Prasitlumkum, Narut

ABSTRACT Background Pulsed field ablation (PFA) is an emerging non‐thermal ablation modality with proven safety in atrial arrhythmia ablation. However, data on its performance for ventricular arrhythmias (VA) remain limited. Objective To evaluate the feasibility, safety, and efficacy of PFA for complex VA in a multicenter real‐world US registry. Methods This retrospective study included consecutive patients undergoing PFA for ventricular tachycardia (VT) or premature ventricular contractions (PVCs) at three Mayo Clinic centers (April 2024 to July 2025). The primary feasibility outcome was the successful delivery of PFA lesions to the intended target substrate. Primary efficacy outcomes included acute procedural success; sustained VT recurrence requiring implantable cardioverter‐defibrillator (ICD) shocks or multiple antitachycardia pacing therapies; and ≥ 80% reduction in PVC burden. Safety outcomes included procedural complications, valvular function, thromboembolic events, renal function, and conduction disturbances. Results Twenty‐six patients were included (13 PVC, 13 VT). Acute success was achieved in all VT ablations (69.2% complete; 30.8% partial) and in 92.3% of PVC ablations. Complications occurred in 11.5% of patients (transient LBBB [ n = 1] and vascular complications [ n = 2]). No thromboembolic events, intracardiac thrombus, or acute kidney injury were observed. Lesions near the mitral valve apparatus did not worsen mitral regurgitation, including in patients with pre‐existing valve disease. After a median follow‐up of 365 days, one patient experienced VT recurrence requiring ICD shocks. Estimated recurrence‐free survival after VT ablation was 61.5% at 12 months; 58.3% of PVC patients achieved ≥ 80% burden reduction. Conclusion PFA for VA appears feasible and acutely effective, with a low rate of procedure‐related complications. While acute success was high, long‐term outcomes were acceptable for VT ablation and relatively modest for PVC ablation, highlighting the need for continued refinement of technology and energy‐delivery strategies. Larger prospective studies are warranted.

ABSTRACT Background Atrial fibrillation (AF) is prevalent in cardiac amyloidosis (CA) and is associated with adverse clinical outcomes. Catheter ablation is increasingly used for rhythm control in this population, yet its clinical outcomes remain uncertain. We performed a systematic review and meta‐analysis to evaluate arrhythmia recurrence and clinical outcomes following catheter ablation compared with medical therapy in patients with CA. Methods We systematically searched MEDLINE, Embase, and Scopus from inception through December 2025 for studies evaluating catheter ablation of atrial arrhythmias in CA. Cohort studies reporting arrhythmia recurrence and/or clinical outcomes were included. The primary outcome was freedom from atrial arrhythmia (AA) following ablation. Secondary outcomes included all‐cause mortality, heart failure hospitalization, and stroke. Random‐effects models were used to pool event rates and odds ratios (ORs). Results Thirteen observational studies comprising 797 patients with CA and AF were included. The pooled rate of freedom from AA following catheter ablation was approximately 50% (95% CI 37%–63%; I 2 = 71.7%). The all‐cause mortality analysis included 4 observational studies comprising 616 patients. Catheter ablation was associated with lower odds of all‐cause mortality (OR 0.26, 95% CI 0.11–0.60; I 2 = 18.4%); however, this association should be interpreted with caution given the retrospective design and risk of bias. No statistically significant differences were observed for heart failure hospitalization or stroke. Conclusions In patients with CA, catheter ablation was associated with modest arrhythmia‐free survival and lower odds of all‐cause mortality. However, all contributing studies were observational cohorts. Randomized studies are needed to confirm these findings.

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.

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.

ABSTRACT Background Pulmonary vein isolation (PVI) is the mainstay treatment for rhythm control in patients with persistent atrial fibrillation (PsAF). However, due to the complex mechanisms of PsAF, the efficacy of PVI alone remains modest. Spatiotemporal electrogram dispersion (STED) ablation is a promising strategy to enhance outcomes. This study aims to evaluate the efficacy of STED ablation plus PVI versus PVI alone in PsAF ablation. Methods A systematic search was conducted to identify studies published up to November 2024 comparing PVI plus STED ablation (PVI‐STED group) versus PVI alone (PVI group) in patients with PsAF. The primary outcomes were AF recurrence and sinus rhythm (SR) conversion. Results Eleven studies (three randomized controlled trials, three prospective cohorts, five retrospective cohorts) involving 1607 patients (mean age of 63.9 ± 9.3 years) were included. The PVI‐STED group was significantly associated with a lower risk of AF recurrence (OR: 0.40, 95% CI: 0.27–0.59, I ² = 25%) and a higher likelihood of SR conversion (OR: 7.04, 95% CI: 1.62–30.62, I 2 = 79%). No significant differences were observed in procedural time (MD: 27.61 min, 95% CI: −29.12 to 84.33, I ² = 97%), ablation time (MD: 4.4 min, 95% CI: −11.3 to 20.0, I 2 = 98%), or fluoroscopy time (0.25 min, 95% CI: −3.4 to 3.9, I 2 = 95%). The overall rate of AEs in the PVI‐STED group was 1% (95% CI: 1%–3%, I 2 = 0%). Conclusion The PVI‐STED approach demonstrated both efficacy and safety in treating PsAF, as evidenced by reduced AF recurrence and improved SR conversion rates.

Atrial fibrillation (AF) and cancer are increasingly recognized as interrelated conditions, with cancer patients showing elevated incidences of AF, and there is evidence that AF may sometimes precede cancer diagnoses. This comprehensive review investigates the epidemiology, pathophysiology, and management challenges associated with AF in cancer patients. Epidemiologically, several cancers are more closely related to increased rates of AF, including lung, colorectal, gastrointestinal, and hematologic malignancies. Mechanistically, both AF and cancer share pathophysiological pathways centered on inflammation, oxidative stress, and common cardiovascular risk factors, such as hypertension, obesity, and diabetes. The inflammatory microenvironment in tumors, marked by increased cytokines and growth factors, promotes atrial remodeling and AF susceptibility. Elevated reactive oxygen species (ROS) levels, driven by the metabolic demands of cancer, further contribute to atrial fibrosis and structural changes. Moreover, many anticancer treatments exacerbate AF risk. Management of AF in cancer patients presents many unique challenges and requires a multidisciplinary approach. Rate and rhythm control strategies are complicated by potential drug–drug interactions and limited data surrounding early implementation of rhythm control strategies in cancer patients. Interventional approaches such as catheter ablation, though effective in maintaining sinus rhythm, carry significant perioperative risk in patients with malignancy. Stroke prevention with anticoagulants is essential but requires cautious administration to avoid heightened bleeding risks, particularly in patients undergoing chemotherapy. Further, the limited applicability of standard risk stratification tools like CHA2DS2-VASc in this population complicate decisions regarding anticoagulation. This review highlights the bidirectional relationship between AF and cancer, the difficulties in management, and the critical need for further research in this field.

Background: PAINESD score was established as a predictor of periprocedural acute hemodynamic instability, long-term mortality and heart failure among patients undergoing catheter ablation for ventricular tachycardia (VT-CA). Objective: To assess the validity of PAINESD score and compare outcomes of high-risk patients undergoing catheter ablation for ventricular tachycardia (VT) with and without mechanical circulatory support (MCS) use during procedure. Methods: We conducted an observational dual-center study of consecutive patients with SHD undergoing VT-CA over a decade (2012-2022). The PAINESD score, based on 7 variables (COPD, age >60 years, general anesthesia, ischemic cardiomyopathy, NYHA class III or IV, ejection fraction <25%, VT storm, and diabetes mellitus), was calculated and categorized into low risk (<10), intermediate risk (10-16), and high risk (>16) as previously reported. Two survival analyses were performed to compare outcomes between different groups: one using all-cause mortality or heart transplant as the event, and another using recurrent or repeat ablation as the event. Multivariable Cox proportional hazards regression models were used to calculate hazard ratios for each PAINESD category and to determine the hazard ratio for the use of MCS among high-risk patients. Results: We found that between 2012 to 2022, 559 ablations were performed on 441 patients. There were 296 (53%), 182 (32.6%) and 81(14.5%) patients in low, medium, and high risk. Using low risk as reference, aHR for medium risk was 2.1 (1.24-3.7; p=0.006) and for high risk was 4.6(2.54-8.3; p <0.001). Among patients with high PAINESD score (n=81), 5 patients (6.2%) required MCS (Intra-arterial balloon pump (IABP)=1, ECMO only=1, ECMO+IABP=1, bypass=2). 4/5 (80%) patients on MCS stayed on them post procedure, except one patient on IABP. In this cohort, there was no difference between patients with and without MCS in primary outcome [aHR= 1.6 (0.48-5.4); p=0.43] and in secondary OUTCOME [1.29 (0.3-5.5; p=0.735)]. Conclusion: PAINESD was a significant predictor of mortality or heart failure, but it did not help in prediction of recurrence of VT, or repeat VT-CA.

Background: Patients undergoing epicardial access for ventricular tachycardia (VT) have a higher rate of complications and VT recurrence post-procedure. Data regarding electrophysiological factors driving the outcomes are scant. Objective: To compare the factors and outcomes associated with epicardial vs endocardial VT ablation. Methods: A single-center, retrospective study of patients undergoing catheter ablation for scar-related VT was conducted. Data collected included demographics, comorbidities, medications, relevant laboratory abnormalities, electrocardiograms, echocardiograms, detailed procedural characteristics, and outcomes. Results: Our cohort of 554 patients had 89 (16.1%) epicardial and 465 (83.9%) endocardial VT ablations. Patients undergoing epicardial ablation had a greater frequency of NICM, and more patients had undergone sympathetic modulation for VT (p < 0.05) but had lesser frequency of valve surgery, and CABG. Epicardial ablation was associated with greater use of both short-term (<3 months) and long-term (>6 months) anti-arrhythmic drugs (AAD) (p<0.01). Epicardial access was obtained by micropuncture or needle-in-needle technique for 22.5% (n=20) of patients. Except for more use of general anesthesia and the lesser usage of drugs for VT induction during epicardial procedures, there were no significant differences. Epicardial ablation had a higher risk of acute complications (<30 days) after the procedure (driven by pericarditis) (25% vs 7.8%, p<0.01). On survival analysis, epicardial access was associated with an increase in VT recurrence and repeat ablation (p<0.01) during a mean follow-up of 1072 days. On multivariate analysis, after adjusting for age, sex and comorbidities, epicardial access was an independent predictor of VT recurrence or repeat ablation [aHR 1.61 (CI: 1.18- 2.2)] Conclusion: Patients undergoing epicardial ablations with fewer comorbidities demonstrated increased AAD usage prior to and after the procedure, and a higher risk of acute complications after the procedure. Epicardial access was an independent predictor of VT recurrence or repeat ablation.