Anna-Sophie Eberl

Aims: Pulsed field ablation (PFA) is an established technology for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). However, data on long-term outcome remain scarce. With this work, we aim to contribute valuable long-term data on catheter ablation with PFA. Methods and results: We conducted a retrospective analysis of our single-centre data of 339 patients (63% paroxysmal AF, 37% persistent AF), as well as of 55 redo procedures in patients, who underwent first PVI with a pentaspline PFA catheter. During the median follow-up (FUP) of 752 (391–1486) days, 34% patients (n = 116) experienced arrhythmia recurrence after a blanking period of 90 days, with a median time to recurrence of 218 (90–1161) days. Multivariate analysis showed electrical cardioversion at the end [HR 1.97 (95% CI 1.17–3.33), P = 0.011] and AF at the beginning of the procedure [HR 1.73 (95% CI 1.04–2.88), P = 0.034] being independently associated with a higher risk of arrhythmia recurrence. Additional anterior flower applications were protective in the univariate (P = 0.025) analysis. Atrial tachycardia (AT) was present in 16, 37, 0, and 0% after the first, second, third, and fourth procedure, respectively. In 55 analysed redo procedures, 104/221 veins (47%) were reconnected (0/1/2/3/4 reconnected veins: 9%/31%/27.3%/27.3%/5.4%). Analysis of multiple procedure outcome estimates improved long-term arrhythmia-free survival, with an overall success rate of 86% after ≥2 procedures. Conclusion: PV reconnections are frequent in patients presenting for repeat ablations, especially at the anterior PV aspect. A multiple procedure approach estimates arrhythmia-free survival in 86% of patients. Procedures with additional anterior lesions at the right pulmonary veins (RPVs) could be protective for recurrences.

Zusammenfassung: Die neuen Richtlinien des European Resuscitation Council (ERC) knüpfen an Bewährtes an, enthalten jedoch auch einige gut umsetzbare Neuerungen für die klinische Praxis. Die vier Grundpfeiler des Advanced Life Support (ALS) – hochqualitative Thoraxkompressionen, frühe Defibrillation, adäquate Beatmung und Medikamentengabe – bleiben bestehen, wurden jedoch in einigen Details präzisiert. Eine Aufwertung erfährt unter anderem der Einsatz der Sonographie. Insgesamt bieten die neu erschienenen Richtlinien eine praxisnahe und klar strukturierte Zusammenfassung für das empfohlene Vorgehen sowohl während als auch bei drohendem Herz-Kreislauf-Stillstand.

Background: Heart failure (HF) and atrial fibrillation often coexist and exacerbate each other, creating a therapeutic challenge when both are present. This case presents a patient with suspected tachycardia-induced cardiomyopathy (TIC) progressing to cardiogenic shock, managed with guideline-directed medical therapy (GDMT) for HF and pulmonary vein isolation (PVI) as an additional therapeutic pillar. Case summary: We report the case of a 57-year-old male with de novo atrial fibrillation and TIC leading to cardiogenic shock. As rhythm control was initially unsuccessful, mechanical circulatory support was required despite GDMT. A thorough diagnostic work-up was performed, excluding coronary artery disease and structural heart diseases as underlying HF causes, making TIC the most likely diagnosis. After rhythm stabilization was achieved, haemodynamic stabilization followed subsequently. Later on, the patient underwent successful PVI. At the 12-month follow-up, no AF recurrence occurred, and the patient presented with HF with improved ejection fraction. Conclusion: Treatment of HF with GDMT should be performed simultaneously and harmonized with rhythm and rate control. This case highlights the role of early rhythm control and the potential of left ventricular ejection fraction improvement after PVI in patients with TIC.

Understanding the biophysics of electroporation—the mechanism by which pulsed electric fields achieve tissue ablation—is essential for advancing this emerging technology. In this review, we summarize key publications from past years to provide an overview of current knowledge and future perspectives. We discuss the fundamental principles of PFA at the cellular, physical, and technical levels, along with its potential benefits and limitations. A deeper understanding of these biophysical mechanisms and the parameters required to create durable lesions may contribute to improved clinical outcomes and drive future innovation.

Aims: Initial clinical studies of pulsed field ablation (PFA) to treat atrial fibrillation (AF) indicated a >90% durability rate of pulmonary vein isolation (PVI). However, these studies were largely conducted in single centres and involved a limited number of operators. We aimed to describe the electrophysiological findings and outcomes in patients undergoing repeat ablation after an initial PF ablation for AF. Methods and results: In the MANIFEST-REDO study, we investigated patients who underwent repeat ablation due to clinical recurrence—AF or atrial tachycardia (AT)—following first-ever PVI with a pentaspline PFA catheter (Farawave, Boston Scientific Inc.). At 22 centres, 427 patients (age 64 ± 11 years; 37% female) were included. Of note, the recurrent arrhythmia leading to the repeat ablation was paroxysmal AF (51%), persistent AF (30%), or AT (19%). At the repeat procedure, the PV reconnection rates were 30% (left superior pulmonary vein), 28% (left inferior pulmonary vein), 33% (right superior pulmonary vein), and 32% (right inferior pulmonary vein). In 45% of patients, all PVs were durably isolated at the beginning of the repeat procedure, with the previous use of any imaging or mapping modality being univariately associated with durable PVI. After a post-redo follow-up period of 284 (90–366) days, the primary effectiveness endpoint (freedom from documented AF/AT lasting ≥30 s after 3-month blanking without class I/III antiarrhythmic drugs or symptoms) was achieved in 65% of patients, with significant differences between groups (PAF 65% vs. PersAF 56% vs. AT 76%; P = 0.04). Persistent AF as recurrent arrhythmia after the initial PFA ablation predicted AT/AF recurrence after repeat ablation [hazard ratio 1.241 (95% confidence interval 1.534–1.005); P = 0.045]. The procedural complication rate was 2.8%. Conclusion: In repeat procedures for AF/AT performed after an index procedure with PFA for AF, PV reconnections are not uncommon. Repeat procedures can be performed safely and with an acceptable subsequent success rate.

Aims: We aimed to assess the acute and midterm efficacy of premature ventricular contraction (PVC) ablation guided by multielectrode and point-by-point (PbP) mapping. Methods and results: This is a retrospective, international multicentre study of consecutive patients referred for PVC ablation in 10 hospital centres from January 2017 to December 2021. Based on the mapping approach, two cohorts were identified: the ‘Multipolar group’, where a dedicated high-density mapping catheter was employed, and the ‘PbP group’, where mapping was performed with the ablation catheter. Procedural endpoints, safety, and acute (procedural) and midterm efficacies were assessed. Of the 698 patients included in this study, 592 received activation mapping [46% males, median age of 55 (41–65) years]—248 patients in the Multipolar group and 344 patients in the PbP group. A higher number of activation points [432 (217–843) vs. 95 (42–185), P < 0.001], reduced mapping time (40 ± 38 vs. 61 ± 50 min, P < 0.001), and shorter procedure time (124 ± 60 vs. 143 ± 63 min, P < 0.001) were reported in the Multipolar group. Both groups had high acute success rates (84.7% with Multipolar mapping vs. 81.3% with PbP mapping, P = 0.63), as well as midterm efficacy (83.4% vs. 77.4%, P = 0.08), with no significant differences in the risk of adverse events (6.0% vs. 3.5%, P = 0.24). However, for left-sided PVC ablation specifically, there was a higher midterm efficacy in the Multipolar group (80.7% vs. 69.5%, P = 0.04), with multipolar mapping being an independent predictor of success [adjusted OR = 2.231 (95% CI, 1.476–5.108), P = 0.02]. Conclusion: The acute and midterm efficacies of PVC ablation are high with both multipolar and PbP mapping, although the former allows for quicker procedures and may potentially improve the outcomes of left-sided PVC ablation.