Muthu, Padmapriya

Background: Cavotricuspid isthmus ablation (CTI) is a first line therapy in patients with typical atrial flutter. With the advent of Pulsed Field (PF) as a new energy source, we sought to evaluate the use of PF for CTI ablation. A systematic literature search was conducted on the use of PF for CTI-flutter up to December 2024. A meta-analysis was performed for studies reporting pooled data, while a patient-level summary was done for reports with available individual data. The mean number of PF applications, acute success rate, and prevalence of coronary vasospasm were evaluated. Results: Eleven studies with pooled data from 155 patients were included. All patients had an acute block of the CTI. The mean number of PFA applications was 7.78 (95% CI 6.53–9.48). The incidence of ST-elevation was 0.04% (95% CI 0-2.23%). Subclinical vasospasm was documented in 45% (95% CI 32%–59%) of patients who underwent periprocedural coronary angiography. Prophylactic use of nitrates showed a trend toward reducing the incidence of subclinical vasospasm (RR 0.24, 95% CI 0.06–1.06, p=0.059). Twelve cases with patient-level data were included; six reported complications, including ST elevation and conduction disturbances. Conclusion: PFA for CTI flutter demonstrates high acute success; however, evidence regarding the durability of the block is limited. Clinical vasospasm with ST segment elevation is uncommon but can lead to life-threatening complications. The incidence of subclinical vasospasm is high, and nitrates trend toward reducing this phenomenon. To date, the role of PFA for this condition appears to be limited.

ABSTRACT Introduction Atrial fibrillation (AF) is the most common arrhythmia, and atrioventricular (AV) node ablation with pacemaker implantation is a therapeutic option for refractory cases. However, AV node ablation in patients with bioprosthetic tricuspid valves poses technical challenges. Methods An 84‐year‐old male with an EVOQUE transcatheter tricuspid valve replacement underwent AV node ablation (AVNA) under intracardiac echocardiography (ICE) guidance. Results Successful AV block was achieved with precise catheter positioning, improving the patient's symptoms and ventricular rate control. Conclusion This case demonstrates the feasibility of AVNA in patients with tricuspid bioprostheses, demonstrating feasibility with ICE guidance.

This is the first reported case of atrioventricular node ablation (AVNA) in a patient with an EVOQUE transcatheter tricuspid valve, performed for refractory atrial fibrillation with uncontrolled ventricular rates. This case highlights the feasibility and importance of advanced imaging techniques in managing arrhythmias in patients with bioprosthetic valves, offering insights into expanding therapeutic options for complex cardiovascular conditions.

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.