Ablation of persistent atrial fibrillation and atypical atrial flutter (AAFL) is limited by the durability of pulmonary vein isolation, progression of underlying atrial myopathy, and incomplete formation of linear and focal lesions from radiofrequency energy. Tissue characteristics and proximity to vulnerable tissue such as the esophagus and phrenic nerve play a role. Herein, we demonstrate that a focal form factor with dual-energy capability using predominantly pulsed field ablation (PFA) and integrated high-density mapping can yield improved results for complex AAFL circuits. We analyzed data from consecutive patients at Minneapolis Heart Institute who underwent de novo or repeat ablations for AAFL or persistent atrial fibrillation between January and June 2025. Ablation was performed in all patients using the Affera (Medtronic) ablation system with the Sphere 9 dual-energy lattice tip focal form factor. Patients were followed for up to 6 months. Our cohort included 209 patients treated with Affera, of whom 74 patients (median age 72 [62,78], 55
BACKGROUND:Artificial intelligence (AI)-based electrocardiogram (ECG) analysis has emerged as a promising adjunct to human ECG interpretation in suspected ST-segment elevation myocardial infarction (STEMI). OBJECTIVES:To expand knowledge in this evolving field, the authors retrospectively analyzed the performance of a novel AI-ECG model in patients with cardiac catheterization laboratory activation for suspected STEMI. METHODS:Consecutive patients were gathered from a multicenter U.S. STEMI registry (2018-2022) and categorized into 3 clinical cohorts based on the presence or absence of angiographic culprit and troponin elevation: acute myocardial infarction (AMI) with culprit, AMI without culprit, and no-AMI. Cardiac catheterization laboratory-activating ECGs were analyzed using an AI-ECG model trained to identify acute coronary occlusion and classified as occlusion myocardial infarction, OMI(+) or not, OMI(-). RESULTS:The study included 2,523 patients, 68.3% male, with a median age of 63 years. AMI with culprit was present in 2076 (82.3%), AMI without culprit in 314 (12.4%), and no-AMI in 133 (5.3%). Among AMI with culprit patients, the model correctly identified 93.8% as OMI(+). Sensitivity for TIMI flow 0/1, 2, and 3 was 96.3%, 93.1%, and 86.9% respectively; P < 0.001. The model correctly identified 79.7% of no-AMI patients as OMI(-). The AUCROC was 0.952 (95% CI: 0.924-0.966). The AMI without culprit cohort included takotsubo syndrome OMI(+) = 78%, MI with nonobstructive coronary arteries OMI(+) = 61%, and myopericarditis OMI(+) = 67%. CONCLUSIONS:In suspected STEMI, this AI-ECG model correctly identified nearly all patients with acute coronary obstruction and most of those without AMI. If prospectively validated, this approach could improve management of patients with suspected AMI.
Tricuspid regurgitation (TR) is a common yet historically neglected condition associated with poor outcomes. Traditionally managed conservatively, TR has recently gained renewed attention, thanks to advances in surgical and transcatheter interventions. Selecting the optimal therapy, however, requires an integrated and systematic approach considering TR aetiology, stage of the disease, comorbidities, operative risk, and anatomical feasibility. This review describes a standardized stepwise work-up for patients with TR from the referral centre to the expert heart valve centre (HVC). It provides practical algorithms and structured protocols covering clinical and biological assessment, multimodality imaging (echocardiography, computed tomography, cardiac magnetic resonance), and invasive haemodynamic evaluation. The document highlights the importance of multidisciplinary collaboration, involving imagers, heart failure specialists, interventional cardiologists, electrophysiologists, and surgeons, in line with the new recommendations of the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease. By harmonizing diagnostic standards and promoting a structured approach to patient assessment within HVCs, this review aims to facilitate timely referral and ensure consistent evaluation and management of patients with this complex and often underestimated condition.
Abstract Introduction Subcutaneous implantable cardioverter defibrillators (S-ICDs) and extravascular-implantable cardioverter-defibrillators (EV-ICDs) have emerged as alternative defibrillation options to avoid the complications of transvenous leads. However, their sensing electrodes' extracardiac locations may increase their susceptibility to oversensing which may cause painful, and potentially arrhythmogenic, inappropriate shocks (IAS). Objective The objective of this study was to compare the causes of IAS between the S-ICD and EV-ICD. Methods The FDA’s Manufacturer and User Facility Device Experience (MAUDE) database was queried for IAS reports submitted by the two manufacturers from January 2024 to September 2025. Outcomes included 1) oversensing noise, T-waves oversensing (TWOS), P-waves oversensing (PWOS), and electromagnetic interference (EMI), and 2) misinterpreting supraventricular tachycardia (SVT), atrial fibrillation (AF), and sinus tachycardia (ST) as ventricular tachycardia (VT) or ventricular fibrillation (VF). Results The search found 1,900 S-ICD and 68 EV-ICD IAS reports. Oversensing of unspecified noise and TWOS caused significantly more IAS by S-ICDs vs EV-ICDs (RR = 2.13, CI: 1.24-3.68, p<0.01; RR = 8.88, CI: 2.26-34.84, p<0.01, respectively), while IAS due to misinterpreting SVT, AF, and ST as VT/VF (RR = 0.32, CI: 0.24-0.44, p<0.01), PWOS (RR = 0.1, CI: 0.05-0.21, p<0.01), and EMI (RR = 0.15, CI: 0.09-0.25, p<0.01) were more common with EV-ICDs than SC-ICDs (Table 1, Figure 1). Oversensing of myopotential noise was not different between the two groups. Only with S-ICD, sense B-noise, air entrapment, and intrinsic morphology changes were causes of IAS (Table 1). In 8 S-ICD and 1 EV-ICD reports, there was more than one cause of IAS. Conclusion The causes of IAS are significantly different between S-ICDs and EV-ICDs. The incidence and reasons for these major differences as well as the long-term clinical consequences of these differences require further investigation. If confirmed, this may assist in individualizing device selection to patient-specific risk profiles and encourage targeted follow-up strategies.Table 1Figure 1
Functional/Secondary tricuspid regurgitation (STR) accounts for over 85% of clinically significant tricuspid regurgitation (TR) and is associated with adverse prognosis and impaired quality of life. Advances in percutaneous tricuspid valve (TV) interventions underscore the need to differentiate TR etiologies, mechanisms, and phenotypes. STR is subdivided into atrial (A-STR), caused by right atrial dilation and tricuspid annular enlargement without significant leaflet tethering, and ventricular (V-STR), resulting from right ventricular dilation/dysfunction with leaflet tethering. A-STR, increasingly prevalent with aging and atrial fibrillation, typically presents with preserved right ventricular function, whereas V-STR reflects more advanced disease, is associated with RV dysfunction and, often, left ventricular systolic dysfunction and remodeling and/or left-sided valve disease, carrying higher mortality, compared with A-STR. Cardiac implantable electronic device (CIED) related TR is emerging as a distinct entity, while organic-TR arises from intrinsic structural abnormalities of the valve apparatus. Echocardiography, particularly three-dimensional imaging, is essential for accurate phenotyping and helps in procedural planning. Medical therapy remains primarily symptomatic, with diuretics as first-line therapy and targeted treatment of underlying cardiac pathology. In A-STR, rhythm control strategies, including catheter ablation for atrial fibrillation, may reverse annular remodeling. Surgical repair, preferably annuloplasty, is recommended in selected patients, often when concomitant left-sided surgery is needed. Transcatheter edge-to-edge repair offers a safe and increasingly used alternative, providing symptomatic improvement. The effects on outcomes are likely dependent on the time of intervention and the STR phenotype.
