Pulsed field ablation (PFA) for the treatment of atrial fibrillation offers potential safety benefits compared to thermal ablation modalities. However, the high voltage electric pulses required to irreversibly electroporate myocardial cells present a unique clinical challenge in regard to patients with cardiac implantable electronic devices (CIEDs). The strong electric fields of PFA can induce voltages and currents in CIED leads, which may result in electromagnetic interference (EMI) or even permanent damage to the device itself, requiring reset or replacement. Limited evidence exists on PFA procedures in patients with CIEDs. Historically, clinical trials have excluded patients with CIEDs, which leaves evidence from real-world clinical practice to fill this critical evidence gap. This review describes the potential hazards when performing PFA in patients with CIEDs, current real-world evidence in such patients, and recommended workflows to mitigate risk and prioritize patient safety.

Pulsed Field Ablation (PFA) is an emerging energy modality for cardiac ablation, offering shorter atrial dwell times and reduced collateral damage compared to thermal methods. However, energy-related complications, specifically gaseous microbubble formation and hemolysis, require further evaluation. Microbubble formation, driven by electrolysis, boiling, and degassing, poses a potential risk for embolic events. Similarly, hemolysis results from unintended energy dissipation into the bloodstream, affecting kidney function. Both complications can be mitigated through optimized waveform and catheter design and other procedural strategies. Enhancing PFA safety requires a deeper understanding of its biophysical interactions and continuous refinement of ablation protocols to minimize risks while preserving clinical efficacy.

Electrode design and reliable contact assessment are critical for creating durable pulsed field ablation (PFA) lesions to treat atrial fibrillation while minimizing collateral damage. This review introduces a novel "map-and-ablate" PFA catheter featuring flat electrodes, thermal contact assessment, and fully customizable electrode selection. We explore how electrode design impacts energy delivery and electric field direction, the importance of reliable contact assessment in ensuring lesion durability, and how customized electrode selection may minimize collateral damage.

The use of insertable cardiac monitors (ICM) for arrhythmia monitoring continues to grow steadily. However, ICM performance remains less than perfect, and the volume of transmitted data poses a challenge to clinics. Here, we evaluate the impact of three improvements implemented in the LUX-Dx II+ ICM for atrial fibrillation (AF), pause, and bradycardia detection.

Changes in tricuspid regurgitation (TR), mitral regurgitation (MR), and left ventricular ejection fraction (LVEF) are frequently noted after right ventricular apical (RVA) pacemaker implantation but prior studies evaluating whether left bundle branch area (LBBA), deep septal (DS), or leadless pacemaker implantation modify risk for those changes are limited. This study aims to compare changes in TR, MR, and LVEF after implantation of RVA, LBBA, DS, and leadless pacemakers.

Radiofrequency (RF) ablation has long been the standard treatment for atrioventricular nodal reentrant tachycardia (AVNRT) in children. However, cryoablation (CA) has gained popularity due to its safety profile and acceptable long-term success rates. Comparative data on different CA catheter tip sizes in pediatric AVNRT are limited.

Pulsed field ablation (PFA) is a cutting-edge treatment for arrhythmias that targets cardiac tissue with rapid, high-voltage electric current pulses, resulting in irreversible electroporation. Freed from the constraints of traditional radiofrequency (RF) ablation, the non-thermal mechanism and myocardial selectivity of PFA has improved procedural safety aspects and efficiency over RF ablation. However, catheter development thus far has focused on waveforms and voltage, such that critical aspects related to the physics of energy delivery at the tissue-blood interface were often overlooked. When delivering high-voltage pulsed electric fields, differences in electrical impedance, catheter geometry, and field strength impact the resulting precision and durability of lesions; principles that warrant a deeper understanding to inform and optimize future catheter designs. This article examines the engineering considerations behind the success of the first industrial iterations of PFA, with a comparison of catheter form factors for current systems that impact energy delivery, workflow, safety, and performance. We also address the initial assumptions and misconceptions related to PFA design and the development of current generation catheters as considerations for the future of ablation and mapping.

A 47-year-old male with Wolff-Parkinson-White syndrome (WPW) and left ventricular hypertrophy (LVH) was admitted for transient loss of consciousness. Intracardiac electrophysiological examination identified a left posterior septal accessory pathway, which was successfully ablated via radiofrequency catheter ablation. Postoperative electrocardiogram (ECG) showed J-ST segment elevation in anterior leads V2-V4. At 2-week follow-up, the J point and ST segment elevation in leads V2-V4 had diminished but not fully resolved. Due to the electrotonic modulation mechanism, WPW patients may develop anterior ST-segment elevation post-ablation, and LVH may prolong the time for the ST segments to normalize.

Although radiofrequency ablation is effective for treating left ventricular papillary muscle (PM) arrhythmias, procedural complications like catheter entrapment and risk of PM injury are incompletely understood. Furthermore, cardiac catheters lack tensile force monitoring at the catheter tip, creating procedural blind spots that prevent the detection and potential mitigation of such complications. Therefore, this study aimed to evaluate the force required to rupture PMs before and after ablation, providing insights into procedural safety and potential risks associated with PM ablation.

Cryoballoon ablation is a safe and efficient rhythm control strategy in patients suffering from atrial fibrillation (AF). Diagnosis-to-ablation time (DAT) has been defined as a predictor of ablation outcomes, but the impact of early ablation among non-paroxysmal AF is unclear. The aim of this study was to examine the impact of early cryoballoon ablation on AF recurrence in a prospective single-center cohort of non-paroxysmal AF patients.

A 66-year-old male patient with a conduction system pacing (CSP) pacemaker, implanted after a pace-and-ablate strategy for persistent, poorly rate-controlled atrial fibrillation, presented to the outpatient clinic with worsening dyspnea. Laboratory findings and ECG were indicative of an anterolateral ST-segment elevation myocardial infarction (STEMI), confirmed by coronary angiography showing occlusion of a large diagonal branch. STEMI diagnosis in paced patients is often challenging due to altered ventricular activation. However, this case demonstrates that surface ECG remains interpretable with CSP, which preserves physiological activation, allowing accurate localization of ischemia even in the presence of a pacemaker.

Optimal management in patients presenting with persistent atrial fibrillation, cardiomyopathy, and atrial as well as ventricular dyssynchrony with left bundle branch block is unclear.

While radiofrequency ablation (RFA) and cryoablation (CBA) are established treatments for atrial fibrillation (AF), pulsed field ablation (PFA) offers potential benefits. This study compares PFA's procedural outcomes with RFA and CBA.

Right ventricular (RV) lead implantation can be technically challenging, particularly in patients with anatomical variations or a history of cardiac surgery. Innovative lead placement techniques may be required to achieve successful outcomes in such cases. We report the case of an 84-year-old male with a history of degenerative complete heart block and prior cardiac implantable electronic device (CIED) infection, who required re-implantation. Due to a dilated right atrium, RV endocardial lead placement was performed using an alpha loop configuration. This approach enabled successful navigation through complex right atrial (RA) anatomy and stable lead positioning.

Atrial fibrillation (AF) is the most prevalent cardiac arrhythmia globally, causing a major burden on many determinants of quality of life, including sleep quality. The aims of the study were to describe sleep quality in a sample of patients with AF in a tertiary center in Lebanon, examine associations between sleep quality and the number and discomfort level of AF symptoms, and identify the predictors of sleep quality in these patients.

Right ventricular (RV) pacing typically produces left bundle branch block (LBBB) morphology. Right bundle branch block (RBBB) patterns during RV lead placement raise concerns for malpositioning.

Pulsed-field ablation (PFA) using a circular multielectrode catheter is a novel approach for cavotricuspid isthmus (CTI) ablation, but optimal procedural strategy is not well established. We report two cases where intracardiac echocardiography (ICE) guidance was essential for achieving durable conduction block. ICE enabled identification of suboptimal contact missed under fluoroscopy, guiding catheter repositioning, or configuration change to adapt to anatomical challenges, including a CTI pouch. This stepwise, ICE-guided approach improved lesion delivery, prevented conduction gaps, and may help avoid repeat procedures. This report highlights the value of ICE for optimizing CTI ablation with PFA.

Obese patients with atrial fibrillation (AF) are at an increased risk of thromboembolic and bleeding events. While direct oral anticoagulants (DOACs) are the standard therapy for stroke prevention in AF, their use is associated with a significant bleeding risk in this population. Comparative data of left appendage atrial occlusion (LAAO) vs. DOACs in this group are currently lacking.

Pulsed field ablation (PFA) is an emerging non-thermal catheter ablation (CA) modality for the treatment of atrial fibrillation (AF), PFA has shown a relatively similar success rate but offers improved safety compared to thermal approaches such as radiofrequency ablation (RFA) and cryoballoon ablation (Cryo). Although its clinical benefits are well established, comparative data on its economic impact remain limited.

Implantable cardioverter defibrillator (ICD) therapy can prevent sudden cardiac death, but poses a risk of inappropriate device therapy (IDT), which is linked to worse outcomes and reduced quality of life. On the other hand, ICDs can function as an early warning system for atrial arrhythmias.