Interventional Electrophysiology Research Articles

Electrophysiological Cardiovascular Magnetic Resonance (EP-CMR)-Guided Interventional Procedures: Challenges and Opportunities.

Cardiovascular magnetic resonance (CMR) imaging excels in providing detailed three-dimensional anatomical information together with excellent soft tissue contrast and has already become a valuable tool for diagnostic evaluation, electrophysiological procedure (EP) planning, and therapeutical stratification of atrial or ventricular rhythm disorders. CMR-based identification of ablation targets may significantly impact existing concepts of interventional electrophysiology. In order to exploit the inherent advantages of CMR imaging to the fullest, CMR-guided ablation procedures (EP-CMR) are justly considered the ultimate goal. Electrophysiological cardiovascular magnetic resonance (EP-CMR) interventional procedures have more recently been introduced to the CMR armamentarium: in a single-center series of 30 patients, an EP-CMR guided ablation success of 93% has been reported, which is comparable to conventional ablation outcomes for typical atrial flutter and procedure and ablation time were also reported to be comparable. However, moving on from already established workflows for the ablation of typical atrial flutter in the interventional CMR environment to treatment of more complex ventricular arrhythmias calls for technical advances regarding development of catheters, sheaths and CMR-compatible defibrillator equipment. CMR imaging has already become an important diagnostic tool in the standard clinical assessment of cardiac arrhythmias. Previous studies have demonstrated the feasibility and safety of performing electrophysiological interventional procedures within the CMR environment and fully CMR-guided ablation of typical atrial flutter can be implemented as a routine procedure in experienced centers. Building upon established workflows, the market release of new, CMR-compatible interventional devices may finally enable targeting ventricular arrhythmias.

Electrophysiological assessment of atrial tachycardia substrates in patients with repaired tetralogy of Fallot

Abstract Introduction Adults with repaired tetralogy of Fallot (rToF) are most often referred to Adult Congenital Heart Disease centers for atrial tachycardia (AT) and radiofrequency catheter ablation (RFCA) is often required. A systematic evaluation of the mechanisms and recurrences of arrhythmias in these patients is lacking. Methods 28 patients with rToF referred for catheter ablation to the Interventional Electrophysiology Unit of our center between January 2013 and January 2023 were evaluated. Pts underwent electrophysiologic study (EPS) with 3D electroanatomic high density mapping. Evaluation of right atrial bipolar voltage and activation mapping of the AT was performed. Intra-atrial re-entrant tachycardias (IART), focal AT (FAT), other. Activation mapping was performed to identify the critical isthmus for IART. FATs were localized according to the earliest unipolar signal. Whenever possible, all the induced tachycardias were treated besides the arrhythmia which represented the clinical indication to EPS. RFCA was aimed at the earliest activation point for FAT and at the critical isthmus for IART, anchoring lesion to fixed obstacles (valve annuli or atriotomy scar). All patients provided written informed consent for participating in the study. Results Among 28 adult (age 47±13 years) patients (females n=14, 50%), 53 AT were documented: 34 (64%) IART, 11 (21%) FAT and 8 (15%) atrial fibrillation (AF). Mean tachycardia cycle length (excluding AF) was 307±95 ms. At least 2 ATs were induced in 12 pts during index EPS. Among IARTs, incisional IART (IARTinc, atriotomy and superior and inferior vena cava orifices, SVC and IVC, respectively) was the prevalent critical part of the circuit (n=22, 52%), while CTI was the second mechanism (n=20, 48%). In three pts, due to non-inducibility, a pre-emptive lesion set comprising in one case CTI and in two cases CTI+SVC-atriotomy-IVC line was performed. 2 patient underwent scheduled pulmonary veins isolation and CTI ablation. Among FAT, in 3 cases the AT was mapped in the coronary sinus, in two at the tricuspid annulus, in the remaining at the crista terminalis, at the right appendage base, at the posterolateral incision scar or between atriotomy and SVC. In 6 patients AF was induced but not ablated. During a median follow up of 23 months (interquartile range, 6-37) recurrence occurred in 8 pts (18% of pts, 15% of tachycardias). Patients with recurrences were younger (43±7 vs. 48±17 y, p=0.04); no differences were found according to critical isthmus location (4 CTI and 4 IARTinc, 50%, p=ns). Conclusions Among rToF pts with AT, IART is the prevalent mechanism and atriotomy scar is the prevalent critical isthmus. FAT location is much more variable. Atrial fibrillation burden is not negligible. Long-term freedom from AT in this clinical setting is encouraging.

Pulsed Field Energy in Atrial Fibrillation Ablation: From Physical Principles to Clinical Applications.

Atrial fibrillation, representing the most prevalent sustained cardiac arrhythmia, significantly impacts stroke risk and cardiovascular mortality. Historically managed with antiarrhythmic drugs with limited efficacy, and more recently, catheter ablation, the interventional approach field is still evolving with technological advances. This review highlights pulsed field ablation (PFA), a revolutionary technique gaining prominence in interventional electrophysiology because of its efficacy and safety. PFA employs non-thermal electric fields to create irreversible electroporation, disrupting cell membranes selectively within myocardial tissue, thus preventing the non-selective damage associated with traditional thermal ablation methods like radiofrequency or cryoablation. Clinical studies have consistently shown PFA's ability to achieve pulmonary vein isolation-a cornerstone of AF treatment-rapidly and with minimal complications. Notably, PFA reduces procedure times and has shown a lower incidence of esophageal and phrenic nerve damage, two common concerns with thermal techniques. Emerging from oncological applications, the principles of electroporation provide a unique tissue-selective ablation method that minimizes collateral damage. This review synthesizes findings from foundational animal studies through to recent clinical trials, such as the MANIFEST-PF and ADVENT trials, demonstrating PFA's effectiveness and safety. Future perspectives point towards expanding indications and refinement of techniques that promise to improve AF management outcomes further. PFA represents a paradigm shift in AF ablation, offering a safer, faster, and equally effective alternative to conventional methods. This synthesis of its development and clinical application outlines its potential to become the new standard in AF treatment protocols.

Interventional electrophysiology in Bulgaria in 2023: data from the electronic registry BG-EPHY

This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) cardiac ablations in 2023. Material and methods. This is a retrospective study of a full one-year sample of the BG-EPHY registry. Sex and age distribution of the patients, number of ablations, use of electroanatomic mapping (EAM), irrigated and cryoablations, distribution of different types of arrhythmias, acute procedural success, and complications are presented. Results. In 2023 nine EP centers performed 2021 ablations in 1309 men (61.8%) and 807 women, incl. 20 ablations in pediatric patients (1%). EAM was used in 941 procedures (46.6%), irrigated-tip catheter – in 1121 (55.5%), cryocatheter – in 420 (20.8%), and intracardiac echocardiography – in 43 (2.1%). The most frequently performed ablation was pulmonary vein isolation (46.4%), followed by ablation for AV nodal reentrant tachycardia (16.3%) and typical atrial flutter (15.2%). The acute success was over 98%, while intraprocedural complications were less than 2%. Conclusion. The national registry of electrophysiology collects systematically and continuously basic data on all ablations of cardiac arrhythmias performed in  the country. In 2023, after the end of the COVID-19 pandemic, the number of ablations increased compared to 2022, but at a slightly slower rate. Distribution of EP procedure types was similar to previous years. Acute success was very high, while intraprocedural complications were rare. 

Same day discharge after interventional electrophysiology procedures, first German experience

Abstract Background and purpose In most European countries, the current postprocedural gold standard following electrophysiological (EP) interventions implies the overnight monitoring of the patients in the hospital. Due to limited healthcare capacities and an increasing safety profile of ablation procedures, the mandatory overnight monitoring is under debate. Same day discharge protocol (SDD) ablation might be a safe and efficient alternative. We present the first German experience on SDD for EP interventions. Methods Patients receiving interventional EP procedures with a maximum of two VAs were discharged on the day of procedure, after the hemostasis and ambulation were proven. The VA hemostasis was achieved either by using a vascular closure system (VCS) or by a figure-of-eight suture followed by compressive bandage application. All patients were scheduled for a medical visit the day after procedure for groin examination and suture removal. Results A total of 12 patients (25% females, median age 64 (57.3, 66.8) years, median BMI 30.5 (22.3, 33.7) Kg/m2) undergoing EP procedures followed the SDD protocol in our center. All patients had an atrial fibrillation (AF) diagnosis, 66.7% of them paroxysmal. Five (45.5%) patients had a CHA2DS2VASc score of 1. A total of 4 (33.3%) patients presented arterial hypertension, 3 (25%) diabetes mellitus, 1 a history of stroke, 1 of myocardial infarction and 1 had chronic kidney disease and kidney transplantation. Eleven (91.7%) patients were under oral anticoagulation. The most common procedure was AF ablation, in 10 (83.3%) patients, while 1 (8.3%) patient underwent cavotricuspid isthmus (CTI) ablation and 1 (8.3%) a left atrial appendage closure procedure. In 10 (72.7%) AF ablations the energy source was cryoenergy, in 1 laserenergy and in 1 electroporation. The CTI ablation was performed by means of radiofrequency. A VCS was used in 7 (58.3%) patients. Six of these patients received 2 VCSs, while the patient with PFA based ablation had a single vascular access, thus only one VCS. The procedure was reported successful in all cases, and no intraprocedural complication occurred. During the next day visit, a groin hematoma has reported in 2 (16.7%) patients, no one requiring further therapeutical measures or hospitalization. All the other patients had no puncture related complications. The median FU time was 46.5 (26, 90.3) days. During FU only one patient had an unplanned ambulatory visit due to flecainide intolerance. Readmission during FU was reported in only 2 patients, none of them procedure related. Conclusions In selected patients undergoing EP procedures SDD seems to be safe and feasible. This approach increases healthcare capabilities, patients' comfort and reduces the cost of medical care.

Atrial fibrillation catheter ablation associated silent cerebral emboli: A narrative review.

The incidence of silent cerebral emboli (SCE) associated with atrial fibrillation catheter ablation (AFCA) is much higher than that of stroke/transient ischemic attack (TIA). Interventional electrophysiologists have been increasingly alerted to asymptomatic cerebral infarction over the years. Plentiful studies revealed that diagnostic definitions, detection modalities, energy sources, ablation strategies, perioperative anticoagulation regimens, and patient-related factors were associated with the risk of AFCA-associated SCE. Studies related to non-interventional procedures found that SCE may prompt stroke, cognitive decline, and dementia later in life, suggesting a possible role of AFCA-associated SCE in the cognitive function of patients with AF. However, there is no consistent evidence for this view to date. Given that the majority of patients with AF being elderly and the increased risk of cognitive impairment in AF itself, efforts should be made to minimize the occurrence of AFCA-associated SCE.

Utilization of 3D mapping systems in interventional electrophysiology and its impact on procedure time and fluoroscopy-Insights from the "Go for Zero Fluoroscopy" project.

The implementation of 3D mapping systems plays an important role in interventional electrophysiology (EP) in recent years. The aim of the present study was to evaluate use of 3D mapping systems regarding fluoroscopy and procedure duration. In the "Go for Zero Fluoroscopy" project 25 European centers provided data of consecutive EP procedures. Data on use of 3D mapping systems as well as utilization of contact force catheters and multipolar mapping catheters were associated with fluoroscopy time, dose area product (DAP), and procedure duration. A 3D mapping system was used in 966 (54%) cases. Use of 3D mapping for atrioventricular nodal reentry tachycardia (AVNRT) was associated with reduced fluoroscopy time (p<0.001), DAP (p=0.04) but increased procedure time (p=0.029). Moreover, fluoroscopy time (p<0.001) and DAP (p=0.005) were significantly lower in the 3D mapping group in ablation of typical atrial flutter. However, the procedure time (p<0.001) increased. Use of 3D mapping in the ablation of accessory pathway (AP) was associated with reduced fluoroscopy time (p<0.001) and DAP (p<0.001) with no significant increase in procedure time (p=0.066). In the case of atrial fibrillation, a 3D mapping system was used in 485 patients (75.8%). Additional use of a contact force catheter was associated with lower fluoroscopy time (p<0.001) and DAP (p<0.001). Use of a multipolar mapping catheter was associated with lower fluoroscopy time (p=0.002). The implementation of 3D mapping systems in the ablation of ventricular tachycardias resulted in a significant increase in the procedure time (p=0.001) without significant differences regarding the DAP (p=0.773) and fluoroscopy time (p=0.249). Use of 3D mapping systems in ablation of supraventricular tachycardias is associated with lower radiation exposure. Nevertheless, the procedure time often increases, except in the case of ablation for AP. Use of contact force catheters and multipolar mapping catheters is associated with yet lower radiation exposure values. Prospective randomized studies are needed to further elucidate potential benefit of these technological tools.

Interventional electrophysiology in bulgaria in 2022: data from the electronic registry BG-EPHY

This study presents data from the national electronic registry BG-EPHY on electrophysiologic (EP) cardiac ablations in 2022. Material and methods: This is a retrospective study of a full one-year sample of the BG-EPHY registry. Sex and age distribution of the patients, number of ablations, use of electroanatomic mapping (EAM), irrigated and cryoablations, distribution of different types of arrhythmias, acute procedural success and complications are presented. Results: In 2022 seven EP centers performed 1369 ablations in 872 men (63.7%) and 497 women (57% increase compared to previous year), incl. 15 ablations in pediatric patients (1.1%). EAM was used in 746 procedures (54.5%), irrigated-tip catheter &amp;ndash; in 814 (59.5%), cryoballoon catheter &amp;ndash; in 130 (9.5%), and intracardiac echocardiography &amp;ndash; in 33 (2.4%). The most frequently performed ablation was pulmonary vein isolation (40.2%), followed by ablation for AV nodal reentrant tachycardia (18.6%) and typical atrial fl utter (16.6%). The acute success was over 98%, while intraprocedural complications were less than 2%. Conclusion: The national registry of electrophysiology collects systematically and continuously basic data on all ablations of cardiac arrhythmias performed in the country. In 2022, during a subsiding COVID-19 pandemic and with the inclusion of new centers the number of ablations increased compared to 2021. Distribution of EP procedure types was similar to previous years. Acute success was very high, while intraprocedural complications were rare.

Practical guidance to reduce radiation exposure in electrophysiology applying ultra low-dose protocols: a European Heart Rhythm Association review.

Interventional electrophysiology offers a great variety of treatment options to patients suffering from symptomatic cardiac arrhythmia. Catheter ablation of supraventricular and ventricular tachycardia has globally evolved a cornerstone in modern arrhythmia management. Complex interventional electrophysiological procedures engaging multiple ablation tools have been developed over the past decades. Fluoroscopy enabled interventional electrophysiologist throughout the years to gain profound knowledge on intracardiac anatomy and catheter movement inside the cardiac cavities and hence develop specific ablation approaches. However, the application of X-ray technologies imposes serious health risks to patients and operators. To reduce the use of fluoroscopy during interventional electrophysiological procedures to the possibly lowest degree and to establish an optimal protection of patients and operators in cases of fluoroscopy is the main goal of modern radiation management. The present manuscript gives an overview of possible strategies of fluoroscopy reduction and specific radiation protection strategies.

Cardiac tamponades related to interventional electrophysiology procedures are associated with higher risk of short-term hospitalization for pericarditis but favourable long-term outcome.

To investigate the association of iatrogenic cardiac tamponades as a complication of invasive electrophysiology procedures (EPs) and mortality as well as serious cardiovascular events in a nationwide patient cohort during long-term follow-up. From the Swedish Catheter Ablation Registry between 2005 and 2019, a total of 58 770 invasive EPs in 44 497 patients were analysed. From this, all patients with periprocedural cardiac tamponades related to invasive EPs were identified (n = 200; tamponade group) and matched (1:2 ratio) to a control group (n = 400). Over a follow-up of 5 years, the composite primary endpoint-death from any cause, acute myocardial infarction, transitory ischaemic attack (TIA)/stroke, and hospitalization for heart failure-revealed no statistically significant association with cardiac tamponade [hazard ratio (HR) 1.22 (95% CI, 0.79-1.88)]. All single components of the primary endpoint as well as cardiovascular death revealed no statistically significant association with cardiac tamponade. Cardiac tamponade was associated with a significantly higher risk with hospitalization for pericarditis [HR 20.67 (95% CI, 6.32-67.60)]. In this nationwide cohort of patients undergoing invasive EPs, iatrogenic cardiac tamponade was associated with an increased risk of hospitalization for pericarditis during the first months after the index procedure. In the long-term, however, cardiac tamponade revealed no significant association with mortality or other serious cardiovascular events.

Immediate pericardial protamine administration in acute pericardial tamponade

Abstract Funding Acknowledgements Type of funding sources: None. Aims Cardiac tamponade (CT) is the most common life-threatening complication of interventional electrophysiology. Urgent drainage by percutaneous pericardiocentesis and anticoagulation reversal are required. Immediate direct protamine administration to the pericardial space to the patient has not been described. This study was designed to assess the efficacy and safety of immediate intrapericardial protamine administration (IPPA) in CT as a complication of interventional electrophysiologic procedure. Methods A retrospective case series of IPPA performed for CT was collected. Urgent drainage by percutaneous pericardiocentesis and IPPA were performed to achieve hemodynamic stabilization without emergent surgery. Results Eleven cases of IPPA were included in two tertiary heart centres. Electrophysiological procedures were performed for ventricular tachycardia (n =3), atrial fibrillation (n = 3), left accessory pathway (n = 1), and premature ventricular contraction (n =4) with transseptal (n = 10) and/or retroaortic routes (n =3). Pericardial drainage was performed by percutaneous pericardiocentesis for all 11 patients. Surgical haemostasis was not required for our cohort. The mean volume of drained pericardial fluid was 486ml (200-1200) Mean IPPA dosage was 209mg (100-800). Mean systemic protamine dosage was 86mg(50-100). No complication was observed on the follow-up. Conclusion IPPA is a feasible, safe, and useful technique for salvage therapy in CT. Conclusion IPPA is a feasible, safe, and useful technique for salvage therapy in ACT in interventional electrophysiology.

PO-02-141 SEEING THE HEART WITHOUT FLUOROSCOPY: ADVANCES IN AF ABLATIONS

Fluoroscopic imaging has historically played a critical role in interventional electrophysiology (EP). However, ionizing radiation carries significant and well-documented risks to both patients and staff. Advancements in non-fluoroscopic imaging methods, via electroanatomic mapping and intracardiac echocardiography, have provided electrophysiologists with the technology for performing catheter ablations with minimal to no fluoroscopic radiation. Through various fluoroscopy reduction techniques, there is now a means to reduce fluoroscopy exposure during each step of an atrial fibrillation (AF) ablation. Assess how the utilization of fluoroscopy reducing techniques over time has contributed to electrophysiologists performing AF ablations (both paroxysmal and persistent) with minimal to zero use of fluoroscopy. We reviewed 6240 AF ablations from 2009 to 2022 performed at Brigham and Women’s Hospital by electrophysiologists utilizing minimal fluoroscopy as well as those performing fluoroscopy-free ablations. Procedure characteristics include percentage of cases that were performed without the use of fluoroscopy as well as the trend in both fluoroscopic dose and time per case. Of the 6240 (4025 (65%) and 2215 (35%) paroxysmal and persistent, respectively) AF ablations performed since 2009, 1129 (18.1%) have been performed without the use of fluoroscopy. However, since 2017, which was the first year a fluoroscopy-free ablation was performed, 40.9% of ablations have been performed without fluoroscopy. For the most recent year 2022, of the 622 ablations performed, 356 (57.2%) were performed without the use of fluoroscopy. Since 2017, there is no difference in intraprocedural complications in cases performed without fluoroscopy compared to those with fluoroscopy (0.8 % vs 0.9%; P=0.55). There was also an overall reduction in the average fluoroscopy time (excluding non-fluoroscopy operators) with the average time in 2022 being 7.399 minutes, as compared to the average fluoroscopy time in 2017 of 22.329 minutes. Through advancements in fluoroscopy reduction techniques and imaging technologies, there has been a trend towards an AF ablation being performed predominantly without the use of fluoroscopy without an increase in intraprocedural complications. Amongst electrophysiologist who continue to use fluoroscopy, incorporation of these fluoroscopy reduction techniques has also led to a significant reduction in overall per case fluoroscopic time.

Cardiology: what's new in 2022

The year of 2022 was marked by many novelties in the fields of interventional cardiology, heart failure, electrophysiology, cardiac imaging, and congenital heart disease. These advances will certainly change our daily practice, on top of improving the diagnosis and treatment of many heart conditions. In addition, the European Society of Cardiology has updated its guidelines on pulmonary hypertension, ventricular arrhythmias and sudden death, cardiovascular assessment of patients undergoing non-cardiac surgery. The members of the Cardiology division of Lausanne University Hospital (CHUV) here present the publications which they considered to be the most important of the past year.

Arrhythmias in Pregnancy. Experience of the Multidisciplinary Team

Arrhythmia is the main cause of pregnancy-related hospitalizations. Potential risk of arrhythmias during pregnancy is associated with hypercoagulation and increased risk of thromboembolism.&#x0D; The aim. To increase patients’ safety and to improve maternal and perinatal outcomes by choosing the optimal medical strategy.&#x0D; Methods. We present the experience of multidisciplinary care for 54 pregnant and parturient women (32 with tachy-, 20 with bradyarrhythmia and 2 with ventricular asynchrony) who were admitted to the cardiac surgery facility from December 2013 to February 2022. Pacemakers were implanted in 15 cases of complete atrioventricular block radiofrequency ablation was performed in 12 cases.&#x0D; Results. There were no near misses and maternal losses in our group of patients. Two programmed perinatal losses were provided in patients with rhythm disorders and complex congenital heart defects. Type and place of delivery were chosen by the multidisciplinary team. There were nine childbirths at a specialized cardiac surgery clinic. There were no perinatal losses among patients who underwent rhythm interventions. In our group of patients, electrical cardioversion was performed in three cases, the pregnancies ended successfully with the birth of healthy newborns.&#x0D; Conclusions. Arrhythmias in all trimesters of pregnancy and the postpartum period are a common reason for seeking medical attention and hospitalization during pregnancy.Most of the arrhythmias are hemodynamically insignificant and don’t require hospitalization. Maternal risk stratification of major cardiac events during pregnancy, childbirth and the postpartum period is the cornerstone for choosing a strategy of medical care for pregnant women with arrhythmias. Patients with hemodynamic manifestations of tachy- and bradyarrhythmias, as well as patients with life-threatening types of rhythm disturbances are in the focus of attention of pregnancy heart team. Preconceptional management of patients with life threating arrhythmias is the best type of care in these patients. Pregnancy and delivery in high-risk class patients should be managed in an experienced center with on-site interventional electrophysiology techniques. Rhythm interventions have extremely limited indications and can be conducted when less invasive treatment strategy is unsuccessful.

Abstract 11545: The Role and Impact of a Women in Cardiology Mentorship Program on Female Residents

Introduction: Women are underrepresented in Cardiology, especially in interventional specialties. This study sought to evaluate the impact that a formal Women in Cardiology (WIC) mentorship program would have on female internal medicine residents. Hypothesis: We hypothesized that a formal mentorship program would positively impact female residents’ decision to pursue a career in Cardiology, and hoped to highlight this through this study. Methods: A formal WIC Mentorship Program was established at our institution, which featured educational content, open discussions and networking opportunities. Members of the program included female cardiologists from various sub-specialties, cardiology fellows and medical residents. An anonymous survey was then conducted to evaluate the impact of this program on female residents. This survey was completed by 100% of the participants. Results: After involvement in the WIC mentorship program female residents indicated that they: 1) were more interested in pursuing a procedural subspecialty (interventional cardiology or electrophysiology) (5/7, 71.43%); 2) were more comfortable approaching female fellows and attendings (7/7, 100%); 3) were more aware of the diversity of possible careers in Cardiology (6/7, 85.71%) 4) felt female mentorship was important for their future career (7/7, 100%) 5) found the program helpful and would attend future meetings (7/7 100%). Potential factors that discouraged women from pursuing cardiology were explored. The majority of residents indicated that concerns over work-life balance had discouraged them (4/7; 57.14%). A smaller portion of residents indicated concerns over radiation exposure (2/7; 28.57%) and discrimination (3/7; 42.86%) had discouraged them. All residents subsequently indicated that their concerns were addressed and lessened by the mentorship program. Conclusions: The importance and positive impact of mentorship were highlighted in this study. The adoption of similar mentorship programs across other institutions may be utilized to encourage interested female residents to pursue a career in cardiology, especially in procedural subspecialties.

The Expanding Uses of Medical Extended Reality in the Cardiac Catheterization Laboratory: Pre-procedural Planning, Intraprocedural Guidance, and Intraprocedural Navigation

The use of innovative imaging practices in the field of interventional cardiology and electrophysiology has led to significant progress in both diagnostic and therapeutic capabilities. 3D reconstructions of 2D images allows a proceduralist to develop a superior understanding of patient anatomy. Medical extended reality (MXR) technologies employ 3D interactive images for the user to improve depth perception and spatial awareness. Although MXR procedural navigation is a relatively new concept, the potential for use within interventional cardiology and EP is significant with the eventual goal of improving patient outcomes and reducing patient harm. This review article will discuss the current landscape of MXR use in the catheterization lab including pre-procedural planning, intraprocedural planning and intraprocedural guidance in diagnostic cardiac catheterization, valvar and coronary interventions, electrophysiology studies, and device implants.

Feasibility and safety of interventional electrophysiology and catheter ablation in the South African public sector: Challenges and opportunities for comprehensive cardiac electrophysiology in South Africa.

The spectrum and outcomes of catheter ablation procedures performed in South Africa are unknown, and therefore, the feasibility of interventional electrophysiology in the South African public sector is undetermined. This study was a retrospective review of all patients that underwent invasive electrophysiology procedures and catheter ablation at Groote Schuur Hospital (GSH) and the University of Cape Town Private Academic Hospital (UCTPAH) between 01 January 2013 and 31 December 2020.One thousand one hundred eighty-six invasive electrophysiology procedures were performed during the study period. Of these were 1102 catheter ablation procedures. There were 76 redo catheter ablation procedures, predominantly for atrial fibrillation (AF), which accounted for 39% (30/76) of the repeat procedures. There were only 0.8% (9/1102) catheter ablation related complications which were mostly access related. Atrial fibrillation accounted for most of the ablation procedures, 28.9% (318/1102); these were mainly performed at UCTPAH than at GSH, 300 vs 18 p< .0001. Cavotricuspid isthmus (CTI) dependent atrial flutter ablation was the second most commonly performed catheter ablation procedure, accounting for 21.6% (238/1102) of the catheter ablation procedures. More CTI dependent atrial flutter ablations were performed at GSH than a UCTPAH, 156 vs 82 p< .0001. The overall success rate of catheter ablation was 92%. A broad spectrum of catheter ablation procedures was performed with a high success rate and limited complications, thus demonstrating the feasibility of safe cardiac electrophysiology and catheter ablation in the South African public sector.

10-year follow-up of interventional electrophysiology: updated German survey during the COVID-19 pandemic

IntroductionThis study provides an update of survey-based data providing an overview of interventional electrophysiology over the last decade. Overall infrastructure, procedures, and training opportunities in Germany were assessed.MethodsBy analyzing mandatory quality reports, German cardiology centres performing electrophysiological studies were identified to repeat a questionnaire from 2010 and 2015.ResultsA complete questionnaire was returned by 192 centers performing about 75% of all ablations in Germany in 2020. In the presence of the COVID-19 pandemic, a total of 76.304 procedures including 68.407 ablations were reported representing a 38% increase compared to 2015. The median number of ablations increased from 180 in 2010 to 377 in 2020. AF was the most common arrhythmia ablated (51 vs. 35% in 2010). PVI with radiofrequency point-by-point ablation (64%) and cryo-balloon ablation (34%) were the preferred strategies. Less than 50 (75) PVI were performed by 31% (36%) of all centres. Only 25 and 24% of participating centres fulfilled EHRA and national requirements for training centre accreditation, respectively. There was a high number of EP centres with no fellows (38%). The proportion of female fellows in EP increased from 26% in 2010 to 33% in 2020.ConclusionComparing 2020, 2010 and 2015, an increasing number of EP centres and procedures were registered. In 2020, more than every second ablation was for therapy of AF. In the presence of an increasing number of procedures, training opportunities were still limited, and most centres did not fulfill recommended EHRA or national requirements for accreditation.Graphical abstract

The blanking period after atrial fibrillation ablation: an European Heart Rhythm Association survey on contemporary definition and management.

The use of a blanking period (BP) after an atrial fibrillation (AF) ablation procedure is a common practice, but recent data questions the benign nature of early recurrences of atrial tachyarrhythmias (ERATs). A physician-based survey was carried out by the European Heart Rhythm Association (EHRA) to investigate the current definition and applicability of BP and ERAT management. An online questionnaire was sent to clinical and interventional electrophysiologists. A total of 436 respondents (88% interventional electrophysiologists) reported observing ERATs in 25% (interquartile range 15-35) of patients, less commonly in paroxysmal AF (PAF) compared with persistent AF (persAF). The median reported duration of BP used by respondents was 90 days, with 22% preferring a shorter BP duration for PAF patients compared with persAF. Half of the patients with ERATs are expected to also experience late recurrences (LR). Isolated episodes of ERATs are treated conservatively by 99% of the respondents, but repeat ablation during the BP is preferred by 20% of electrophysiologists for multiple ERATs and by 16% in patients with organized atrial tachyarrhythmias. In conclusion, ERATs are commonly observed after AF ablation, particularly in persAF patients, and are perceived as predictors of LR by half of the respondents. A general adherence to a 90-day BP duration was observed. During this time period, ERAT is mainly treated conservatively, but repeat ablation during the BP is occasionally offered to patients with multiple ERATs and those with organized atrial tachyarrhythmias.

A history of collaboration between electrophysiologists and arrhythmia surgeons.

Introduction: The notion that medically‐refractory arrhythmias might one day be amenable to interventional therapy slowly began to appear in the early 1960's. At that time, there were no “interventional electrophysiologists” or “arrhythmia surgeons” and there was little appreciation of the relationship between anatomy and electrophysiology outside the heart's specialized conduction system. Methods: In this review, we describe the evolution of collaboration between electrophysiologists and surgeons. Results: Although accessory atrio‐ventricular (AV) connections were first identified in 1893 and the Wolff‐Parkinson‐White (WPW) syndrome was described 37 years later (1930), it was another 37 years (1967) before those anatomic AV connections were proven to be responsible for the clinical syndrome. The success of the subsequent surgical procedures for the WPW syndrome, AV node reentry tachycardia, automatic atrial tachycardias, ischemic and non‐ischemic ventricular tachycardias and atrial fibrillation over the next two decades depended on a close, sometimes daily, collaboration between electrophysiologists and surgeons. In the past two decades, that tight collaboration was largely abandoned until the recent introduction of “hybrid procedures” for the treatment of atrial fibrillation. Conclusions: A retrospective assessment of the 50 years of interventional therapy for arrhythmias clearly demonstrates the clinical benefits of a close collaboration between electrophysiologists and arrhythmia surgeons, regardless of which one is actually performing the intervention.