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BACKGROUND: Pulsed field ablation is now widely used for atrial fibrillation (AF) ablation, but atrial tachyarrhythmia recurrence remains common and postablation risk tools are limited. We assessed whether a validated sinus‑rhythm artificial intelligence— enabled ECG AF probability score, and its early postablation change, predicts recurrence after pulsed field ablation. METHODS: We studied consecutive patients undergoing index pulsed field ablation across 3 Mayo Clinic sites (February 2024–March 2025) with ≥1 sinus‑rhythm ECG within 180 days preprocedure. Baseline artificial intelligence—enabled ECG AF score (range 0–1) was the mean across baseline ECGs. Recovery indices (RI30/60/90), defined as mean postprocedure artificial intelligence—enabled ECG score within days 1–30/60/90 minus baseline, predicted post‑blanking recurrence using corresponding 30‑, 60‑, and 90‑day blanking windows. The primary outcome was time to first documented AF/atrial flutter/atrial tachycardia episode >30 seconds, ascertained via clinic ECGs, ambulatory monitoring, and device interrogations. Cox regression adjusted for prespecified clinical and echocardiographic covariates assessed associations; Harrell C‑statistic quantified discrimination. RESULTS: Among 1052 patients (67±10 years; 33% women), median baseline score was 0.35; 320 (30%) recurred over 188 days. Higher baseline score independently predicted recurrence (hazard ratio per 0.1 increase, 1.08 [95% CI, 1.03–1.14]). Scores rose on day 0 after ablation, then declined over subsequent weeks, with persistently higher, less‑improving trajectories among patients who recurred (time×recurrence interaction P <0.001). Day 0 score was not independently associated with recurrence after adjustment. Attenuated early recovery (higher recovery index) was independently associated with recurrence, most robustly for RI-90 (hazard ratio per 0.1 increase, 1.15 [95% CI, 1.07–1.24]), and improved discrimination beyond baseline and covariates (C‑statistic, 0.63–0.67; ΔC=0.04). Findings were consistent in a historical thermal ablation cohort. CONCLUSIONS: Baseline and early postablation dynamics of a sinus‑rhythm artificial intelligence—enabled ECG AF probability score are associated with pulsed field ablation recurrence and may aid multivariable risk stratification; prospective validation is warranted.

Abstract Background Vagally mediated syncope and functional bradyarrhythmias can cause recurrent symptoms, injury and a need for permanent pacing, yet standard therapies do not address the underlying autonomic reflex. Cardioneuroablation (CNA) targets this mechanism, but adoption has been limited by uncertainty about patient selection, procedural endpoints and durable outcomes. Methods We studied 95 consecutive patients with vagally mediated syncope (n=78) or functional bradyarrhythmia (n=17) who underwent CNA at a single center by a single lead operator under a uniform, prospectively maintained protocol. Extracardiac vagal stimulation (ECVS) was performed before and after ablation to confirm vagally mediated sinus or atrioventricular (AV) nodal responses and to verify their attenuation. Outcomes through 1 year included clinical recurrence, quality of life, pacing burden and pacemaker extraction. Results Before ablation, ECVS provoked sinus pauses in 95.8% of patients and AV block in 91.6%; after ablation, sinus pauses were abolished in every patient and residual AV block was present in 4.2%. One-year freedom from recurrent syncope and from bradyarrhythmia-related events was 93.8% and 94.1%. Syncope burden fell from a median of 2.7 episodes per year to none, and disease-specific quality of life improved substantially (P<0.001). Among patients with pre-existing devices, atrial pacing burden fell from a median of 22% to 0%. There were no strokes, deaths or myocardial infarctions. Conclusions In this single-center cohort, physiology-guided CNA was associated with durable symptom control, improved quality of life and reduced pacing across vagally mediated bradyarrhythmia syndromes. Multicenter controlled studies are needed to confirm these findings.

Abstract Introduction Despite its prevalence, risk stratification for tachycardia-induced cardiomyopathy remains poorly understood. A deep learning model developed at Mayo Clinic uses standard 12-lead electrocardiograms (ECGs) to predict reduced LVEF (≤35%) in the general population with high accuracy (AUC 0.93) Purpose We investigated the performance of AI-ECG in predicting systolic dysfunction among patients with atrial fibrillation and rapid ventricular response, and compared it with NT-proBNP. Methods We conducted a retrospective study (IRB approval #25-000904) of adult patients (age ≥ 18 years) evaluated across our Clinic enterprise with atrial fibrillation and rapid ventricular response (heart rate &gt;100 bpm), including AF occurring in-hospital and AF at presentation, between January 2017 and May 2025. We excluded patients with a known history of heart failure with reduced EF (&lt;50%). We also collected data on NT-proBNP levels when available within one week of the ECG and echocardiogram. Results A total of 11,801 patients were included, with a mean age of 73.2 +- 12.6 years, 48.6% female and 94.8% White. A combination of AI ECG low EF probability cutoff of 75% had specificity of 96% and 98% NPV in ruling out LVEF &lt; 35%. A combination of AI ECG low EF probability cutoff of 17% and LVEF &lt;35% provided the best balance of sensitivity and specificity, 66% and 78%, respectively with an accuracy of 78%. NT-proBNP data was available on 5,279 patients (48%). Mean NT-proBNP level was 4090 pg/mL. Based on ROC curve analysis, AI ECG was superior to NT-proBNP in predicting LVEF &lt;35% (AUC 0.72 vs 0.59), with accuracy of 77% versus 47% at Youden’s cutpoints of AI-ECG probability of 17% and NT-proBNP level of 1767 pg/mL, respectively Conclusions Our study demonstrates the utility of AI-ECG in predicting reduced LVEF among patients with AF RVR. AI-ECG demonstrated excellent specificity and NPV in ruling out reduced LVEF, serving as a powerful clinical screening tool to assist with the pharmacologic choice of rate control and could change the timing of further echocardiographic evaluation. Our study offers novel insights paving the way for future investigations to help fine-tune and further delineate the role of AI ECG in risk stratifying patients with suspected tachycardia-induced cardiomyopathy, guiding therapeutic and diagnostic clinical decisions

Abstract Introduction Atrial fibrillation (AF) is a major contributor to stroke risk, yet many cases remain undiagnosed due to its silent and paroxysmal nature. To address this, multiple risk scores have been developed to predict incident AF. This study aimed to evaluate the predictive accuracy of five widely used clinical AF prediction tools (i.e., CHARGE-AF, CHA2DS2-VASc, mC2HEST, HATCH, and HAVOC) among patients undergoing long-term continuous monitoring with implantable loop recorders (ILRs). Methods We conducted a retrospective cohort study across three major US academic medical centers, including patients with ILRs and no prior diagnosis or ECG evidence of AF. Clinical variables used to calculate each risk score were extracted from electronic health records. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Kaplan-Meier survival analysis and Cox proportional hazards models were used to evaluate the association between each score’s risk categories and incident AF (defined as any episode lasting ≥6 minutes). Calibration was assessed using calibration plots and Brier scores. Results A total of 3,895 patients were included (mean age 61 ± 17 yrs.; 51% male). Incident AF was detected in 879 patients (22%) over a median follow up of 17 months (IQR 8-35). Table 1 presents baseline characteristics and device detected AF event data during follow up. CHARGE-AF had the highest AUC (0.68) but also the highest Brier score (Fig. 1). Failure curves showed clear risk stratification across all tools (Fig. 2). Calibration plots (Fig. 3) demonstrated modest agreement between predicted and observed risk across all models. Using CHARGE-AF as the reference, pairwise comparisons of Brier scores via the Wilcoxon signed-rank test showed lower calibration accuracy than CHA2DS2-VASc (p = 0.03), mC2HEST (p = 0.001), and HAVOC (p = 0.001), with no significant difference compared to HATCH (p = 0.15). Conclusions In patients undergoing continuous rhythm monitoring with ILRs, commonly used AF prediction scores demonstrated modest discriminatory ability and similar calibration performance. These findings suggest that existing risk models, which were largely developed in cohorts with clinically diagnosed AF, may not optimally translate to continuously monitored populations. Future work is needed to develop and validate AF prediction models specifically in cohorts undergoing long-term continuous cardiac monitoring.Figure 1Figure 2-3

ABSTRACT Background Superior vena cava isolation (SVCI) is performed as an adjunct to pulmonary vein isolation (PVI) for atrial fibrillation, yet whether an empiric or trigger‐guided strategy is preferable remains uncertain. Prior meta‐analyses have been largely restricted to index procedures in paroxysmal AF and have not explicitly stratified by ablation strategy. We sought to address these gaps through a systematic review of available randomized evidence. Methods Major databases were searched through November 2025 for RCTs comparing PVI+SVCI versus PVI alone. Trials were stratified by strategy: empiric SVCI (performed irrespective of SVC ectopy) or trigger‐guided SVCI (performed only upon demonstrated SVC triggers). The primary outcome was atrial tachyarrhythmia recurrence (≥30 s) beyond the blanking period. Random‐effects models, pre‐specified subgroup analyses, meta‐regression, and GRADE certainty assessment were performed. Results Eight RCTs ( n = 1231) were included; most enrolled paroxysmal AF, while two incorporated non‐paroxysmal AF subtypes and one evaluated repeat ablation procedures. Overall, SVCI+PVI significantly reduced recurrence versus PVI alone (97/604 vs. 135/627; RR 0.77, 95% CI 0.61–0.97; p = 0.03; I 2 = 0%). On stratified analysis, empiric SVCI demonstrated a significant recurrence reduction (RR 0.70, 95% CI 0.53–0.92; p = 0.01; I 2 = 0%), while trigger‐guided SVCI did not reach statistical significance (RR 0.80, 95% CI 0.37–1.74; p = 0.57; I 2 = 52%). In paroxysmal AF ( n = 1038), adjunctive SVCI significantly reduced recurrence compared with PVI alone (RR 0.68, 95% CI 0.52–0.90; p = 0.01; I 2 = 0%). Fluoroscopy time was longer with SVCI; total procedure duration was comparable. Major complications were infrequent but numerically higher with SVCI+PVI (15/604 vs. 7/627; RR 1.96, 95% CI 0.87–4.38; p = 0.10). Meta‐regression identified no significant effect modifiers. GRADE certainty was high for overall and empiric analyses, and moderate for trigger‐guided SVCI. Conclusions Empiric SVCI significantly reduced AT/AF recurrence as an adjunct to PVI, while trigger‐guided SVCI did not demonstrate a significant benefit. These findings suggest SVC isolation confers benefit independent of prior trigger documentation, supporting the role of empiric SVCI as an adjunct to AF ablation.

Background: Contemporary data on trends in survival after incident atrial fibrillation (AF) are limited. Methods: Residents of a 27-county area in southern Minnesota and western Wisconsin with new-onset atrial fibrillation or atrial flutter between 2013 and 2023 were identified. An electronic algorithm requiring 1 inpatient code or 2 outpatient codes separated by >7 days but within 1 year was used to define AF. Patients were followed for all-cause mortality through March 31, 2025. Standardized mortality ratios of observed versus expected survival were calculated, and time trends in survival were examined using Cox regression adjusting for demographics, cardiovascular risk factors, comorbid conditions, and area-level measures of socioeconomic status and rurality. Results: There were 44,930 individuals identified with incident AF from 2013-2023 (56.4% male; mean (SD) age 72.8 (13.5) years; 95.8% were non-Hispanic white). Within the first 90 days, the risk of all-cause mortality was greatly elevated compared with individuals of a similar age and sex distribution in the general population (standardized mortality ratios 12.6, 95% CI, 12.1-13.0 and 3.8, 95% CI, 3.6-4.0 for the first 30 days and 31 to 90 days after diagnosis, respectively). This excess risk was observed for all age groups but was greatest in the youngest age group (standardized mortality ratios among 18-64 year olds for the first 30 days: 49.9, 95% CI, 44.6-55.7 and 31 to 90 days: 11.1, 95% CI: 9.4-13.1; Figure ). In the youngest age group, the excess risk persists through 5 years post AF, however, in the oldest age group the excess risk only persisted through 1 year. Survival within the first 90 days improved over the study period (adjusted hazard ratio [aHR], 0.88; 95% CI, 0.79-0.99 for 2023 vs 2013); likewise, among 90-day survivors, survival improved between 2013 and 2023 (aHR,0.82; 95% CI, 0.76-0.88). These trends were driven by improvements in the younger age groups, particularly for death among 90-day survivors (aHR for 18-64 years, 0.66, 95% CI, 0.52-0.83; 65-74 years: 0.77, 95% CI: 0.65-0.90; 75-84 years, 0.84, 95% CI: 0.75-0.95; 85+ years, 0.99, 95% CI: 0.98-1.01). Conclusion: In a Midwestern community, the excess risk of death is high within the first 90 days after incident AF. Furthermore, survival after AF has improved between 2013 and 2023, with the improvement greatest in younger age groups.

BACKGROUND: Radiofrequency (RF) ablation of premature ventricular complexes (PVCs) originating from the left ventricular summit may be unsuccessful, highlighting the need for alternative approaches. We aimed to assess the efficacy and safety of a novel dual-modality focal catheter in treating left ventricular summit PVCs in patients who had failed previous RF ablation. METHODS: Patients were prospectively enrolled and underwent a redo ablation procedure using an irrigated, contact-force sensing, dual-modality focal catheter (TactiFlex Duo, Abbott) under compassionate use indication. The ablation strategy, including the choice of energy modality (monopolar pulsed field [PF], RF, or both), was left to the operator’s discretion. Safety assessments included serial biomarkers, renal function, and CMR within 36 hours. Efficacy was defined as ≥80% reduction in PVC burden with symptom resolution at 3-month follow-up. RESULTS: Six consecutive patients (4 men; mean age, 53.8±15 years) with symptomatic left ventricular summit PVCs and a prior failed RF ablation (range, 1–2) were prospectively enrolled. All PVCs had an inferior axis, with a left bundle V1 morphology observed in 4 of 6 cases (mean burden, 30.1±5.3%). Acute suppression of PVCs was achieved in all cases. Acute suppression with a single PF application in the great cardiac vein-anterior interventricular vein occurred in 2 patients, while 3 patients required additional RF, PF, or combined RF+PF applications at adjacent sites. One patient with an inaccessible great cardiac vein-anterior interventricular vein was successfully treated in the left ventricular outflow tract with RF+PF application. Transient, reversible left anterior descending vasospasm was observed during PF delivery in 2 of 5 cases that underwent PF application adjacent to a coronary artery, despite pretreatment with intracoronary nitroglycerin without ECG or hemodynamic sequelae. All patients had durable suppression of PVCs at follow-up. CONCLUSIONS: In its first human application, dual-modality ablation was feasible and effective for refractory left ventricular summit PVCs. Transient coronary vasospasm occurred, though it was reversible and without acute clinical consequences.