Catheter ablation-induced atrioesophageal fistula (AEF) is one of the most devastating complications of catheter ablation in atrial fibrillation patients and is associated with extraordinarily high morbidity and mortality. Mucosal ulceration, erosion and erythema are milder variants of esophageal injury. Esophageal ulceration is an indicator for increased risk of progression to AEF. In case of clinical suspicion of esophageal perforation with or without fistula a computed tomography with contrast-medium is obligatory to exclude a cardiac fistula before performing esophageal endoscopy. Published strategies to prevent esophageal injury are the use of esophageal temperature probes, mechanical esophagus deviating devices and active esophageal cooling devices. Furthermore, many different strategies were tested to reduce the risk of esophageal injury by modifying ablation techniques and RF ablation parameters in order to limit ablation lesion depth at left atrial posterior wall.Confirmation of an AEF requires urgent cardiac surgery. A conservative or endoscopic approach without surgical intervention is associated with excessively high mortality in case of AEF according to current literature.In case of esophageal perforation without fistula different endoscopic strategies or conservative approaches in combination with a high vigilance for potential progression to fistula have been suggested.A timely, multi-disciplinary and consequently performed standard approach is crucial for a successful management of clinically relevant ablation-induced esophageal complications including esophageal perforation and AEF.The risk of AEF after atrial fibrillation ablation using pulsed field ablation (PFA) techniques seems to be extremely low. Histological esophageal alterations after PFA ablation at left atrial posterior wall have been recently described in an animal experimental study. However, despite the fact that no case of AEF after PFA has been published so far, every new PFA ablation catheter and PFA ablation protocol should also be tested for safety regarding potential esophageal injury.

Cardiac implantable device procedures in patients with congenital heart defects often pose amajor challenge due to the often very complex anatomy and should be planned and performed by an interdisciplinary team in centers suitable for this. This review article gives apractical guide on how apacemaker or defibrillator implantation can be successfully performed in patients with complex congenital heart defects based on representative case examples.

Catheter-assisted ablation of supraventricular tachycardia, especially of atrial fibrillation, often results in atrial tachycardia (AT) in the further course. ATs are favored by incomplete linear lesions, scarring of the atria or persistent pulmonary vein connections, and vary in incidence depending on the type of the preceding procedure. This article discusses different forms of postablation AT in terms of diagnosis, treatment options, and perspectives for prevention and effective treatment. Overview-based review of the literature and case-based experiences from our own center on incidence, mapping methods, and ablation strategies as well as emerging technologies. The reported incidence of postablation ATs varies widely (4-36%), depending on patient selection and procedural complexity. Invasive diagnostics are mainly based on ultra-high-resolution mapping methods, while classical electrophysiological maneuvers are less reliable in this patient population. The therapy of choice is reablation, as drug options are less effective. Depending on the mechanism of AT, focal or linear ablation strategies are preferred, with variable success and more frequent recurrences than with initial ablations. Newer catheter designs and improved lesion control are gaining importance. Atechnically precise and completely transmural initial ablation remains acentral predictor of long-term rhythm stability. Multimodal approaches and individualized strategies are key to the future to sustainably reduce the incidence and recurrence of postablation AT.

The case of a36-year-old female patient with recurrent reflex syncope characterized by predominant cardioinhibition and episodes of asystole lasting up to 9s, as documented by an implantable loop recorder, is reported. Given her young age and symptomatic burden, cardioneuroablation (CNA) was performed without complications as an alternative to pacemaker implantation, in accordance with European Heart Rhythm Association (EHRA) recommendations. In this case, CNA has shown to be an effective and safe treatment option for managing recurrent cardioinhibitory reflex syncope. CNA should particularly be considered and offered in specialised centres for symptomatic patients under 40years of age, in which treatment options beyond conservative measures remain limited.

Wolff-Parkinson-White (WPW) syndrome is characterised by accessory pathways that bypass the normal atrioventricular conduction system. Precise preprocedural localisation is pivotal for optimising ablation strategy, minimising complications, and reducing radiation exposure. This review systematically analyses ECG-based algorithms for accessory pathway localisation, including classical and recent rule-based approaches, as well as modern deep learning models. Classical algorithms showed variable accuracy ranging from 72% (Milstein) to 92% (D'Avila, St. George). Modern rule-based algorithms demonstrate significantly improved performance: EASY-WPW achieved 93% accuracy (sensitivity 92%, specificity 99%), and SMART-WPW reached 97% (sensitivity 96%, specificity 100%) using a12-location clock-face model. DL approaches achieved an 84% accuracy with AUROC 0.92, significantly outperforming classical algorithms (Milstein AUROC 0.81, Arruda AUROC 0.80). The DL model enables automatic analysis, reduces interobserver variability, and identifies parahisian pathways and locations requiring transseptal puncture. Both EASY-WPW and SMART-WPW showed excellent results in pediatric populations. Both validated ECG algorithms and deep learning models represent valuable tools for preinterventional planning in patients with WPW syndrome. Modern rule-based algorithms offer excellent diagnostic accuracy with sensitivities and specificities exceeding 90%. The integration of artificial intelligence (AI) and multimodal approaches promises further improvements in accessory pathway localisation.

The analysis of atrial rhythm is a fundamental step in the interpretation of a resting electrocardiogram. Careful identification of P waves is essential; however, their presence alone does not necessarily indicate sinus rhythm. A systematic assessment of P-wave morphology and axis, as well as a focused search for non-conducted P waves, is crucial for accurate classification of the underlying cardiac rhythm. Ectopic atrial rhythms, atrial tachycardias, and atrial flutter typically exhibit P-wave patterns that differ from those seen in normal sinus rhythm. Normal sinus rhythm originates in the region of the superior vena cava and propagates from right to left and from cranial to caudal across both atria. The present case highlights common diagnostic pitfalls in a patient with clearly discernible P waves.