Sanghamitra Mohanty

Pulsed field ablation has rapidly reshaped the landscape of atrial fibrillation ablation by offering a nonthermal, tissue-selective alternative to conventional thermal energy. This review highlights the scientific foundations, preclinical evidence, and engineering advances that established pulsed field ablation as a safer, faster, and more precise technology. We discuss how irreversible electroporation achieves myocardial selectivity, the pivotal studies that confirmed preservation of nearby structures, and the evolution of modern catheter systems designed for efficient and durable lesion creation. As pulsed field ablation platforms continue to mature, they are redefining procedural safety standards and expanding therapeutic possibilities in cardiac electrophysiology.

Aims: Intracardiac echocardiography (ICE) facilitates left atrial (LA) reconstruction during atrial fibrillation (AF) ablation. The artificial intelligence–based CARTOSOUND FAM (AIFAM) module enables automated three-dimensional LA reconstruction without the need for a dedicated pre-ablation mapping catheter. While this workflow has been described previously in radiofrequency ablation, its application and outcome in pulsed field ablation (PFA) remain limited. The objective of this study is to evaluate the feasibility, safety, and arrhythmia-free outcomes of a no-pre-mapping AIFAM-guided workflow during PFA using the variable-loop circular catheter (VLCC). Methods and results: Patients undergoing PFA AF ablation using VLCC were screened and those using AIFAM-guided ablation without pre-map were included in the analysis. The LA shell was created using the AI-based ICE module from the right atrium without the need for a LA mapping catheter and was used as the only reference shell for PFA energy delivery. Baseline demographics, AF subtype, comorbidities, procedural details, and follow-up outcomes were analysed. Recurrence was assessed using a 60-day blanking period and Kaplan–Meier survival analysis. A total of 412 patients underwent AF ablation using VLCC during the study period. Among them, 210 patients (mean age 68.1 ± 10.2 years; 54.8% male) underwent AIFAM-guided ablation without pre-map and were analysed. Atrial fibrillation subtype was paroxysmal in 52% and non-paroxysmal in 48%. Concomitant AF ablation and left atrial appendage occlusion (LAAO) were performed in 76 patients (36%). The mean CHA2DS2-VASc score was 3.4 ± 1.7, and the mean left ventricular ejection fraction was 56.2 ± 11.1%. All patients underwent pulmonary vein isolation, with additional PF lesions including posterior wall isolation in 87.5% and superior vena cava ablation in 60.5%. Skin-to-skin procedure time and LA dwell time were 78.8 ± 29.1 min and 47.1 ± 18.8 min for ablation alone and 87.3 ± 22.9 min and 54.6 ± 13.0 min for concomitant AF ablation and LAAO. Acute procedural success was achieved in 100% of cases. One acute non-catheter-related vascular complication (0.5%), and no late complications were documented. Among 184 patients with at least one follow-up, freedom from arrhythmia survival after the 60-day blanking was 77.7% in paroxysmal AF and 71.8% in non-paroxysmal AF at 270 days. Conclusion: AIFAM enables safe and reliable LA reconstruction for successful PFA ablation, including concomitant AF ablation and LAAO using VLCC, and reduces the need for pre-ablation mapping in select patients undergoing index ablation. This strategy demonstrated high acute success, low complication rates, and favourable arrhythmia freedom in a contemporary cohort.

Introduction: The LockeT external suture retention device addresses the shortcomings of manual compression (MC), and other vascular closure devices—namely, prolonged immobilization, resource utilization, and costs. Objective: In this study, we compare the safety and effectiveness of LockeT to that of MC. Methods: We performed a prospective, single‐center study of patients (N) undergoing atrial fibrillation ablation, randomized 1:1 to MC or LockeT. Each vascular access site (n) was included for analysis. Assessments included hemostasis at two hours (HA2H), time to ambulation (TTA), time to (TTD) and same‐day discharge (SDD), groin complications, and a patient comfort assessment. Cost analysis was also performed. Results: Patients were randomized to MC ( N = 49; n = 98) or LockeT ( N = 52; n = 102). Procedural times (119 [IQR 91−155] vs. 106 [IQR 84−127], p = 0.104) and maximum sheath size (8.5 [IQR 8.5−11] vs. 8.5 [IQR 8.5−11], p = 0.730) were no different. Neither HA2H (95.5% vs. 99%, p = 0.129) nor SDD rates (23.5% vs. 36.0%, p = 0.06) differed. However, TTA was significantly less (5.1 [IQR 3.9−6.5] vs. 4.4 [IQR 3.4−5.3], p = 0.017) in those with LockeT. In patients with SSD, the TTD was significantly shorter (6.0 [IQR 4.8−6.5] vs. 4.6 [IQR 4.3−4.9], p < 0.001). The cumulative complications were also significantly less (11.2% vs. 2.9%, p < 0.001) with LockeT. Conclusion: The LockeT is associated with lower TTA, without major complications, and with effective hemostasis. It also limits post‐procedural time for groin management. However, further evaluation of the device is needed.

Background: New‐onset migraine or exacerbation of pre‐existent migraine has been reported following catheter ablation for atrial fibrillation (AF). We assessed the incidence of migraine following pulsed‐field ablation (PFA). Methods: Consecutive AF patients undergoing PFA using either Farawave or Pulse Select or Sphere 9 catheter systems were included in this multicenter study and prospectively followed up for new migraine or an increase in the severity of the pre‐existent headache. Migraine was labeled as “new onset” if the condition was diagnosed for the first time after the index ablation without any previous history, recent or remote. Anti‐arrhythmic drugs and oral anticoagulation were prescribed for 2 months after the procedure. Results: A total of 2148 AF patients undergoing PFA procedures (Farawave: 1477; Pulse Select: 369; and Sphere 9: 392) at the participating centers were included in the analysis. A history of migraine was present in 32 (1.48%) patients, of which 6(18.75%) reported an increase in frequency of migraine in the immediate post‐ablation period. New‐onset migraine was diagnosed in 31 (1.4%) post‐PFA patients. Of these 31 patients, 25 (80.6%) underwent PFA using the Farapulse system, Sphere 9 in 5 (16.12%), and Pulse Select in 1 (3.22%) patient. The incidence of new‐onset migraine was comparable between different systems; 1.69% (95% CI 1.10%−2.49%), 1.65% (95% CI 0.54%−3.82%), and 0.27% (95% CI 0.01%−1.50%) for Farapulse, Sphere 9, and Pulse Select, respectively. Mean duration of onset was 3.08 ± 0.67 days post‐procedure. In the multivariable regression analysis, BMI was found to be the only predictor of new‐onset migraine (OR = 1.402; 95% CI 1.002–1.987; p ‐value = 0.031). Conclusion: New‐onset migraine was observed to be uncommon in patients undergoing PFA. Although the incidence rate was comparable among the three platforms analyzed, the Farawave system showed a higher trend. Of note, BMI was an independent predictor of new migraine.

Introduction: Sinus node dysfunction (SND) may be observed following atrial fibrillation ablation (AFA), leading to urgent pacemaker (PPM) implantation. However, the incidence of PPM implantation and the long‐term outcomes are not well known. Objective: To assess the incidence and outcomes of PPM implantation for SND immediately after AFA and assess the long‐term requirement for pacing. Methods: We conducted a multi‐center, retrospective study of patients who underwent AFA from 2018 to 2024 and received PPM for SND during the same hospitalization. We assessed the patient and procedural characteristics, post‐PPM complications, and atrial pacing percentage (AP%) at 30 and 90 days. Results: Of the 8772 patients who underwent AFA, 178 patients (2.0%) received PPM implantation for SND during the same admission. The mean age was 78.6 ± 6.0 years; 48.3% were female, and 51.9% had non‐paroxysmal atrial fibrillation; 14.6% required temporary pacing. PPM implantation was associated with complications, including pocket hematoma (10.7%) and lead malfunction (1.2%). One patient required PPM explantation for pocket erosion following pocket hematoma. At 30 days, 33.1% of patients had AP > 50% with a mean AP% of 34.1 ± 39.2%. At 90 days, 31.5% patients had AP > 50% with a mean AP% of 33.7 ± 39.0%, and 6.7% were PPM‐dependent. Conclusions: While the incidence of PPM implantation for Sinus node dysfunction immediately following atrial fibrillation ablation is low, it is associated with an increased risk of complications, especially pocket hematoma. The need for atrial pacing decreased during follow‐up. Hence, extending the monitoring period must be considered before PPM implantation.

Rare coding genetic variants may exert large effects on risk of common disease, yet their contribution to disease architecture and their utility in gene prioritization remain limited by inadequate sample sizes. Here, we performed a massive-scale rare variant association study (RVAS), analyzing over 1.1 million sequenced participants among which 130,000 had atrial fibrillation (AF). Through a multi-mask burden testing approach, we identified 15 genes significantly associated with AF through rare large-effect variation. Integrative analyses revealed strong convergence between genes implicated by rare and common variation, and highlighted instances where RVAS data may aid in GWAS prioritization. Nevertheless, several RVAS genes were not among GWAS loci ( FAM189A2 , ACTC1 , FNIP1 , FBN1 ), or were not nominated through contemporary GWAS prioritization ( KDM5B , ZFP36L2 ). Finally, we observed that ultra-rare protein-disrupting variants - concentrated in a small number of large-effect size genes - explained at least 2% of AF susceptibility across European and African ancestry groups. These findings refine the genetic architecture of AF, while highlighting the value and cost of RVAS for genomic discovery in common disease.

Background/Objectives: To develop and preliminarily evaluate a practical Python-based program for dynamic intracardiac blood flow visualization and the extraction of new quantitative parameters, serving as an initial step toward future flow-based cardiac evaluation. Methods: The method was technically explored across five imaging modalities (angiography, MRI, ICE, TEE, TTE) using standard diagnostic hardware. Preliminary testing used ECG-gated ICE DICOM images from sixteen patients undergoing first-time AF ablation. Results: The program produced dynamic full-chamber flow visualizations and automatically computed two image-derived surrogate markers of flow-pattern behavior, the *turbulence index (TI)* and *blood mobility fraction (BMF)*, across cardiac cycles. Distinct preliminary flow patterns were observed between sinus rhythm and atrial fibrillation. Outputs are exportable for AI analysis. Conclusions: This proof-of-concept approach demonstrates feasibility for routine intracardiac flow assessments, and introduces TI and BMF as potential flow-based biomarkers for future prognostic use after additional validation.

Introduction: Vascular closure devices, used for the percutaneous closure of the femoral venous access‐sites following electrophysiology (EP) procedures, are known to require shorter time to hemostasis compared to manual compression. The new VASCADE MVP_XL (Haemonetics Corp., USA) was designed for procedures utilizing large procedural sheaths, with a resorbable patch with 58% higher collagen content than the earlier VASCADE‐MVP system, for better efficacy. Objective: We aimed to compare the safety and efficacy of VASCADE MVP‐XL and VASCADE MVP in consecutive patients with atrial fibrillation (AF) undergoing procedures utilizing large sheaths (i.e. Farapulse pulsed‐field ablation and left atrial appendage closure procedure). Methods: Based on the device used to achieve access‐site hemostasis, AF patients undergoing EP procedures were classified into group 1: MVP‐XL ( n = 151) and group 2: MVP ( n = 423). The closure device was deployed under ultrasound guidance and included 2–4 min of gentle compression followed by approximately 2 h of bedrest. Fluoroscopy was used for proper positioning and accurate deployment of the collagen patch. All procedures were conducted under uninterrupted anticoagulation. The access‐sites were examined immediately after the procedure, after the 2 h bed‐rest and before discharge. Results: Baseline characteristics were similar between the groups except the procedure type (Watchman) and rivaroxaban use. Time to final sheath pull, time to ambulation and time to discharge were similar between the groups. Access‐site bleeding occurred in 13 patients (3.1%) in the MVP group versus none (0%) in the MVP‐XL group ( p = 0.029). Time to hemostasis was significantly shorter in the MVP‐XL group. Conclusion: VASCADE MVP‐XL has a better safety and efficacy profile compared to the VASCADE‐MVP system, especially in procedures involving large sheaths.