Background and Aims: The prediction of the first major arrhythmic event (MAE) is still an unmet need in the recently defined scenario of non-dilated left ventricular cardiomyopathy (NDLVC). Methods: A cohort of 337 patients with NDLVC and no history of MAE was retrospectively identified at two large centres. Patient-tailored diagnostic workup included cardiac magnetic resonance (CMR), endomyocardial biopsy, and genetic testing. The primary endpoint was the occurrence of the first MAE, including sustained ventricular tachycardia (VT), ventricular fibrillation, or appropriate implantable cardioverter-defibrillator therapy, by 60-month follow-up. A pool of 216 NDLVC patients from 11 European centres served as a validation cohort. Results: In the study cohort (mean age 37 ± 15 years, 62% male), the mean left ventricular ejection fraction (LVEF) was 52 ± 8%, and 79% of patients had late gadolinium enhancement (LGE) at baseline CMR. By 60-month follow-up, 51 patients (15%) experienced a MAE. The primary endpoint was predicted by male sex [hazard ratio (HR) 2.4, 95% confidence interval (CI) 1.3–4.4, P = .007], baseline non-sustained VT (HR 3.1, 95% CI 1.7–5.6, P < .001), LVEF < 45% (HR 5.5, 95% CI 2.7–11.0, P < .001), septal (HR 2.0, 95% CI 1.0–4.0, P = .046) and ring-like pattern of LGE (HR 1.3, 95% CI .6–2.6, P = .54), pathogenic/likely pathogenic variants in guideline-defined high-risk genes (HR 4.6, 95% CI 2.3–9.1, P < .001), and biopsy/CMR-proven myocardial inflammation (HR 15.7, 95% CI 6.1–40.3, P < .001). The results were confirmed in the validation cohort (Uno’s C-index 0.81, 95% CI .75–.88). A novel risk score was subsequently derived. Conclusions: In NDLVC, male sex, non-sustained VT, LVEF < 45%, septal and ring-like LGE, high-risk genotypes, and myocardial inflammation predicted the first episode of MAE by 60 months.

Introduction: The assessment of the ventricular myocardial substrate critically depends on the size of mapping electrodes, their orientation with respect to wavefront propagation, and interelectrode distance. We conducted a dual‐center study to evaluate the impact of microelectrode mapping in patients undergoing catheter ablation (CA) of ventricular tachycardia (VT).Methods: We included 21 consecutive patients (median age, 68 [12], 95% male) with structural heart disease undergoing CA for electrical storm (n = 14) or recurrent VT (n = 7) using the QDOT Micro catheter and a multipolar catheter (PentaRay, n = 9). The associations of peak‐to‐peak maximum standard bipolar (BV_c) and minibipolar (PentaRay, BV_p) with microbipolar (BV_μMax) voltages were respectively tested in sinus rhythm with mixed effect models. Furthermore, we compared the features of standard bipolar (BE) and microbipolar (μBE) electrograms in sinus rhythm at sites of termination with radiofrequency energy.Results: BV_μMax was moderately associated with both BV_c (β = .85, p < .01) and BV_p (β = .56, p < .01). BV_μMax was 0.98 (95% CI: 0.93−1.04, p < .01) mV larger than corresponding BV_c, and 0.27 (95% CI: 0.16−0.37, p < .01) mV larger than matching BVp in sinus rhythm, with higher percentage differences in low voltage regions, leading to smaller endocardial dense scar (2.3 [2.7] vs. 12.1 [17] cm², p < .01) and border zone (3.2 [7.4] vs. 4.8 [20.1] cm², p = .03) regions in microbipolar maps compared to standard bipolar maps. Late potentials areas were nonsignificantly greater in microelectrode maps, compared to standard electrode maps. At sites of VT termination (n = 14), μBE were of higher amplitude (0.9 [0.8] vs. 0.4 [0.2] mV, p < .01), longer duration (117 [66] vs. 74 [38] ms, p < .01), and with greater number of peaks (4 [2] vs. 2 [1], p < .01) in sinus rhythm compared to BE.Conclusion: microelectrode mapping is more sensitive than standard bipolar mapping in the identification of viable myocytes in SR, and may facilitate recognition of targets for CA.

Background: There is no evidence evaluating efficiency, effectiveness, and safety outcomes in older patients in the context of pulsed‐field ablation technology for the ablation of atrial fibrillation. We aimed to compare safety, efficacy, and acute and long‐term outcomes of pulsed‐field ablation in older patients (≥75 years) with younger ones. Methods: We enrolled consecutive patients who had undergone atrial fibrillation ablation with the pulsed‐field ablation FARAPULSE system (Boston Scientific) at 15 centers. Patients were stratified by age (<65, 65–74, and ≥75 years) and efficacy and safety profiles of these groups were compared. Results: A total of 1082 patients were included: 108 (10%) were ≥75 years old, 374 (34.6%) were 65–74 years old and 600 (55.4%) were <65 years old. Older patients displayed a more pronounced risk profile compared with their younger counterparts, characterized by a significant higher burden of comorbidities. No differences in terms of procedural metrics were found. Pulmonary vein isolation was achieved in all patients. An overall low rate of procedural‐related complications was reported (3.0%) without difference between young and older patients ( P =0.241). During a mean follow‐up of 342±111 days, a primary efficacy end point occurred in 605 of 748 (80.9%) patients with available outcome information. The arrhythmia recurrence rate ranged from 14.4% in patients <65 years old to 26.9% of older patients ( P =0.011). Conclusions: Drawing from these findings, using the FARAPULSE system for atrial fibrillation ablation in older patients demonstrated swift, safe, and effective acute outcomes, mirroring a comparable pattern observed in younger patients and recurrence rates in line with the literature in older patients. Registration: URL: clinicaltrials.gov ; Unique Identifier: NCT05617456.

Background: Psoriasis is linked to an increased risk of atrial fibrillation (AF). However, data on the electrophysiological substrate and outcomes of AF ablation in patients with psoriasis are lacking. Methods: We conducted a retrospective, multicenter study involving 48 patients with psoriasis (median age, 66 years [56–72]; 79% male) and paroxysmal (n=25.52%) or persistent AF (n=23.48%) who underwent ablation at 4 high‐volume institutions between 2018 and 2023. Propensity score‐matching identified 96 controls without psoriasis undergoing AF ablation at the same institutions. The primary end point was survival free from atrial tachyarrhythmia recurrence after an 8‐week blanking period. Results: Baseline clinical characteristics were well balanced between groups. However, patients with psoriasis had higher CRP (C‐reactive protein) than controls (0.85 mg/dL [0.45–1.2] versus 0.3 mg/dL [0.3–0.4], P <0.001) and a greater burden of left atrial low‐voltage regions at electroanatomical mapping (20% [11%–20%] versus 5% [5%–10%]; P =0.013). Over a median follow‐up of 20 (13–32) months, atrial tachyarrhythmia recurrence occurred in a higher proportion of patients with psoriasis (40% versus 24%, log‐rank P =0.023). Patients with psoriasis also had a slightly higher risk of acute coronary syndrome (log‐rank P =0.045), with similar risks of death (log‐rank P =0.517) and procedural complications (2% versus 2%, P =1.000), whereas no stroke occurred. Multivariable analysis identified early recurrence within blanking period (adjusted hazard ratio [aHR], 5.9, P <0.001), preablation CRP levels (aHR, 1.2, P =0.016), and psoriasis history (aHR, 2.2, P =0.046) as predictors of atrial tachyarrhythmia recurrence. In the group with psoriasis, the optimal CRP cutoff associated with atrial tachyarrhythmia recurrence was found to be 1 mg/dL. Conclusions: Psoriasis is associated with low‐grade systemic inflammation, more severe electroanatomical markers of atrial cardiomyopathy, and worse postablation outcomes. The association between CRP levels and rhythm outcomes suggests that inflammation may drive recurrences among patients with psoriasis undergoing AF ablation.

Although mitral valve prolapse (MVP) is the most prevalent valvular abnormality in Western countries and generally carries a good prognosis, a small subset of patients is exposed to a significant risk of malignant ventricular arrhythmias (VAs) and sudden cardiac death (SCD), the so-called arrhythmic MVP (AMVP) syndrome. Recent work has emphasized phenotypical risk features of severe AMVP and clarified its pathophysiology. However, the appropriate assessment and risk stratification of patients with suspected AMVP remains a clinical conundrum, with the possibility of both overestimating and underestimating the risk of malignant VAs, with the inappropriate use of advanced imaging and invasive electrophysiology study on one hand, and the catastrophic occurrence of SCD on the other. Furthermore, the sports eligibility assessment of athletes with AMVP remains ill defined, especially in the grey zone of intermediate arrhythmic risk. The definition, epidemiology, pathophysiology, risk stratification, and treatment of AMVP are covered in the present review. Considering recent guidelines and expert consensus statements, we propose a comprehensive pathway to facilitate appropriate counseling concerning the practice of competitive/leisure-time sports, envisioning shared decision making and the multidisciplinary “sports heart team” evaluation of borderline cases. Our final aim is to encourage an active lifestyle without compromising patients’ safety.

Background: The VARIPULSE platform is an advanced Pulsed Field Ablation (PFA) system fully integrated with electro-anatomical mapping system, employing a variable loop circular catheter (VLCC) for atrial fibrillation (AF) ablation. The objective of the study is to assess for the first time the feasibility, safety, and procedural impact of AI (artificial intelligence)-assisted ICE (intracardiac echocardiography) mapping with the CARTOSOUND FAM Module compared with conventional electroanatomical mapping during PFA. Methods: In this retrospective, multicenter study, 157 consecutive patients undergoing PFA for paroxysmal or persistent AF were included. Patients were divided into two groups: ICE-guided cohort (n = 64) and non-ICE-guided cohort (n = 93). Propensity score matching (PSM) was used to adjust for baseline differences. Results: AI-assisted ICE mapping was feasible in all cases. Compared with conventional mapping, it significantly reduced LA (left atrium) mapping time (median 5 vs. 8 min; p < 0.001), LA dwell time (33.5 vs. 38.5 min; p = 0.001), and fluoroscopy time (7.5 vs. 14 min; p < 0.001). The total number of PFA applications was similar across groups (p = 0.136). No major adverse events occurred in either cohort during the procedure or within the first month of follow-up. Conclusions: AI-assisted ICE mapping using the CARTOSOUND FAM Module enables accurate anatomical reconstruction and significantly optimizes procedural efficiency in PFA. This approach supports further development toward radiation-sparing and potentially fluoroscopy-free PFA workflows. For the first time, it addresses a gap in the current evidence regarding the use of ICE in PFA, building on evidence already established for radiofrequency ablation procedures.