Aims: Patients with end-stage renal disease (ESRD) and atrial fibrillation present a challenge for thromboembolic prevention, given their elevated risks of both thromboembolism and bleeding. Anticoagulants carry a higher bleeding risk in this population without clear evidence of thromboembolic benefit. This study aims to define the role of left atrial appendage occlusion (LAAO) as a preventive strategy for patients with ESRD. Methods and results: A systematic literature review was conducted to identify studies reporting outcomes in patients with ESRD who underwent LAAO. Meta-analyses of aggregate and individual patient data were performed to evaluate acute and long-term outcomes and compare them with those of patients without ESRD. Seventeen studies reporting data from 24 127 patients, including 1047 with ESRD, were included. Procedural complications were more common in patients with ESRD (RR 2.23; P = 0.02), with a pooled rate of 4% (95% CI, 1–9%). There was no significant difference in thromboembolic event rates during follow-up between the groups (IRR 1.44; P = 0.16), but major bleeding incidence was higher among patients with ESRD (IRR 1.84; P < 0.01). Individual patient-level data from seven studies comprising 4745 patients (268 with ESRD) were obtained and analysed. Similarly, there was no significant association between ESRD and stroke/TIA incidence (HR, 1.22; 95% CI, 0.66–2.26), but major bleeding was higher on patients with ESRD (HR, 1.65; 95% CI, 1.01–2.69). Conclusion: LAAO represents a feasible option for thromboembolic prevention in patients with ESRD, although these patients have an increased risk of complications and bleeding.

BACKGROUND: Cavotricuspid isthmus (CTI) ablation is frequently performed either as a standalone procedure or in combination with pulmonary vein isolation. With the rapid adoption of pulsed field ablation for atrial fibrillation, it is essential to delineate the utility of this modality in treating CTI-dependent atrial flutter (AFL). This study aims to evaluate the procedural and clinical outcomes of CTI ablation using pulsed field energy. METHODS: We conducted a retrospective analysis of consecutive patients who underwent pulsed field ablation for CTI-dependent AFL between January 2024 and March 2025. The primary end points were acute procedural success, periprocedural complications, and CTI-dependent AFL recurrence during follow-up. RESULTS: A total of 132 patients underwent CTI nonthermal ablation. The median age was 69.5 years, and 27.3% were female. The Farawave catheter was used in 93.9% of cases, PulseSelect in 4.5%, and Sphere-9 in 1.5%. Acute block was achieved in 99.2% of patients, although 8 required adjunctive radiofrequency ablation to complete the line. Periprocedural complications included transient ST-segment elevation in 2 patients and transient conduction disturbances in 3. During a median follow-up of 114 days (n=131), 5 patients (3.8%) experienced recurrence of typical AFL. The 6-month typical AFL-free survival estimate was 93.6%. CONCLUSIONS: Pulsed field ablation appears to be a feasible and effective strategy for CTI-dependent AFL. However, anatomic variability may limit its universal applicability with current catheter designs. Although acute procedural success is high, the long-term durability of the CTI block and its comparative efficacy versus conventional thermal ablation remain areas requiring further investigation.

Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions.

Exercise stress electrocardiogram (ECG) (ESE) is a widely used, noninvasive diagnostic tool for detecting coronary artery disease (CAD). Despite its widespread use, the diagnostic accuracy of ESE remains suboptimal. This study aimed to develop and evaluate an artificial intelligence (AI) model, using a transformer-based architecture, to enhance the diagnostic performance ofESEs. Patients who underwent coronary angiography within 2 months of the ESE were eligible for inclusion. An AI model processed exercise stress ECG images into time-series data. A transformer-based architecture was employed to integrate temporal ECG features and predict CAD. Model performance in predicting severe CAD was first evaluated using 5-fold cross-validation on a test subset from the original cohort, and subsequently on a second validation cohort. We developed a model using a total of 1,200 ECGs. An additional validation cohort of 91 patients was also analyzed. On the initial test subset, the AI model demonstrated a sensitivity of 93.6%, specificity of 93.2%, and overall accuracy of 93.4%. Notably, the model improved sensitivity with an absolute increase of 40.9% in women and 44.6% in men. In the second validation cohort, the model achieved an accuracy of 78%, with a sensitivity of 64.6% and a specificity of 93%. This study presents a proof of concept demonstrating that an AI-based model for stress ECG interpretation is feasible and shows acceptable performance.

Aims: The clinical significance of early recurrences during the blanking period following pulmonary vein isolation (PVI) remains uncertain, particularly after pulsed field ablation (PFA). This study aimed to evaluate the prognostic impact of early recurrences at 30-, 60-, and 90-day thresholds on outcomes following PFA for atrial fibrillation (AF). Methods and results: Consecutive patients who underwent PFA for AF across multiple centres within the Mayo Clinic health system were included. The primary endpoint was AF-free survival. Kaplan–Meier and multivariate Cox regression analyses were performed to compare outcomes between patients with and without early recurrences using 30-, 60-, and 90-day thresholds. A total of 1162 patients were included. The estimated AF-free survival at 1 year was 70%. Early recurrences within 30-, 60-, and 90-days post-ablation were significantly associated with late recurrences beyond 90 days (hazard ratio [HR] 5.9, 95% confidence interval [CI] 4.4–7.9, P < 0.01; HR 6.6, 95% CI: 5.0–8.6, P < 0.01; and HR 9.1, 95% CI: 7.0–11.7, P < 0.01, respectively). These findings remained significant among patients undergoing continuous rhythm monitoring. Early recurrences within 30 days in this subgroup were significantly associated with a 1-year AF burden >1% or the need for repeat AF ablation (odds ratio 25.0, 95% CI: 6.6–126.8, P < 0.01). Conclusion: Early recurrences following PFA are strongly predictive of long-term arrhythmia recurrence and are unlikely to represent transient inflammatory phenomena. Accordingly, the applicability of the conventional blanking interval after PFA should be reconsidered.

Epicardial access for ventricular arrhythmia (VA) ablation is a challenging and relatively uncommon procedure during ventricular ablation. This study aimed to assess the outcomes, predictors of success, and complications associated with pericardial access during these procedures. This multicenter, retrospective, observational study included data collected over 20 years (2004–2024) from all Mayo Clinic sites performing VA ablation with epicardial access. A total of 265 patients were included in the analysis: 196 for VT ablation and 69 for PVC ablation. Among them, 184 (69%) had at least 1 previous VA ablation, 51 (19.2%) had ischemic cardiomyopathy, 53 (20%) had structurally normal hearts, and 164 (61.9%) had nonischemic cardiomyopathies (NICMs). Three presented with concomitant ischemic cardiomyopathy and NICM. Within the NICM group, the most common diagnoses were dilated cardiomyopathy (n = 80 [30.2%]), arrhythmogenic right ventricular cardiomyopathy (n = 34 [12.8%]), and sarcoidosis (n = 15 [5.7%]). Acute success, defined as noninducibility, was achieved in 100 (61.7%) of 162 patients tested, while partial success (clinical arrhythmia noninduciblility) was observed in 47 (29%). Before discharge, VT recurred in 20 patients (10.2%). During a median follow-up of 61 months, events were observed as follows: 60 (35.5%) patients died, 26 (13.3%) underwent heart transplantation, and 62 (31.6%) required a repeat ablation for VAs. The event-free survival rates were 50% (95% confidence interval 43%–58%) at 1 year. Successful VT ablation with epicardial access can be achieved in select cases, though event-free survival remains suboptimal. Advanced disease stage and persistent inducibility at the end of the procedure are predictors of poor outcomes.