Giacomo Mugnai

Ventricular fibrillation (VF) is the primary arrhythmia causing sudden cardiac death. While typically linked to structural heart disease, a significant subset of VF episodes—especially in younger individuals—is triggered by focal ectopy from the His‐Purkinje system (HPS). The HPS possesses distinct electrophysiological properties that make it inherently susceptible to arrhythmogenesis. It serves a dual role, acting as both a primary source of initiating premature ventricular complexes through abnormal automaticity and triggered activity (early and delayed afterdepolarizations), and as a critical substrate maintaining VF via micro‐re‐entrant circuits. This narrative review comprehensively synthesizes current knowledge on Purkinje‐triggered VF, from its epidemiology and clinical setting to its underlying pathophysiological and ionic mechanisms of arrhythmia initiation and perpetuation. Finally, we critically evaluate contemporary diagnostic and management strategies, contrasting conventional focal trigger‐based ablation with evolving substrate‐based approaches such as Purkinje “de‐networking.”

Cardiovascular disease represents the leading cause of death in patients with Anderson-Fabry disease (FD), with sudden cardiac death (SCD) being one of the most frequently reported causes of mortality. However, a significant diagnostic gap persists in identifying patients at risk, as current stratification tools are inadequate for predicting lethal arrhythmic events. This narrative review resumes the existing peer-reviewed literature regarding the pathophysiology of FD arrhythmias and evaluates the diagnostic limitations of the current standard intermittent monitoring tools, such as the 24-hour Holter. Standard monitoring tools, such as the 24-hour Holter often miss paroxysmal, asymptomatic arrhythmias. Recent studies using implantable loop recorders (ILRs) show a significantly higher burden of arrhythmias than previously recognized. Myocardial fibrosis, identified as late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR), is strongly associated with malignant arrhythmias, together with the degree of left ventricular hypertrophy (LVH). Current consensus statements may underestimate the need for continuous monitoring in FD. By providing a comprehensive narrative synthesis of available observational and registry data, this paper proposes an updated, exploratory risk-stratification clinical guide for the extension of countinuous rhythm monitoring in high-risk subgroups of FD.

This review examines the protocols and rationale for stopping antiarrhythmic drugs (AADs) before interventional electrophysiology (EP) procedures to establish a drug‐free baseline, ensuring diagnostic accuracy and procedural success. The review provided a detailed analysis of procedure‐specific AADs washout requirements for supraventricular tachycardia, atrial fibrillation, and ventricular tachycardia ablation, and a comprehensive, drug‐by‐drug guide to calculate washout periods, based on pharmacokinetic and pharmacodynamic principles. This guide details the half‐life, metabolism, and elimination pathways for all major AAD classes, and gives specific, actionable recommendations for adjusting wash‐out times based on patient‐specific factors, including age, renal function, and hepatic impairment. The aim is to provide clinicians with evidence‐based guidance for standardizing AADs washout, thereby improving the safety and success of interventional EP procedures.

Aims: This study aimed to assess current clinical practices in the diagnosis and management of atrial fibrillation (AF) among patients with active cancer or a history of cancer therapy. Methods and results: A 25-item, physician-based survey was developed by the European Heart Rhythm Association in collaboration with the European Society of Cardiology Council of Cardio-Oncology and the International Cardio-Oncology Society. The survey was disseminated electronically. A total of 380 participants from 74 countries completed the questionnaire, with respondents primarily working as electrophysiologists (30%), general cardiologists (25%), and cardio-oncologists (22%). Nearly two-thirds reported that active cancer ‘definitely’ or ‘most probably’ influenced clinical decisions regarding AF diagnosis and management. When AF was diagnosed, rhythm control was the preferred management strategy for symptomatic patients, while rate control was favoured for asymptomatic individuals. A little over 40% reported that a history of cancer therapy ‘definitely’ or ‘most probably’ influenced clinical decisions regarding AF. The rhythm control was the most common strategy (40%). In both populations, opportunistic screening for AF and direct oral anticoagulants (DOACs) were preferred strategies. A high level of uncertainty was noted concerning the role of invasive treatment options. Conclusion: The survey revealed that, despite the lack of robust evidence specific to this patient cohort, contemporary treatment of AF in patients with active cancer or a history of cancer therapy generally follows guidelines developed for the broader AF population. These findings highlight the urgent need for more dedicated data to inform clinical decision-making in cardio-oncology patients with AF.

The role of cardiac implantable electronic devices (CIEDs), including implantable cardioverter-defibrillators (ICDs) and cardiac resynchronization therapy (CRT) devices, in patients supported with left ventricular assist devices (LVADs) remains controversial. Although ICDs clearly reduce the risk of sudden cardiac death (SCD) and improve outcomes in advanced heart failure (HF), their benefit in patients with continuous-flow mechanical circulatory support is less certain. Initial small studies involving LVAD patients, particularly those with older pulsatile devices, suggested that ICDs confer a survival benefit during LVAD support. However, more recent evidence has been inconsistent. Some studies show modest protection against arrhythmic death, whereas others show no improvement in overall mortality. Similarly, CRT does not appear to offer significant additional hemodynamic benefits after LVAD implantation, and current evidence does not strongly support its routine continuation. Device-related complications—including lead failure, infection, electromagnetic interference, and inappropriate shocks—are major clinical concerns that can offset potential benefits. Accordingly, current guidelines recommend maintaining pre-existing ICD or CRT devices in LVAD patients but do not endorse the routine implantation of new devices after LVAD placement. The existing evidence highlights the need for a nuanced and individualized approach to CIED therapy in patients with LVAD. Future research should focus on randomized trials, registry-based analyses, and the exploration of novel technologies such as leadless pacing, subcutaneous ICDs, and advanced programming algorithms. Patient-centered outcomes, particularly quality of life and ethical considerations—such as ICD deactivation in end-of-life scenarios—must be considered in decision-making in this evolving field.