Right atrial appendage aneurysm, or giant right atrial appendage, is extremely rare, with very few cases reported in scientific literature. We sought to systematically review the published cases of right atrial appendage aneurysm in terms of age, sex, clinical presentation, electrocardiography, imaging (chest X-ray, echocardiography, CT/cardiac magnetic resonance), and outcome. An electronic search for case reports, case series, and related articles published until March 2025 was carried out, and clinical data were extracted and analysed. Forty-four cases of right atrial appendage aneurysm were identified with a clear male prevalence (68.2%) and commonly presenting in the third decade of life. Palpitation (27.3%) and dyspnoea (18.2%) were the most common clinical presentations, whereas 40.9% of right atrial appendage aneurysm patients were asymptomatic. Electrocardiography was done in 77.3% of the sample. It displayed an atrial arrhythmia (atrial fibrillation or flutter, atrial tachycardia, supraventricular tachycardia) in 31.8%. A chest X-ray was done in 65.9%. Echocardiography was the most common diagnostic modality (93.2%). Right atrial appendage aneurysm diagnosis was confirmed on CT and/or MRI in 79.5%. The mean size of the right atrial appendage aneurysm was 93 × 70 mm. In 12 patients (27.3%), an associated congenital cardiac abnormality was found, mostly in the form of an atrial septal defect/patent foramen ovale (22.7%). Half of the patients (50.0%) were treated surgically, whilst 47.8% were treated medically with close follow-up. One patient experienced right atrial appendage aneurysm reduction in size after atrial septal defect device closure. One death (2.3%) was reported also. Although very uncommon, right atrial appendage aneurysm can be linked to considerable morbidity. Surgical removal is recommended for patients who are symptomatic.

Catheter ablation is now the preferred early treatment option in children due to its high success rate and low complication rate. The aim of this study was to evaluate the outcomes of patients who underwent electrophysiology studies and a catheter ablation procedure in our centre. Paediatric patients who underwent catheter ablation in our hospital between 2017 and 2024 and were followed up or referred for ablation from another centre were retrospectively screened. Patients who had an intracardiac defibrillator, pacemaker, or ventricular arrhythmia were excluded from the study. The data were screened from a total of 586 patients (M/F = 300/286). The procedure was applied to 288 (49 %) patients with atrioventricular re-entry tachycardia (Wolf Parkinson White 86.4%-n:249; occult accessory pathway 13.9%- n:39), and to 270 (45%) with atrioventricular nodal re-entry tachycardia. Eleven (1.8%) patients with focal atrial tachycardia, 11 (1.8%) with frequent extrasystole or ventricular tachycardia, 6 (1%) with supraventricular premature beat (SVE), and 2 patients with a Mahaim diagnosis underwent the procedure. Fluoroscopy was used during the procedure in 75 (12.8%) patients, and the mean duration of fluoroscopy was 5.2 ± 3.2 mins (range 0.2-19.6 mins). Of these 75 patients, trans-septal punction was performed on the left side for the procedure to be applied in 71 patients. Of the patients diagnosed with atrioventricular re-entry tachycardia, fluoroscopy was used in 4. The results of this study of catheter ablation performed at our institution have shown acute success and recurrence rates similar to those of previously published studies.

We described a 14-year-old boy who underwent catheter ablation for atrial tachycardia that had difficulty in creating the whole circuit of 3D map due to widely spread scar after repeated surgery for multivalvular heart disease. The classical atrial entrainment method was very effective in planning the catheter ablation for the invisible circuit of the atrial tachycardia.

BackgroundRemote monitoring (RM) of patients with pacemakers and implantable cardiac defibrillators (ICDs) allows quicker detection of device and health related complications compared to conventional follow-up. RM reduces hospitalization and mortality of patients, but increases the work burden on the health care professional. False positive (FP) arrhythmia alarms of pacemakers and ICDs further complicate RM. Deep learning models can help healthcare professionals by automatically reviewing RM episodes, filter out FP alarms, and improve patient security.PurposeTo create a deep learning model which automatically classifies Atrial Tachycardia or Atrial Fibrillation (AT/AF) alerts of Biotronik pacemakers and ICDs into true AT/AF, noise, and oversensing alarms.MethodsA residual network (Resnet) is designed to classify AT/AF episodes using atrial and ventricular intracardiac electrograms of AT/AF episodes, provided by three hospitals (80% train set, 20% validation set). The optimal combination of different layers, structures, and hyperparameters of the Resnet is determined by grid search and manual tuning. The resulting Resnet is trained with a focus on maintaining high true AT/AF sensitivity and is externally tested on a test set supplied by a fourth hospital. Lastly, real-time clinical validation was conducted using a chrome plug-in for two weeks in a hospital, as shown in figure 1. The performance of the model is quantified using the f1-score, to provide a balance between the positive predictive value and sensitivity, and adequately assess model performance on imbalanced data. All episodes are blind and independently labelled by two RM experts, a third RM expert settled conflicts between the two RM experts.ResultsThe Resnet consists of a residual block (of 128 filters of length 640) and max pooling layer, four residual blocks for feature learning (with 128, 128, 64, 64 filters of length 640, 640, 320, 320, respectively), a global pooling layer, and two dense layers. The train/validation set consisted of 8892 episodes of 911 patients, the test set consisted of 1858 episodes of 237 patients, and the clinical data of 307 episodes of 68 patients. The train/validation and test set had similar distributions of true AT/AF (86%), noise (13%), and oversensing (1%). The Resnet model identified true AF episodes, noise, and oversensing alarms of the test set with a f1-score of 99.1%, 96.0%, and 73.3%, respectively. The clinical data consisted of 291 AT/AF (94.8%), 12 noise (3.9%), and 4 oversensing (1.3%) episodes. The Resnet achieved f1-scores of the 99.0%, 73.7%, and 88.9%, for the AT/AF, noise, and oversensing episodes, respectively.ConclusionThe Resnet accurately identifies true AT/AF, noise, and oversensing as the root-cause behind the AF alerts in Biotronik pacemakers and ICDs. The ability of this model to detect true AT/AF with a high f1-score encourages future usage of this Resnet in hospitals to reduce the RM work burden.

Monopolar biphasic focal pulsed field ablation directly at the atrioventricular junction and from within the non-coronary cusp: The PFA-CONDUCT study.

From Mapping to Clipping: The Role of Thoracoscopic Left Atrial Appendage Clipping in Refractory Focal Left Atrial Tachycardia

Atrial tachycardias (AT) represent an increasingly recognized cause of morbidity and mortality. Over the past decade, the mechanistic understanding and therapeutic concepts guiding AT treatment have undergone rapid progress. Catheter ablation has become the most effective therapy for maintaining sinus rhythm in patients with regular AT, while mapping and ablation concepts and technologies have improved significantly. Accordingly, international cardiac electrophysiology professional societies aimed at outlining best practices on the management of regular AT, with a special focus on indications, timing, and technical aspects of AT mapping and ablation. After reviewing and discussing available evidence, including a systematic literature review and meta-analysis, an expert writing group summarized current knowledge and practice and has proposed strategies in the here outlined 10-Point Plan for SMART-AT care (Standardized Management and Ablation Roadmap for Treatment of Patients with Atrial Tachycardia).

Pulmonary Vein Isolation (PVI) is considered to be the primary strategy for atrial fibrillation (AF) ablation. However, recurrence of AF and atrial tachycardia was observed to occur often after PVI, which led to the proposition of performing additional ablations such as linear lesions, left atrial (LA) posterior wall isolation, substrate modification, and electrocardiogram (EGM)-based approaches as add-ons to PVI or alternative strategies. While numerous randomized controlled trials have been conducted in this regard, the efficacy of these strategies compared with PVI alone has been ambiguous, with some trials showing significant improvement and others showing no superiority over PVI alone. Thus, a systematic review and meta-analysis were conducted to address this ambiguity and assess the efficacy of additional or alternative ablation strategies as compared with Pulmonary Vein Isolation alone. To assess whether additional or alternative ablation strategies lead to better outcomes as compared with PVI alone. We included only Randomized Controlled trials comparing Pulmonary Vein Isolation alone with Pulmonary Vein Isolation along with additional ablations or alternative ablation strategies in adults with persistent or paroxysmal Atrial Fibrillation. A thorough literature search was performed, and data were extracted in a tabulated form. A random-effects meta-analysis was performed, and afterwards, subgroup analyses were done to individually assess the efficacy of the most commonly used additional ablation strategies. A total of 65 studies with 10,760 participants were included. The mean age was 57 years, with approximately 68% male participants. The Additional Ablation group was associated with a significantly lower Risk Ratio (0.76, 95% CI: 0.70,0.82. P < 0.00001) of the composite primary outcome compared with PVI alone. While additional ablation strategies beyond pulmonary vein isolation (PVI) have been associated with a trend towards improved outcomes, current evidence does not conclusively demonstrate superior efficacy over PVI alone. Further research is needed to clarify the potential benefits of adjunctive ablation approaches and to determine whether individualized strategies may improve outcomes in selected patient populations.

Ivabradine is a hyperpolarization-activated cyclic nucleotide-gated channel blocker that has an off-label indication for arrhythmias in pediatric patients. The primary objective was identification of the line of therapy and type of arrhythmia for which ivabradine was initiated. The secondary objective was to evaluate the initial and peak ivabradine doses, tolerance in partially fed patients (i.e., patients not receiving full feeds at the time of ivabradine initiation), number of patients continued home on ivabradine, concomitant drug interactions with a class C, D, or X classification, and adverse effects. A retrospective study of hospitalized patients <18 years of age receiving ivabradine for arrhythmias between January 1, 2021 and November 30, 2023. Data variables included demographics, ivabradine dosing regimens, concomitant anti-arrhythmic medications, percentage of ivabradine course while receiving full enteral feeds, concomitant medications with drug-drug interactions, and adverse effects (bradycardia [defined as <100 beats/min in neonates and <50 beats/min in infants and children], atrial fibrillation, vision changes, and emesis attributed to ivabradine). Seventeen patients were included. The most frequent arrhythmia indication was atrial tachycardia and ivabradine was most frequently used as a third-line anti-arrhythmic. Ten (58.8%) received ivabradine despite not being on full enteral feeds. The median initial and peak ivabradine doses were 0.05 mg/kg/dose and 0.07 mg/kg/dose, respectively, and it was most frequently administered every 12 hours. Only 1 patient required a dose decrease for a noted adverse effect. Most patients (94.1%) had a Class C drug-drug interaction, and 3 had a Class X interaction. Ten (58.8%) were discharged home on ivabradine. Ivabradine was safe and effective as additive therapy for the treatment of pediatric arrhythmias. Larger studies of ivabradine use in pediatric arrhythmias are needed.

The electrocardiogram (ECG) is a fundamental diagnostic tool in pediatrics for detecting arrhythmias. Its simplicity, low cost, and speed make it an accessible test for primary care pediatricians, especially when supported by a detailed medical history and physical examination. We present the case of a 10-year-old boy with no relevant medical history and clinically asymptomatic who, during a scheduled check-up, was found to have a slightly elevated heart rate and irregular rhythm on auscultation. At first glance, the ECG appeared normal, but after systematic review, ectopic atrial tachycardia (EAT) was detected, which was subsequently visualized on a 24-hour Holter monitor, where persistent ectopic activity was observed in more than 50% of the recording. The patient was referred to cardiology, where initial treatment with bisoprolol was started, followed by radiofrequency ablation with complete resolution of the arrhythmia. Although uncommon in children, AET can be silent and constitute a potential cause of tachycardia-induced cardiomyopathy. This case highlights the importance of systematic ECG interpretation in primary care, as well as the value of careful history taking and physical examination, even in the face of seemingly trivial findings. Early diagnosis and a coordinated approach with cardiology can prevent complications and improve prognosis.

Retrograde ethanolization of the vein of Marshall (VOM) has been identified as an adjunct technique in the treatment of persistent atrial fibrillation (AF) and left atrial tachycardia, as stated in the last consensus statement on ablation of AF. However, there is a lack of high-volume data on the technique. Through the collection of data from worldwide centers, we performed this international survey that aims to analyze the safety and procedural characteristics of VOM ethanolization in patients referred for treatment of AF or left atrial tachycardia. We included 5579 patients (66 years; range, 20-93) from 26 centers, who underwent VOM ethanolization between 2008 and 2024 for persistent AF (81%), paroxysmal AF (9%), or left atrial tachycardia (10%) under deep sedation (53%) or general anesthesia (47%). A concomitant mitral isthmus line was attempted in 79% of the cases, achieving mitral isthmus block in 98% of patients. There were 0.92% of periprocedural serious adverse events, including 0.09% of peri-procedural death (5 patients). Three patients developed hemodynamic collapse immediately after VOM ethanolization, causing the death of 1 due to anaphylactic shock. One patient died following surgical drainage of pericardial effusion 3 weeks after the procedure. The 3 other deaths were not directly related to VOM ethanolization. Pericardial effusion was observed in 123 patients (2.2%) at the time of or immediately after the procedure, requiring drainage in 20 patients (0.36%) and later in 32 additional patients (0.57%), including 5 (0.09%) requiring drainage. Pacemaker implantation was required in 2 patients (0.04%), 1 for high-grade atrioventricular block and 1 for sinus node dysfunction. This international survey shows that VOM ethanolization is predominantly performed in patients with persistent AF. It is associated with rare but potentially life-threatening adverse events. Mitral isthmus line ablation results in a very high rate of block when performed concomitantly.

Epicardial connection after radiofrequency mitral isthmus ablation.

Atrial Tachycardia in the Neonate.

We describe the case of a 31-year-old male with incessant left atrial appendage tachycardia and resultant severe left ventricular systolic dysfunction. Despite medical therapy, catheter ablation and surgical excision of the left atrial appendage with the AtriClip device, the tachycardia persistent. Following detailed multimodality workup including computational modelling with recreation of virtual implantation scenarios, the tachycardia was eventually terminated with pulsed field ablation and percutaneous left atrial appendage occlusion.

Comparison of Extended Cryoballoon, Standard Cryoballoon, and Radiofrequency Catheter Ablation in Patients With Persistent AF.

BackgroundCardiac electrophysiology has undergone significant advances in the therapeutic strategies of cardiac arrhythmias due to the implementation of invasive procedures as radiofrequency catheter ablation of arrhythmogenic substrates, foci and circuits. The Electrophysiology Council of the Argentine Society of Cardiology decided to create a registry of this procedure with free and anonymous participation of the main electrophysiology laboratories in our country. ObjectiveTo recognize the number of catheter ablation procedures, epidemiological data of patients, indications, outcomes and complications based on the information provided by the participant centers during the studied period. Material and MethodsBetween February 2000 and May 2008, 13 patients with this diagnosis had an We performed a prospective and consecutive registry of the procedures reported from November 2007 to March 2009 (16 months). A case report form was available at the SAC’s website in order to be completed on line. The information was transmitted through the Internet using optional users’ names and passwords to ensure the security and privacy of patients and participant centers. The information could also be submitted via mail or e-mail. ResultsA total of 30 centers provided information about 762 catheter ablation procedures (average: 47 procedures per month). Radiofrequency was used in 98.7% of patients (752/752) and cryothermia in 1.3% (10/162). Eighty four percent of procedures were made by operators who perform ± 50 procedures per year and 67.6% (515/762) by operators with up to 100 cases per year. The procedure was successful in 93.4% (709/762) of patients, and 3% had complications (23/762). Mean age was 42 years (5-94) and 56.3% were men. Most patients (76%) had no structural heart disease; 83.7% presented symptoms. Catheter ablation was indicated as primary therapy due to: symptoms, refractory medical treatment or high arrhythmic risk in 712 patients (93.5%); the procedure was performed due to recurrences in 20 cases (2.6%) and to failed ablation in 30 (3.9%). The arrhythmogenic substrates or circuits treated were: atrioventricular nodal tachycardia (30%; 237/786); atrial fibrillation (3.6%; 28/786); atrial flutter (21.5%; 171/786); atrial tachycardia (4.3%; 34/786); macroreentrant atrial tachycardia (0.8%; 7/786); manifest accessory pathway (24%; 186/786); concealed accessory pathway (8.6%; 68/786); idiopathic ventricular tachycardia (2.5%; 20/786); ischemic ventricular tachycardia (0.9%; 7/786); ventricular tachycardia associated with other heart diseases (0.9%; 7/786); AV node ablation (1.9%; 15/786) and ventricular premature beats (0.9%; 7/786). The complications were: complete AV block (n=2), pericardial effusion (n=2), hematoma at the puncture site (n=4), catheter entrapment, first degree AV block, traumatic LBB; aortic dissection, intolerance to the procedure, crural neuropathy, femoral artery pseudoaneurysm and deep venous thrombosis. ConclusionsThis first registry of catheter ablation in our country provides important and useful information about this procedure and shows an adequate immediate success rate (93.4%), similar to those reported by international registries, with low incidence of morbidity or non severe complications (3%). This procedure can be considered safe and efficient.

Catheter ablation (CA) for atrial fibrillation (AF) has limited efficacy. The vein of Marshall (VOM) is associated with autonomic innervation and has arrhythmogenic roles in AF, which can be ablated with ethanol infusion. However, the impact of VOM ethanol infusion (VOMEI) on the recurrence of atrial tachyarrhythmia (ATA) remains unclear. We systematically searched PubMed, Embase, and Cochrane databases for randomized controlled trials (RCTs) and observational studies comparing CA with versus without VOMEI in patients with AF. Outcomes were ATA recurrence and mitral isthmus (MI) block rate. ATA recurrence was defined as AF, atrial flutter, or atrial tachycardia following the index procedure. Sensitivity analyses were performed after restricting to patients with persistent AF, undergoing a re-do procedure, and RCTs. This meta-analysis included 4 RCTs and 16 observational studies, comprising a total of 4732 patients, of whom 2105 (44%) underwent VOMEI. The mean follow-up ranged from 12 to 46.8 months. Compared with CA alone, VOMEI was associated with a significantly lower ATA recurrence (OR: 0.51; 95% CI: 0.40-0.65; p < 0.01) and significantly higher rates of MI block rate (OR: 4.41; 95% CI: 2.47-7.88; p < 0.01). Subgroup analysis also revealed significantly lower ATA recurrence with adjunctive VOMEI in patients with persistent AF at baseline (OR: 0.47; 95% CI: 0.35-0.64; p < 0.01), those undergoing a re-do procedure (OR: 0.44; 95% CI: 0.33-0.61; p < 0.01), and after restricting to RCTs (OR: 0.58; 95% CI: 0.44-0.76; p < 0.01). In patients with AF, adjunctive VOMEI combined with CA was associated with reduced ATA recurrence compared to CA alone, particularly in those with non-paroxysmal AF at baseline or undergoing a repeat ablation. Additionally, VOMEI was linked to significantly higher rates of mitral isthmus block, which may have contributed to the observed outcomes.

Indian experience with cryoablation for paroxysmal and persistent atrial fibrillation.

How often is multifocal atrial tachycardia mistaken for atrial fibrillation in the emergency department?

Primary or iatrogenic left atrial tachycardias (LATs) can occur in patients undergoing atrial fibrillation (AF) catheter ablation. We aimed to investigate the background characteristics of the occurrence of LATs during and after AF catheter ablation. We retrospectively studied 5465 consecutive patients who underwent catheter ablation of AF with and without ATs between March 2014 and September 2021. LATs were defined as ATs with those circuits or origins that were partially or completely included in the LA. The LAT and non-LAT groups included 388 and 5077 patients, respectively. A total of 504 LATs (macroreentry, 80.2%; localized reentry, 10.9%; focal activation, 8.9%) consisted of 31 (6.2%) primary and 473 (93.8%) iatrogenic LATs. A multivariate analysis demonstrated that a female gender, non-paroxysmal AF, ischemic heart disease (IHD), hypertrophic cardiomyopathy (HCM), cardiac sarcoidosis, larger LA diameter, left ventricular hypertrophy (LVH), and prior LA linear and electrogram-based ablation were independent positive predictors of LATs (odds ratios [ORs]: 2.00, 1.56, 3.37, 1.85, 16.9, 1.04, 1.90, 2.35 and 3.06; p < 0.05). Further, an older age, non-paroxysmal AF, IHD, and larger LA diameter were independent positive predictors of primary LATs (ORs: 1.08, 17.1, 4.95, and 1.12; p < 0.05). A female gender, non-paroxysmal AF, larger LA diameter, prior LA linear and electrogram-based ablation, and the presence of IHD, HCM, cardiac sarcoidosis, and LVH may increase the risk of LATs associated with AF catheter ablation, and an older age, non-paroxysmal AF, larger LA diameter, and IHD may increase the risk of primary LATs, especially macroreentrant LATs.