Rodriguez, Juan F.

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 Aims Patients with end-stage renal disease (ESRD) and atrial fibrillation present a challenge for thromboembolic prevention, given their elevated risks of both thromboembolism and bleeding. Anticoagulants carry a higher bleeding risk in this population without clear evidence of thromboembolic benefit. This study aims to define the role of left atrial appendage occlusion (LAAO) as a preventive strategy for patients with ESRD. Methods and results A systematic literature review was conducted to identify studies reporting outcomes in patients with ESRD who underwent LAAO. Meta-analyses of aggregate and individual patient data were performed to evaluate acute and long-term outcomes and compare them with those of patients without ESRD. Seventeen studies reporting data from 24 127 patients, including 1047 with ESRD, were included. Procedural complications were more common in patients with ESRD (RR 2.23; P = 0.02), with a pooled rate of 4% (95% CI, 1–9%). There was no significant difference in thromboembolic event rates during follow-up between the groups (IRR 1.44; P = 0.16), but major bleeding incidence was higher among patients with ESRD (IRR 1.84; P &lt; 0.01). Individual patient-level data from seven studies comprising 4745 patients (268 with ESRD) were obtained and analysed. Similarly, there was no significant association between ESRD and stroke/TIA incidence (HR, 1.22; 95% CI, 0.66–2.26), but major bleeding was higher on patients with ESRD (HR, 1.65; 95% CI, 1.01–2.69). Conclusion LAAO represents a feasible option for thromboembolic prevention in patients with ESRD, although these patients have an increased risk of complications and bleeding.

ABSTRACT 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 individual case reports were reviewed and summarized. The mean number of PF applications, acute success rate, and prevalence of coronary vasospasm were evaluated. 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. 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 tend toward reducing this phenomenon. To date, the role of PFA for this condition appears to be limited.

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: 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.