Peter Kupo

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.

Aims: Atrial fibrillation is the most common sustained cardiac arrhythmia, associated with considerable morbidity and mortality. Early detection is essential for optimal management. While wearable smart devices have shown promise, smartphone applications using photoplethysmography have also emerged as potential screening tools, but their diagnostic accuracy has not been adequately validated. This study aimed to compare the diagnostic performance of two commercially available photoplethysmography-based smartphone applications. Methods and results: In this prospective multicentre study, consecutive patients from three cardiology centres underwent simultaneous recordings with the FibriCheck® and Preventicus Heartbeats® applications and a 12-lead electrocardiogram during hospital admission or outpatient evaluation. Electrocardiograms were independently interpreted by blinded cardiologists. Diagnostic accuracy, rate of inconclusive recordings, technical performance, features, and pricing were compared between the two applications. A total of 206 patients (median age 69.5 years, 64.1% male) with 216 electrocardiograms were analysed; atrial fibrillation was present in 43.1%. Successful photoplethysmography recordings were obtained in 97.7% of FibriCheck (mean attempts 1.2 ± 0.7) and 87.5% of Preventicus Heartbeats (1.6 ± 1.3) measurements. Sensitivity and specificity were 89.0% and 100.0% for FibriCheck, and 86.4% and 99.0% for Preventicus Heartbeats. Inconclusive reading rates (where the algorithm indicated a suspicion of mild arrhythmia) were 8.5% and 11.1%, respectively. Conclusion: Both smartphone applications demonstrated high and comparable diagnostic accuracy for atrial fibrillation detection in a real-world population. These tools represent a viable, non-invasive option for early rhythm screening and follow-up, potentially improving patient outcomes, although further refinement is needed to reduce inconclusive recordings.

Background: Cavotricuspid isthmus (CTI) ablation is the preferred treatment for typical atrial flutter, performed using various techniques. This study aimed to compare procedural and follow-up data between point-by-point and continuous “dragging” radiofrequency (RF) catheter ablation methods. Methods: This retrospective, single-center study included 121 consecutive patients who underwent first-time RF CTI ablation for typical atrial flutter between January 2023 and August 2024. Patients were assigned to point-by-point ( n = 49) or continuous dragging ( n = 72) groups. All procedures were performed under conscious sedation using irrigated-tip catheters and intracardiac echocardiography. Patients with prior CTI ablation, cardiac surgery, or concomitant ablation were excluded. Procedural and follow-up outcomes were compared between groups. Results: The continuous dragging technique significantly shortened the time from the first to last ablation [12 (6; 27) min vs. 18 (11; 32) min; p < 0.05] and the time from the first ablation to the first CTI block [9 (8; 17) min vs. 13 (8; 25) min; p < 0.01]. Additionally, total ablation time [484 (285; 774) s vs. 704 (449; 955) s; p < 0.01] and energy usage [20,613 (11,191.5; 33,257.3) J vs. 25,717 (17,251.8; 36,420) J; p < 0.05] were lower in the dragging group. The dragging technique also increased the first pass block rate (69.4% vs. 46.2%; p < 0.01). There was no significant difference in overall procedure time [55 (46; 66) min vs. 58.5 (45; 72) min; p = 0.46], fluoroscopy duration (41 ± 6 s vs. 55 ± 8 s; p = 0.14), or acute reconnection rate (27.8% vs. 30.8%; p = 0.80). Both groups achieved a 100% acute success rate with no major complications. There was no significant difference in the rate of recurrence between the two groups (2.77% vs. 2.04%, p = 1.0) during the long-term follow-up (13.4 ± 3.8 months). Conclusion: The continuous “dragging” RF ablation technique for CTI ablation in typical atrial flutter enhances procedural outcomes compared to the point-by-point method, demonstrating reduced ablation time, lower energy consumption, and a higher first pass block rate, all without compromising efficacy or safety.

Background: Atrial fibrillation is the most common sustained arrhythmia worldwide. Pulmonary vein isolation (PVI) is the most effective catheter ablation technique for treating paroxysmal atrial fibrillation (pAF). Common ablation methods include point-by-point radiofrequency (RF) ablation and single-shot techniques such as cryoballoon ablation (CB). This single-center, prospective study aimed to compare the efficacy of ablation index-guided RF ablation (AI-RF) and CB in patients with symptomatic, antiarrhythmic-resistant pAF. Methods: A total of 154 patients undergoing initial PVI were divided into two groups (CB: 51, AI-RF: 103), based on the operators’ decision. Procedural data (total procedure time, fluoroscopy time, radiation dose, complication rate) and recurrence rates were analyzed over a 12-month follow-up period. Results: The CB group had a significantly shorter total procedure time compared to the AI-RF group (64 [57; 74.8] minutes vs. 92 [76; 119] minutes; p < 0.001). However, the CB group experienced higher fluoroscopy times (559 [395; 868] seconds vs. 167 [126; 224] seconds; p < 0.001) and a greater fluoroscopy dose (21.8 [11.7; 40.1] mGy vs. 7.65 [5.21; 14.5] mGy; p < 0.001). Recurrence rates were similar during both the blanking period (11.7% vs. 10.7%; p = 0.84) and the 12-month follow-up period (22.7% vs. 13.4%; p = 0.22). No major complications were reported during this study. Conclusions: In this single-center study, there were no significant differences in long-term recurrence or complication rates between the CB and AI-RF groups for patients with antiarrhythmic-refractory, symptomatic pAF. While the CB group benefited from a significantly shorter procedure time, it required a higher fluoroscopy dose and a longer fluoroscopy time.

Dual antiplatelet therapy (DAPT), which is essential in AMI management, combines aspirin with a P2Y12 receptor antagonist. This study compared the effectiveness of potent P2Y12 inhibitors versus clopidogrel in AMI patients treated with percutaneous coronary intervention (PCI). Methods: 65,986 AMI patients included in a nationwide prospective registry who underwent PCI and received DAPT were studied. In total, 9,014 patients received potent P2Y12 inhibitors, and 56,074 received clopidogrel. This study focused on mortality, recurrent myocardial infarction, stroke, repeat revascularization, and major adverse cardiovascular events (MACE) over seven years. The analysis utilized unadjusted models and inverse probability of treatment weighting (IPTW) to compare prognosis, and decision curve analyses were constructed to aid clinical decision making. Results: Potent P2Y12 inhibitors significantly reduced mortality risk (unadjusted hazard ratio (HR): 0.58; IPTW HR: 0.68) and MACE (unadjusted HR: 0.66; IPTW HR: 0.78). Diabetic patients showed greater benefits (HR:0.45). In patients at high bleeding risk, the mortality rate was 13% (HR: 0.87, p = 0.08). For patients aged 75–79, the HR for mortality was 0.82, whereas for those aged >80 years, it was 0.79, indicating significant mortality risk reduction. Similar trends were observed for MACE. Conclusion: This study demonstrated that potent P2Y12 inhibitors are more effective than clopidogrel in reducing mortality and MACE in patients with AMI and underscored their potential role in improving outcomes across diverse patient subgroups. The trend was consistent even during the COVID-19 pandemic. These findings highlight the need for personalized DAPT strategies, particularly for high-bleeding-risk patients, and challenge current guidelines favoring clopidogrel use in older patients.

Background: Atrioventricular node (AVN) ablation is an effective treatment for atrial fibrillation (AF) with uncontrolled ventricular rates despite maximal pharmacological treatment. Intracardiac echocardiography (ICE) can help with visualizing structures, positioning catheters, and guiding the ablation procedure. We compared only fluoroscopy-guided and ICE-guided AVN ablation regarding patients with permanent AF. Methods: Sixty-two consecutive patients underwent AVN ablation were enrolled in our retrospective single-center study (ICE group: 28 patients, Standard group: 34 patients). Procedural data, acute and long-term success rate, and complications were analyzed. Results: ICE guidance for AVN ablation significantly reduced fluoroscopy time (0.30 [0.06; 0.85] min vs. 7.95 [3.23; 6.59] min, p < 0.01), first-to-last ablation time (4 [2; 16.3] min vs. 26.5 [2.3; 72.5] min, p = 0.02), and in-procedure time (40 [34; 55] min vs. 60 [45; 110], p = 0.02). There was no difference in either the total ablation time (199 [91; 436] s vs. 294 [110; 659] s, p = 0.22) or in total ablation energy (8272 [4004; 14,651] J vs. 6065 [2708; 16,406] J, p = 0.28). The acute success rate was similar (ICE: 100% vs. Standard: 94%, p = 0.49) between the groups. Conclusions: In our retrospective trial, ICE-guided AVN ablation reduced fluoroscopy time, procedure time, and first-to-last ablation time. There was no difference in ablation time, total ablation energy, acute and long-term success, and complication rate.

Pulmonary vein isolation (PVI) stands as a widely practiced cardiac ablation procedure on a global scale, conventionally guided by fluoroscopy. The concurrent application of electroanatomical mapping systems (EAMS) and intracardiac echocardiography offers a means to curtail radiation exposure. This study aimed to compare procedural outcomes between conventional and our initial zero-fluoroscopy cases in patients with paroxysmal or persistent atrial fibrillation (AF), undergoing point-by-point PVI. Our prospective observational study included 100 consecutive patients with AF who underwent point-by-point radiofrequency PVI. The standard technique was used in the first 50 cases (Standard group), while the fluoroless technique was used in the subsequent 50 patients (Zero group). The zero-fluoroscopy approach exhibited significantly shorter procedural time (59.6 ± 10.7 min vs. 74.6 ± 13.2 min, p < 0.0001), attributed to a reduced access time (17 [16; 20] min vs. 31 [23; 34.5] min, p < 0.001). Comparable results were found for the number of RF applications, total ablation energy, and left atrial dwelling time. In the Zero group, all procedures were achieved without fluoroscopy, resulting in significantly lower fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p < 0.0001) and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p < 0.0001). The acute success rate was 100%, with no major complications. Zero-fluoroscopy PVI is feasible, safe, and associated with shorter procedure times compared to the standard approach, even in cases without prior experience in zero-fluoroscopy PVI.

Introduction: Pulmonary vein isolation (PVI) represents the cornerstone of catheter ablation procedures in patients with symptomatic paroxysmal/persistent atrial fibrillation (AF). Conventionally, PVI is performed using fluoroscopy, but it can also be performed using the zero-fluoroscopy (ZF) technique with the assistance of electroanatomical mapping systems and intracardiac ultrasound, achieving fluoroscopy-free procedures. Purpose: Our study aimed to compare procedural data of ablation-index guided point-by-point radiofrequency (RF) PVI performed with non-zero-fluoroscopy (NZF) vs. ZF approaches. Methods: We enrolled 100 consecutive patients undergoing PVI for antiarrhythmic drug- refractory AF in our prospective observational study. In the first 50 cases, PVI was performed using the NZF technique, and in the other 50 cases, the ZF technique was applied. Procedural time, fluoroscopy exposure, ablation parameters, and the occurrence of complications were compared between the two groups. Results: Compared to the NZF group, procedural time (59.6±10.7 min vs. 74.6±13.2 min, p<0.0001) was significantly shorter in the ZF group. This difference was mainly driven by the time from puncture to the beginning of left atrial mapping, which was significantly longer in the NZF group (17 [16; 20] min vs. 31 [23; 34.5] min, p<0.001). No differences were found between the two approaches in the number of RF applications (81 [73; 103] vs. 83 [71; 91], p=0.67), total ablation energy (54986 ± 13093 Ws vs. 55500 ± 11907 Ws, p=0.48), and the left atrial dwelling time (41.5 [36; 52.5] min vs. 40.5 [35; 46], p=0.14). No complications occurred in either group. In the ZF group, complete elimination of fluoroscopy was achieved in all cases, resulting in significant differences in fluoroscopy time (0 [0; 0] sec vs. 132 [100; 160] sec, p<0.0001] and dose (0 [0; 0] mGy vs. 4.8 [4.1; 8.2] mGy, p<0.0001) compared to the NZF technique. The acute success rate was 100% in the study population, and no complications occurred during the study period. Conclusion: Ablation-index guided ZF PVI is feasible and safe. Using this technique, the procedure time can be shortened besides achieving a similar acute success rate without increasing complications.

Introduction: Catheter ablation is the preferred treatment for typical atrial flutter (AFl), although it can pose challenges due to anatomical abnormalities. The integration of 3D electroanatomical mapping systems (EAMS) has notably diminished the need for fluoroscopy in AFl ablation procedures. Intracardiac echocardiography (ICE) has also demonstrated advantages in reducing radiation exposure during AFl ablation. Nevertheless, there is a lack of evidence on the feasibility of ICE-guided, zero-fluoroscopy AFl ablation without the use of EAMS. Methods: In this prospective study, we enrolled 80 patients with CTI-dependent AFl. The initial 40 patients underwent ablation guided by standard fluoroscopy along with ICE (Standard ICE group), whereas the remaining 40 patients underwent zero-fluoroscopy ablation exclusively using ICE (Zero ICE group). Procedure outcomes, including acute success, procedural duration, fluoroscopy duration, radiation dose, and any associated complications, were compared between the groups. Results: Both groups achieved a 100% acute success rate. In the Zero ICE group, the zero-fluoroscopy approach was successfully executed in 39 out of 40 cases (97.5%). There were no significant differences in procedure time (55.5 (46.5; 66.8) min vs. 51.5 (44.0; 65.5), p=0.50) and puncture to first ablation time (18 (13.5; 23) min vs. 19 (15; 23.5) min, p=0.50) between the groups. The Zero ICE group had significantly lower fluoroscopy time (57 (36.3; 90) sec vs. 0 (0; 0) sec, p<0.001) and dose (3.17 (2.27; 5.63) mGy vs. 0 (0; 0) mGy, p<0.001 compared to the Standard ICE group. Total ablation time was longer in the Standard ICE group (597 (447; 908) sec vs. 430 (260; 750), p=0.02), but total ablation energy (22458 (14836; 31116) Ws vs. 17043 (10533; 29302) Ws, p=0.10) did not differ significantly. First-pass bidirectional conduction block of the CTI and acute reconnection rates were comparable between the groups. No complications or recurrences were noted during the follow-up period. Conclusion: ICE-guided, zero-fluoroscopy CTI ablation for AFl using only ICE is feasible and safe. This method effectively eliminates radiation exposure without compromising procedural duration, total ablation time, or acute success rates.isthmus ablation by ICE

(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping.