Premature ventricular contractions (PVCs) are common arrhythmia encountered in patients with and without structural heart disease. Although often benign and asymptomatic, they may also cause palpitations, exercise intolerance, presyncope, and reduced quality of life, and in some patients can contribute to PVC-induced cardiomyopathy or trigger malignant ventricular arrhythmias. Their clinical significance depends on symptom burden, PVC frequency, ventricular function, and the presence of underlying myocardial disease. Diagnostic evaluation includes electrocardiography, ambulatory rhythm monitoring, echocardiography, exercise testing, and cardiac magnetic resonance imaging for tissue characterization and risk stratification. Management ranges from reassurance and lifestyle modification to pharmacologic therapy and catheter ablation. Beta-blockers and nondihydropyridine calcium channel blockers remain common first-line options, whereas antiarrhythmic drugs may be considered in carefully selected patients. Catheter ablation is an effective treatment for symptomatic PVCs, high PVC burden, and PVC-induced cardiomyopathy, with high procedural success rates and favorable effects on arrhythmic burden and ventricular function. Novel approaches, including electrocardiographic imaging-guided planning, pulsed field ablation, stereotactic radioablation, neuromodulation, and renal denervation, may further expand future therapeutic options. This review summarizes the pathophysiology, clinical implications, diagnostic evaluation, and contemporary management of PVCs, with emphasis on medical therapy, catheter ablation, and emerging treatments.

Aim: This retrospective cohort study assessed differences in procedure-related complications and death among old patients with atrial fibrillation (AF) undergoing catheter ablation (CA) procedure with versus without use of intracardiac echocardiography (ICE) and advanced three-dimensional (3D) electroanatomical mapping. Materials & methods: Using the Medicare Database, a retrospective cohort of AF patients ≥65years of age who underwent CA procedure were identified, and categorized into two cohorts: CA without ICE/3D mapping versus CA with ICE/3D mapping. Outcomes including a composite of complications (any), cardiac perforation, esophageal fistula and death, respectively, in the 30-day period post-CA were assessed. Inverse probability of treatment weighting method was used for covariate balancing. Cox regression models were performed to evaluate outcomes. Results: There were 35,490 patients in CA without ICE/3D mapping cohort and 170,762 in the CA with ICE/3D mapping cohort. Cox regression model revealed that patients who underwent CA without ICE/3D mapping use were ∼3.5-times more likely to have 30-day any complication versus those who had CA with ICE/3D mapping (7.3% vs 2.2%, log-rank test p<0.001; hazard ratio: 3.507; 95% CI: 3.307-3.720, p<0.001). The incidence of cardiac perforation (2.5% vs 0.1%, log-rank test p<0.001), atrio-esophageal fistula (0.03% vs 0.01%, log-rank test p=0.03) and death (1.6% vs 0.2%, log-rank test p<0.001) were significantly higher among patients without ICE/3D mapping versus those who had CA with ICE/3D mapping. Conclusion: The absence of ICE and 3D mapping during CA procedures was associated with significantly increased risk of complications and death among Medicare eligible patients with AF.

Sex-based differences in atrial fibrillation (AF) symptom burden and response to rhythm control strategies are recognised. Whether female and male patients differ in escalation to atrioventricular (AV) node ablation after AF catheter ablation remains uncertain. To evaluate sex differences in AV node ablation following AF ablation in a large real-world cohort. Adults undergoing first-time AF ablation between 2015 and 2024 were identified from a global federated research network. Patients with prior AV node ablation or cardiac implantable electronic devices were excluded. Female and male patients were compared before and after 1:1 propensity score matching for demographics, AF type, heart failure phenotype, co-morbidities, medication use and prior cardioversion. The primary outcome was AV node ablation within 5 years. Secondary outcomes included repeat AF ablation, electrical cardioversion and all-cause mortality. Pre-specified falsification endpoints (pneumonia and intestinal obstruction) were assessed to evaluate residual confounding. Before matching (28,004 female; 52,137 male), AV node ablation occurred in 2.5% of female and 1.1% of male patients (risk ratio [RR] 2.31, 95% CI 2.07-2.58). After matching (24,377 female and 24,377 male), baseline characteristics were well balanced, yet AV node ablation remained more frequent in female than male patients (2.3% vs. 1.2%; RR 1.94, 95% CI 1.68-2.23). Female patients were also more likely to undergo repeat AF ablation (14.7% vs. 14.1%; RR 1.04, 95% CI 1.01-1.08), whilst mortality was modestly lower (4.5% vs. 4.9%; RR 0.91, 95% CI 0.84-0.99; p = 0.027). Falsification endpoints did not differ between groups after matching. Female patients were more likely than male patients to undergo AV node ablation following AF ablation despite robust adjustment, suggesting important sex-based differences in downstream AF management.

Linking the heart-eye-brain axis: Ocular and cerebral blood flow changes after catheter ablation in atrial fibrillation.

Glucagon-like peptide-1 receptor agonists versus sodium-glucose cotransporter-2 inhibitors in adults with type 2 diabetes and atrial fibrillation: a multicenter comparative effectiveness cohort study of cardiovascular and arrhythmic outcomes.

Despite advancements in radiofrequency ablation (RFCA) technology and strategy, the long-term rhythm outcomes of persistent atrial fibrillation (PeAF) remain suboptimal. Since the vein of Marshall (VOM) is situated within the mitral isthmus (MI) area and covers local neural innervation and fiber networks, its pathophysiological role in mediating and maintaining atrial fibrillation (AF) and causing arrhythmia recurrence has garnered increasing attention. Ethanol infusion into the vein of Marshall (EIVOM) may complement RFCA by delivering anatomically targeted chemical injury along the VOM course, thereby facilitating contiguous MI lesion formation and durable MI block. We performed a narrative review of mechanistic, procedural, and clinical evidence regarding EIVOM in AF ablation, with emphasis on MI block, rhythm outcomes, technical limitations, complications, and its potential role in pulsed field ablation (PFA)-based workflows. Available evidence indicates that EIVOM facilitates durable MI block by targeting VOM-related epicardial connections and may improve rhythm outcomes when combined with RFCA in selected PeAF ablation strategies. Its clinical application is influenced by procedural and anatomical factors, while safety considerations and its potential complementary role in PFA-based workflows remain important areas for further evaluation. EIVOM is a promising adjunct to RFCA, particularly for facilitating durable MI block and reducing residual epicardial conduction. Further standardized multicenter studies are needed to refine patient selection, procedural integration, safety optimization, and its role in contemporary AF ablation.

Angioplasty for Pulmonary Vein Stenosis after Atrial Fibrillation Ablation.

Atrial fibrillation is a common cardiac arrhythmia associated with serious complications such as stroke, heart failure, and mortality. Catheter ablation is frequently used for drug-resistant cases but requires femoral venous access and anticoagulation, increasing the risk of vascular complications. Manual compression is the standard method for post-ablation hemostasis, though it can be time-consuming and uncomfortable, whereas figure-of-eight sutures have emerged as a potential alternative. To compare safety and procedural outcomes of figure-of-eight sutures versus manual compression for venous hemostasis after ablation. A systematic literature search was conducted across Cochrane Library, PubMed/MEDLINE, Scopus, and Embase up to February 2026 to identify studies comparing figure-of-eight (Fo8) sutures with manual compression for post-ablation femoral venous hemostasis. Randomized controlled trials and observational cohort studies were included. Data extraction and quality assessment were performed independently by two reviewers, with discrepancies resolved by a third reviewer. Statistical analyses and meta-analyses were performed using RevMan software version 5.4. Nine studies with a total of 2,125 patients were analyzed. Figure-of-Eight (Fo8) suturing demonstrated no significant difference compared with manual compression for total, major, or minor vascular access site complications, bleeding, or hematoma. However, FO8 suturing was associated with significantly shorter time to hemostasis, earlier ambulation, and reduced time to discharge. Figure-of-eight suturing is as safe as manual compression for post-ablation femoral venous hemostasis, showing no increase in vascular access-site complications, bleeding, or hematoma. It provides the added benefit of faster hemostasis, earlier ambulation, and reduced discharge time.

Adults with congenital heart disease increasingly survive into later adulthood, exposing the long-term limitations of a morphologic right ventricle supporting the systemic circulation. Heart failure and arrhythmias are common, frequently coexist, and represent leading causes of morbidity and mortality in this population. This review examines the mechanisms linking systemic right ventricular dysfunction and arrhythmogenesis and their implications for contemporary management. Recent literature highlights that chronic systemic loading of the right ventricle promotes maladaptive structural, electrical, and inflammatory remodeling, creating a substrate for atrial and ventricular arrhythmias. Conversely, arrhythmias exacerbate systemic right ventricular dysfunction through loss of atrioventricular synchrony, tachycardia-mediated impairment, dyssynchrony, and hypoxemia, mechanisms to which systemic right ventricular physiologies are particularly susceptible. Advances in catheter ablation, device therapy, cardiac resynchronization, and conduction system pacing have expanded therapeutic options, although evidence guiding patient selection and timing remains limited. Failure of the systemic right ventricle and arrhythmias are tightly interwoven processes that evolve over time. Integrating mechanistic insights with longitudinal imaging, electrophysiologic phenotyping, and individualized risk assessment may improve arrhythmia management, refine device strategies, and support more personalized approaches to preserving systemic right ventricular function.

Considerations for Atrial Fibrillation Ablation: Comment.

Children with recurrent syncope with prolonged pauses who have failed traditional therapies may be candidates for a cardioneuroablation as an alternative to pacemaker implantation. This article reviews cardioneuroablation in the pediatric population. Cardioneuroablation has been used in adults for cardioinhibitory syncope for more than 2 decades with promising results. Despite the heterogenous patient population and variation in technical approaches to the procedure, between 85 and 90% of patients have a significant reduction in syncope and improvement in quality of life. While the data in children is limited, reports have shown similar success. Catheter ablation of ganglionated plexuses can be performed by ablating in the right or left atrium or both. The long-term effects in disrupting the sympathovagal imbalance remains unknown. Cardioneuroablation may be an option for select children with cardioinhibitory syncope who have failed standard medical approaches. Early results of vagal ablation in children have been promising. Future long-term registries following cardioneuroablation is needed.

In recent decades, clinical practice has been founded on the principles of evidence-based medicine, where therapeutic decisions arise from the integration of clinical expertise, patient preferences, and scientific evidence derived from controlled studies and meta-analyses. The advent of artificial intelligence (AI) in health care, however, is driving a significant evolution in clinical research, owing to its ability to analyze large volumes of heterogeneous data and overcome the limitations of traditional statistical approaches. The availability of large-scale datasets, increasing computational capability, and reduced storage costs have supported the transition towards a "data-intensive" research model, progressively integrated with conventional methods. Within cardiology, arrhythmology represents one of the fields in which AI finds extensive application. The analysis of complex electrophysiological signals, data from implantable devices, advanced cardiac imaging, and clinical parameters enables the development of algorithms capable of identifying patterns not detectable by human interpretation. These tools have already demonstrated practical utility in the early diagnosis of arrhythmias, risk stratification, procedural planning and guidance for catheter ablation, prediction of response to cardiac stimulation therapies, and optimization of remote device monitoring. Among the key emerging benefits, AI promises increasingly personalized care, enabling more targeted interventions while reducing overtreatment. Furthermore, the development of "digital twins" opens the possibility of simulating patient-specific therapeutic scenarios to support complex clinical decision-making. This manuscript provides an overview of current evidence, emerging applications, and remaining challenges related to the integration of AI in arrhythmology, highlighting its potential to drive a transition towards predictive, preventive, and personalized cardiovascular medicine.

Acute pericarditis is an uncommon complication of thermal atrial fibrillation (AF) ablation, whereas milder pericardial inflammatory symptoms, typically pleuritic or positional chest pain, are more common and negatively affect post-procedural recovery. Pulsed field ablation (PFA), a non-thermal modality with tissue-selective properties, may reduce collateral pericardial injury. We compared post-procedural pericardial inflammatory symptoms and recovery after AF ablation using PFA vs. radiofrequency ablation (RFA). This single-center observational study with prospective data collection included 150 patients undergoing catheter ablation for paroxysmal or persistent AF using focal PFA (n = 75) or RFA (n = 75). Patients were identified from the procedural workflow during the study period. Post-procedural pericardial inflammatory symptoms, chest pain severity (5-point scale), anti-inflammatory therapy use, length of hospital stay, and biomarkers of inflammation (CRP) and myocardial injury (hs-TnT) were assessed during hospitalization and structured post-discharge follow-up. Baseline characteristics were similar between groups. Post-procedural chest pain occurred more frequently after RFA than PFA (32% vs. 5.3%, p < 0.001), despite a significantly greater proportion of patients in the PFA group receiving lesion sets beyond pulmonary vein isolation (94.7% vs. 73.3%, p < 0.001). Anti-inflammatory therapy was prescribed more frequently after RFA (20% vs. 2.7%, p = 0.001), and hospital length of stay was longer [2 (1-2) vs. 1(1-1) days, p = 0.03). Procedure duration was shorter with PFA (86 ± 36 vs. 122 ± 55 min, p < 0.001). Median hs-TnT levels were higher after PFA [1288 (865-2137) vs. 1001 (652-1368] ng/L, p = 0.01), whereas CRP levels were similar [10.4 (4.9-23.3) vs. 10.5 (6.9-27.3) mg/L; p = 0.38]. PFA was associated with fewer post-procedural pericardial inflammatory symptoms, reduced need for anti-inflammatory therapy, and faster recovery compared with RFA. These findings suggest reduced pericardial irritation and improved patient-centered recovery after AF ablation.

Direct Oral Anticoagulants in Primary and Secondary Prevention of Thrombotic Events: 2026 ACC Scientific Statement: A Report of the American College of Cardiology.

The variable-loop circular catheter (VLCC, VARIPULSE) is a pulsed-field ablation (PFA) catheter equipped with a Tissue Proximity Indication (TPI) function, which monitors catheter-tissue contact. Although TPI-negative sites have been reported to contribute to gap formation, no studies have evaluated the utility of real-time function. This study assessed the success rate of pulmonary vein isolation (PVI) using the VLCC, incorporating the activated TPI function as the primary setting from the start of the procedure, representing an activated TPI function-guided ablation approach. Between February 1 and September 3, 2025, 60 consecutive patients underwent PFA using the VLCC. After creating the 3D geometry using CARTOSOUND FAM before ablation, PVI using the VLCC was performed with the activated TPI function. After an initial two-by-two PFA set, the catheter orientation was adjusted to target areas without visible TPI-positive tags. After applying an additional PFA application to ensure a circumferential TPI function-on tags, a voltage map was created using a multielectrode catheter, and the rate of residual potentials was compared. Using an activated TPI function-guided PFA strategy, a first pass isolation was successfully achieved in 90% of patients (54/60) and in 97.1% of pulmonary veins (231/238). Multielectrode catheter mapping revealed residual antrum potentials in some cases, necessitating additional PFA applications in 3.8% of the pulmonary vein antrum (9/238). Activated TPI function-guided PFA was associated with a low incidence of residual PV potentials, suggesting its potential utility to improve lesion continuity and procedural efficacy.

Reconnection of the pulmonary veins (PVs) is the primary cause of atrial fibrillation (AF) episodes after pulmonary vein isolation (PVI). Cryoballoon ablation does not always include the isolation of the carina due to anatomic variants and carina width has been associated with increased re-ablation rate in previous radiofrequency ablation studies. Aim of our study was to assess the impact of carina width on the re-ablation rate after cryoballoon-PVI. We included 518 patients who underwent cryoballoon ablation for AF between 2015 and 2022. Each patient underwent contrast enhanced chest computed tomography (CT) scan prior to ablation. We measured the shortest distance between the superior and inferior PV (carina width) and the size of the left atrium in CT images. In patients referred to re-ablation due to recurring symptomatic and ECG documented AF we defined the reconnected veins. The minimum follow up after prior PVI was 1 year. In all patients the right carina was wider than the left (8.04 ± 4.49 mm vs. 5.25 ± 3.03 mm, p < 0.059). One fifth (n = 102) of the patients underwent re-ablation for AF. Left carina width was significantly associated with re-ablation rate (in re-ablation group 6.4 ± 2.7 mm vs. in no re-ablation group 4.9 ± 3.0 mm, p < 0.001) whereas right carina width was not (8.3 ± 3.0 mm vs. 7.9 ± 3.6 mm, p = 0.421, respectively). Left atrium (LA) was larger in the re-ablation group, but the size of the LA did not correlate with the left carina width (r = 0.075; p = 0.111). However, there was a significant correlation between the size of the LA and the width of the right carina (r = 0.251, p < 0.001). Also, in the re-ablation group a significant correlation between right carina width and reconnection of the right PV's (RPV) was detected, which was not seen in the left PV's (LPV) (p = 0.015; p = 0.360, respectively). The left carina width and LA size are associated with the success rate of primary cryoballoon-PVI. However, there was a correlation between the right carina width and the reconnection of the RPV's leading to re-ablation. It seems that recognition of anatomical variants could be useful in the decision of ablation technique, but further studies are needed.

Arrhythmogenic substrates within the atrial myocardium may contribute to the initiation of atrial fibrillation (AF). The relationship between nonuniform isochrone-areas in late activation mapping and arrhythmogenic substrates remains undetermined. Sixty-two patients (66 ± 10 years, 47 males, non-paroxysmal AF [n = 30], second ablation procedure [n = 8]) who undergoing catheter ablation for AF were enrolled. High-density left atrial (LA) activation mapping was performed during atrial pacing after pulmonary vein (PV) isolation. Late activation mapping was retrospectively reconstructed. Nonuniform isochrone-areas were defined as regions of nonuniform and mottled conduction-zones characterized by the crowding of ≥ 3 color-isochrones within a 1-cm radius in late activation mapping. The relationship between nonuniform isochrone-areas and arrhythmogenic substrates associated with AF was evaluated. Non-PV triggers were identified in 11 patients (AF-triggers:12; short runs of premature atrial complexes:4), located in the LA wall (posterior:7; anterior:6; septum:2; roof:1). Patients with non-PV triggers had significantly more nonuniform isochrone-areas than those without (median [interquartile range] 5.0 [3.0-6.0] vs. 2.0 [1.0-4.0], p < 0.001). In multivariate logistic analysis for the presence of non-PV triggers, after adjusting for confounders such as non-paroxysmal AF, heart failure-history, and presence of low-voltage areas, the presence of nonuniform isochrone-areas on the LA low-posterior wall was an independent indicator for the presence of non-PV triggers (odds ratio: 6.9 [95% CI:1.1-44.1], p = 0.040). Of the 52 nonuniform isochrone-areas observed in the 11 patients with non-PV triggers, 20 areas corresponded to non-PV trigger sites. Identification of nonuniform isochrone-areas located on LA low-posterior wall in late activation mapping may indicate the potential source for non-PV triggers.

Cholesterol crystal embolism syndrome (CCES) represents a catastrophic complication of endovascular procedures. While mechanical trauma during left atrial catheter ablation acts as a known trigger, the specific embolic risks associated with Vein of Marshall ethanol infusion (VOM-EI) remain unexplored. A 66-year-old male with severe atherosclerosis and chronic kidney disease underwent persistent atrial fibrillation ablation involving VOM-EI (8 mL of ≥ 99.7% dehydrated ethanol). Six hours post-procedure, he developed extensive, non-pruritic livedo reticularis. He remained hemodynamically stable (lowest blood pressure 111/78 mmHg) but rapidly progressed to anuric acute kidney injury (creatinine peaking at 542 µmol/L) and severe systemic inflammation. Diagnostic evaluation effectively ruled out contrast-induced nephropathy, hypotensive acute tubular necrosis, and autoimmune vasculitis. Given the rapid deterioration, specific eosinophiluria testing and renal biopsy were deferred; however, sterile pyuria, classic skin lesions, and recent vascular intervention established a highly probable clinical diagnosis of CCES. Treatment with intermittent hemodialysis and high-dose intravenous methylprednisolone (40 mg/day) rapidly suppressed the inflammatory storm and facilitated substantial renal recovery. In patients with severe aortic plaque burden, VOM-EI, alongside established factors like transseptal catheter manipulation and systemic anticoagulation, may act as a potential trigger for CCES. Although a definitive diagnosis via biopsy was not feasible, we believe that early recognition and prompt corticosteroid therapy contributed substantially to the patient's clinical recovery.

Pulsed field ablation (PFA) has emerged as a novel non-thermal energy source for catheter ablation. While its use in atrial arrhythmias has expanded rapidly, clinical experience with ventricular PFA remains limited. This study aimed to evaluate the feasibility, safety, and clinical outcomes of focal PFA for the treatment of complex ventricular arrhythmias. This single-center observational study included patients undergoing catheter ablation for ventricular arrhythmias using focal PFA. The study population consisted of patients with challenging arrhythmia substrates, including redo procedures and cases requiring an intraprocedural switch from conventional radiofrequency ablation to focal PFA as a bail-out strategy. Acute procedural success, complications, and arrhythmia recurrence during follow-up were assessed. A total of 20 patients underwent ventricular PFA. Acute procedural success, defined as elimination of the target premature ventricular complex or noninducibility of sustained monomorphic ventricular tachycardia, was achieved in 95% of cases. During a mean follow-up of 663 ± 318 days, arrhythmia recurrence occurred in 10 patients (50%), including 6 of 9 (67%) with ventricular tachycardia and 4 of 11 (36%) with premature ventricular complexes. The overall complication rate was 15%, including one major vascular complication and two minor complications. Focal PFA demonstrated high acute procedural success and an acceptable safety profile in complex ventricular arrhythmias. These findings support its feasibility as an additional energy modality in challenging substrates. Larger prospective studies are needed to further define its role and long-term efficacy.

Cardiac electrograms form the foundation of contemporary clinical electrophysiology and are essential for activation mapping, substrate characterization and catheter ablation of cardiac arrhythmias. Electrogram morphology, however, is not solely determined by myocardial electrophysiology, but also by multiple technological factors related to signal acquisition and processing. Electrode size, interelectrode spacing, electrode orientation, tissue coupling, filtering settings and annotation algorithms all influence electrogram morphology, voltage and activation timing. Consequently, identical myocardial activation patterns may generate markedly different electrograms depending on the recording configuration used. Recent advances in high-density mapping technologies, multi-electrode electrogram reconstruction and advanced signal-processing techniques have further expanded the possibilities and complexity of electrogram interpretation. This review discusses the biophysical principles underlying cardiac electrogram formation and examines the technological determinants that influence electrogram characteristics. In addition, the properties, advantages and limitations of different electrogram types, including unipolar, bipolar, multipolar, omnipolar and Laplacian electrograms, are reviewed together with their implications for voltage and activation mapping. A comprehensive understanding of both the physiological basis and technological limitations of electrogram acquisition remains essential for accurate electrogram interpretation and responsible advancement of cardiac arrhythmia mapping and ablation strategies.