Arrhythmia & Electrophysiology Review

The recently established non-thermal, single-shot pulsed field ablation (PFA) is a potential tool for achieving rapid pulmonary vein isolation (PVI) to cause cell death by electroporation, yet data regarding this state-of-the-art technology remain sparse. In this meta-analysis, we included 3,857 patients from 20 studies. There was no significant difference in AF recurrence between the PFA and control groups. Subgroup analysis showed that additional ablation beyond PVI has a similar rate of AF recurrence to PVI alone (10% versus 13%, respectively)...

BACKGROUND: Atrioventricular (AV) conduction ablation has been achieved by targeting the area of penetration of the conduction axis as defined by recording a His bundle potential. Ablation of the His bundle may reduce the possibility of a robust junctional escape rhythm. It was hypothesised that specific AV nodal ablation is feasible and safe. METHODS: The anatomical position of the AV node in relation to the site of penetration of the conduction axis was identified as described in dissections and histological sections of human hearts...

Ventricular arrhythmias associated with mitral valve prolapse (MVP) and the capacity to cause sudden cardiac death (SCD), referred to as 'malignant MVP', are an increasingly recognised, albeit rare, phenomenon. SCD can occur without significant mitral regurgitation, implying an interaction between mechanical derangements affecting the mitral valve apparatus and left ventricle. Risk stratification of these arrhythmias is an important clinical and public health issue to provide precise and targeted management...

This updated guidance is designed to help with implantation and follow-up with agreed standards of practice. The update includes new guidance on subcutaneous defibrillators, leadless pacemakers and conduction system pacing. It includes new guidance on considerations at the time of a potential box change and techniques to be considered to minimise the risk of infection.

BACKGROUND: Outcomes of device-detected AF remain unclear in individuals without a prior history of AF. METHODS: A meta-analysis was conducted to evaluate outcomes in individuals with no prior history of AF who experienced device-detected AF. Outcomes assessed were clinical AF, thromboembolism and all-cause mortality. A fixed-effects model was used to calculate RRs with 95% CI. RESULTS: Compared to individuals who did not experience device-detected AF, those who did had increased risks of clinical AF (RR 3...

The European Society of Cardiology guidelines for the management of adult congenital heart disease patients recommend screening for arrhythmias and bradycardias in symptomatic patients, often being done by means of an ambulatory 24-48-hour Holter or implantable loop recorder (ILR). However, nowadays non-invasive instruments, such as patches, smartwatches and smartphones based on single-lead ECGs that perform extended monitoring, are also available. The aim of this narrative review was to assess whether these instruments, when they detect arrhythmias and bradycardias in patients with adult congenital heart disease, will lead to meaningful changes in clinical care...

Computational models of cardiac electrophysiology have gradually matured during the past few decades and are now being personalised to provide patient-specific therapy guidance for improving suboptimal treatment outcomes. The predictive features of these personalised electrophysiology models hold the promise of providing optimal treatment planning, which is currently limited in the clinic owing to reliance on a population-based or average patient approach. The generation of a personalised electrophysiology model entails a sequence of steps for which a range of activation mapping, calibration methods and therapy simulation pipelines have been suggested...

AF is a prevalent condition that is associated with various modifiable and unmodifiable risk factors. Drug-induced AF, despite being commonly under-recognised, can be relatively easy to manage. Numerous cardiovascular and non-cardiovascular agents, including catecholaminergic agents, adenosine, anti-tumour agents and others, have been reported to induce AF. However, the mechanisms underlying drug-induced AF are diverse and not fully understood. The complexity of clinical scenarios and insufficient knowledge regarding drug-induced AF have rendered the management of this condition complicated, and current treatment guidelines follow those for other types of AF...

Percutaneous left atrial appendage occlusion aims to reduce the risk of stroke in patients with AF, particularly those who are not good candidates for systemic anticoagulation. The procedure has been studied in large international randomised trials and registries and was approved by the National Institute for Health and Care Excellence in 2014 and by NHS England in 2018. This position statement summarises the evidence for left atrial appendage occlusion and presents the current indications. The options and consensus on best practice for pre-procedure planning, undertaking a safe and effective implant and appropriate post-procedure management and follow-up are described...

No abstract text is available yet for this article.

Pulsed field ablation (PFA) is a novel energy form for the catheter ablation of cardiac arrhythmias, which uses electrical fields to mediate myocardial death via irreversible electroporation and other modalities. It is believed to offer relative tissue specificity, lowering - or even eliminating - the risk of complications associated with thermal energy, such as atrio-oesophageal fistulas. The proposed superior safety profile compared to thermal ablation has contributed to the enthusiastic implementation of PFA into clinical practice and is supported by early preclinical and clinical data...

Left atrial appendage occlusion (LAAO) is a suitable alternative to oral anticoagulant therapy to prevent stroke in patients with AF. Most procedures are performed under transoesophageal echocardiography (TOE) guidance, which facilitates transseptal puncture, reduces the risk of procedurerelated complications and provides an additional method for device selection and real-time monitoring during device deployment. However, TOE has significant shortcomings, including the need for general anaesthesia/deep sedation as well as a significant risk of procedure-related adverse events...

Catheter ablation is the treatment of choice for patients with symptomatic accessory pathways (APs) causing recurrent atrioventricular reciprocating tachycardia or in situations where APs conduct rapidly, posing a risk of sudden cardiac death. Conventional AP mapping relies on point-by-point assessment of local electrograms looking closely for pathway electrograms or early atrial or ventricular electrograms, which may be challenging and time consuming. Recently, open window mapping (OWM) using 3D navigational systems has emerged as a novel technique to help localise and ablate APs...

Postural orthostatic tachycardia syndrome (POTS) is a chronic debilitating condition of orthostatic intolerance, predominantly affecting young females. Other than postural tachycardia, symptoms of POTS include a spectrum of non-cardiac, systemic and neuropsychiatric features. Despite the availability of widespread pharmacological and non-pharmacological therapeutic options, the management of POTS remains challenging. Exaggerated parasympathetic withdrawal and sympathetic overdrive during postural stress are principal mechanisms of postural tachycardia in POTS...

Cardiac resynchronisation therapy (CRT) reduces the risk of heart failure-related hospitalisations and all-cause mortality, as well as improving quality of life and functional status in patients with persistent heart failure symptoms despite optimal medical treatment and left bundle branch block. CRT has traditionally been delivered by implanting a lead through the coronary sinus to capture the left ventricular epicardium; however, this approach is associated with significant drawbacks, including a high rate of procedural failure, phrenic nerve stimulation, high pacing thresholds and lead dislodgement...

The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group...

BACKGROUND: The prognostic impact of ventricular tachycardia (VT) catheter ablation is an important outstanding research question. We undertook a reconstructed individual patient data meta-analysis of randomised controlled trials comparing ablation to medical therapy in patients developing VT after MI. METHODS: We systematically identified all trials comparing catheter ablation to medical therapy in patients with VT and prior MI. The prespecified primary endpoint was reconstructed individual patient assessment of all-cause mortality...

Sudden cardiac arrest (SCA) is a common cause of death. The majority of SCA is caused by ventricular arrhythmia due to underlying CHD. Aborted SCA with no apparent diagnosis after initial assessment with ECG, echocardiography and coronary assessment is referred to as unexplained cardiac arrest (UCA). Systematic evaluation of such patients may reveal a specific diagnosis in up to half of patients before a diagnosis of idiopathic VF is assigned. Specific diagnoses include inherited cardiac conditions, such as latent cardiomyopathies or inherited primary electrical disease...

No abstract text is available yet for this article.

Radiation-associated cardiovascular disease, an increasingly recognised disease process, is a significant adverse effect of radiation therapy for common malignancies that involve the chest, and include lymphomas, lung, mediastinal and breast cancers. Two factors contribute to the increasing incidence of radiation-associated cardiovascular disease: advances in malignancy detection and the improved survival of cancer patients, by which many symptoms of radiation-associated cardiovascular disease, specifically radiation-associated arrhythmias, present years and/or decades following initial radiotherapy...