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Competing Interests: Disclosures The corresponding author as well as the remaining authors have nothing to disclose.

Background: Left atrial appendage closure (LAAC) for prevention of stroke is validated in patients with nonvalvular atrial fibrillation (NVAF) contraindicated to oral anticoagulation. General anaesthesia (GA) is often used for procedural guidance by transesophageal echocardiography (TEE); however, its use may be challenging in some patients. The aim of the study was to evaluate the safety and the midterm efficacy of a mini-invasive LAAC strategy using micro-TEE under procedural sedation., Methods: Comparison by propensity score of 2 cohorts of consecutive patients who underwent LAAC: standard TEE-guided LAAC (3-dimensional [3D] TEE under GA) and mini-invasive LAAC strategy (micro-TEE under procedural sedation). The primary endpoint was a composite of embolic or bleeding events, significant per procedural complication, and cardiovascular deaths within 3 months after LAAC., Results: In total, 432 patients were included (78.7 ± 8 years old, 32.4% of women, CHA 2 DS 2 VASC score: 4.9 ± 1.1); 127 patients underwent mini-invasive LAAC strategy and were compared with 305 patients standard TEE-guided LAAC. The mini-invasive strategy was achieved in 122 of 127 (96.1%) planned patients. The primary endpoint occurred in 11.2% of patients from the mini-invasive LAAC strategy group and in 10.3% of patients from the standard TEE group (absolute difference = 0.9% [-6.4; 4.5], hazard ratio = 1.11 [0.56; 2.19], P = 0.76). Procedural times, fluoroscopy duration, and hospital stays were shorter in the mini-invasive LAAC strategy group (P < 0.001)., Conclusions: The mini-invasive LAAC strategy is safe and effective compared with the standard TEE-guided LAAC strategy. A mini-invasive LAAC strategy may also be an important tool to help physicians to treat more patients as LAAC indications evolve in the future., (Copyright © 2024 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF., (© 2024. The Author(s).)

Acute myocarditis is associated with cardiac arrhythmia in 25% of cases; a third of these arrhythmias are ventricular tachycardia (VT) or ventricular fibrillation (VF). The implantation of a cardiac defibrillator (ICD) following sustained ventricular arrhythmia remains controversial in these patients. We sought to assess the risk of major arrhythmic ventricular events (MAEs) over time in patients implanted with an ICD following sustained VT/VF in the acute phase of myocarditis compared to those implanted for VT/VF occurring on myocarditis sequelae. Our retrospective observational study included patients implanted with an ICD following VT/VF during acute myocarditis or VT/VF on myocarditis sequelae, from 2007 to 2017, in 15 French university hospitals. Over a median follow-up period of 3 years, MAE occurred in 11 (39%) patients of the acute myocarditis group and 24 (60%) patients of the myocarditis sequelae group. Kaplan-Meier MAE rate estimates at one and three years of follow-up were 19% and 45% in the acute group, and 43% and 64% in the sequelae group. Patients who experienced sustained ventricular arrhythmias during acute myocarditis had a very high risk of VT/VF recurrence during follow-up. These results show that the risk of MAE recurrence remains high after resolution of the acute episode.

Background: Wall thickness (WT) in post-myocardial infarction scar is heterogenous, with channels of relatively preserved thickness bordered by thinner scar., Objective: This study sought to determine whether 3-dimensionally-reconstructed computed tomography (CT) channels correlate with electrophysiological isthmuses during ventricular tachycardia (VT)., Methods: We retrospectively studied 9 postinfarction patients (aged 57 ± 15 years, 1 female) with 10 complete VT activation maps (cycle length 429 ± 77ms) created using high-resolution mapping. Three-dimensionally-reconstructed WT maps from CT were merged with the activation map during sinus rhythm (SR) and VT. The relationship between WT and electrophysiological characteristics was analyzed., Results: A total of 41 CT channels were identified (median 4 per patient), of median (range) length 21.2 mm (17.3-36.8 mm), width 9.0 mm (6.7-16.5 mm), and area 1.49 cm 2 (1.00-1.75 cm 2 ). WT in the channel was significantly thicker in the center than in the edge (median 2.4 mm vs 1.5 mm, P < .0001). Of 3163 (2493-5960) mapping points in SR, 382 (191-1115) local abnormal ventricular activities (LAVAs) were identified. One patient had a maximal proportion of LAVAs in 3-4 mm, 3 patients in 2-3 mm, 2 in 1-2 mm, and 2 in 0-1 mm. The VT isthmuses of all 10 VTs corresponded with 1-4 CT channels. Twenty-one of the 41 CT channels (51.2%) corresponded to a VT isthmus (entrance, mid, or exit). Electrophysiological VT isthmuses were more likely to be associated with CT channels that were longer (P = .04, odds ratio [OR] 1.05/mm), thinner (but not less than 1 mm) (P = .03, OR 0.36/mm), or parallel to the mitral annulus (P = .07, OR 3.93)., Conclusion: VT isthmuses were always found in CT channels (100% sensitivity), and half of CT channels hosted VT isthmuses (positive predictive value 51%). Longer and thinner (but >1 mm) CT channels were significantly associated with VT isthmuses., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Atrial tachycardias (ATs) are often seen in the context of atrial fibrillation (AF) ablation., Objectives: To evaluate the role of the Marshall bundle (MB) network in left atrial (LA) ATs using high-density 3-dimensional mapping., Methods: A total of 199 ATs were mapped in 140 patients (112 male, mean age: 61.8 years); 133 (66.8%) were macroreentrant and 66 (33.2%) were scar-related reentry circuits. MB-dependent ATs were suggested by activation mapping analysis and confirmed with entrainment along the circuit., Results: The MB network participated in 60 (30.2%) reentrant ATs: 31 perimitral ATs (PMATs) and 29 localized reentry circuits. Of 60 MB-related ATs, 49 (81.6%) terminated with radiofrequency (RF) ablation: 44 (73.3%) at the MB-LA junction and 5 (8.3%) at the MB-coronary sinus (CS) junction, while 9 (15%) terminated after 2.5-5 cc of ethanol infusion inside the vein of Marshall (VOM). Of the 31 PMATs, 17 (54.8%) terminated at the MB-LA junction, 5 (16.1%) at the MB-CS junction, and 7 (22.6%) with ethanol infusion. Of the 29 localized reentry circuits using the MB, 27 (93.1%) terminated at the MB-LA junction, none at the MB-CS junction, and 2 (6.9%) after ethanol infusion. Recurrences were mostly observed after RF ablation (18 of 37 patients, 49%) compared to ethanol infusion (1 of 9 patients, 11%) (P = .06)., Conclusions: MB reentrant ATs accounted for up to 30.2% of the left ATs after AF ablation. Ablation of the MB-LA or CS-MB connections or ethanol infusion inside the VOM is required to treat these arrhythmias., (Copyright © 2019 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Aims: To compare the arrhythmic response to isoproterenol and exercise testing in newly diagnosed arrhythmogenic right ventricular cardiomyopathy (ARVC) patients., Methods and Results: We studied isoproterenol [continuous infusion (45 µg/min) for 3 min] and exercise testing (workload increased by 30 W every 3 min) performed in consecutive newly diagnosed ARVC patients. Both tests were evaluated with regard to the incidence of (i) polymorphic premature ventricular contractions (PVCs) and couplet(s) or (ii) sustained or non-sustained ventricular tachycardia (VT) with left bundle branch block [excluding right ventricular outflow tract VT]; and compared to a control group referred for the evaluation of PVCs without structural heart disease. Thirty-seven ARVC patients (63.5% male, age 38 ± 16 years) were included. The maximal sinus rhythm heart rate achieved during isoproterenol testing was significantly lower compared to exercise testing (149 ± 17 bpm vs. 166 ± 19 bpm, P < 0.0001). However, the incidence of polymorphic ventricular arrhythmias was much higher during isoproterenol testing compared to exercise testing [33/37 (89.2%) vs. 16/37 (43.2%), P < 0.0001]. Interestingly, isoproterenol testing was arrhythmogenic in all 15 patients in whom baseline PVCs were reduced or suppressed during exercise testing. During both isoproterenol and exercise testing, control group presented a low incidence of ventricular arrhythmias compared to ARVC patients (8.1% vs. 89.2%, P < 0.0001 and 2.7% vs. 43.2%, P < 0.0001, respectively)., Conclusions: The incidence of polymorphic ventricular arrhythmias is significantly higher during isoproterenol compared to exercise testing in newly diagnosed ARVC patients, suggesting its potential utility for the diagnosis.

Background: Anatomic macroreentrant atrial tachycardias (MATs) are conventionally reported to depend on the cavotricuspid isthmus, the mitral isthmus, or the left atrial roof, and are commonly seen following catheter ablation for atrial fibrillation., Objectives: To define the precise circuits of anatomic MAT with ultrahigh-resolution mapping., Methods: In 57 patients (mean age, 62 years; 10 female) who developed ≥1 anatomic MAT, we analyzed 88 MAT circuits including 16 peritricuspid, 42 perimitral, and 30 roof-dependent circuits, using high-density mapping and entrainment., Results: Of 16 peritricuspid atrial tachycardias (ATs), 8 (50.0%) showed a circuit not limited to the tricuspid annulus. However, cavotricuspid isthmus ablation terminated the tachycardia in all patients. Similarly, 26 of 42 perimitral ATs (61.9%) showed a circuit not limited to the mitral annulus, and a low-voltage zone <0.1 mV around the mitral annulus was associated with nontypical perimitral ATs (P < .0001). The practical isthmus was not in the mitral isthmus in 13 of these 26 perimitral ATs (50%). Finally, 22 of 30 roof-dependent ATs (73.3%) had a circuit not rotating around both pairs of pulmonary veins. Brief assessment of the activation direction on the posterior wall in relation to that on the septal, anterior, and lateral wall helped deduce the circuit of roof-dependent AT in 27 of 30 (90.0%). Practical isthmus was not in the roof in 8 of 22 (36.4%). Practical isthmuses mapped with the system were significantly shorter than the usual anatomic isthmuses (16.1 ± 8.2 mm vs 33.7 ± 10.4 mm) (P < .0001)., Conclusions: High-density mapping successfully identified the precise circuits and the practical isthmus of anatomic MATs in patients with prior atrial fibrillation ablation., (Copyright © 2017 Heart Rhythm Society. All rights reserved.)

Although catheter ablation has been successful in reducing the recurrence of ventricular tachycardia in patients with ischemic disease, outcomes in patients with nonischemic cardiomyopathy (NICM) have not met with the same results. Success is predicated on a methodical approach to diagnosis of disease type and identification of critical substrate, and the ablation strategies used. Cardiac MRI with delayed enhancement is able to identify areas of substrate involvement, particularly in situations when conventional catheter mapping is not able to do so. Radiofrequency needle, irrigated bipolar radiofrequency, and transcoronary alcohol ablation are effective and alternative techniques to endocardial and epicardial ablation., (Copyright © 2016 Elsevier Inc. All rights reserved.)