Josef Kautzner

Aims: Cardioneuroablation (CNA) attenuates excessive parasympathetic input to the sinus and atrioventricular (AV) nodes by ablating atrial ganglionated plexi (GP), while preserving sympathetic innervation and intrinsic nodal function. It offers a mechanism-directed alternative to permanent pacing in selected patients with reflex syncope, functional AV block, or symptomatic vagally mediated sinus bradycardia. This review translates that physiological rationale into a practical, reproducible procedural framework. Methods and Results: Current evidence is synthesised with the collective procedural experience of the writing group. Successful implementation rests on careful patient selection, accurate identification of the cardioinhibitory phenotype, and a structured, physiology-guided procedure. Implantable loop recorders are central to documenting spontaneous events and distinguishing sinus- from AV-nodal mechanisms, complemented by tilt-table and atropine testing. During ablation, extracardiac vagal stimulation (ECVS) provides the most robust physiological endpoint for confirming vagal attenuation; where ECVS is unavailable, surrogate markers can guide the procedure, albeit with recognised limitations. Practical workflows are set out, including phenotype-driven GP targeting, the ablate–test–ablate sequence, and distinct strategies for sinus-node– and AV-node–predominant phenotypes. Technical considerations, safety, laterality of ablation, and challenging scenarios—recurrence after apparently successful CNA, athletes with functional bradyarrhythmias, and CNA during atrial fibrillation ablation—are also addressed. Conclusion: By emphasising procedural implementation and physiological endpoints, and situating CNA within the broader management of vagally mediated bradyarrhythmias, this review offers a reproducible, phenotype-guided framework to support its safe and effective use. It reflects current evidence and accumulated procedural experience rather than formal recommendation.

Cardioneuroablation (CNA) has emerged as a therapeutic option for functional bradyarrhythmias and reflex syncope, achieved through parasympathetic denervation via atrial ganglionated plexi ablation. Although efficacy data are encouraging, safety evidence remains limited and heterogeneous. We performed a comprehensive review of complications associated with CNA and integrated these findings with a single-centre experience of 377 consecutive procedures performed in the Institute for Clinical and Experimental Medicine, Prague, Czech Republic, between 2014 and 2026. Reported complications were infrequent and included vascular access complications, pericardial effusion, phrenic nerve injury, coronary artery injury, transient sinus node dysfunction and atrioventricular conduction disturbances. Post-procedural manifestations related to autonomic modulation included inappropriate sinus tachycardia, reduced exercise tolerance and occasional atrial arrhythmias, whereas the impact on ventricular arrhythmogenesis remains uncertain. In our institutional cohort, the overall major complication rate was 1.9% (7/377), including 0.3% (1/377) requiring intervention. No complication resulted in permanent damage or sequelae. CNA appears to have an acceptable safety profile in experienced centres, although complications are probably underrecognised or underreported and long-term prospective data are needed.

Aims: Obesity is one of the strongest risk factors for the development of atrial fibrillation (AF), and its reduction is associated with the alleviation of AF burden. The HOBIT-AF study aimed to evaluate the impact of complex weight loss interventions on AF recurrence rate in obese individuals after catheter ablation (CA). Methods and results: The HOBIT-AF was a randomized controlled trial with a 15-month treatment period (3–18 months post CA) involving complex weight-reducing interventions in the active arm. The primary outcome was the change in AF/atrial tachycardia (AT) burden assessed from baseline and the final 14-day Holter monitoring. A total of 167 individuals (aged 59 years, body mass index of 35.6 kg/m2) were randomized into the active (n = 85) and control group (n = 82). At the end of the treatment period, a mean reduction of 6.8 ± 7.0% of the initial body weight accompanied by improvement of metabolic parameters was achieved in the active group. The AF/AT burden change was 0.6 ± 2.5% (95% CI: −4.2–5.5%) in the active group and −0.9 ± 1.8% (95% CI: −4.5–3.0%) in the control group. The AF/AT recurrence-free survival during the 3–18-month follow-up period was comparable between groups (70.4% vs. 69.6%). Conclusion: HOBIT-AF trial showed that despite the beneficial effect of body weight reduction on metabolic profile of obese patients with predominantly paroxysmal AF after CA, no reduction in AF/AT recurrence was observed in comparison with control patients. This may be likely due to low AF burden after previous CA, limiting further improvement.

BACKGROUND: Obesity is a major risk factor for atrial fibrillation and heart failure. We aimed to characterize left atrial (LA) structural and functional changes across body mass index (BMI) strata in patients with atrial fibrillation referred for catheter ablation. METHODS: We studied 1040 consecutive patients (67% men; mean age, 62 years; 71% in sinus rhythm). Participants were stratified by BMI (2 ). Comprehensive echocardiographic assessment of LA structure and function was integrated with invasive LA pressure measurements obtained via transseptal access during the ablation procedure. Associations across BMI strata were evaluated using regression analyses. RESULTS: Patients with higher BMI had larger estimated total blood and plasma volumes along with higher LA volumes and pressures, greater cyclic wall stress, and a rightward shift of the estimated LA pressure-volume relationship. Conversely, estimated operant LA stiffness did not differ across BMI strata. BMI-related differences in LA volume were attenuated by body surface area indexing but preserved with height-based indexing. Conventional volumetric indices of LA phasic function were similar across BMI strata, whereas available LA strain indices (n=107) were lower with greater adiposity, consistent with worse LA phasic function. Compared with patients without heart failure, those with heart failure exhibited more pronounced structural, functional, and hemodynamic atrial remodeling, consistent with a more advanced atrial myopathy phenotype. CONCLUSIONS: In patients undergoing atrial fibrillation ablation, higher BMI is associated with a predominantly load-related pattern of LA remodeling, characterized by larger LA volume and pressures, greater cyclic wall stress, and a rightward shift of the estimated pressure-volume relationship. BMI-associated early atrial remodeling may precede overt atrial dysfunction, potentially contributing to the link between excess adiposity, atrial fibrillation, and heart failure with preserved ejection fraction.

Aims: Early rhythm-control improves cardiovascular outcomes in patients with atrial fibrillation (AF). Its effectiveness in patients with cancer is unclear. This study evaluated the effects of cancer history on early rhythm control in the EAST-AFNET 4 trial. Methods and results: This secondary analysis of EAST-AFNET 4 compared patients with and without a history of cancer, including active cancer and cancer in remission. Outcomes included the primary outcome, a composite of cardiovascular death, stroke, or hospitalization for worsening heart failure or acute coronary syndrome; the safety outcome, a composite of death, stroke, and serious adverse events related to rhythm control; and rhythm at 24 months. Cancer history was available in 2779 of 2789 patients (99.6%). Cancer history was present in 216 of 2779 (7.8%; 19 with active cancer; mean age, 73 years; 95 [44%] women; mean CHA2DS2-VASc score, 3.5). During a follow-up of 8.6 years, early rhythm control reduced the primary outcome in patients with and without a history of cancer (Pinteraction = 0.23) with high rates of sinus rhythm at 24 months (cancer: 84.9%, without cancer: 81.8%; Pinteraction = 0.60). In patients with a cancer history, there was a signal for more safety outcomes with early rhythm control [early rhythm control 36/116 (31%) patients with event, 22 deaths; usual care 20/100 (20%) patients with event, 18 deaths; Pinteraction = 0.055]. Conclusion: Early rhythm control therapy appears effective in patients with AF and a history of cancer but may be less safe than in patients without cancer, in this hypothesis-generating analysis. This could be a play of chance but warrants further research into the safety and efficacy of rhythm control therapy in patients with a cancer history. Trial Registration: ClinicalTrials.gov Identifier: NCT01288352

Aims: Electrical ventricular dyssynchrony is a hallmark of intraventricular conduction disease in heart failure with reduced ejection fraction. Although cardiac resynchronization therapy (CRT) is effective, a proportion of patients with electrical dyssynchrony evidenced by an electrocardiogram (ECG) remain non-responders. Besides the QRS duration, visualization and quantification of the depolarization sequence could contribute to improving CRT response. The study aimed to evaluate the CineECG-derived mean temporo-spatial isochrone trajectory of depolarization in CRT patients. Methods and results: Among the adult cohort of 121 patients who underwent CRT implantation, there were 93 (33% female) responders and 28 (7% female) non-responders. ECGs recorded before and immediately after CRT implantation were collected and analysed using the CineECG modality with a generic heart/torso model. The CineECG-derived path directions were computed for the QRS on anteroposterior, interventricular, and apicobasal axes within the cardiac anatomy. Spatial depolarization characteristics were tested for the association with left ventricle reverse-remodelling at 6-month follow-up. The pre-implantation depolarization sequence was predominantly from the right to the left ventricle, and after the CRT implant, it has been transformed into an apicobasal direction. In multivariate logistic regression, the pre-implant QRS duration, apicobasal depolarization gradient, and CRT-induced QRS shortening independently predicted CRT response. The Akaike information criterion indicated that combining all three yielded the strongest predictive model. Conclusion: CineECG-derived depolarization gradients, which reflect ventricular activation sequence, changed significantly after CRT, and the pre-implantation apicobasal gradient independently predicted echocardiographic outcome, with a less pronounced gradient associated with better haemodynamic response.

Background: Population-level data on preclinical heart failure (HF) remain limited because most epidemiological studies focus on symptomatic HF. We therefore developed an administrative-data algorithm to classify HF stages across the national population and describe temporal trends, stage transitions, and mortality across the HF continuum. Methods: Using a claims-based staging framework adapted from the Universal Definition of HF, we classified HF stages from ICD-10 codes, prescription records, and medical procedures. We applied this algorithm to the Czech population, linking the National Registry of Reimbursed Health Services to National mortality records from 2015 to 2024. Results: In 2024, 27.8% of the Czech population met criteria for Stage A HF and 8.2% for Stage B. Over 10 years, the prevalence of both preclinical stages increased beyond what could be explained by population aging alone, with age-standardized prevalence rising by 9.5% for Stage A and 19.2% for Stage B. Age-standardized 1-year mortality showed a steep stepwise gradient, from 0.69% in Stage A to 1.69% in Stage B, 3.06% in Stage C, and 7.27% in Stage D. Among 52,172 individuals with incident clinical HF in 2024, more than 95% had previously met administrative criteria for Stage A or Stage B. Conclusion: Administrative surveillance of the HF continuum using routinely collected healthcare data provides a scalable administrative framework for population-level monitoring of HF burden. In Czechia, both preclinical and clinical HF burdens increased over time beyond population aging alone, underscoring the need for earlier preventive strategies targeting preclinical disease. Clinical Perspective: We developed a nationwide administrative-data algorithm that classifies the full heart failure continuum (Stages A–D) using routinely collected ICD-10 diagnoses, prescription claims, and procedure codes, showing that both preclinical and clinical HF burdens are rising beyond what population aging explains. More than 95% of individuals who developed clinical HF had previously met administrative criteria for Stage A or Stage B, suggesting that progression to overt disease is often preceded by an identifiable preclinical phase that may represent an opportunity for prevention. This scalable, low-cost surveillance framework enables health systems to identify at-risk populations, track HF trends over time, and target preventive strategies toward preclinical stages, an approach that could be adapted internationally to inform policy and resource allocation. Graphical Conclusion: A population-wide HF staging system based on administrative data enables surveillance of the HF epidemic. In Czechia, the burden of preclinical and clinical HF is increasing.

Intracardiac echocardiography (ICE) is an imaging technique that provides real-time, detailed visualization of intracardiac structures during various interventional procedures performed in the electrophysiology laboratory. Over the past decades, ICE has evolved beyond simply assisting with transseptal puncture, becoming an auxiliary tool in numerous aspects of cardiac interventions. This scientific statement offers a comprehensive, systematic overview of current applications of ICE across different clinical scenarios. The existing evidence regarding the benefits of ICE is primarily derived from observational studies, which complicates the formulation of definitive advice for its clinical use. Thus, this document aims to serve as a practical roadmap, emphasizing the key benefits of the technique. The document covers fundamental principles of ICE imaging, standardized views, its role in transseptal puncture, ablation of supraventricular and ventricular arrhythmias, reduction of procedural radiation, early detection and management of periprocedural complications, identification of infective endocarditis, and the role of ICE for endomyocardial biopsy and left atrial appendage occlusion procedures.