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Atrial tachycardias (AT) represent an increasingly recognized cause of morbidity and mortality. Over the past decade, the mechanistic understanding and therapeutic concepts guiding AT treatment have undergone rapid progress. Catheter ablation has become the most effective therapy for maintaining sinus rhythm in patients with regular AT, while mapping and ablation concepts and technologies have improved significantly. Accordingly, international cardiac electrophysiology professional societies aimed at outlining best practices on the management of regular AT, with a special focus on indications, timing, and technical aspects of AT mapping and ablation. After reviewing and discussing available evidence, including a systematic literature review and meta-analysis, an expert writing group summarized current knowledge and practice and has proposed strategies in the here outlined 10-Point Plan for SMART-AT care (Standardized Management and Ablation Roadmap for Treatment of Patients with Atrial Tachycardia).

Pulsed field ablation (PFA) represents one of the most significant technological advances in atrial fibrillation (AF) therapy in recent decades. By harnessing irreversible electroporation, PFA produces myocardial lesions within milliseconds, enabling rapid and efficient pulmonary vein (PV) isolation. Early clinical experience from pivotal investigational device exemption (IDE) trials has shown acute and one-year arrhythmia-free outcomes that are non-inferior to conventional radiofrequency (RF) and cryothermal ablation. The large MANIFEST-17 K registry, encompassing over 17 000 patients treated with the Farawave system, reported an exceptionally low 0.98% major complication rate with no atrio-oesophageal fistula, phrenic nerve injury, or PV stenosis. These findings have accelerated PFA adoption across many centres. However, as experience broadens, nuances in lesion formation and durability are becoming evident. Factors such as contact force, catheter rotation, pulse train configuration, and target tissue geometry influence lesion depth and transmurality. While PV isolation appears consistently durable, data remain limited for non-PV targets such as the posterior wall, mitral isthmus, and cavotricuspid isthmus. Moreover, novel PFA-specific complications including transient left atrial dysfunction, haemolysis, and coronary artery spasm warrant ongoing vigilance. PFA has undoubtedly transformed expectations for procedural safety and efficiency. Yet whether it should already be considered the standard technique for all AF ablation candidates remains an open question. This Controversy piece explores the balance between innovation and evidence, examining whether PFA's rapid rise represents the inevitable new standard or a technology still undergoing critical refinement.

Aims: Anatomical studies have documented a close topographical relationship between the ganglionated plexi (GP) containing parasympathetic inputs to the sinus node (SN) and atrioventricular node (AVN) and the epicardial fat pads (FPs) within the Waterston's interatrial groove. We aimed to investigate the feasibility and outcomes of a novel anatomical approach to cardioneuroablation (CNA) that targets the atrial areas adjacent to the interatrial FPs identified with intracardiac echocardiography (ICE).

Methods and results: About 17 patients [37.3 ± 10.2 years, 47% female] undergoing CNA for recurrent vasovagal syncope and documented sinus pauses (n = 13, 76%) and/or AVN block (AVB, n = 4, 16%) were included. The right superior RS-FP containing the RS-GP (target for SN vagal denervation) and the right inferior RI-FP containing the RI-GP (target for AVN vagal denervation) were identified with ICE and reconstructed on a 3D electroanatomic map. At baseline, all patients had provocable sinus pauses/AVB with extracardiac high-frequency vagal stimulation (ECVS). The target FPs could be identified in all patients and were adjacent to septal LA and RA sites covering an average surface area of 3.7 ± 1.4 cm2 and 2.97 ± 1.21 cm2, respectively. A total of 33 ± 15 RF ablations (30-40W, 60 s) were delivered to cover the target LA/RA area. A > 25% shortening of the PP interval was observed within the first 1-2 RF lesions in all cases. After ablation, complete abolition of sinus pauses/AVB response with ECVS was achieved in all patients, and 2 mg of atropine infusion resulted in no PP/PR interval change. After a median follow-up of 12 months (range 4-25 months), 16 patients (94%) remained free of recurrent symptoms (1 patient underwent repeat CNA for recurrent pre-syncope and AVB, 1 patient underwent PPM implant following ECG recording of asymptomatic diurnal AVB).

Conclusion: An ICE-guided anatomical approach to CNA targeting visible FPs at the Waterston's groove is a feasible and effective strategy to achieve SN/AVN vagal denervation, with good outcomes at mid-term follow-up.

Aims: Device-detected subclinical atrial fibrillation (DDAF) is increasingly documented either with implantable cardiac electronic devices (CIED) or with consumer-based mobile or wearable monitors. We aimed to investigate phisician's reaction to DDAF, which management is still matter of debate.

Methods: This is a physician-based survey with 24 multiple-choice questions.

Results: A total of 222 physicians from 46 countries responded the survey. DDAF is frequent, occurring in >10% of CIEDs follow-up for 37% of respondents. Oral anticoagulation is prescribed according to CHA2DS2-VA and AF duration; 34% of the respondents initiate anticoagulation with AF >24 h, 26% with AF >6 h, and 15% with AF >5-6 min. Respondents from non-European countries and Mediterranean Europe are more likely to prescribe diagnostic exams and therapy than respondents from North Europe. Systematic long-term AF screening with implantable loop recorder (ILR) after cryptogenic stroke ranges from 43 ± 27% of ILR implanted for that purpose in Mediterranean countries to 10 ± 20% in North Europe. The majority of responders recommends the use of consumer-based devices to screen for AF mainly in specific situations (undiagnosed palpitations, ischaemic stroke, or AF burden monitoring) and not routinely, just according to CHA2DS2-VA or age.

Conclusion: AF screening is not routinely performed, either in primary or secondary prevention of stroke. Device-detected AF is not uncommon and generally managed based on thromboembolic risk and duration of episodes; the cut-offs of AF duration, global burden, and number of episodes are yet to be determined in terms of role and clinical value. Clinicians' approaches to subclinical AF remain heterogeneous.

Aims: A novel impedance filtering function that averages impedance values was developed to mitigate cardiac and respiratory oscillations. We aimed to evaluate the clinical significance of averaging real-time impedance in predicting steam pops (SPs) and lesion characteristics.

Methods and results: Radiofrequency (RF) ablation was performed in 20 swine using a flexible-tip temperature-controlled power regulation catheter. Both unfiltered and filtered (averaged) impedance values were recorded using the EnSite™ X system. For each RF application, absolute (ΔImp-drop) and relative (%Imp-drop) impedance drops were quantified. Associations between impedance parameters and SP occurrence, atrial lesion transmurality, and ventricular lesion dimensions were evaluated. Among 959 lesions, SPs occurred in 36 applications (3.8%), all within the ventricles. Notably, 6 SPs occurred within 90 s despite RF power ≤ 40 W, with 4 during left ventricular ablation under low systolic blood pressure (<40 mmHg). Lesions with SPs exhibited significantly greater unfiltered and averaged ΔImp-drop and %Imp-drop (all P < 0.001). Averaged %Imp-drop showed the highest predictive value for SPs (AUC = 0.93), with a 20.9% cut-off yielding 88.9% sensitivity and 85.5% specificity. The time to reach the initial 10%, 15%, and 20% reduction in averaged %Imp-drop was not associated with SP occurrence. Both unfiltered and averaged impedance drops correlated with atrial transmural lesion formation. Averaged impedance drops significantly improved estimation of lesion depth, surface area, and volume compared with unfiltered values (P < 0.01).

Conclusion: The averaged relative impedance drop demonstrated the strongest association with SP occurrence, and averaging impedance provided a more accurate assessment of lesion characteristics than unfiltered measurements.

Aims: Left ventricular ejection fraction (LVEF) remains the key determinant in the evaluation for the risk of sudden cardiac death (SCD). Myocardial fibrosis has gained increasingly more interest in the context of various myocardial diseases. We determined the spectrum of LVEF and evaluated the association between myocardial fibrosis and pre-SCD LVEF in a population-based SCD cohort.

Methods and results: The Fingesture study and clinical data have been collected from consecutive autopsy-verified SCD victims from Northern Finland between 1998 and 2017 (n = 5869). The cause of death was verified in medicolegal autopsy in all subjects. Electronic health records were used to identify those with pre-mortem echocardiography data. The extent of myocardial fibrosis at autopsy was characterized macroscopically and from histology samples. The LVEF recorded median 2 years (interquartile range 1-5) prior to SCD was evaluated in 716 SCD subjects. Proportional LVEF values were as follows: 62.7% (n = 449) normal LVEF (≥50%), 21.9% (n = 157) mildly reduced LVEF (36-49%), and 15.4% (n = 110) severely reduced LVEF (≤35%). At autopsy 19.6% (n = 140) had substantial, 53.8% (n = 386) moderate, and 22.1% (n = 158) mild fibrosis, and 4.5% (n = 32) had no myocardial fibrosis. The extent of myocardial fibrosis and LVEF had poor correlation (Spearman's ρ 0.21, CI 0.141-0.285, P < 0.001). Only 21.4% of those with substantial fibrosis at autopsy had LVEF ≤35%.

Conclusion: The proportion of SCD subjects with LVEF ≤35% is low, and the prevalence of myocardial fibrosis is high. The LVEF has a weak correlation with the extent of myocardial fibrosis. Our study suggests that LVEF is a poor surrogate of myocardial fibrosis in SCD victims.

Aims: Ventricular tachycardia (VT) in ischaemic heart disease (IHD) requires complex management strategies including catheter ablation (CA) and anti-arrhythmic drugs (AADs). The aim of this study is to compare efficacy and safety of CA vs. AADs in patients with IHD and VT.

Methods and results: We performed a meta-analysis of randomized controlled trials (RCTs) enrolling patients with IHD and ICD randomized to CA or AADs. Primary outcome was appropriate ICD therapy. Secondary outcomes included inappropriate ICD therapy, cardiovascular (CV) re-hospitalization, all-cause/CV mortality, and adverse events. Subgroup analyses were conducted for amiodarone and sotalol, with an exploratory evaluation of a composite endpoint (ICD shock, VT storm, all-cause death). Four RCTs including 947 patients (mean age 68 ± 2 years; 93% male) were analysed. CA significantly reduced the risk of appropriate ICD therapy compared with AADs (149/470 [31.7%] vs. 229/477 [48.0%]; RR 0.81; 95% CI [0.67, 0.97]; P = 0.02). Among secondary outcomes, CA decreased the incidence of CV re-hospitalization [RR 0.84; 95% CI (0.72, 0.99); P = 0.04] and adverse events [RR 0.42; 95% CI (0.28, 0.62); P < 0.01], while no differences were observed in all-cause/CV mortality and inappropriate ICD therapy. In subgroup analyses, CA was superior to sotalol in reducing the composite endpoint of ICD shock, VT storm and all-cause death [RR: 0.82, 95% CI (0.69, 0.98), P = 0.03]; whereas, no significant benefit was seen compared to amiodarone [RR: 0.92; 95% CI (0.78, 1.09), P = 0.32].

Conclusion: In ischaemic heart disease and VT, CA compared with anti-arrhythmic drugs is associated with a reduction of appropriate ICD therapy, cardiovascular re-hospitalization, and adverse events with benefits most evident versus sotalol.