Ventricular tachycardias represent a complex clinical challenge, particularly due to the intricate arrhythmic circuits and diverse substrates found in ischemic and non-ischemic cardiomyopathies. This review explores the significant advancements in mapping, imaging, and ablation technologies that have transformed the management strategies for ventricular arrhythmias. Recent innovations such as pulsed-field ablation and high-resolution imaging modalities like cardiac magnetic resonance and multi-detector computed tomography have refined our approach to ablate ventricular tachycardias. The evolution of surgical and hybrid ablation techniques also highlights an adaptive response to cases unmanageable by conventional interventions. Furthermore, we discuss the integration of new diagnostic tools and detailed substrate analysis, which are pivotal in enhancing procedural outcomes and reducing recurrence. This synthesis of current practices with emerging technologies offers a promising direction toward more effective and personalized management of VT, underlining the need for continuous advancement in both technological capabilities and procedural strategies.

BACKGROUND:Conduction system pacing (CSP) using His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBAP) is an evolving alternative to traditional right ventricular pacing (RVP), promising better physiological outcomes. This study evaluates the safety, feasibility, and performance of HBP and LBAP with Medtronic SelectSecure 3830 leads. METHODS:We conducted a single-center retrospective analysis of 490 patients undergoing HBP or LBAP. The study assessed implant success rates, pacing thresholds, device longevity, and complication rates over an average follow-up of 28 months for HBP and 14 months for LBAP. RESULTS:The implantation success rate was 85% for HBP and 97.4% for LBAP. LBAP demonstrated lower and more stable pacing thresholds, with initial values of 0.8V at 0.5 ms rising slightly to 0.9V at 0.5 ms, and fewer device revisions compared to HBP, whose initial pacing threshold of 1.3V at 0.8ms increased to 1.68 V at 0.7ms. Complications were minimal and similar across both groups. The need for fewer device revisions and potential for prolonged device life highlighted LBAP as potentially more cost-effective. Cardiac function measured by LVEF remained stable across both groups. CONCLUSIONS:Both HBP and LBAP are safe and feasible with comparable safety profiles. LBAP may offer advantages in terms of stability, fewer revisions, and extended device longevity. The study underscores the need for further research into optimal lead positioning and long-term outcomes of CSP, particularly for LBAP.

This novel case documents the successful use of transcatheter aortic valve implantation to treat severe aortic insufficiency arising from aortic root dissection following the repair of an ascending aortic aneurysm in a 75-year-old female patient. After she presented with symptoms of congestive heart failure, investigation revealed new severe aortic insufficiency and an acute aortic dissection. Given the prohibitive risks of reoperation, a self-expanding 27-mm Portico (St Jude Medical) prosthetic aortic valve was deployed, resulting in substantial clinical improvement without procedural complications. This case highlights the versatility of transcatheter aortic valve implantation in managing complex aortic disease and emphasizes the critical role of multidisciplinary evaluation and careful prosthesis selection.

INTRODUCTION:Infective endocarditis (IE) is an increasingly important condition with significant morbidity and mortality. With advancements in cardiovascular interventions including prosthetic valve implantation and utilization of intracardiac devices, the prevalence of IE is rising in the modern era. Early detection and management of this condition are critical.AREAS COVERED:This review presents a contemporary review of the applications of multi-modality imaging in IE, taking a comparative approach of the various imaging modalities.EXPERT OPINION:Transthoracic and transesophageal echocardiography are essential imaging modalities in establishing the diagnosis of IE, as well as evaluating for complications of IE. Other imaging modalities such as cardiac computed tomography and nuclear imaging play an important role as adjuvant imaging modalities for the evaluation of IE, particularly in prosthetic valve IE and cardiovascular implantable device associated IE. It is crucial to understand the strengths, weaknesses, and clinical application of each imaging modality, to improve the diagnosis, management, and outcomes of patients with IE.

Cardiac resynchronization therapy (CRT) has revolutionized heart failure (HF) management, offering benefits in morbidity, mortality, and symptom alleviation. However, optimal response rates are not universally achieved, necessitating enhanced patient-selection strategies. Myocardial scar patterns, quantified by delayed-enhancement cardiac magnetic resonance (DE-CMR), have been implicated in CRT outcomes. We conducted a meta-analysis of observational studies assessing CRT responses by performing a systematic literature search using PubMed, Embase, Ovid MEDLINE, Scopus, the Cochrane Library, ScienceDirect, and the Web of Science. Scar burden, left ventricular ejection fraction (LVEF), left ventricular end-systolic volume (LVESV), and left ventricular end-diastolic volume (LVEDV) were evaluated. CRT response rates among ischemic and non-ischemic cardiomyopathy patients were also explored. This meta-analysis incorporated eight studies meeting the eligibility criteria. CRT responders exhibited a significantly lower scar burden (-11.7%; 95% confidence interval, 6.6%-16.8%) compared to non-responders, supporting the predictive value of scar quantification (I 2 = 95.25%; P < .001). Responders demonstrated an increased mean LVEF (from 25.2% to 31.9%), while non-responders showed modest changes (from 23.3% to 24.4%). Responders experienced a decrease in mean LVESV from 158.8 to 132.8 mL, contrasting with a more stable mean LVESV value in non-responders (reduction from 160.9 to 157.6 mL). Responders experienced a reduced mean LVEDV from 219.4 to 196.7 mL, while non-responders showed more minimal changes (from 213.4 to 210.6 mL). Limited data suggested a CRT response rate of 34.7% in ischemic cardiomyopathy; non-ischemic data were insufficient. In conclusion, DE-CMR, assessing the scar burden, emerges as a valuable tool for predicting the CRT response. A lower scar burden correlates with improved responses, supporting the role of DE-CMR in refining patient selection for CRT. This meta-analysis contributes insights into personalized CRT strategies, emphasizing the potential of imaging modalities to enhance therapeutic outcomes in HF patients. Further research is warranted to solidify these findings and refine clinical applications.

BACKGROUND The short-term safety, feasibility, and performance of the Medtronic SelectSecure 3830-69 cm pacing lead for conduction system pacing (CSP) has been reported; however, its longer-term performance is not well established. OBJECTIVE The purpose of this study is to examine the long-term performance of the 3830 lead for His Bundle Pacing (HBP) and Left Bundle Branch Area Pacing (LBBAP). METHODS We retrospectively reviewed all cases of CSP performed with the Medtronic SelectSecure 3830-69 cm pacing lead at Cleveland Clinic Florida between May 2016 and October 2021. RESULTS Of 515 attempts, HBP achieved an 85% success rate (340 cases), while LBBAP demonstrated a higher success rate of 97.4% (150 cases). The mean follow-up was 28 months for HBP and 14 months for LBBAP, with patient ages averaging 75 and 77 years, respectively. Only 7% of the cohort had an ejection fraction below 50%. The primary indications for HBP were sick sinus syndrome (35.5%), atrioventricular block (35.2%), cardiac resynchronization therapy (10%), and refractory atrial fibrillation (18.8%), with similar distributions for LBBAP. The HBP group’s capture threshold at implant was 1.3 ± 0.8 V at 0.8 ± 0.2 ms, which significantly increased at chronic follow-up to 1.68 ± 1.3 V at 0.7 ± 0.3 ms (p <0.001), whereas the LBBAP group’s capture threshold remained stable from 0.8 ± 0.5 V at 0.5 ± 0.3 ms to to 0.9 ± 0.5 V at 0.5 ± 0.3 ms, (p= 0.35). Lead revisions were more common in the HBP group (50 cases) than in the LBBAP group (5 cases), with exit block rates of 11.7% and 3%, respectively. CONCLUSION Using the 3830 lead for HBP can result in significantly elevated thresholds, loss of His-bundle capture, and frequent lead revision rates at long-term follow-up. These issues are less commonly seen when the lead is used for LBBAP. ### Competing Interest Statement Dr. Baez-Escudero, serve as a consultant to Abbott and Aziyo biologics. All other authors have reported that they have no relationships relevant to the content of this paper to disclose. ### Funding Statement After beginning our work we came to know of an opportunity for funding via Medtronic's investigator-initiated research program to which we were accepted. However, we assure you that any potential conflict of interest has not influenced the design, execution, or reporting of this study, and our findings are presented objectively. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Institutional Review Board Cleveland Clinic Foundation 9500 Euclid Avenue Cleveland, OH 44195 Telephone: 800.223.2273 Fax: 216.445.4094 I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data will be made available upon reasonable request. * CSP : Congestive Heart Failure CSP : Conduction System Pacing HBP : His Bundle Pacing LBBAP : Left Bundle Branch Area Pacing RVP : Right Ventricular Pacing

BACKGROUND:Data are limited regarding infective endocarditis (IE) complicating left atrial appendage occlusion (LAAO) device procedures. This systematic review examines the etiology, diagnosis, and management of infective endocarditis (IE) following LAAO. METHODS:A comprehensive search of six databases was performed between 2007 and 2022. In selecting studies, articles were included if they provided information about IE complicating LAAO, with relevant clinical and imaging details. Articles were excluded if they were editorials, study protocols, letters, or abstracts. RESULTS:We identified seven cases of IE complicating LAAO published between 2007 and 2022, from the United States and Europe, highlighting the exceedingly rare reported incidence of the condition. Staphylococcus aureus is the predominant organism implicated in LAAO infections. Echocardiography is a key imaging modality for diagnosing LAAO IE. Both antibiotic therapy and surgical intervention in appropriate patients are important for managing LAAO device-related IE. CONCLUSIONS:The limited data in the current literature regarding LAAO IE underscores the need for prospective clinical trials to establish evidence-based guidelines for infection prophylaxis, diagnosis, and management. Our findings emphasize the importance of vigilance for device-related infections, especially as the use of LAAO devices continues to grow worldwide.

Abstract Aims Transthyretin cardiac amyloidosis (ATTR‐CA) is most often associated with heart failure with preserved ejection fraction (HFpEF). However, patients may present with impaired systolic function at the time of diagnosis, which has not been widely investigated. We sought to explore the prevalence of various heart failure (HF) phenotypes and their associated clinical characteristics at the time of ATTR‐CA diagnosis. Methods We performed a single‐centre retrospective cohort study of consecutive patients with ATTR‐CA evaluated between February 2016 and December 2022. Data on patient demographics, comorbidities, imaging and laboratory findings were compared across HF phenotypes (age: 78.1 ± 8.6 years, with 91.1% male). A total of 21.6% (n = 46) presented with heart failure with reduced ejection fraction (HFrEF), 17.8% (n = 38) with heart failure with mildly reduced ejection fraction (HFmrEF) and 60.6% (n = 129) with HFpEF at the time of diagnosis with ATTR‐CA. Those presenting with HFrEF or HFmrEF were more likely to be African American and had significantly worse New York Heart Association (NYHA) functional class, higher N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) and higher serum creatinine levels as compared with those with HFpEF. Conclusions Although ATTR‐CA is traditionally thought to be seen primarily among patients with HFpEF, our data suggest that ATTR‐CA has a higher prevalence among patients with HFrEF, which underscores the importance of heightened clinical suspicion regardless of ejection fraction when considering ATTR‐CA. Furthermore, although comorbidities are similar, patients with HFmrEF and HFrEF had a worse symptom burden.

BACKGROUND:In patients with transthyretin cardiac amyloidosis (ATTR-CA), renal dysfunction is a poor prognostic indicator. Limited data are available on variables that portend worsening renal function (wRF) among ATTR-CA patients.OBJECTIVES:This study assesses which characteristics place patients at higher risk for the development of wRF (defined as a drop of ≥10% in glomerular filtration rate [GFR]) within the first year following diagnosis of ATTR-CA.METHODS:We included patients with ATTR-CA (n = 134) evaluated between 2/2016 and 12/2022 and followed for up to 1 year at our amyloid clinic. Patients were stratified into two groups: a group with maintained renal function (mRF) and a group with wRF and compared using appropriate testing. Significant variables in the univariate analysis were included in the multivariable logistic regression model to determine characteristics associated with wRF.RESULTS:Within a follow-up period of 326 ± 118 days, the median GFR% change measured -6% [-18%, +8]. About 41.8% (n = 56) had wRF, while the remainder had mRF. In addition, in patients with no prior history of chronic kidney disease (CKD), 25.5% developed de novo CKD. On multivariable logistic regression, only New York Heart Association (NYHA) class ≥III (odds ratio [OR]: 3.9, 95% confidence interval [CI]: [1.6-9.3]), history of ischemic heart disease (IHD) (OR: 0.3, 95% CI: [0.1-0.7]), and not receiving SGLT-2i (OR: 0.1, 95% CI: [0.02-0.5]) were significant predictors of wRF.CONCLUSION:Our study demonstrated that the development of de novo renal dysfunction or wRF is common following the diagnosis of ATTR-CA. Additionally, we identified worse NYHA class and no prior history of IHD as significant predictors associated with developing wRF, while receiving SGLT-2i therapy appeared to be protective in this population.

Patients with transthyretin amyloid cardiomyopathy (ATTR-CM) benefit from disease-modifying agents such as tafamidis. However, the survival benefit of tafamidis in elderly patients (age ≥80 years) is not reported. This study aimed to assess the survival of patients with ATTR-CM aged 80 years and older who were treated with tafamidis compared with patients aged <80 years. We conducted a retrospective analysis of patients with ATTR-CM who underwent tafamidis treatment, aged 45 to 97 years at the time of diagnosis between January 1, 2008, and May 31, 2021. A total of 484 patients were included, with 208 in the ≥80 years group and 276 in the <80 years group. The cohort was followed up for mortality outcomes, and hazard ratios with 95% confidence intervals were calculated. After a median follow-up of 18.5 months, 72 deaths were recorded in the entire cohort. Kaplan–Meier curves showed no differences in survival probability between the 2 groups at 30 months (p for log-rank test=0.76). The survival rates for patients aged ≥80 years who underwent treatment at 1, 2, 3, 4, and 5 years were 94.7%, 86.0%, 77.0%, 77.0%, and 38.5%, respectively. The corresponding rates for patients aged <80 years who underwent treatment were 93.2, 84.8, 74.4, 68.2, and 64.6%, respectively. In the multivariable analysis, the hazard ratio (95% confidence interval) of the mortality comparing treatment patients aged ≥80 years with those aged <80 years was 0.81 (0.41 to 1.61). In conclusion, tafamidis treatment is associated with similar reductions in mortality in older and younger patients with ATTR-CM.