Aims: The feasibility and safety of the lattice-tip catheter for ventricular arrhythmia (VA) ablation in humans remain largely unknown. This study aimed to assess feasibility, safety profile as well as patient outcomes after VA ablation with a lattice-tip catheter in a multicentre European registry. Methods and results: All 18 European centres using the AFFERA system in September 2024 agreed to participate. Clinical, procedural, and follow-up data (minimum 3 months) were systematically collected and analysed. A total of 126 patients (18% female; mean age 59 ± 16 years) underwent VA ablation using the lattice-tip catheter during the inclusion period. Ablation indications included ventricular tachycardia (VT) in 99, premature ventricular complexes (PVCs) in 23, and ventricular fibrillation (VF) in 4 patients. Major and minor acute complications were observed in 7 (6%) and 18 (14%) procedures, respectively. They included thrombo-embolic event (n = 2), major bleeding (n = 2), ventricular fibrillation induction (n = 1), tamponade due to epicardial access (n = 1), and cardiogenic shock due to prolonged VT mapping (n = 1). Within the first month post-procedure, three patients died [from multi-organ failure (n = 2) and sepsis (n = 1)], two had worsening heart failure, one myocardial infarction, one sepsis, and one major gastro-intestinal bleeding. After a mean follow-up of 5.6 ± 3.7 months, absence of recurrence was 78% for PVC, 70% for VT, and 100% for VF. Conclusion: In this complex population with refractory VA, ablation using the lattice-tip catheter appears feasible and relatively safe. In the absence of large, randomized trials, exhaustive registry is of key importance to ensure safety and efficacy of new catheter technologies.

Atrial fibrillation (AF), the most common arrhythmia, is associated with increased morbidity, mortality, and healthcare costs. Evidence indicates that rhythm control offers superior cardiovascular outcomes compared to rate control, especially when initiated early after the diagnosis of AF. Catheter ablation remains the single best therapy for AF; however, it is not free from severe complications and only a small percentage of AF patients in the Western world ultimately receive ablation. Ensuring that AF ablation is safe, effective, and efficient is essential to make it accessible to all patients. With the limitations of traditional thermal ablative energies, pulsed field ablation (PFA) has emerged as a novel non-thermal energy source. PFA targets irreversible electroporation of cardiomyocytes to achieve cell death without damaging adjacent structures. Through its capability to create rapid, selective lesions in myocytes, PFA presents a promising alternative, offering enhanced safety, reduced procedural times, and comparable, if not superior, efficacy to thermal energies. The surge of new evidence makes it challenging to stay updated and understand the possibilities and challenges of PFA. This review aims to summarize the most significant advantages of PFA and how this has translated to the clinical arena, where four different catheters have received CE-market approval for AF ablation. Further research is needed to explore whether adding new ablation targets, previously avoided due to risks associated with thermal energies, to pulmonary vein isolation can improve the efficacy of AF ablation. It also remains to see whether a class effect exists or if different PFA technologies can yield distinct clinical outcomes given that the optimization of PFA parameters has largely been empirical.

Premature ventricular contractions (PVCs) represent a common and clinically significant cardiac arrhythmia, contributing to a spectrum of cardiovascular disorders. Accurate localization of the origin of PVCs is essential for devising targeted therapeutic strategies and refining our comprehension of ventricular arrhythmogenesis. Traditionally, the 12-lead ECG has been the go-to diagnostic tool for PVCs. However, individual anatomical differences and inter-patient electrophysiology variability limit its effectiveness. This study presents a new method that combines electrocardiographic imaging (ECGI) with the concept of cardiac digital twins (ECGI-DT) to improve the accuracy of pinpointing the source of PVCs. By simulating a database of PVCs, we developed an ECGI-DT capable of estimating the origins of PVCs with much greater precision than possible previously. This study shows a notable improvement in identifying the initial site of PVC origin using ECGI-DT compared to ECGI alone: the average localization error dropped from 30.69 ± 23.71 mm with standard ECGI to 7.81 ± 3.82 mm using the ECGI-DT method. This marked reduction in error highlights the potential of ECGI-DT in revolutionizing PVC diagnosis and treatment. With its ability to provide more accurate and reliable data, ECGI-DT could improve the planning of catheter ablation treatments, a preferred intervention for managing PVCs that face challenges such as high costs and in some cases long procedure times.

BACKGROUND: Identification of fast ventricular tachycardia (FVT; cycle length <320 ms) isthmuses is often hindered by hemodynamic instability during sustained FVT and by rate-dependent (functional) scar properties. Comparing ultra-high-density voltage heterogeneity maps (0.1–1.5 mV) of the scar area during sinus rhythm (SR) and FVT may delineate the rate-dependent components of the FVT isthmus (FVTI) and improve substrate identification during SR. METHODS: Thirty Large White swine with anterior myocardial infarction underwent cardiac magnetic resonance imaging for signal intensity mapping, followed by electrophysiological studies at 4 and 16 weeks post-infarction. FVTIs were defined as corridors of high-frequency electrograms spanning electric diastole and completing reentrant circuits in activation maps. Voltage heterogeneity mapping during FVT and SR was performed to identify voltage channels and delineate functional substrate. Statistical comparisons were performed using the Student t test, with data presented as mean±SD. RESULTS: Sixty ventricular tachycardias were induced, including 27 monomorphic episodes with a cycle length < 320 ms. Of these, 25 exhibited reentrant activation with identifiable FVTI. All FVTIs were housed within channels identified in voltage heterogeneity maps during FVT and signal intensity maps; 22 of 25 (88%) colocalized with a channel visible in SR voltage maps. Comparing FVT and SR voltage maps revealed that (1) dense scar area (<0.1 mV) was larger in FVT than in SR maps (1.5±0.3 versus 0.1±0.2 cm ² , P <0.001), (2) voltage channels sustaining FVTI in FVT were longer than in SR (18.7±7.1 versus 14.6±6.1 mm, P =0.047), and (3) while all channels in FVT maps were bordered by dense scar (<0.1 mV), only 4 in SR exhibited this feature, indicating a functional substrate in 84% of FVTIs. CONCLUSIONS: FVTIs are located within channels identified in voltage heterogeneity maps during SR and FVT. These channels colocalize with heterogeneous tissue channels in signal intensity maps. Comparative analysis of SR and FVT voltage maps enables delineation of functional borders.

Background: Atrial Fibrillation (AF) treatment strategies are suboptimal and clinical predictors of success are limited. Artificial Intelligence (AI) has arisen as a powerful tool for treatment efficacy prediction. Objective: We developed an AI‐driven platform for the stratification of patients based on noninvasive Electrocardiographic Imaging (ECGI) biomarkers and clinical parameters to evaluate and predict optimal patient treatment. Methods: We evaluated 204 patients treated according to clinical guidelines and characterized them at the electrophysiological level using ECGI recordings during AF. ECGI signals were calculated to obtain frequency and rotational biomarkers. Baseline clinical characteristics and treatment after inclusion were registered. Results: A clustering algorithm was calibrated taking three different variables for 1 year outcome prediction: (1) AF type (paroxysmal or persistent); (2) ECGI complexity score (calculated based on highest dominant frequency, median dominant frequency, and mean rotor time); and (3) type of treatment: rhythm control (drugs, AF ablation) or rate control. The cluster analysis classified patients into five groups: Low electrophysiological complexity patterns were associated with an improved outcome after ablation, regardless of the time duration of the AF. Intermediate complexity scores in paroxysmal AF had a favourable outcome with rhythm control treatments, but not in persistent AF patients. Cluster patterns with higher electrophysiological complexity were associated with a higher probability of AF recurrence, both in paroxysmal and persistent groups. The performance of the algorithm predicting the outcome was (AUC: 0.73 (0.63–0.81)), increasing overall performance with respect to conventional persistent and paroxysmal classification (AUC: 0.58 (0.48–0.68); p < 0.05). This algorithm was evaluated on the 20% test set, obtaining 90% prediction success. Conclusions: AI‐driven analysis that combined clinical information with ECGI biomarkers increased the performance of conventional classification methods for AF treatment stratification.

Background: Ventricular tachycardias (VTs) are a life-threatening complication of patients with end-stage left ventricular dysfunction, and are a frequent cause for considering advanced therapies. Their management in patients supported by a left ventricular assist device (LVAD) presents unique challenges, requiring a multidisciplinary approach to tailored strategies. Case summary: We present the case of a 70-year-old male with a history of VTs who underwent HeartMate 3 (Abbott, USA) implantation for advanced heart failure secondary to ischaemic cardiomyopathy and refractory VTs. Following LVAD implantation, he developed an electrical storm refractory to a combination of antiarrhythmic drugs and both radiofrequency and pulse-field catheter ablations. Due to persistent VT, neuromodulation of the sympathetic nervous system was considered as a last-resort strategy. Percutaneous radiofrequency ablation of the stellate ganglion was unsuccessful; however, left surgical sympathectomy effectively controlled the arrhythmias. The patient has remained free of arrhythmic events at 1-year follow-up. Discussion: Management of VTs in LVAD carriers is typically stepwise, beginning with correction of reversible triggers and the use of antiarrhythmic drugs. However, monotherapy is often insufficient, and achieving arrhythmic control often depends on a multimodal approach. In cases refractory to conventional measures, escalation to catheter ablation, neuromodulation techniques, and stereotactic arrhythmia radioablation may prove effective.