ABSTRACT Background Coronary air embolism is a rare but potentially fatal complication during catheter ablation for atrial fibrillation (AF). Use of large‐bore sheaths, such as those required for balloon‐based catheter ablation, in the setting of unstable respiratory control may increase the risk. Methods We retrospectively evaluated consecutive patients who underwent first‐time cryoballoon ablation (CBA) for AF from January 2017 to December 2024. Patients were divided into two groups according to respiratory management strategy: adaptive servo‐ventilation (ASV, n = 266) and laryngeal mask with mechanical ventilation (LM, n = 225). The incidence of complications was compared, with a primary focus on air embolism. Results A total of 491 patients (median age 68 years, 71.3% male) were included. Coronary air embolism occurred in 5 patients (1.9%) in the ASV group and in none of the patients in the LM group (absolute risk difference, 1.9%; 95% CI, −0.1% to 4.3%; p = 0.066). In one patient with coronary air embolism, brain MRI performed on the day of the procedure incidentally revealed an asymptomatic acute cerebral embolic lesion. Other complications included two cases of cardiac tamponade in the ASV group and two cases of transient phrenic nerve palsy in the LM group. Conclusions Coronary air embolism was numerically less frequent in patients undergoing cryoballoon ablation with laryngeal mask ventilation than in those managed with ASV, although the difference did not reach statistical significance. Further prospective studies are warranted to clarify the potential role of respiratory management in procedural safety.
ABSTRACT Twin atrioventricular (AV) nodes constitute a rare and highly complex electrophysiological substrate for tachycardia in heterotaxy syndrome (complex cardiac heart disease). We present the case of an 18‐year‐old male with right atrial isomerism, asplenia, univentricular physiology, and a Glenn shunt, who presented with a regular wide‐QRS tachycardia associated with severe hemodynamic decompensation. High‐density electroanatomical mapping identified two distinct His bundle recordings separated by 20.3 mm. Together with two non‐preexcited QRS morphologies and different conduction properties, these findings supported suspected twin AV node‐mediated macroreentry, with proposed anterograde conduction via the inferior‐posterior system and retrograde conduction through the superior‐anterior system; complete circuit mapping and entrainment were not possible. Following an initial procedure complicated by pulseless electrical activity clinically attributed to post‐cardioversion myocardial stunning, a second electrophysiological study prioritized functional characterization during sinus rhythm and atrial pacing without preablation reinduction of the clinical tachycardia. Selective ablation of the superior‐anterior His region preserved AV conduction and was followed by noninducibility of the clinical tachycardia. A separate isthmus‐dependent flutter was also ablated. At two months, clinical assessment, ECG, and 24‐hour Holter monitoring showed no documented recurrence or new AV block.
ABSTRACT Background Bioelectric impedance analysis (BIA) is a useful clinical tool in pediatric heart disease, but concerns regarding cardiac implanted electronic devices (CIEDs) limit its use. This study's goal was to assess the impact of BIA on CIED settings in pediatric patients. Methods This single‐center cohort study included two groups: a retrospective cohort of patients under 21 years old who had CIED interrogation within 12 months before and after BIA use, and a smaller prospective cohort who had CIED interrogation immediately before and after BIA use. The prospective group also underwent real‐time monitoring for electrical interference during BIA. Exclusion criteria included age, implanted loop recorders, and incomplete data. Analysis used either a paired t ‐test or a Wilcoxon signed‐rank test as appropriate, with p ‐value < 0.05 considered statistically significant. Results The retrospective cohort included 55 patients with 80 total tests. A statistically but not clinically significant difference in lead impedance was observed (513 [456, 627] v 513 [399, 593] ohms, p < 0.0001), though no differences were found in electrogram amplitudes, thresholds, or programmed output. When patients with multiple tests were analyzed, there remained a statistically significant difference in lead impedance (513 [399, 614] v 513 [375, 592] ohms, p = 0.0002) but not in other CIED parameters. In the prospective cohort ( n = 10), no electrical interference was appreciated during BIA, and there were no before‐and‐after differences in CIED sensing amplitudes. No inappropriate shocks or premature device failures occurred. Conclusions BIA was not associated with adverse events or meaningful changes in CIED function in this pediatric cohort.
Abstract Background Registry studies from 2000–2010 demonstrated underutilization of primary prevention ICD therapy. As heart failure therapies have reduced sudden cardiac death, investigators have questioned guidelines derived from trials conducted two decades prior, particularly in non‐ischemic cardiomyopathy (NICM) and elderly subgroups. We characterized contemporary referral determinants, decision‐making processes, and outcomes of primary prevention ICD therapy in a diverse, under‐represented population. Methods In this retrospective single‐center cohort study, we reviewed records of all patients meeting Class I criteria for primary prevention ICD in 2019. Multivariable logistic regression identified factors associated with ICD referral, and time‐varying Cox models compared all‐cause mortality by implantation status through 2022. Results Of 559 eligible patients, 345 (62%) were referred and 227 (41%) underwent implantation. Referral was associated with male gender, care coordination by a cardiologist rather than a generalist, and lower social vulnerability index (SVI) score. No decision‐making rationale was documented for a plurality of non‐referred and non‐implanted patients; documented rationales identified potential intervention targets. ICD implantation was not associated with all‐cause mortality (aHR 0.74, 95% CI 0.49–1.12). In exploratory analyses stratified by cardiomyopathy type, implantation was associated with lower mortality in ischemic cardiomyopathy (aHR 0.51, 95% CI 0.27–0.95) but not in NICM (aHR 1.11, 95% CI 0.63–1.95). Conclusion Many eligible patients are never referred for ICD therapy. Female gender, generalist care coordination, and high SVI were associated with non‐referral. The exploratory association of implantation with lower mortality in ischemic cardiomyopathy was not significant in propensity score overlap‐weighted analyses. The NICM estimate was imprecise.
ABSTRACT Background Atrial fibrillation (AF) remains a challenging arrhythmia to manage, and catheter ablation is a cornerstone therapy. Pulsed Field Ablation (PFA) has recently emerged as a novel non‐thermal alternative to Contact Force Radiofrequency (CF‐RF) ablation. This meta‐analysis compares the efficacy, safety, and procedural efficiency of PFA versus CF‐RF in patients with persistent atrial fibrillation. Methods A systematic review and meta‐analysis were conducted using randomized controlled trials and cohort studies identified from MEDLINE, Embase, and Cochrane databases. Primary outcomes included 12‐month freedom from atrial arrhythmia (AF, atrial flutter, or atrial tachycardia), procedure duration, fluoroscopy time, and major complications. Subgroup analyses were performed based on PFA device type (Farapulse vs. HT‐9000Pro) and patient characteristics, including left atrial size and AF duration. Results Seventeen studies met inclusion criteria. PFA was associated with significantly higher 12‐month freedom from atrial arrhythmia compared with CF‐RF (OR = 1.36, 95% CI 1.26–1.47, p < 0.001). Procedure time was markedly shorter with PFA (MD = −40.5 minutes, p < 0.001), while fluoroscopy time also showed a significant reduction (MD = −1.8 minutes, p = 0.001). Major complications were significantly lower with PFA (1.2% vs. 2.8%; OR = 0.44, 95% CI 0.35–0.57, p < 0.001). Conclusion In persistent AF, PFA, demonstrates superior efficacy, safety, and procedural efficiency compared with CF‐RFA, supporting its role as a potential first‐line ablation strategy. Larger multicenter trials with long‐term follow‐up are needed to confirm durability and device‐specific outcomes.
