Faculty Bibliography

BACKGROUND:Vein of Marshall (VOM) ethanol ablation is effective in preventing recurrence in patients with persistent atrial fibrillation (AF) as a de novo strategy. There is minimal data on its use in recurrent AF. OBJECTIVE:We investigated the efficacy of VOM ethanol ablation for recurrence despite initial AF ablation. METHODS:Retrospective analysis was performed of persistent AF patients who underwent repeat ablation after an initial ablation for persistent AF. All patients had pulmonary vein isolation (PVI), posterior wall isolation (PWI), and cavotricuspid isthmus (CTI) during their previous ablation(s). At redo ablation, controls underwent confirmation and completion of previous ablation steps, substrate modification, and a search for non-PV triggers. Cases had additional VOM ethanol ablation combined with mitral isthmus ablation. RESULTS:One hundred and seven patients (49 VOM, 60 control) were included. There was no difference in AF recurrence at 1-year comparing VOM patients (47%) and controls (38%), (p = 0.39). Within the VOM group, the mean AF burden decreased from 38% preablation to 10% 12-months post (p = 0.003). The proportion of recurrent persistent AF decreased from 65% preablation to 26% post (p = 0.004). There was no significant difference in reduction in AF burden or proportion of recurrent persistent AF when comparing VOM cases and controls. Six percent of VOM patients developed intraprocedural left atrial appendage (LAA) isolation. CONCLUSIONS:In patients with previous PVI, PWI, and CTI ablation, VOM ethanol ablation did not demonstrate a reduction in AF recurrence or burden when compared with a strategy of substrate modification and trigger ablation alone and increases the risk of LAA isolation.

BACKGROUND:Pulmonary vein (PV) isolation is the cornerstone of radiofrequency (RF) ablation for atrial fibrillation (AF) and PV reconnection is a common cause of recurrent AF. The relationship between PV ostial wall thickness (WT) and durable PV isolation is a matter of ongoing investigation. Additionally, the relationship between catheter impedance and WT is not well understood. We studied the relationship between PV ostial WT, ablation lesion metrics, and PV reconnection. METHODS:16 patients were identified who underwent an initial and redo AF ablation procedure and had a cardiac CTA analyzed using ADAS-3D imaging software performed prior to the initial ablation. Ablation lesion metrics from the initial ablation procedure were collected from the electroanatomic mapping software. Reconnected and isolated PV were identified based on electroanatomic mapping data collected at the redo AF ablation procedure. Patients with reconnected PV exhibited thicker left atrial walls (1.4 mm vs 1.2 mm, P < 0.05) and reconnected veins exhibited thicker ostial walls (1.7 mm, vs 1.5 mm, P < 0.05). LA volume, number of ablation lesions, and ablation lesion time were not significantly different between reconnected and isolated PV. Impedance drop during ablation was greater in patients with reconnected PV compared to patients with isolated PV (- 9.0 Ω vs - 6.6 Ω, P < 0.05). There was no correlation between PV ostial WT and ablation lesion impedance drop. CONCLUSION/CONCLUSIONS:PV reconnection was associated with thicker LA and PV ostial WT. Future studies will examine whether targeting thicker PV ostial tissue with more aggressive lesion metrics or different ablation technology can improve PV isolation and ablationoutcomes.

BACKGROUND:Pulsed field ablation (PFA) is emerging as the preferred energy source for atrial fibrillation ablation, largely because of its promising safety profile, including lower risks of esophageal injury, pulmonary vein stenosis, and phrenic nerve injury. However, rare complications may only emerge after treating many thousands of patients. OBJECTIVES/OBJECTIVE:This study sought to determine the real-world utilization and safety profile of the pentaspline PFA catheter in the United States. METHODS:In this retrospective analysis, invitations were sent to U.S. centers performing PFA with the pentaspline catheter. Centers submitted data on patient demographics, procedural details, and adverse events (AEs). The main outcomes included the incidence of major and minor procedure-related AEs. RESULTS:Of the 435 centers contacted, 102 participated, averaging 5.1 operators per center (range 1-16 operators per center). Each center treated a median of 412 patients (range 26-1,961 patients), totaling 41,968 patients between February 2024 and July 2025. The median patient age was 68 years (range 17-99 years), and 56% were male. Most patients underwent first-time ablation (73%), primarily for paroxysmal (54%) or persistent atrial fibrillation (37%). Pulmonary vein isolation was performed in 93% of patients, with extravenous lesions on the posterior wall (57%), cavotricuspid isthmus (31%), or mitral isthmus (14%). Major AEs occurred in only 0.63% of patients, including cardiac tamponade (0.16%), vascular injury requiring intervention (0.18%), and stroke (0.10%). Importantly, no cases of esophageal fistula, persistent phrenic nerve paralysis, or pulmonary vein stenosis occurred. Mortality at 30 days was rare (0.04%), but there was a potential signal for rare (0.019%) unexplained sudden death/cardiac arrest. Rare AEs included coronary spasm (0.10%) and acute renal failure requiring dialysis (0.02%). Minor complications were reported in 2.05%, mainly vascular issues (0.96%), pericarditis (0.52%), and self-limited esophageal dysmotility (0.04%). CONCLUSIONS:In a real-world setting of unselected U.S. patients, PFA demonstrated a safety profile consistent with preferentiality to functional myocardial tissue ablation, without evidence of esophageal fistula or pulmonary vein stenosis. The major complication rate was ∼0.6%-mostly vascular AEs and pericardial tamponade. Stroke (∼1 in 1,000) and death (∼1 in 2,000) were rare. These data indicate that the initial implementation of pentaspline PFA has been overall safe.

AIMS/UNASSIGNED:We aimed to develop and externally validate a convolutional neural network (CNN) using sinus rhythm electrocardiograms (ECGs) and CHARGE-AF features to predict incident paroxysmal atrial fibrillation (AF), benchmarking its performance against the CHARGE-AF score. METHODS AND RESULTS/UNASSIGNED:We curated 157 192 sinus ECGs from 76 986 patients within the New York University (NYU) Langone Health system, splitting data into training, validation, and test sets. Two cohorts, from suburban US outpatient practices and Greek tertiary hospitals, were used for external validation. The model utilizing the sinus ECG signal and all CHARGE-AF features achieved the highest test set area under the receiver operator curve (AUC) (0.89) and area under the precision recall curve (AUPRC) (0.69), outperforming the CHARGE-AF score alone. Model robustness was maintained in the external US cohort (AUC 0.90, AUPRC 0.67) and the European cohort (AUC 0.85, AUPRC 0.78). Subgroup analyses confirmed consistent performance across age, sex, and race strata. A CNN using ECG signals alone retained strong predictive ability, particularly when simulating missing or inaccurate clinical data. CONCLUSION/UNASSIGNED:Our CNN integrating sinus rhythm ECGs and CHARGE-AF features demonstrated superior predictive performance over traditional risk scoring alone for detecting incident paroxysmal AF. The model maintained accuracy across geographically and clinically diverse external validation cohorts, supporting its potential for broad implementation in AF screening strategies.

• LAAO devices are used for patients with AF intolerant of anticoagulation. • Periprocedural multimodality imaging is crucial for successful device deployment. • LAAs with bifid morphologies are uncommon and pose procedural challenges. • We describe closure of a bifid LAA using 2 side-by-side lobe-and-disk devices.

OBJECTIVES/OBJECTIVE:Assess the characteristics and management of patients with LAA thrombus despite compliance with oral anticoagulation (OAC). BACKGROUND:Atrial fibrillation guidelines consider 4 weeks of uninterrupted OAC sufficient to avoid transesophageal echocardiography to rule out left atrial appendage thrombus. However, some patients may exhibit persistent thrombus despite compliance with OAC. METHODS:Clinical history, management, and outcomes were reviewed for patients with LAA thrombus on preprocedural TEE presenting for an AF related procedure between 2021 and 2024. RESULTS:Sixty-five (1.8%) of 3653 preprocedural TEEs exhibited LAA thrombus. OAC compliance of at least 4 week was documented in 39 (60%) of these patients, including Apixaban 64%, Rivaroxaban 23%, Warfarin 8%, Dabigatran 5%. Two of these patients (3%) experienced an embolic event and 8 (12%) died during the follow up period. Resolution of LAA thrombus was documented in 12/32 patients, 6 who switched to Dabigatran, 2 to Eliquis, 1 to Warfarin, and 3 remained on Eliquis. LAA-occlusion was successfully performed in seven patients with persistent LAA thrombus. CHADS-VASc 3 or greater, HFrEF, or valvular AF were present in 37/39 of these patients. CONCLUSION/CONCLUSIONS:For 3653 patients who underwent Preprocedural TEE, 39 exhibited LAA thrombus despite compliance with OAC. Switching OAC or maintaining the same agent for longer period of time resolved the thrombus in 31% of cases. LAA-O was effective in cases where the thrombus did not resolve. Patients with non-valvular AF, compliance with OAC > 4 weeks, CHADS-VASc ≤ 2, and normal EF exhibited the lowest probability for not having a thrombus on TEE.

BACKGROUND:The diagnosis of cardiac sarcoidosis (CS) is often challenging, particularly in atypical cases. CASE SUMMARY/METHODS:This case involves a previously healthy 33-year-old woman who was found to have a biatrial mass and evidence of a diffuse inflammatory or neoplastic process on multimodality imaging. Percutaneous biopsy of the cardiac mass was performed, and histopathologic examination revealed granulomas consistent with CS. DISCUSSION/CONCLUSIONS:This case adds to the growing number of reports of CS manifesting as an intracardiac mass. TAKE-HOME MESSAGES/CONCLUSIONS:The clinical presentation of CS is highly variable, and it may rarely manifest as an intracardiac mass. The diagnosis of cardiac sarcoidosis is often challenging, particularly in patients with atypical presentations. Indeterminate cardiac masses often require direct tissue sampling because the changes in treatment and prognosis are substantial.

BACKGROUND:Identifying nearfield and farfield signals is critical to mapping and ablating cardiac arrhythmias. This assessment is qualitative, depending on the "sharpness" of pulmonary vein (PV) electrograms. Electrogram peak frequency (PF) analysis is hypothesized to be a quantitative measure of signal proximity. OBJECTIVE:To confirm if PF defines nearfield versus farfield electrical signals and if it can be used during ablation to establish pulmonary vein isolation (PVI). METHODS:We created a cohort of 30 patients with AF undergoing PVI. Left atrial and PV maps of PF were generated before and after PVI. In the first 10 patients with paroxysmal AF (cohort 1), a cutoff value was selected to predict nearfield versus farfield signals. This cutoff was validated in a cohort of 10 patients with paroxysmal AF (cohort 2) and a cohort of 10 patients with persistent AF (cohort 3). RESULTS:PF was lower in farfield electrograms than nearfield electrograms. A PF cutoff of 300 Hz had a sensitivity of 93.2% (95% CI 81.3% - 98.6%) in cohort 1, 90.0% (95% CI 76.3 - 97.2) in cohort 2, and 98.6% (95% CI 90.1 - 99.7%) in cohort 3 for differentiating farfield from nearfield electrograms. The specificity was 100.0% (95% CI 98.2% - 100.0%) and the AUC was 0.99 (95% CI 0.97 - 1.00) in all patients. CONCLUSIONS:We confirmed the hypothesis that PF distinguishes nearfield from farfield electrograms. PF analysis improves the recognition of PV isolation. Mapping and ablation strategies utilizing PF should be pursued to improve ablation outcomes.