Rodriguez-Riascos, Juan

Background: Pulsed Field Ablation (PFA) has gained widespread adoption for pulmonary vein isolation (PVI) due to its tissue selectivity and safety profile. However, its role in cavotricuspid isthmus (CTI) ablation for typical atrial flutter is less defined. This study compares CTI ablation using PFA versus radiofrequency ablation (RFA) in patients undergoing PVI exclusively with PFA. Research Question: We hypothesized that in patients undergoing PFA-based PVI, CTI ablation using PFA would reduce procedure and fluoroscopy times without increasing complication or flutter recurrence rates compared to RFA. Methods: We retrospectively analyzed patients who underwent CTI ablation with either PFA or RFA alongside PFA PVI between 2024 – 2025 across all Mayo Clinic sites. Baseline characteristics, procedural parameters, acute success, and 12-month arrhythmia recurrence were compared between groups. All patients received standard follow-up, including ECGs and Holter monitoring. Results: A total of 350 patients were included (CTI PFA: n = 126; CTI RFA: n = 224). Patients in the PFA group were older (68.8 ± 8.5 vs. 65.7 ± 10.1 years; p <0.01) and had higher CHA2DS2-VASc scores (2.84 ± 1.57 vs. 2.45 ± 1.45; p = 0.02). Fluoroscopy (18.9 ± 9.1 vs. 25.2 ± 23.3 min; p < 0.01 ) and procedure times (172.6 ± 22.4 vs. 224.7 ± 74.2 min; p < 0.01) were significantly lower in the PFA group. Complication rates (8.7% vs. 4.9%; p = 0.15) and typical flutter recurrence (3.1% vs. 1.7%; p = 0.46) were similar between groups during a mean follow-up of 125 days. Conclusion: In patients undergoing PVI with PFA, CTI ablation using PFA is associated with significantly reduced procedure and fluoroscopy times compared to RFA, without increased complications or arrhythmia recurrence. These findings support the feasibility and efficiency of PFA for typical flutter ablation when performed during PFA-based AF procedures.

Background: Pulsed field ablation (PFA) has become a cornerstone for atrial fibrillation ablation. Multiple platforms have been developed and approved worldwide, and routine screening for asymptomatic brain injury (ABI) has been included in several trials as part of the safety assessment of this technology. The incidence by catheter/platform, predictors of occurrence, and clinical impact remain incompletely understood. Research Question: In patients with atrial fibrillation undergoing pulmonary vein isolation, does the incidence of ABI vary between different PFA platforms? Methods: We searched the MEDLINE/PubMed, Embase, and Cochrane Central Register of Controlled Trials databases for studies reporting on patients who underwent PFA and post-procedure brain MRI to screen for ABI. The review was conducted in accordance with PRISMA guidelines. A random-effects proportion meta-analysis was performed, with subgroup analysis based on the PFA platform used. For studies including a thermal ablation control group, risk ratio (RR) was used to compare outcomes. Finally, a meta-regression was conducted to identify potential predictors of ABI incidence. Results: A total of 19 studies reporting data from 742 patients who underwent post-ablation brain MRI were included in this review. The pooled incidence of silent cerebral events (new findings visible only on DWI sequences) and silent cerebral lesions (new findings on both DWI and FLAIR sequences) was 5% each (95% CI, 3%–8%). The pooled incidence of any ABI was 10% (95% CI, 8%–13%). A platform-level subgroup analysis demonstrated comparable outcomes across the platforms with available data (Figure 1). The meta-regression included age, sex, CHA2DS2-VASc score, and incidence of symptomatic stroke/TIA, but no statistically significant associations were identified. In the four studies that included a thermal ablation control group, there was no significant difference in ABI incidence between PFA and thermal ablation (RR: 1.37; 95% CI, 0.68–2.74; P = 0.38; I2 = 16%) (Figure 2). Seven studies reported follow-up MRI in patients who presented with an ABI. Among 20 patients with ABI after ablation, radiologic lesions persisted in 2 patients. Conclusion: ABI is a relatively frequent finding following PFA; however, current evidence does not reveal significant differences between available platforms. Radiologic findings tend to be transient, suggesting a limited long-term clinical impact.

Background: A blanking period allowing for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has historically been standardized to 90 days. With the recent introduction of pulsed field ablation (PFA) for PVI and emerging in vitro data suggesting a shorter inflammatory timeframe, it remains unclear whether recurrences during this 90-days period reflect incomplete procedural success or merely transient inflammatory changes. Research Question: In patients undergoing PVI with PFA, do early AF recurrences at 30, 60, and 90 days predict late AF recurrences beyond the standardized 90-day blanking period? Methods: Patients undergoing PFA for AF were retrospectively included. Procedures were performed under general anesthesia, and high-density (HD) mapping, with PVI and additional ablation lines applied at the operator’s discretion. PFA catheters included Farawave, PulseSelect, and Sphere-9. AF recurrences were defined as documented episodes on 12-lead ECG or cardiac monitoring devices, confirmed by interpretation from an experienced cardiologist. Survival analyses were conducted based on the occurrence of early recurrences at 30, 60, and 90 days post-ablation. Kaplan-Meier curves and hazard ratios were reported. This study was approved by our institutional review board. Results: To the best of our knowledge, this is the largest real-world study reporting outcomes of PFA for AF in the United States. A total of 1,214 patients were included in the analysis. Mean age was 66.4 years; 31.9% were female, and 22.4% underwent redo PVI. Six-month AF recurrence-free survival was 79% (95% CI, 75–83%) for the overall cohort. Patients experiencing early recurrence at 30, 60, and 90 days had a significantly higher risk of AF recurrence beyond the standardized 90-day blanking period (HR 4.0, 95% CI 2.7–5.9, P < 0.01; HR 5.0, 95% CI 3.6–7.1, P < 0.01; and HR 6.9, 95% CI 4.9–9.6, P < 0.01, respectively). Conclusion: Early recurrences at 30, 60, and 90 days post-ablation are strongly associated with atrial fibrillation recurrence beyond the 90-day blanking period. These findings challenge the traditional concept of blanking period after PFA and suggest that early recurrence may indicate incomplete procedural success rather than transient inflammation.

Background: Spontaneous coronary artery dissection (SCAD) is increasingly recognized as a cause of acute coronary syndrome, particularly in young to middle-aged women. While most presentations are associated with preserved left ventricular ejection fraction (LVEF), a subset of patients present with acute systolic dysfunction. The characteristics of patients who recover their LVEF are not clearly defined. Methods: We retrospectively analyzed 495 patients with angiographically confirmed SCAD treated at three Mayo Clinic sites (Arizona, Rochester, and Florida) from 1994 to 2023. Patients with a prior history of myocardial infarction, coronary artery disease, and congenital heart disease were excluded. Baseline LVEF at SCAD presentation was categorized into <35%, 35–39%, 40–49%, and ≥50%. Follow-up LVEF was assessed by echocardiography performed between 30 days and 1 year post-SCAD. The primary outcome was improvement in LVEF to ≥50% at follow-up. Results: A total of 495 SCAD patients were included. At presentation, 26% had reduced LVEF: 6% had LVEF <35%, 5% had LVEF between 35–39%, and 15% had LVEF between 40–49%. Patients who did not normalize their EF at follow-up were slightly younger (45 vs. 48 years, p=0.04), were more likely to have had an in-hospital cardiac arrest (13% vs. 4%, p=0.01), required mechanical circulatory support during their care, and had SCAD involving the left main artery (11% vs. 2%, p=0.01). Predictors of EF normalization included SCAD which involved the obtuse marginals (15% vs. 4%, p<0.05). The group with the lowest EF at presentation had the highest probability of persistent EF <50% at follow-up (32% for those with LVEF <35%) while patients who had normal EF at presentation had a 6% chance of having EF <50% at follow-up (Figure 1). Conclusions: Our study shows that the majority of SCAD patients have normal EF at presentation. 80% of those with reduced EF at presentation will normalize at follow-up. Predictors of low EF at follow-up included dissection involving the left main artery, lower EF at SCAD presentation, in-hospital arrest and use of mechanical circulatory support.

Abstract Background Cardiac sarcoidosis (CS) is a rare condition associated with electrical conduction disturbances. Ventricular tachycardia (VT) may be a life-threatening manifestation of CS. Immunosuppressants and antiarrhythmic drugs (AADs) are considered first-line management, but for refractory cases, an implantable cardioverter-defibrillator (ICD) and VT ablation may be required. Purpose This study aims to document predictors for complete acute success after VT ablation in patients with CS. Methods This was a post hoc analysis from an observational study that included patients who underwent VT ablation for cardiac sarcoidosis at our institution from 2007 to 2024. Patients with suspected, clinically diagnosed, or histologically diagnosed CS, according to the JCS 2016 guidelines, were included. The cohort was divided into two groups: patients with complete acute success, defined as no VT induced at the end of the procedure, and patients with no acute success, which included patients with partial success, unsuccessful procedures, and no inducibility test at the end of the procedure. After univariate analysis, variables with an uneven distribution between the two groups (p &lt; 0.1) were included in a multivariate logistic regression analysis. Results A total of 95 patients were enrolled. Complete acute success was achieved in 40 patients (42%). The mean age was 56.7 ± 10.1 years, and 14 (15%) patients were female. Extracardiac sarcoidosis involvement was reported in 38 (40%) patients. Only one patient in the complete acute success group did not have an ICD. Before VT ablation admission, 40 (42%) patients were on immunomodulators, and 78 (82%) on AADs. The mean ejection fraction in the complete acute success group was 44.5% ± 11.9, compared to 41.7 ± 12.0 in the no-complete success group. Among the 53 patients who underwent a PET scan in the 6 months before ablation, 17 (32%) showed active inflammation based on 18FDG uptake, with no significant difference between the two groups. LGE was present in 57 of 58 patients with a cardiac MR before ablation. Septal involvement was more common in the complete success group (86% versus 58%; OR, 4.41; 95% CI, 1.02-27.5; P = 0.039). A multifocal distribution was also more common in the complete success group (95% versus 67%; OR, 10.17; 95% CI, 1.3-468; P = 0.011). Fluoroscopy and total procedure time were comparable between both groups. The presence of clinical VT with an RBBB morphology was more common in the no-complete success group (54% versus 79%; OR, 0.31; 95% CI, 0.09-1.02; P = 0.03). In the multivariate analysis, epicardial LGE was associated with lower odds of complete acute success (adjusted OR, 0.087; 95% CI, 0.008-0.944; P = 0.04). Conclusions In our population, the presence of epicardial LGE on cardiac MR prior to VT ablation was an independent predictor of no complete acute success.

Background: Cardiac sarcoidosis (CS) is a rare condition marked by conduction disturbances, and ventricular tachycardia (VT) resulting from reentrant pathways. VT ablation is typically considered for patients with refractory VT. This systematic review aims to synthesize reported outcomes and identify potential predictors for the success of VT ablation in CS patients. Methods: A systematic literature review was conducted following the PRISMA guidelines, searching PubMed, Cochrane, Embase, and Scopus databases up to May 2024. A random-effects model was used to evaluate electrophysiologic and procedural variables and compare outcomes to identify potential predictors of success. Results: After excluding duplicates, 473 titles and abstracts were screened. Twenty-five studies were fully reviewed, and 9 studies comprising data from 311 CS patients who underwent VT ablation were included. The mean age of patients was 50.5 years, with 30% being female. Epicardial mapping was performed in 29% (CI 22-36%; 72/251) of cases, and 96% (CI 77-100%; 65/72) of those underwent epicardial ablation. The prevalence of VT storm before the procedure was 28% (CI 16-42%; 89/259), with a suppression success rate of 84% (CI 73-93%; 64/76). The acute complete success rate defined as lack of inducibility was 58% (CI 49-66%; 174/307). During follow-up, which ranged from 19 to 58 months, 34% (CI 21-48%; 113/271) of patients survived free from the composite outcome of death, transplantation, or VT recurrence. Patients with acute success had fewer inducible VTs (MD –1.1; CI: -1.8 to -0.5; p < 0.001). No other variables were significantly associated with acute success. However, patients with acute success tended to be older than those with partial or unsuccessful outcomes (MD 7.5; CI: -0.2 to 15.1; p = 0.055). Conclusion: VT ablation in patients with CS shows acceptable acute success rates. Patients presenting with VT storm have a high rate of arrhythmia acute suppression. A lower number of inducible VTs is associated with higher acute success rates. Despite these results, the prognosis remains poor, with a significant proportion of patients experiencing disease recurrence, death, or requiring heart transplantation.

Introduction: Pulmonary Vein Isolation (PVI) has become the cornerstone during ablation of Atrial Fibrillation. The primary goal of the procedure is to prevent potential arrhythmogenic triggers from accessing the main left atrial substrate. However, incomplete fibrosis leading to PV reconnection has been identified as the primary reason for AF recurrence. It is unclear whether immediate voltage mapping and additional lesions delivered to areas of residual or recovered voltages will improve the outcome. This study evaluates the 1-year success and long-term recurrence-free survival in patients who underwent post-procedure voltage mapping (PPVM) to identify residual Low-Voltage Areas (LVAs) to guide the delivery of additional ablation lesions. Methods: We analyzed 588 patients who underwent PVI from 2015 to 2023. Of these, 243 had PPVM done to determine LVAs and guide additional ablation lesions. The control arm comprised 345 patients who underwent PVI by the same operators without PPVM. The primary endpoints were 1-year success and longer-term recurrence-free survival. Secondary endpoints were the incidence of complications and the prevalence of LVAs in patients who underwent PPVM. Results: Patients who underwent remapping were older than the control arm (68.3 vs 65.6 years, p = 0.005). There were no other significant differences in baseline characteristics between the two groups. At 1-year follow-up, the success rates were 79% in the treatment arm compared to 72% in the control arm (p = 0.038). Patients in the intervention arm had a recurrence-free survival rate of 65% and 54% at 2 and 4 years, respectively, compared to 62% and 43% in the control arm (p = 0.044). The prevalence of LVAs in the treatment arm was 56.8%. Additionally, complication rates were not increased in the remapping arm (3% vs 8%, p = 0.012). Conclusion: PPVM-guided incremental ablation lesions improve the 1-year success rate and recurrence-free survival at 2 and 4 years compared to traditional PVI without increasing complications due to additional lesion delivery.