Effect of biventricular pacing on ventricular tachycardia recurrence after catheter ablation.

Ethanol Infusion in the Vein of Marshall during Atrial Fibrillation Ablation: A Systematic Review and Meta-Analysis.

Pulsed field ablation (PFA) has emerged to an innovative approach to achieve pulmonary vein isolation (PVI) in atrial fibrillation (AF) treatment. Despite its fast adoption and promising safety profile, insights into immediate ablation effects and lesion characteristics and their influence on follow-up arrhythmia recurrence using ultra-high-density mapping (UHDM) are sparse. This study aims to evaluate acute lesion dynamics and formation and their clinical impact using UHDM. This study enrolled 204 patients undergoing PVI with a pentaspline PFA system. UHDM was used for pre- and post-ablation assessment of the pulmonary veins (PV) and left atrium (LA). Clinical and mapping data were analyzed to define immediate lesion formation. Machine learning (ML) techniques, including SMOTE for data augmentation, were utilized to predict the recurrence of atrial tachycardia during follow-up and understand their underlying mechanisms. UHDM of immediate outcomes showed typical isolation patterns around the PV ostia. UHDM revealed a significantly narrowed electrically intact bridge on the LA roof. Furthermore, UHDM detected 14 non-isolated PV gaps in 13 patients, matching the typical lesion distribution. Gaps were undetected by the pentaspline PFA catheter.During follow-up, LA roof-dependent tachycardia was the most common recurrent arrhythmia (n = 11, 5.4%). ML model demonstrated size of the electrically intact tissue-bridge within the LA roof after PFA combined with LA size as predictors of occurrence of this specific tachycardia (AUC, 0.86; Sens., 0.86; Spec., 0.82).Additionally, ML models identified LA size and persistent AF as key predictors of gap presence (AUC, 0.88; Sens., 0.90; Spec., 0.83). ML models build with UHDM and clinical data can identify patients at risk for LA roof-dependent atrial tachycardia during follow-up and ablation gaps. Ablation strategies adapted to this information may potentially improve long-term outcomes in AF management.

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

ABSTRACTHis bundle pacing (HBP) has recently emerged as a physiologic pacing strategy that preserves ventricular synchrony and may improve outcomes in patients with heart failure and conduction abnormalities. Optimization of the atrioventricular (AV) delay plays a pivotal role in ensuring hemodynamic efficiency in patients with conduction system pacing. We report a 41‐year‐old male with dilated cardiomyopathy and severe heart failure (NYHA class IV, EF 16%), who was initially implanted with a cardiac resynchronization therapy (CRT) device. Despite multiple attempts to reposition the right and left ventricular leads, QRS duration during biventricular pacing widened from 140 to 185 ms. The right ventricular lead was subsequently repositioned to the His bundle (His‐optimized CRT, HOT‐CRT). Following AV delay optimization, the QRS duration narrowed to 120 ms, improving hemodynamic function. At 15‐month follow‐up, the patient remained clinically stable, able to perform moderate physical activity, with an improved EF of 25% and no recurrence of ventricular tachycardia. HOT‐CRT combines the physiologic advantage of His bundle pacing with optimized AV conduction timing, which is particularly valuable in patients with prolonged PR interval and nonresponse to conventional CRT. AV delay optimization ensures proper atrioventricular synchrony, enhances left ventricular filling, and contributes to improved cardiac output. This case highlights the significance of individualized AV delay adjustment in conduction system pacing to maximize therapeutic outcomes. Optimization of AV delay is essential for maximizing the benefits of conduction system pacing, especially in HOT‐CRT recipients. Attention to QRS morphology and duration during device implantation can help identify patients who will benefit most from individualized AV programming.

Multiparametric Electrogram Feature Analysis for Ventricular Tachycardia Functional Extra-Stimulus Substrate Mapping.

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.

Glob Acad J Med Sci, 2025; 7(6): DOI : https://doi.org/ Abstract PDF Full-Text e-Pub Purpose: This systematic review’s aim is to evaluate the role of autonomic markers in predicting supraventricular tachycardia (SVT) recurrence after catheter ablation. Understanding these markers can help to identify patients at higher risk of recurrence and improve post-procedural management. Methodology: A full literature review has been conducted using 12 electronic databases, such as PubMed, ScienceDirect, Springer, MDPI and Oxford Academic. It has covered studies in English from 1999 to 2025. The PRISMA 2020 guidelines for systematic reviews have been followed in the review. Studies have been chosen using the PICO framework: adult patients with SVT who undergo catheter ablation (Population), evaluation of autonomic markers like heart rate variability (HRV), baroreflex sensitivity (BRS), skin sympathetic nerve activity (SKNA), and P-wave alternans (Intervention), comparison with normal or baseline values (Comparator), and recurrence or non-recurrence of SVT as the outcomes (Outcome). Both qualitative and quantitative data were extracted, including statistical measures such as odds ratios, hazard ratios and predictive accuracy metrics. Findings: HRV is the most studied and widely applied autonomic marker. Early post-ablation HRV changes correlate with recurrence risk in AF studies, but evidence in SVT is limited and largely hypothetical. BRS, SKNA and PWA have showed potentiality but have been underexplored in SVT. Clinical and procedural factors, such as accessory pathway location and ablation strategy, is influencing the recurrence rates. In Bangladesh, HRV has been measured in tertiary centers, while other markers are not routinely applied due to resource constraints. Conclusion: Autonomic markers have promising potential to predict SVT recurrence, but no robust SVT-specific studies are there. Future research should focus on multicenter prospective studies with standardized measurement protocols and integration of clinical factors to develop reliable predictive models.

The occurrence of a left free-wall (LFW) accessory pathway (AP) with concentric activation sequences in the coronary sinus (CS) during orthodromic atrioventricular reentrant tachycardia (OAVRT) is an uncommon phenomenon. Using three-dimensional (3D) mapping system in eight patients with LFW-AP (mean age 44±9.9 years), we systematically analyzed mitral annular (MA) activation during OAVRT. The primary location of the APs was in the left lateral region in seven patients. The tachycardia, characterized by varying CS sequences, remained sustainable in three patients and was inducible in four patients following the initial ablation at the earliest retrograde atrial insertions. The tachycardia cycle length (TCL) was comparable to the baseline TCL (345.4±94.2 vs. 345.6±93.4ms; p = 0.99). Moreover, the tachycardia was terminated by ablating the earliest retrograde atrial activation region adjacent to the initial ablation site. One patient with a history of left lateral AP ablation exhibited mitral isthmus (MI) block, and the left anterior AP was successfully ablated. Following a mean follow-up of 50.5 months, no recurrence of tachycardia was reported by any patient. LFW-AP with concentric CS activation sequences represents a distinctive electrophysiological entity, our study demonstrates detailed mapping in the vicinity of the MA is imperative to localize the secondary atrial insertion site of the AP or to identify multiple APs in close proximity to the initial ablation site. This retrospective study does not require clinical trial registration.

Supraventricular tachycardia is the most common sustained arrhythmia in childhood. It is characterized by a rapid heart rhythm originating above the ventricles, usually caused by an accessory pathway or a nodal reentry mechanism. In infants, it may present with irritability, poor feeding, or signs of heart failure; in older children, with palpitations or dizziness. We present the case of a 7-year-old girl who attended the emergency department, referred from her health center due to an episode of palpitations. An electrocardiogram was performed, showing findings consistent with supraventricular tachycardia. The patient was hemodynamically stable, and the episode initially resolved with vagal maneuvers. During her stay in the emergency department, she experienced recurrent and persistent supraventricular tachycardia episodes that required intravenous adenosine administration up to 0.2 mg/kg on two occasions. The baseline electrocardiogram obtained after resolution of the tachycardia showed sinus rhythm with signs of ventricular preexcitation (delta wave and short PR interval), findings consistent with Wolff-Parkinson-White syndrome. Our aim is to highlight the importance of early detection of this condition and, through this clinical case, to focus on the fundamental aspects of its etiology, diagnosis, and therapeutic management.

BackgroundSupratherapeutic flecainide concentrations may result in wide complex cardiac dysrhythmias, which are normally treated with hypertonic sodium bicarbonate therapy. Previous cases have suggested that in acute toxicity, serum alkalinization may impair the elimination of flecainide.Case SummaryWe present a single case of chronic flecainide toxicity. A 69‐year‐old patient began taking oral flecainide 1 month prior and developed recurrent wide complex tachycardia (WCT) that was refractory to treatment with sodium bicarbonate and repeated defibrillations. Further arrhythmias stopped after the resolution of alkalosis and treatment with lidocaine. Serum flecainide concentrations were notable for an apparent rise from initial levels following serum alkalinization.DiscussionMedication interactions and pharmacodynamic testing could not account for increasing serum flecainide concentrations following treatment. No evidence of supratherapeutic ingestion was identified. Tissue redistribution as a result of serum alkalinization likely contributed to impaired elimination in a patient with chronic flecainide toxicity.ConclusionsSerum alkalinization from sodium bicarbonate administration has implications in the length of stay and need for adjunctive therapies in the treatment of flecainide toxicity.

Abstract Background Low-voltage area (LVA) ablation following pulmonary vein isolation (PVI) has shown potentially improved outcomes in persistent atrial fibrillation (AF) but may increase atrial tachycardia (AT) recurrence. This study investigates how LVA ablation affects arrhythmia recurrence patterns with specific focus on diabetic status. Methods This study is a subanalysis of the SUPPRESS-AF trial (Ref 1) including patients with persistent AF undergoing initial catheter ablation procedure. After PVI, those with significant LVAs (bipolar voltage &amp;lt;0.5mV covering ≥5 cm² of left atrial surface) were randomized 1:1 to either additional LVA ablation (PVI+LVA group) or no further ablation (PVI-alone group). The primary endpoint was 1-year freedom from AF/AT recurrence without antiarrhythmic drugs. Recurrences were classified by arrhythmia type (AF or AT) and analyzed according to diabetes status and ablation strategy. Results Of 1,347 persistent AF patients, 343 (25.5%) had significant LVAs and were randomized: 265 non-diabetic (137 PVI-alone, 128 PVI+LVA) and 77 diabetic patients (35 PVI-alone, 42 PVI+LVA). As reported previously, PVI+LVA ablation showed numerically higher freedom from AF/AT recurrence than PVI-alone (61% [% [15%-34%] vs. 30% [24%-36%], p=0.316). Among the four treatment subgroups, AT recurrence rate was substantially higher in diabetic patients receiving PVI+LVA ablation (23.8%) compared to other groups (non-DM/PVI-alone: 7.3%, non-DM/PVI+LVA: 9.4%, DM/PVI-alone: 8.6%; p=0.035), whereas AF recurrence rate showed no significant difference across the same groups (non-DM/PVI-alone: 35.8%, non-DM/PVI+LVA: 23.4%, DM/PVI-alone: 25.7%, DM/PVI+LVA: 21.4%, p=0.106). Conclusions The increased incidence of AT recurrence following LVA ablation was observed predominantly in diabetic patients, suggesting diabetes-specific arrhythmogenic substrates may influence ablation outcomes. These findings highlight th95% CI, 53%-68%] vs. 50% [42%-57%]) in the overall population. AT as first recurrence was significantly more frequent in the PVI+LVA group compared to PVI-alone (36% [24%-49%] vs. 18% [10%-30%], p=0.029). When stratified by diabetic status, the proportion of AT as first recurrence was significantly higher in diabetic versus non-diabetic patients (42% [25%-61%] vs. 22% [14%-31%], p=0.036), while AF recurrence rates were similar (23e importance of considering diabetic status when planning LVA ablation strategies for persistent AF management.Figure

Abstract Background Our previous study, SUPRESS-AF, demonstrated the efficacy of low-voltage area (LVA) ablation following pulmonary vein isolation (PVI) to improve outcomes in patients with persistent atrial fibrillation (AF). Diabetes mellitus is an established risk of atrial LVA formation. In this study, we examined the impact of diabetic status on arrhythmia type at first recurrence by focusing on the diabetic status. Methods This sub-analysis of the SUPPRESS-AF, a multicenter randomized controlled trial, included patients with persistent AF undergoing initial AF ablation. Following pulmonary vein isolation (PVI), patients with LVAs (defined as areas with a bipolar peak-to-peak voltage of &amp;lt;0.5mV) covering ≥5 cm² of the left atrial surface were randomly allocated to undergo LVA ablation (PVI+LVA-ablation arm) or not (PVI-alone arm) in a 1:1 fashion. The primary endpoint was freedom from AF/atrial tachycardia (AT) recurrence without antiarrhythmic drug use after initial ablation during 1-year follow-up. In this study, we defined the cutoff value of left atrial LVA as ≥15cm2. We divided patients into diabetic and non-diabetic groups and compared the primary endpoint with stratification for LVA extent and ablation strategy. Results Of 1,347 patients with persistent AF, 343 (25.5%) demonstrated left atrial LVAs and were randomized. In the non-DM group, the PVI+LVA-ablation arm showed significantly lower AT/AF recurrence rates than the PVI-alone arm (35% vs. 49%, P = 0.018). Conversely, patients in the DM group showed a numerically higher recurrence rate in the PVI+LVA-ablation arm than in the PVI-alone arm (48% vs. 40%, P = 0.290). Subgroup analysis showed that in non-DM patients with wide LVAs, PVI+LVA ablation was superior to PVI alone (36% vs. 55% recurrence; P = 0.020). In contrast, in the DM group with narrow LVAs, PVI+LVA ablation led to a significantly higher recurrence rate than PVI alone (58% vs. 30%; P = 0.037), while outcomes in the non-DM/narrow LVA subgroup and the DM/wide LVA subgroup were similar regardless of treatment strategy (P = 0.322 and 0.303, respectively). Conclusions Although LVA ablation following PVI provides a clear benefit for non-diabetic patients—especially those with wide LVAs—diabetic patients with narrow LVAs demonstrate significantly worse outcomes with this approach. These findings underscore the importance of tailoring ablation strategy to both DM status and the extent of LVA in patients with persistent AF.Fig1 Fig2

Abstract Background Low-voltage area (LVA) ablation is one of the therapeutic options for patients with persistent atrial fibrillation (AF) who are refractory to conventional treatments. However, in some cases, complete elimination of LVAs is challenging due to the risk of damage to the esophagus and physiological conduction system, as well as the presence of excessively extensive LVAs. It has not been clear whether incomplete LVA ablation increased the risk of arrhythmia recurrence. Methods This study is a post-hoc sub-analysis of the multicenter randomized controlled trial SUPPRESS AF. In the SUPPRESS AF trial, patients with persistent AF were randomly assigned in a 1:1 ratio to undergo LVA ablation or not if their left atrial LVAs covered ≥5 cm² on a voltage map after pulmonary vein isolation. The primary endpoint was freedom from AF/atrial tachycardia (AT) recurrence, monitored using 24-hour Holter ECGs and twice-daily portable ECG recordings, without antiarrhythmic drugs during the 1-year follow-up period after the initial ablation. In the present study, clinical outcomes were compared among three groups: no LVA ablation, complete LVA ablation, and incomplete LVA ablation. Results Among the 341 patients included, 170 underwent LVA ablation, with 37 cases remaining incomplete. The LVA non-complete group had significantly larger LVAs compared to the no LVA and LVA complete groups (22.0 [12.9, 36.0] cm² vs. 14.0 [8.7, 24.3] cm² and 12.2 [8.1, 19.0] cm², respectively; p=0.005, Table). Reasons for incomplete LVA ablation included concerns about damage to the esophagus and the physiological conduction system (including the His bundle and anterior transverse conduction) in 29 patients, excessive breadth of the LVA in 4 patients, and inability to manipulate the ablation catheter to some LVAs in 4 patients. Arrhythmia-free survival was comparable among the three groups (Figure). However, arrhythmia recurrence with AT forms was more frequently observed in the complete LVA ablation group than the no LVA ablation group (Figure). Conclusion This post-hoc sub-analysis of a randomized controlled trial did not identify any clear disadvantages of incomplete LVA ablation. Complete LVA ablation may be associated with an increased risk of AT recurrence. These results highlighted the lack of satisfactory understanding of the LVA ablation procedure.Table Figure

Abstract Background The efficacy of catheter ablation (CA) for persistent atrial fibrillation (PerAF) remains suboptimal with pulmonary vein isolation (PVI) alone. Left atrial (LA) low-voltage area (LVA) ablation has emerged as a potential strategy to improve outcomes. Although the SUPPRESS-AF randomized controlled trial did not demonstrate the overall superiority of additional LVA ablation, subgroups analyses indicated that certain patients cohort may derive greater benefit. This study aimed to identify patients suitable for additional LVA ablation in PerAF. Methods This post-hoc sub-analysis of the SUPPRESS-AF multicenter randomized controlled trial included patients with PerAF undergoing initial CA. After PVI, those with LVAs, defined as regions with a bipolar peak-to-peak voltage &amp;lt;0.5 mV covering ≥5 cm² of the LA surface, were randomly assigned in a 1:1 ratio to either receive additional LVA ablation (PVI+LVA ablation arm) or undergo PVI alone (PVI-alone arm). In a prespecified subgroup analysis, factors associated with a lower AF/atrial tachycardia (AT) recurrence rate in the PVI+LVA ablation arm compared to the PVI-alone arm included age ≥75 years, NYHA functional class ≥II, LA diameter ≥45 mm, absence of diabetes, and LVA size ≥20 cm². Each factor was assigned 1 point and total score was defined as the effective LVA ablation (ELVA-ABL score). The association between the ELVA-ABL score and AF/AT recurrence was analyzed in the PVI+LVA-ABL arm. Receiver operating characteristic (ROC) analysis was used to determine the optimal ELVA-ABL score cutoff for predicting AF/AT recurrence. Kaplan-Meier survival analysis and Cox proportional hazards models were used to assess AF/AT-free survival between the PVI+LVA-ABL and PVI-alone arms stratified by the ELVA-ABL score. Results Among 1347 patients who underwent initial CA for PerAF, 343 (25.5%) patients with LVAs were assigned to PVI+LVA-ABL arm (n=170) or PVI-alone arm (n=171). In PVI+LVA-ABL group, ROC analysis identified an optimal ELVA-ABL score cutoff of 3 for predicting AF/AT recurrence. Patients with an ELVA-ABL score ≥ 3 demonstrated significantly better AF/AT-free survival in the PVI+LVA-ABL arm compared to the PVI-alone arm (HR: 0.63, 95% CI: 0.41–0.97, p=0.038). In contrast, patients with an ELVA-ABL score &amp;lt;3 showed no significant difference in outcomes between the PVI+LVA-ABL and PVI-alone arms (HR: 1.45, 95% CI: 0.80–2.61, p=0.222).(Figure) Conclusion This post-hoc sub-analysis of the SUPPRESS-AF trial suggests that LVA ablation improves outcomes in patients with a higher ELVA-ABL score. These findings may help refine patient selection criteria for LVA ablation in PerAF.

Abstract Background/Introduction Both endocardial and combined endo-epicardial ventricular tachycardia (VT) ablation approaches have been utilized in patients with ARVC. Although there are data from single-center studies on both these approaches, there is paucity of data on direct comparison of these 2 ablation approaches. Methods We searched major electronic databases for studies that had compared endocardial ablation to combined endo-epicardial VT ablation in patients with ARVC. The outcomes were pooled using a random-effects model, and the results were expressed as risk ratios (RR) with corresponding 95% confidence intervals (CI). Statistical heterogeneity was assessed using the I2 statistic and all analyses were conducted using RStudio. Primary outcomes: VT/VF recurrence Secondary/safety outcomes: Major complications Results From the 11 studies utilized in our meta-analysis, a total of 633 patients were included. Endo-epicardial ablation was associated with a 30% relative risk reduction (RRR) in ventricular arrhythmia (VA) recurrence when compared with endocardial ablation alone (risk ratio [RR], 0.70; 95% confidence interval [CI], 0.53-0.93; P &amp;lt; .0001). There was also an absolute risk reduction (ARR) for ventricular tachycardia recurrence of 28.34%, with a number needed to treat (NNT) of 3.53. However, the endo-epicardial ablation group was also associated with a higher risk of major complications when compared to the endocardial ablation group alone (risk ratio [RR], 3.58; 95% confidence interval [CI], 1.01-12.71; P = 0.37). This was associated with an attributable risk (AR) of 2.81%, and a number needed to harm (NNH) of 35.58. Conclusion(s) Through our meta-analysis, we observed that a combined endocardial-epicardial VT ablation approach was associated with a significant reduction in VT recurrence when compared with endocardial ablation alone. On balance, endo-epicardial ablation is also associated with greater risk of major complications when compared with endocardial ablation alone, thus shedding light on avenues for further study of this approach.Findings of Endo-Epicardial vs Endo

Background: Although pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) management, recurrence of AF and atrial tachycardia (AT) remains a significant challenge. Concurrently, atrial antitachycardia pacing (A-ATP) delivered by cardiac implantable electronic devices (CIEDs) is clinically effective in suppressing atrial arrhythmias. This study aimed to investigate which ablation strategies in addition to PVI have more beneficial effect on the success of A-ATP in patients with refractory AF and AT. Methods: We retrospectively analyzed all AF/AT episodes detected via remote monitoring over a 9-month period, (4 to 12 months post-ablation) in 24 patients (mean age: 77.4 ± 9.1 years, male: 58.3%) who underwent catheter ablation and had CIEDs with A-ATP. Episodes in which A-ATP was delivered were extracted and divided into two groups based on termination outcome documented by the device. Linear ablation strategies in this study included the roof, bottom, lateral mitral, and anterior mitral lines. We stratified AF/AT episodes into two groups according to the number of linear ablation lines (low: 0–1, high: ≥2), and evaluated A-ATP success rates between the two groups. Results: Among the 24 patients, 14 received PVI alone either with defragmentation, or with a single additional line, such as a roof or lateral mitral line. The remaining 10 underwent PVI with posterior wall isolation (roof and bottom lines), with some also undergoing an additional line, including the lateral or anterior mitral line. A total of 2,577 AF/AT episodes were recorded in 24 patients. Of these, 1,287 episodes (49.9%) were treated with A-ATP, resulting in successful termination in 762 episodes (59.2%). Among the episodes treated with A-ATP, 425 were in the low group and 862 in the high group. A significant difference in A-ATP success rates was observed between the two groups: 43.5% in the low group versus 66.9% in the high group (P&lt;0.001). Logistic regression analysis further confirmed that the high linear ablation group was significantly associated with A-ATP success (odds ratio: 2.63, P&lt;0.001). Conclusion: The current study revealed that successful A-ATP in terminating atrial arrhythmias is significantly associated with more extensive linear ablation strategies, including posterior wall isolation and additional linear ablations. This finding highlights the potential benefit of combining catheter ablation and device-based A-ATP therapy in managing refractory AF and AT.

Background: Pulsed field ablation (PFA) is an emerging energy source in catheter ablation for atrial fibrillation (AF), offering tissue selectivity and procedural efficiency. While pulmonary vein isolation (PVI) remains the cornerstone of ablation, adjunctive posterior wall isolation (PWI) is increasingly considered, particularly in persistent atrial fibrillation (AF). However, the comparative benefits and risks of PVI + PWI versus PVI alone using PFA remain unclear. This meta-analysis aimed to evaluate the clinical efficacy and safety outcomes of PVI + PWI compared to PVI alone in patients with persistent AF undergoing PFA. Methods: A comprehensive literature search was conducted using PubMed, Embase, and Google Scholar databases. Random-effects models were used to calculate Mantel-Haenszel odds ratios (ORs) with 95% confidence intervals (CIs). The inverse variance method with DerSimonian–Laird (DL) of Tau2 was used to calculate mean differences (MDs) with CIs. Statistical significance was set at p &lt; 0.05. The primary endpoint was the recurrence of atrial fibrillation or atrial tachycardias (AF/AT) over the average follow-up of one year after the procedure. Secondary outcomes included in-hospital complications, mean procedure time, and mean fluoroscopy time. Results: Five studies, including 1,046 patients with persistent atrial fibrillation (AF), were included. There was no statistically significant difference in the recurrence of atrial fibrillation or atrial tachycardia (AF/AT) between patients who underwent PVI alone and those who received additional PWI along with PVI using pulsed field ablation (OR: 0.83; 95% CI: 0.40–1.73, P = 0.62). In-hospital complication rates were higher but not statistically significant with PVI + PWI (OR: 1.74; 95% CI: 0.92–3.30; p = 0.09). The PVI + PWI group had significantly longer mean procedure time (MD: 17.48 minutes; 95% CI: 0.79–34.17; p &lt; 0.05) and fluoroscopy time (MD: 1.99 minutes; 95% CI: 0.02–3.96; p = 0.05). Conclusion: In patients with persistent atrial fibrillation, PVI + PWI using pulsed field ablation did not significantly reduce arrhythmia recurrence compared to PVI alone but was associated with increased procedural and fluoroscopy times and a trend toward higher in-hospital complications. Further large-scale randomized studies are warranted to validate these findings. Keywords: Persistent atrial fibrillation; Catheter ablation; Pulmonary vein isolation; Posterior wall isolation; Pulsed field ablation.

Background: In persistent atrial fibrillation (perAF), atrial remodeling driven by age, biological sex, and comorbidities can create arrhythmogenic substrates beyond the pulmonary veins (PVs). These substrates support localized reentrant drivers that may sustain AF and reduce the efficacy of catheter ablation. However, patient-specific predictors of these driver substrates remain poorly defined. Methods: We studied 96 patients (71 men; median age 64 years) with perAF who underwent pulmonary vein isolation (PVI), bi-atrial multi-electrode mapping (MEM), and targeted driver ablation at a single center. Preprocedural delayed-enhancement MRI (DE-MRI), procedural MEM data, and post-ablation outcomes (assessed at 12–24 months) were analyzed for recurrence of AF or atrial tachycardia (AT). To validate clinical findings, we used a large-animal model of self-sustained perAF (4–8 months), including both male and female animals. In vivo MEM, DE-MRI, and ex vivo transmural optical mapping and histology were performed. Results: Biatrial MEM identified extra-PV reentrant drivers in a patient-specific manner, located in either or both atria. In the left atrium (LA), substrate characteristics—including DE-MRI–validated fibrosis, LA dilation, and heart failure—were associated with the presence of localized drivers and AF/AT recurrence. In patients under 64 years of age, a higher number of right atrial (RA) drivers correlated with increased arrhythmia recurrence. Older women exhibited a greater RA driver burden, associated with increased transmural fibrosis. Preclinical large-animal studies confirmed these findings, demonstrating reentrant drivers co-localized with fibrotic arrhythmogenic substrate regions. Conclusion: Biological sex, age, and chamber-specific atrial remodeling significantly influence AF driver distribution and ablation outcomes in perAF. RA remodeling—particularly in older women—may be a key determinant of arrhythmia persistence. Integration of MEM-defined driver mapping with substrate imaging may enhance ablation precision and improve long-term efficacy.

Background: Myocarditis can present with ST-segment elevations and rising troponin levels, mimicking an acute coronary syndrome. This case highlights a rare presentation of myocarditis secondary to influenza B that mimicked a lateral ST-segment elevation myocardial infarction (STEMI). Case Presentation: A 50-year-old woman presented to the emergency department with shortness of breath and hypoxia, diagnosed with influenza B. Computed tomography revealed superimposed bacterial pneumonia and a complex parapneumonic effusion in the left lower lobe. The patient reported chest pain, and an electrocardiogram (ECG) showed ST-segment elevations in leads I, II, and aVL. Troponin-T was elevated at 723 ng/L. Urgent cardiac catheterization revealed no evidence of coronary artery disease. A chest tube drained the empyema and within 12 hours, ST-segment elevations normalized. Echocardiogram was unremarkable except for a left pleural effusion. Cardiac magnetic resonance imaging could not be obtained due to worsening respiratory status. Management&amp;Outcome: The patient was treated with colchicine and aspirin for presumed myocarditis. The hospital course was complicated by recurrent atrial fibrillation and multifocal atrial tachycardia. After aggressive pulmonary hygiene, the patient recovered and was discharged. The lateral ST-segment elevation was ultimately attributed to localized myocarditis from adjacent inflammation from empyema. Discussion: This case underscores the importance of considering myocarditis in the differential for ST-segment elevations, particularly in the setting of acute infection. This presentation was unique in that ST-segment elevations initially concerning for acute coronary syndrome were instead a result of inflammation localized to the lateral wall of the left ventricle from the empyema. Although cardiac magnetic resonance imaging was unable to be obtained for confirmation, the diagnosis of myocarditis is supported by ECG changes, elevated troponin, and non-obstructive coronary arteries. Conclusion: Myocarditis should remain a key consideration in patients presenting with ST-segment elevations and elevated troponin levels, even when ECG changes localize to a specific coronary territory. This case demonstrates how localized myocardial inflammation from an adjacent empyema can mimic a STEMI pattern, which can resolve following drainage of the empyema. Clinicians should be aware that extracardiac inflammatory processes can trigger regional myocarditis.