Slow pathway (SP) ablation is an established therapy for slow-fast atrioventricular nodal reentrant tachycardia (AVNRT), with high success and low recurrence rates. We report a case in which a complex signal identification (CSI) map with the CARTO system was used during slow-fast AVNRT to localize a fractionated region near the coronary sinus ostium that coincided with the successful SP ablation site.

ABSTRACT Introduction AutoMark Index (AI) is a novel ablation algorithm integrating contact force (CF), radiofrequency (RF) current, and application duration to provide real‐time lesion formation feedback. Data of AI using a flexible‐tip RF ablation catheter for cavotricuspid isthmus (CTI) ablation remain limited. The objective was to evaluate the efficacy and safety of AI‐guided CTI ablation. Methods Consecutive 148 patients undergoing CTI ablation with a CF‐sensing flexible‐tip ablation catheter were included. Outcomes using an AI‐guided protocol (50 W, targeting AI of 50; AI‐50 group, 62 patients) were compared with a conventional protocol (40 W for 20 s; 40‐W group, 86 patients). Results The first‐line success rate showed no difference between the two groups (40‐W group: 72/86 [84.7%] vs. AI‐50 group: 51/62 [82.2%], p = 0.81). The total RF application showed no difference (40‐W group: 12 [9.5–15] vs. AI‐50 group: 12 [9.7–16], p = 0.50); however, significant differences were observed in the total RF duration (40‐W group: 274 [211–372] s vs. AI‐50 group: 180 [138–249] s, p < 0.001), the RF duration for initial block (40‐W group: 225 [163–323] s vs. AI‐50 group: 149 [109–221] s, p < 0.001), and CTI procedural time (40‐W group: 9.2 [6.0–14.6] min vs. AI‐50 group: 6.3 [4.5–9.7] min, p = 0.007). No significant differences were observed in the mean CF, average temperature, and CTI length between the two groups. No major complications were observed in either of the groups. Conclusion AI‐guided CTI ablation protocol is efficient in shortening RF duration for acute bidirectional CTI block and CTI procedure time compared to the conventional 40 W ablation protocol.

Background Light-chain cardiac amyloidosis (AL-CA) is a rare disease caused by amyloid fibril deposition in the myocardium. Evidence on Bachmann's bundle (BB) pacing in patients with AL-CA and sinus node dysfunction (SND) remains scarce. Case Summary A 74-year-old woman with SND and worsening heart failure was admitted to our hospital. An endomyocardial biopsy during pacemaker implantation was helpful in the diagnosis of AL-CA. After the pacing study, it was found that high right atrial septal pacing near the BB region produced a higher P-wave amplitude and shorter duration than sinus rhythm and right atrial appendage pacing. The findings indicate that BB pacing not only preserves sinus rhythm, it also enhances overall cardiac efficiency. Discussion Few reports of BB pacing for SND exist in the literature. This case demonstrates a safe and effective method of improving heart failure outcomes. Take-Home Message BB pacing may be a safe and effective treatment for patients with AL-CA and SND.

INTRODUCTION:Pulmonary vein isolation (PVI) using radiofrequency catheter ablation is an effective treatment for atrial fibrillation; however, esophageal-related complications remain a concern. The first objective of this study was to compare the feasibility of two techniques for visualizing real-time esophageal images: intracardiac echocardiography (ICE-Eso) and preoperative computed tomography (CT-Eso). The second objective was to clarify the predictors of esophageal movement on the day of catheter ablation. METHODS AND RESULTS:Eighty consecutive patients were included in this study. The esophageal location was measured at the centerline of each image on three equally separated imaging sections (upper, middle, and lower sites). Esophageal locations detected on ICE-Eso and CT-Eso were compared with those on contrast esophagography. We also investigated predictors of esophageal movement. A significant difference was found between the two distances in all three sections: upper site (ICE-Eso: 2.5 [interquartile range (IQR) 1.4-3.6] mm vs. CT-Eso: 5.2 [IQR 3.4-7.6] mm, p < 0.001), middle site (ICE-Eso: 2.7 [IQR 1.3-4.3] mm vs. CT-Eso: 5.4 [IQR 3.2-8.3] mm, p < 0.001), and lower site (ICE-Eso: 2.8 [IQR 1.2-5.2] mm vs. CT-Eso: 5.8 [IQR 3.1-10.3] mm, p < 0.001). Multivariate analysis revealed that eating a meal on the morning on the day of catheter ablation (non-fasting) was a predictor of esophageal movement. One patient (1.2%) experienced gastric hypomotility, which resolved completely with medical treatment. CONCLUSION:The results showed that ICE-Eso provided real-time, accurate esophageal location compared to CT-Eso. Therefore, ICE-Eso-guided PVI on the left atrial posterior wall near the esophagus may be a safe method. Additionally, non-fasting on the day of catheter ablation could help to predict esophageal movement.

BACKGROUND:Cryoballoon pulmonary vein (PV) isolation (PVI) requires PV occlusion, which can be challenging to the large PV. The non-occlusive separate freezing, which involves freezing the superior and inferior portions of the PV ostium without complete occlusion, is often useful in these situations. This study aimed to evaluate the efficacy and long-term results of the non-occlusive separate freezing technique and compare the treatment details of POLARx and Arctic Front Advance Pro (AFA-Pro). METHODS:Patients who underwent cryoballoon PVI using the non-occlusive separate freezing between September 2019 and April 2023 in our institution were analyzed and followed up for 1 year. Success rates of PVI by non-occlusive separate freezing and treatment outcomes were compared between POLARx and AFA-Pro. The 1-year arrhythmia-free survival was also evaluated. RESULTS:Overall, 135 PVs were analyzed (POLARx, n = 63; and AFA-Pro, n = 72). The success rates of PVI for the POLARx and AFA-Pro were 55/63 (87.3%) and 52/72 (72.2%), p = 0.04. The nadir temperatures for the POLARx and AFA-Pro were -52.2 ± 4.7°C and -42.4 ± 7.4°C, p < 0.001. No phrenic nerve injury occurred in either group, but two cases of gastric hypomotility were observed using POLARx. The 1-year arrhythmia-free survival rates for POLARx and AFA-Pro were 86.4% and 81.2%, p = 0.47. CONCLUSIONS:The success rate of PVI using the non-occlusive separate freezing technique was approximately 80% and was significantly higher with POLARx than with AFA-Pro. The 1-year arrhythmia-free survival rate was not significantly different.

An 84-year-old woman with complete atrioventricular block and heart failure underwent atrioventricular synchronous leadless pacemaker (Micra AV) implantation under conscious sedation. Despite a successful procedure without immediate complications, routine transthoracic echocardiography revealed left ventricular apical akinesis with basal hyperkinesis, consistent with Takotsubo cardiomyopathy. Multimodality evaluation confirmed the diagnosis, and cardiac function gradually recovered. This rare case highlights stress-induced cardiomyopathy following leadless pacemaker implantation.

This is the case of a 29-year-old female with sudden palpitations due to tachycardia. The atrial activation focusing point (AFP) was presumed to be the atrial entrance site within the reentry circuit of slow/fast atrioventricular nodal reentrant tachycardia by postpacing interval mapping. AFP is a novel ablation site because it is more distal to the His-bundle recording site and more atrial site compared to the conventional SP ablation site.

Journal Article Corrected proof Multimodality intravascular imaging of pulmonary vein re-stenosis after radiofrequency catheter ablation using intravascular ultrasound and non-obstructive generalized angioscopy Get access Koji Sudo, Koji Sudo Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0003-2445-7008 Search for other works by this author on: Oxford Academic PubMed Google Scholar Toru Yoshizaki, Toru Yoshizaki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Corresponding author. E-mail: tyoshizaki@yamanashi.ac.jp Search for other works by this author on: Oxford Academic PubMed Google Scholar Tsuyoshi Kobayashi, Tsuyoshi Kobayashi Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Search for other works by this author on: Oxford Academic PubMed Google Scholar Kenji Kuroki, Kenji Kuroki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-3257-8216 Search for other works by this author on: Oxford Academic PubMed Google Scholar Akira Sato Akira Sato Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-2438-1464 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal - Cardiovascular Imaging, jeae009, https://doi.org/10.1093/ehjci/jeae009 Published: 06 January 2024 Article history Published: 06 January 2024 Corrected and typeset: 18 January 2024

Journal Article Usefulness of endomyocardial biopsy using three-dimensional delivery system for the diagnosis of cardiac amyloidosis with complete atrioventricular block after transcatheter aortic valve implantation Get access Koji Sudo, Koji Sudo Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0003-2445-7008 Search for other works by this author on: Oxford Academic PubMed Google Scholar Kazuto Nakamura, Kazuto Nakamura Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Corresponding author. Tel: +81 55 273 9590, Fax: +81 552 73 6749, Email: kazuton@yamanashi.ac.jp Search for other works by this author on: Oxford Academic PubMed Google Scholar Akira Sato Akira Sato Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-2438-1464 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, ehae137, https://doi.org/10.1093/eurheartj/ehae137 Published: 05 March 2024

Journal Article Corrected proof Left bundle branch area pacing for chronic heart failure with transthyretin cardiac amyloidosis Get access Koji Sudo, Koji Sudo Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0003-2445-7008 Search for other works by this author on: Oxford Academic PubMed Google Scholar Manabu Uematsu, Manabu Uematsu Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Corresponding author. E-mail: umanabu@yamanashi.ac.jp https://orcid.org/0000-0002-5420-424X Search for other works by this author on: Oxford Academic PubMed Google Scholar Jumpei Suzuki, Jumpei Suzuki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Search for other works by this author on: Oxford Academic PubMed Google Scholar Kenji Kuroki, Kenji Kuroki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-3257-8216 Search for other works by this author on: Oxford Academic PubMed Google Scholar Akira Sato Akira Sato Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-2438-1464 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal - Cardiovascular Imaging, jead278, https://doi.org/10.1093/ehjci/jead278 Published: 01 November 2023 Article history Published: 01 November 2023 Corrected and typeset: 08 November 2023

BACKGROUND:The effectiveness of cryoballoon ablation (CBA) of the left atrial (LA) roof in addition to pulmonary vein isolation (PVI) using a novel cryoballoon catheter, POLARx, remains unclear. METHODS:This study compared the efficacy of LA roof line ablation and PVI using POLARx (Boston Scientific) or AFA-Pro (Medtronic) in 100 patients with persistent atrial fibrillation. The right superior pulmonary vein (PV) anchoring and raise-up techniques were consistently used for LA roof line ablation, and rapid right ventricular pacing was applied if the cryoballoon temperature did not reach -40°C. RESULTS:Complete conduction block at the LA roof could be obtained in all patients with POLARx and in 98.0% of patients with AFA-Pro. Rapid right ventricular pacing was needed in 64.0% of patients with AFA-Pro and in no patients with POLARx. During LA roof line ablation, the nadir cryoballoon temperature was significantly lower with POLARx than with AFA-Pro (right: -54.2°C ± 4.4°C vs. -46.0°C ± 5.4°C; central: -56.8°C ± 4.4°C vs. -45.7°C ± 4.8°C; left: -56.1°C ± 4.3°C vs. -46.1°C ± 5.7°C), and the cryoballoon temperature reached -40°C earlier with POLARx than with AFA-Pro (right: 30.8 ± 7.4 s vs. 74.1 ± 37.7 s; central: 28.2 ± 5.2 s vs. 62.9 ± 30.9 s; left: 29.8 ± 5.8 s vs. 69.6 ± 40.7 s). CONCLUSION:The nadir cryoballoon temperature with POLARx was approximately 10°C lower than with AFA-Pro, consistently dropping below -40°C during LA roof line CBA. Thus, a complete conduction block of the LA roof line can be easily accomplished using right superior PV anchoring and the raise-up techniques without the need for rapid right ventricular pacing with POLARx.

Journal Article Corrected proof Impact of left bundle branch area pacing-optimized cardiac resynchronized therapy for transthyretin cardiac amyloidosis Get access Koji Sudo, Koji Sudo Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0003-2445-7008 Search for other works by this author on: Oxford Academic PubMed Google Scholar Manabu Uematsu, Manabu Uematsu Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Corresponding author. E-mail: umanabu@yamanashi.ac.jp https://orcid.org/0000-0002-5420-424X Search for other works by this author on: Oxford Academic PubMed Google Scholar Kazuto Nakamura, Kazuto Nakamura Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Search for other works by this author on: Oxford Academic PubMed Google Scholar Kenji Kuroki, Kenji Kuroki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-3257-8216 Search for other works by this author on: Oxford Academic PubMed Google Scholar Akira Sato Akira Sato Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-2438-1464 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal - Cardiovascular Imaging, jead331, https://doi.org/10.1093/ehjci/jead331 Published: 13 December 2023 Article history Published: 13 December 2023 Corrected and typeset: 03 January 2024

INTRODUCTION:Catheter ablation (CA) is the first-line treatment with a high success rate for patients with symptomatic Wolff-Parkinson-White syndrome, while three-dimensional (3D) mapping systems enable the identification of accessory pathways (APs). We aimed to develop a novel mapping method using wave-speed mapping (WSM) to determine AP locations and CA outcomes. METHODS AND RESULTS:This study included 19 patients diagnosed with atrioventricular (AV) reciprocating tachycardia. We compared local activation time (LAT) mapping and WSM, and analyzed the relationship between the "high-speed islets" in WSM and successful ablation sites. Sixteen APs were located on the left, three on the septum, and one on the right side. The median number of mapping points and mapping time were 1451 points and 14.6 min, respectively. All 20 APs in the 19 patients were eliminated using "high-speed islets" in WSM. Eleven APs (55%) were eliminated after the first ablation application. One patient with an anteroseptal AP close to the AV node underwent cryoablation to avoid an AV block. The AP width in the 3D mapping system was significantly narrower in WSM than in LAT mapping (5.8 ± 4.0 mm vs. 10.4 ± 3.2 mm, p < .001). One patient experienced an AP recurrence, successfully eliminated using WSM-guided CA in a repeat procedure. During 13.1 ± 8.3 months of follow-up, all patients remained free of any supraventricular tachycardias. CONCLUSION:WSM is a novel mapping method for visualizing APs as "high-speed islets" and guides a more precise ablation site than LAT mapping.

High-density mapping in a three-dimensional (3D) electroanatomical mapping system is an effective tool to determine a tachycardia circuit. Identifying the tachycardia circuit is essential in catheter ablation strategies. However, the tachycardia circuit in complex atrial tachycardias (ATs) remains challenging. Two pulmonary vein (PV) gaps related AT are associated with residual PV conduction gaps in previously ablated PVI lines.1

Background Early cardiomyopathy diagnosis allows timely treatment and may help resolve problems that occur after cardiac implantable electronic device (CIED) implantation. Objective This study aims to describe a novel technique for endomyocardial biopsy (EMB) using a 3-dimensional (3D) delivery sheath during CIED implantation. In addition, we investigated 3D delivery-sheath characteristics using sheath deflection during bioptome insertion. Methods This study of 20 patients undergoing CIED implantation analyzed the EMB success rate and pathologic findings. Fluoroscopic images assessed 3D delivery sheath characteristics before and after bioptome insertion in 3 sheaths. CIEDs were implanted for sick sinus syndrome (n =3), atrioventricular conduction disorder (n = 16), and left ventricular dysfunction (n = 1). Fluoroscopic verification was performed using right anterior oblique (RAO) and left anterior oblique (LAO) views. EMB was performed with Selectra 3D (BIOTRONIK, Berlin, Germany), CSP Locator 3D (Abbott, Chicago, IL), and SSPC (Boston Scientific, Marlborough, MA) (12, 4, and 4 patients, respectively). The distance moved toward the right ventricular apex (RVA) in RAO was defined as Dis-RAO (mm) and that moved toward the RVA in LAO was defined as Dis-LAO (mm). Results Among the 3 sheaths, only the CSP Locator 3D and Selectra 3D showed significant differences in Dis-RAO (13.2 ± 2.0 mm vs 19.8 ± 3.8 mm, P < .01) and Dis-LAO (8.1 ± 1.3 mm vs 15.3 ± 3.9 mm, P < .01). A total of 77 EMB samples from 20 patients were collected without any complication, and 4 patients (20%) were diagnosed with cardiac amyloidosis (CA) based on pathologic findings. Conclusion All 3D delivery sheaths were safe and effective for performing EMB from the RVS during CIED implantation, enabling early CA diagnosis in 20% of patients.

Journal Article Dynamical improvement after rescue balloon angioplasty for pulmonary vein occlusion complicated with radiofrequency catheter ablation Get access Koji Sudo, Koji Sudo Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0003-2445-7008 Search for other works by this author on: Oxford Academic PubMed Google Scholar Kenji Kuroki, Kenji Kuroki Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan Corresponding author. Tel: +81-55-273-9590, Fax: +81-55-273-6749, E-mail: keng9696@gmail.com https://orcid.org/0000-0002-3257-8216 Search for other works by this author on: Oxford Academic PubMed Google Scholar Akira Sato Akira Sato Department of Cardiovascular Medicine, University of Yamanashi, Shimokato 1110, Chuo, Yamanashi 409-3898, Japan https://orcid.org/0000-0002-2438-1464 Search for other works by this author on: Oxford Academic PubMed Google Scholar European Heart Journal, Volume 44, Issue 27, 14 July 2023, Page 2498, https://doi.org/10.1093/eurheartj/ehad350 Published: 03 June 2023