BACKGROUND:The safety and effectiveness of concomitant catheter ablation at the time of left atrial appendage (LAA) occlusion (LAAO) are not well characterized. OBJECTIVE:This study aimed to describe the safety and effectiveness of LAAO during concomitant ablation of atrial fibrillation (AF) with LAAO performed as a stand-alone procedure. METHODS:Patients from the Surveillance Postapproval Analysis Plan who underwent concomitant ablation and LAAO were compared with patients who underwent LAAO alone. The primary effectiveness end point was complete seal of the LAA, and the primary safety end point was the occurrence of major adverse events at 45 days. RESULTS:Among 96,968 patients, 1.9% (n = 1844) underwent concomitant ablation; these patients were younger (median 73 [quartile 1, quartile 3 68-78] vs 76 [72-82] years) and had lower CHA2DS2-VASc scores (4 [3-5] vs 5 [4-6]), previous clinically relevant bleeding (32.4% vs 56.6%), or fall risk (30.2% vs 42.2%). The most common discharge drug therapy in the concomitant AF ablation group was direct-acting oral anticoagulant plus aspirin (56.2%), followed by direct-acting oral anticoagulant alone (30.0%). Immediately after implant, patients undergoing concomitant ablation had lower rates of any residual leak (1.6% vs 3.7%; P < .001); no difference was seen at 45 days (15.7% vs 16.9%; P = .29). In-hospital major adverse events were more frequent in those undergoing LAAO with concomitant ablation than LAAO without ablation (1.9% vs 1.2%; P = .0111). In-hospital major bleeding (1.6% vs 1.0%; P = .0073) and pericardial effusion requiring intervention (0.8% vs 0.4%; P = .0108) were more frequent with combined LAAO and AF ablation. At 1 year after the procedure, the composite of all-cause mortality, stroke, or systemic embolism was less frequent in those undergoing LAAO with concomitant ablation (5.2% vs 9.3%; P < .0001). CONCLUSION:Patients undergoing concomitant AF ablation at the time of LAAO are younger and have fewer comorbidities. There was no clinically important difference in LAA seal peridevice leaks with concomitant LAAO; however, there was a higher rate of major bleeding and pericardial effusion requiring intervention.

Paroxysmal supraventricular tachycardia (PSVT) imposes a substantial burden on patients and health care systems. Despite available treatments, a notable gap exists between evidence-based medicine and real-world practice. Acute treatments such as intravenous adenosine require administration in clinical settings. At-home vagal maneuvers are simple and cost-effective yet are often less effective than those administered by health care providers. The pill-in-the-pocket strategy, defined as patient-administered beta blocker or calcium-channel blocker therapy, is limited by delayed onset of action and risk of side-effects, and is not supported by robust clinical evidence or guidelines. Approved in late 2025, etripamil nasal spray represents a promising advancement that may provide a safe, effective, self-administered therapy used outside of health care setting. In this review, we examine the existing evidence and practical limitations of current PSVT treatments and discuss the potential clinical implications of etripamil as a novel, rapidly acting, self-administered therapy for the termination of acute symptomatic PSVT.

BACKGROUND:Intracardiac echocardiography (ICE) is widely used during electrophysiology and structural heart procedures; however, image interpretation remains operator-dependent and procedural views are not standardized. Although artificial intelligence has been increasingly applied to transthoracic and transesophageal echocardiography, applications to ICE remain limited. OBJECTIVES:The objective of the study was to develop and evaluate Auto-Contour, a deep-learning pipeline for multistructure semantic segmentation of ICE anatomy and assess its feasibility for real-time procedural guidance. METHODS:In this retrospective multicenter study, 5,496 deidentified ICE cine loops from 249 procedures of unique patients, including routine clinical cases and the ViewFlex™ X first-in-human study, were analyzed. ICE experts classified each cine into 1 of 20 procedural views and annotated key anatomic structures, including the left atrium, left atrial appendage, pulmonary vein ostia, valves, cusps, papillary muscles, and left ventricle, at end-systole, and end-diastole, yielding 65,117 segmentations. A deep-learning segmentation model was trained using patient-level splits, standard augmentations, and early stopping. RESULTS:Segmentation performance was highest for larger cardiac chambers, with Dice scores of 0.94 for the left atrium and 0.82 for the left ventricle, and corresponding 95th-percentile Hausdorff distance values of 1.18 mm and 3.27 mm. Smaller structures also demonstrated acceptable performance, including the left atrial appendage, pulmonary veins, papillary muscles, and aortic cusps. The mean per-frame inference time was <0.03 seconds. CONCLUSIONS:Auto-Contour demonstrated robust multistructure segmentation of ICE anatomy with real-time inference, supporting prospective evaluation of artificial intelligence-assisted ICE for procedural standardization, efficiency, and safety.

BACKGROUND:The effectiveness of catheter ablation for atrial fibrillation (AF) can only be fully assessed months after the procedure, and many complications do not present until after hospital discharge. Readily available means to monitor patients for quality assurance are hampered by the impracticality of following patients after they leave referral centers. OBJECTIVES:The objective of the study was to determine if a mobile app-based platform that interfaced directly with AF ablation patients using their smartphones might be feasible. METHODS:In the VIBRANT-AF (Volunteers to Investigate Best Results for Ablation and Novel Therapies for Atrial Fibrillation) study, AF catheter ablation patients were monitored with baseline and weekly SMS messages accompanied by mobile application-based questionnaires using the Eureka digital research platform. RESULTS:Among 493 participants enrolled from 17 sites, 4% reported an emergency department visit related to AF or the catheter ablation procedure. Among 236 followed for 1 year, participants completed a median of 25 (IQR: 7-42) electronic visits. A 2-fold increase in response rate was observed among those who completed at least 1 of the first 2 weeks of surveys. Recurrent AF at 1 year was reported in 30% of participants. The validated Atrial Fibrillation Effect on Quality of Life score improved from baseline to 6 months, with sustained improvement at 12 months. Validation of self-reported AF and complications in a subset of the cohort demonstrated substantial agreement with KardiaMobile electrocardiograms and electronic health record data, respectively. CONCLUSIONS:Direct patient-facing, mobile application-based surveillance is feasible following catheter AF ablation, with self-reported rates of effectiveness and complications similar to previous reports using conventional means. (Volunteers to Investigate Best Results for Ablation and Novel Therapies for Atrial Fibrillation [VIBRANT-AF]; NCT05504356).

Background Catheter ablation procedures with transseptal punctures (usually for atrial fibrillation) are often associated with migraine-related visual auras, but the mechanism remains unknown. Whether this phenomenon is mediated by the creation of an atrial septal defect from transseptal puncture or by silent acute brain emboli detected on magnetic resonance imaging related to the procedure remains to be investigated. Objective This study aimed to evaluate whether randomization to a transseptal puncture during catheter ablation for ventricular arrhythmias is associated with postprocedural visual auras and assess the relationship between occipital and parietal lobes acute brain emboli and migraine-related visual auras. Methods In the Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli trial, patients undergoing catheter ablation for ventricular arrhythmias were randomized to ventricular access via transseptal puncture vs a retrograde aortic approach. All had brain magnetic resonance imaging the day after their procedure and underwent a validated migraine assessment at 1 month. Results No differences in postablation visual auras were observed between transseptal (16% of 63) and retrograde aortic approaches (14% of 57; P = .78). However, more participants with acute brain emboli in the occipital or parietal lobes experienced migraine-related visual auras (38% vs 11%; P < .01). After multivariable adjustment, the presence of acute brain emboli was associated with 12-fold greater odds of visual auras. Conclusion Transseptal puncture was not associated with visual auras; however, acute brain emboli involving the visual cortex were associated with such symptoms. These data suggest that transseptal puncture is not causal in migraine-related visual auras and that postprocedure acute brain emboli are apparently not always clinically silent.

BACKGROUND:Catheter ablation of ventricular arrhythmias, one of the most rapidly growing procedures in cardiac electrophysiology, is associated with magnetic resonance imaging-detected brain lesions in more than half of cases. Although a retrograde aortic approach is conventional, modern tools enable entry through a transseptal approach that may avoid embolization of debris from the arterial system. We sought to test the hypothesis that a transseptal puncture would mitigate brain injury compared with a retrograde aortic approach.METHODS:The TRAVERSE trial (Transseptal Versus Retrograde Aortic Ventricular Entry to Reduce Systemic Emboli) was a multicenter randomized controlled comparative effectiveness trial. Patients with left ventricular arrhythmias undergoing catheter ablation procedures were randomly assigned to a transseptal puncture approach compared (1:1) with a retrograde aortic approach. The primary outcome was the presence of an acute brain lesion detected by magnetic resonance imaging. Secondary outcomes included clinically manifest complications, procedural efficacy, and 6-month neurocognitive assessments.RESULTS:Among the 62 patients randomly assigned to a retrograde aortic approach with postoperative brain magnetic resonance imaging, 28 (45%) exhibited an acute brain lesion compared with 19 of the 69 (28%) of those randomized to a transseptal puncture (P=0.036). No differences in clinically manifest complications or procedural efficacy were observed. More patients in the retrograde aortic arm were categorized as having a high likelihood of cognitive impairment at 6 months (33% compared with 19% of those in the transseptal arm), but substantial loss to follow-up was present.CONCLUSIONS:Among patients undergoing left ventricular catheter ablation procedures, a transseptal approach reduced the risk of acute brain lesions by nearly half compared with a retrograde aortic approach without sacrificing safety or efficacy. Given a likely embolic pathogenesis, the brain magnetic resonance imaging findings may reflect a propensity to other organ damage; these findings may extend to other procedures requiring left ventricular entry.REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT03946072.