BACKGROUND:Catheter ablation is an established rhythm control strategy for atrial fibrillation (AF) but carries a small risk of serious complications that may require emergent surgical intervention. Historically, the availability of on-site cardiothoracic surgery (CTS) has been considered an important safety requirement. However, contemporary advances in ablation techniques and peri-procedural care have improved procedural safety, and real-world data evaluating the impact of on-site CTS availability in current practice remain limited. METHODS:We analyzed the National Readmissions Database (NRD) from 2016 to 2021 to identify adults undergoing catheter ablation for AF. Hospitals were classified based on the presence of on-site CTS, defined by the performance of coronary artery bypass graft surgery. Baseline characteristics were compared between groups. Multivariable logistic regression was used to assess the association between on-site CTS availability and in-hospital complications, mortality, discharge disposition, and 30-day all-cause readmissions, adjusting for demographic and clinical covariates. RESULTS:Among 81 471 patients undergoing AF ablation, 3.3% were treated at centers without on-site CTS and 96.7% at centers with CTS. Patients treated at centers without CTS were older, more frequently female, and had a higher comorbidity burden, including greater thromboembolic risk. After multivariable adjustment, on-site CTS availability was not independently associated with in-hospital mortality, cardiac perforation, pericardiocentesis, need for open heart surgery, vascular, pulmonary, or neurological complications, discharge to home, or 30-day readmissions. CONCLUSION:In this large, contemporary national cohort, the availability of on-site cardiothoracic surgery was not independently associated with improved peri-procedural or short-term outcomes following AF ablation.

Pulsed-field ablation (PFA) has demonstrated promising efficacy and safety for atrial fibrillation ablation. However, significant gaps remain regarding its overall performance and long-term outcomes when compared to thermal ablation. We systematically searched Pubmed, Embase and Cochrane Central for studies comparing PFA and thermal ablation for pulmonary vein isolation in patients with paroxysmal or persistent atrial fibrillation reporting at least one outcome of interest. We used risk ratio (RR) with 95

INTRODUCTION:Frailty is increasingly recognized as an important determinant of outcomes in cardiovascular disease, yet its population-level impact among patients hospitalized with cardiac implantable electronic device (CIED) infections remains incompletely defined. We examined the prevalence of frailty and its association with clinical outcomes and utilization of transvenous lead removal (TLR) in a contemporary national cohort. METHODS AND RESULTS:We analyzed the National Readmissions Database from 2016-2021 to identify adults hospitalized for CIED infections. Frailty was defined using the Johns Hopkins adjusted clinical groups frailty-defining diagnoses. Of 288,402 patients hospitalized with CIED infections, 25.1% were classified as frail. Frail patients experienced significantly higher in-hospital mortality (10.8% vs. 4.6%), 30-day mortality (9.2% vs. 5.5%), complications, longer length of stay, lower rates of discharge home, and higher 30-day readmissions compared with non-frail patients (all p < 0.01). TLR was performed less frequently in frail patients (10.8% vs. 13.4%; adjusted odds ratio [aOR] 0.80, 95% CI 0.76-0.83). On adjusted analyses, TLR was independently associated with lower in-hospital mortality, 30-day mortality, and 30-day readmissions in both frail and non-frail patients. CONCLUSION:Among patients hospitalized with CIED infections, TLR was independently associated with lower mortality and readmissions in both frail and non-frail patients, despite lower utilization in frail individuals. Frailty was common (25.1%) and independently associated with significantly worse outcomes. These findings highlight important associations between frailty, treatment patterns, and outcomes that warrant prospective evaluation.

BACKGROUND:Concomitant atrial fibrillation (AF) and gastrointestinal (GI) bleeding present a clinical challenge due to recurrent bleeding risk associated with anticoagulation for AF-associated stroke prevention. Left atrial appendage occlusion (LAAO) offers an alternative stroke prevention strategy, but its impact on recurrent GI bleeding remains unknown. METHODS:This retrospective, multicenter cohort study used the TriNetX database to identify adults with AF on oral anticoagulation and a history of GI bleeding. Patients were stratified by treatment with or without LAAO. 1:1 propensity score matching (PSM) was employed. The primary outcome was recurrent GI bleeding. Cox regression analysis was used to generate hazard ratios (HRs) with 95% confidence intervals (CIs). Odds ratios (ORs) were used to evaluate effect sizes between groups. Kaplan-Meier curves were used for time-to-event analyses. RESULTS:After PSM, 9259 patients were compared in each group. Odds of recurrent GI bleeding were consistently lower in patients undergoing LAAO than without LAAO across all follow-up intervals: at 3 months (OR 0.84; 95% CI 0.78-0.91), 6 months, 1 year, 3 years, and 5 years (OR 0.87; 95% CI 0.82-0.92). Kaplan-Meier analysis demonstrated significantly lower risk of recurrent GI bleeding with LAAO (HR 0.80; 95% CI 0.76-0.84; p < 0.01). CONCLUSION:In patients with AF and prior GI bleeding, LAAO was associated with a significantly lower risk of recurrent GI bleeding at short-term and long-term time intervals.

Background:Knowing the prevalence of patent foramen ovale (PFO) and the increasing number of people who inject drugs (PWID) with right-sided infective endocarditis (RSIE), we aimed to better characterize the syndrome of injection drug use, RSIE, and PFO with systemic embolic events. Method:A systematic search across multiple databases was independently screened using predefined criteria (from inception until September 2025). Published cases of adult PWID diagnosed with RSIE and ischemic stroke or other systemic embolic event were included, provided they had PFO assessment. Individuals were excluded if they had cardiac implantable electronic device (CIED) infections or any other conditions associated with systemic or paradoxical embolism. Results:The review identified 13 studies with 14 young patients, mostly without comorbidities, predominantly infected with Staphylococcus aureus. In most cases, echocardiography revealed large tricuspid valve vegetations. Neuroimaging confirmed multiple ischemic infarcts, while 5 patients showed emboli outside the central nervous system (4 of them as the only systemic embolism). At least 11 (79%) patients had echocardiographic evidence of right-to-left shunting. Management included cardiac surgery in 6 cases that involved valve replacement or repair, percutaneous PFO closure in 2 cases, and percutaneous mechanical aspiration in 1 case. Three patients (21%) died during hospitalization, and only 27.3% patients had outpatient follow-up. Conclusions:RSIE with systemic embolism in PWID with PFO has rarely been reported, affects younger patients without sex predominance, and was usually due to S. aureus with large tricuspid vegetations. Right-to-left shunting was characteristic, and outcomes were poor despite combined medical, surgical, and interventional therapies.

BACKGROUND:Patients with end-stage renal disease (ESRD) undergoing dialysis have an increased risk of pacemaker-related complications due to limited vascular access and increased susceptibility to infection. Leadless pacemakers (LPMs) may mitigate these risks compared with conventional transvenous pacemakers (TPMs), but long-term comparative data in this population remain limited. METHODS:We conducted a retrospective cohort study using the TriNetX Research Network, including adults (≥ 18 years) with ESRD on dialysis who underwent LPM or TPM implantation between May 2016 and December 2020. Propensity score matching (1:1) was performed using demographics and comorbidities. Outcomes assessed over up to 5 years included all-cause hospitalization, heart failure hospitalization, device re-intervention, device-related complications, infection-related hospitalization, pacemaker-induced cardiomyopathy, and all-cause mortality. RESULTS:After matching, 901 patients were included in each group with well-balanced baseline characteristics. LPM implantation was associated with a significantly lower risk of device re-intervention compared with TPM (4.1% vs. 9.3%; hazard ratio [HR] 0.44; 95% confidence interval [CI] 0.28-0.69; p < 0.01). There were no significant differences between groups in all-cause hospitalization (65.5% vs. 68.3%; p = 0.22), heart failure hospitalization (26.9% vs. 30.2%; p = 0.13), all-cause mortality (37.5% vs. 35.3%; p = 0.34), device-related complications (14.5% vs. 14.3%; p = 0.94), infection-related hospitalization (1.6% vs. 2.1%; p = 0.35), or pacemaker-induced cardiomyopathy (9.0% vs. 8.6%; p = 0.66). CONCLUSION:In a large, propensity-matched cohort of patients with ESRD on dialysis, LPMs were associated with fewer device re-interventions and comparable long-term clinical outcomes compared with TPMs.

BACKGROUND:Radiofrequency (RF) ablation of premature ventricular complexes (PVCs) originating from the left ventricular summit may be unsuccessful, highlighting the need for alternative approaches. We aimed to assess the efficacy and safety of a novel dual-modality focal catheter in treating left ventricular summit PVCs in patients who had failed previous RF ablation. METHODS:Patients were prospectively enrolled and underwent a redo ablation procedure using an irrigated, contact-force sensing, dual-modality focal catheter (TactiFlex Duo, Abbott) under compassionate use indication. The ablation strategy, including the choice of energy modality (monopolar pulsed field [PF], RF, or both), was left to the operator's discretion. Safety assessments included serial biomarkers, renal function, and CMR within 36 hours. Efficacy was defined as ≥80% reduction in PVC burden with symptom resolution at 3-month follow-up. RESULTS:Six consecutive patients (4 men; mean age, 53.8±15 years) with symptomatic left ventricular summit PVCs and a prior failed RF ablation (range, 1-2) were prospectively enrolled. All PVCs had an inferior axis, with a left bundle V1 morphology observed in 4 of 6 cases (mean burden, 30.1±5.3%). Acute suppression of PVCs was achieved in all cases. Acute suppression with a single PF application in the great cardiac vein-anterior interventricular vein occurred in 2 patients, while 3 patients required additional RF, PF, or combined RF+PF applications at adjacent sites. One patient with an inaccessible great cardiac vein-anterior interventricular vein was successfully treated in the left ventricular outflow tract with RF+PF application. Transient, reversible left anterior descending vasospasm was observed during PF delivery in 2 of 5 cases that underwent PF application adjacent to a coronary artery, despite pretreatment with intracoronary nitroglycerin without ECG or hemodynamic sequelae. All patients had durable suppression of PVCs at follow-up. CONCLUSIONS:In its first human application, dual-modality ablation was feasible and effective for refractory left ventricular summit PVCs. Transient coronary vasospasm occurred, though it was reversible and without acute clinical consequences.

BACKGROUND:It is unknown whether cardiac resynchronization therapy (CRT) improves systemic metabolomic profile by enhancing left ventricular function. The observational cohort study aimed to investigate the effect of CRT on left ventricular ejection fraction (LVEF) and circulating plasma metabolites in patients who had heart failure with reduced LVEF. METHODS:We prospectively screened patients with ischemic cardiomyopathy and nonischemic cardiomyopathy who received CRT with a defibrillator for LVEF ≤35% according to current guidelines. Clinical assessment included echocardiography and device interrogation. Blood samples for metabolomic analysis were collected before CRT and at 6-month follow-up. Plasma was subjected to gas chromatography-mass spectrometry and 1H nuclear magnetic resonance-based metabolomic analysis. RESULTS:Totally 92 patients were enrolled, with a mean age of 67.3±11.3 years (37.0% female). LVEF was significantly improved from 28.9±7.6% at baseline to 36.0±11.3% at 6 months (P<0.001) and to 40.1±12.6% at 12 months (P<0.001). After CRT, 42 metabolite features were significantly decreased compared with the baseline. The ketone bodies, including 3-hydroxybutyrate (P<0.001) and acetone (P=0.01), were reduced. A branched-chain amino acid, isoleucine, was also decreased after CRT (P=0.01). These metabolomic changes were mainly observed in the nonischemic cardiomyopathy group, while the metabolomic profile in the ischemic cardiomyopathy group was characterized by enhanced amino acid oxidation and elevated levels of lactate and pyruvate. The improvement in LVEF positively correlated with the ratio of changes in ketone bodies and isoleucine. CONCLUSIONS:CRT may modulate the systemic plasma metabolomic profile, which correlated with improvement in left ventricular function in patients with severe heart failure with reduced ejection fraction.

AV nodal ablation (AVNA) with permanent pacemaker implantation has traditionally been considered a “last resort” for patients with atrial fibrillation (AF) who have failed rate- and rhythm-control strategies or are not candidates for them. Principal concerns with this strategy have been the irreversibility of the procedure with subsequent complete pacemaker dependence, permanent loss of AV synchrony, and the risk of pacing-induced cardiomyopathy with conventional right ventricular (RV) pacing. In this review, we examine the indications, techniques, outcomes, limitations, and future directions of AVNA, and evaluate the extent to which its long-standing consideration as a last-resort approach remains appropriate in contemporary AF management. The last two decades have seen major advances in cardiac pacing, including biventricular, conduction system, and leadless pacemakers. Conduction system pacing specifically offers the potential of resynchronization through physiologic activation of the conduction system while carrying a risk profile similar to RV pacing, possibly lowering the threshold to consider AVNA in the right cohort. Leadless pacemakers eliminate lead- and pocket-related complications and reduce infectious risk, making them a desirable choice in select patients, particularly with leadless conduction system pacemakers on the horizon. Special considerations arise in hypertrophic cardiomyopathy and similar restrictive disease states, where conventional AF ablation has limited efficacy, and AVNA may warrant earlier consideration. Conversely, pulsed-field ablation (PFA) has lowered the threshold for AF ablation. Advances in pacing technology, particularly conduction system and leadless pacing, have mitigated many of the historical concerns that relegated AVNA to a last-resort strategy, while parallel advances such as PFA have lowered the threshold for AF ablation itself. Together, these developments warrant reassessment of the role and timing of AVNA in the modern management of refractory AF.

BACKGROUND:There are limited data about the role of cardiac resynchronization therapy (CRT) in adults with congenital heart disease (CHD) and heart failure with reduced ejection fraction (HFrEF). OBJECTIVE:The objectives of this study were (1) to assess the relationship between CRT and clinical outcomes (all-cause mortality and cardiovascular events) and (2) to assess temporal changes in clinical indices of disease severity (New York Heart Association [NYHA] functional class, peak oxygen consumption, N-terminal pro-B-type natriuretic peptide, and left ventricular ejection fraction) post-CRT. METHODS:This is a retrospective study of adults with CHD, biventricular circulation, systemic left ventricle, and HFrEF who received CRT at Mayo Clinic (2003-2023). Clinical indices of disease severity were assessed pre-CRT and 1-year post-CRT. We defined a CRT responder as a patient with an absolute increase in left ventricular ejection fraction ≥10% and an improvement in NYHA functional class by ≥1 unit post-CRT. Intensity of heart failure therapy was assessed using the guideline-directed medical therapy (GDMT) score. RESULTS:Of the 327 patients with CHD and HFrEF, 105 (32%) received CRT (mean age 51 ± 15 years; 72 (68% men). CRT was associated with a 24% decrease in mortality (adjusted hazard ratio [HR] 0.76; 95% confidence interval [CI] 0.51-0.97) and a 21% decrease in cardiovascular events (adjusted HR 0.79; 95% CI 0.63-0.94). Of the 105 patients, 71 (68%) were CRT responders. Higher GDMT score was associated with greater odds of CRT response (adjusted odds ratio 1.28; 95% CI 1.04-1.47). CRT responders had a greater temporal improvement in NYHA functional class, peak oxygen consumption, N-terminal pro-B-type natriuretic peptide level, and a lower risk of cardiovascular events (unadjusted HR 0.73; 95% CI 0.47-0.99). CONCLUSION:These data highlight the clinical benefits of CRT and GDMT for the management of HFrEF in CHD and support the use of these therapies in this population.