CARTO-Guided Atrial Fibrillation Ablation

Atrial Fibrillation (AF) is associated with increased morbidity and mortality and a more severe impairment in quality of life compared with patients with congestive heart failure or myocardial infarction. Left atrial myocardial extensions, known as “myocardial sleeves”, are present in almost all pulmonary veins (PVs), and have been recognized as the main source of triggers that initiate and perpetuate AF

Atrial Fibrillation Ablation Technique: State of the Art

The role of the pulmonary veins in the initiation of atrial fibrillation has clearly been elucidated and has led to catheter ablation of atrial fibrillation (AF) via pulmonary vein isolation, currently achieved with use of radiofrequency energy. The 2011 American guideline update on the management of AF considers catheter ablation as a Class Ia indication in patients without significant structural heart disease refractory to antiarrhythmic drug therapy. The 2011 update on the guidelines for the management of AF by the European Society of Cardiology lists catheter ablation as a class IIa recommendation in patients refractory to antiarrhythmic drug therapy. Catheter ablation may be considered first-line therapy in a select group of patients with paroxysmal AF and no significant underlying structural heart disease if an experienced operator performs the procedure (class IIb indication). It should be kept in mind that the single-procedure success rate is low, with only 40%, 37% and 29% of patients remaining free from recurrent arrhythmias at 1, 2 and 5 years of follow-up, respectively; the success rates increase after two procedures to 87%, 81% and 63% at 1, 2 and 5 years. Patients with longstanding persistent AF have lower success rates compared with patients with paroxysmal or persistent AF. This article focuses on recent developments and new technologies currently under investigation

Long RP Tachycardia with Atrioventricular Block. What is the Tachycardia Mechanism?

A 23-year-old woman underwent electrophysiological study because of a 9-year history of frequent episodes of supraventricular tachycardia. The patient had a normal baseline ECG and no structural heart disease. The baseline AH and HV intervals were 70 and 40 msec, respectively. Incremental atrial pacing and ventricular pacing reproducibly induced a narrow QRS complex tachycardia (cycle length 344 ms) with negative P-wave polarity in inferior leads and positive in V1 lead. During the tachycardia the earliest atrial activation was recorded at the ostium of the coronary sinus, where the AH and HA intervals were 95 and 237 ms, respectively (Fig. 1). What is the mechanism of this tachycardia

QT and QU Interval Prolongation, Bidirectional Ventricular Tachycardia and Aborted Sudden Death. An Andersen-Tawil Syndrome

A 42-year-old lady survived an episode of near-drowning and she was subsequently diagnosed with a rare genetic disease, recently classified as long QT 7 syndrome, for which she received an implantable cardioverter defibrillator. The features of this syndrome are herein described

Catheter Ablation of Ventricular Extrasystoles Originating from the Left Coronary Cusp

We describe the case of a 55-year-old man with frequent premature ventricular extrasystoles displaying inferior axis and positive QRS concordance in precordial leads. The arrhythmia was successfully ablated from the left coronary cusp. The electrocardiographic and electrophysiological characteristics of this arrhythmia are discussed

Torsade de Pointes related to the co-administration of amiodarone and digoxin

A case of acquired long QT syndrome and subsequent torsade de pointes related to the co-administration of amiodarone and digoxin is described in the present case report. The underlying electrophysiologic mechanism of this proarrhythmic event is discussed

Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17K study

Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF.Peer reviewe