is the limiting factor in these patients. Case summary  We present a case report of a hybrid epicardial VT ablation of incessant VTs in a 53-year-old man with advanced heart failure and St.p. LVAD implantation. With this unique clinical case report, we describe an epicardial VT ablation using secondary surgical open-heart access in a patient with therapy-refractory VTs combing left-sided minithoracotomy with high-density (HD) mapping and catheter ablation. Discussion  To the best of our knowledge, the presented approach is the first interdisciplinary case of epicardial VT ablation using secondary surgical open-heart access in an LVAD patient with therapy-refractory VTs. By combing left-sided minithoracotomy with HD mapping and catheter ablation, we could to demonstrate that even in these complex patients epicardial VT ablations can be performed safely and improve quality of life of LVAD patients with recurrent implantable cardioverter-defibrillator shock therapies. [ABSTRACT FROM AUTHOR]

Aims: Pacing the specific conduction system like the Bundle of His (HB) can lead to more physiologic activation patterns compared to traditional right ventricular apical pacing. The aim of this study was to estimate the feasibility and value of electroanatomical mapping (EAM) for HB pacing during the learning curve and its impact on procedural outcome.Methods and Results: Fifteen consecutive patients were treated using EAM of the His bundle region before implantation. Voltage and activation maps of HB potentials were performed. The activation time from His potential to R wave (ECG-reference) was measured and correlated to the HV interval. The atrial and ventricular potentials were blended so the active window could only see the His potential. After completing the activation map, it was transformed into a peak-to-peak voltage map of the HB. With reversed black and white colour scale, the exact point of the maximal His signal amplitude was visualized. Procedural data for the implantation were analysed using this innovative approach. The average total procedural time and fluoroscopy time was 88.2 ± 19.1 min and 10.9 ± 4.5 min, respectively. The 3D mapping time was 18.4 ± 5.1 min. The 13.9 ± 5.1 His potential points were needed in average to complete the map. No periprocedural complications were seen in this cohort. In 86.7% of cases, His bundle pacing was successful. The average threshold for the His bundle stimulation and the R-wave amplitude was 1.62 ± 1 V (@1.0 ms) and 4.8 ± 3.2 mV, respectively. The pacing impedance was 513.5 ± 102.8 Ω. Average paced QRS complex width was 116.9 ± 20.3ms. On average 2.6 ± 1.6 lead positions were targeted to find the optimal pacing site.Conclusion: Electroanatomical mapping-guided implantation of His-bundle leads can facilitate the identification of optimal pacing sites and allow to minimize procedure and fluoroscopy times even during the phase of the learning curve. [ABSTRACT FROM AUTHOR]

Background Cardiac tamponade is one of the most serious complications when performing cardiac interventions. Although most of the patients can be treated effectively using pericardiocentesis, urgent surgery can be necessary in case of continuous bleeding and patients' haemodynamic impairment. Case summary With this unique clinical case report we describe an acute endovascular occlusion of a cardiac perforation utilizing the inflated 28 mm cryoballon at the transseptal puncture site close to the superior part of the coronary sinus ostium in a patient with persistent left superior vena cava (PLSVC) and severe post-procedural tamponade. Prior to this maneuver, 1200 mL of haemorrhagic effusion has been aspirated. Forty-five minutes after cryoballoon-guided occlusion we deflated the balloon and no additional blood could be aspirated over the following 20 minutes. Discussion Cryoballon-guided occlusion of the perforation site saved the patient from immediate cardiac surgery and resulted in stable haemodynamic conditions. This bailout approach was transferred from coronary interventions where occlusion of a perforated vessel using balloon devices is a common technique to achieve acute hemostasis. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF) ablation protocols using energy delivery with very high power and short duration (vHPSD) have been introduced to improve lesion formation. This study reports procedural data of vHPSD ablation in AF patients and analyses characteristics of ablation-induced left atrial (LA) scar formation from cardiac magnetic resonance imaging (MRI)., Methods and Results: Sixty consecutive patients undergoing index pulmonary vein isolation following our institutional Q4U-AF workflow were prospectively enrolled. Ablation was conducted using a contact force sensing catheter allowing for vHPSD ablation using a temperature-controlled ablation mode. Thirty patients underwent cardiac late gadolinium enhancement MRI of the LA 3 months after ablation to assess LA scar. Mean procedural duration was 66.5 ± 14.8 min. Mean ablation time was 4.7 ± 0.9 min with a mean number of 69.9 ± 14.2 applications. First-pass isolation was achieved in 51 patients (85%) for the right pulmonary veins (RPVs), in 37 patients (61.7%) for the left pulmonary veins (LPVs), and in 34 patients (56.7%) for both pulmonary veins (PVs). Magnetic resonance imaging at 3 months post-ablation demonstrated a mean scar width of 14.4 ± 2.6 mm around RPVs and 11.9 ± 1.9 mm at LPVs (P > 0.05). Complete PV encirclement was observed in 76.7% for RPVs, in 76.7% for LPVs, and in 66.7% for both PV pairs. During a mean follow-up of 4.7 ± 1.4 months, arrhythmia recurrence was observed in 3.3% of the patients., Conclusion: Pulmonary vein isolation following a novel vHPSD workflow resulted in short procedure duration and high acute and mid-term efficacy. Magnetic resonance imaging demonstrated durable and transmural PV lesions with homogeneous and contiguous scar formation., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)