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Background: The prevalence and impact of frailty in patients undergoing left atrial appendage closure (LAAC) remains unknow.

Objective: To evaluate the prevalence and prognostic implications of frailty in patients undergoing LAAC.

Methods: The Frail-LAAC trial was an international, multicenter, prospective study that included consecutive patients undergoing LAAC in four University centers (2022-2024). Frailty was assessed pre-procedurally using the Essential Frailty Toolset (EFT) and defined as an EFT score ≥ 3 (and pre-frail as an EFT=1-2). Clinical outcomes were evaluated at follow-up.

Results: A total of 452 consecutive patients were included (mean age: 76±8 years; 34% of women), and frailty was identified in 101 (22.4%) of them. Frail patients were older, more commonly female, and had a higher comorbidity burden. Device success (99.6%) and procedural success (97.3%) were high across all groups, without differences in procedural-related complications. After a median follow-up of 12 (4-22) months, frail patients had a higher risk of all-cause mortality or ischemic events compared to non-frail patients [36.6% vs. 9.4%; adjusted HR = 4.85 (95% CI: 2.85-8.24); p<0.001], primarily driven by an increased mortality risk (33.7% vs. 7.7%; adjusted HR = 5.28 [95% CI: 2.94-9.46]; p<0.001). In contrast, pre-frailty was not associated with mortality compared to robust patients [adjusted HR = 2.87 (95% CI: 0.83-9.98), p = 0.115]. The inclusion of frailty in predictive models significantly improved mortality risk stratification.

Conclusions: Frailty is common in patients undergoing LAAC and is associated with a five-fold increased mortality risk. Incorporating frailty assessment into pre-procedural evaluations enhance risk stratification, highlighting the need for careful patient selection, particularly in those with advanced frailty, to optimize outcomes and avoid futile interventions.

Background: Interatrial block (IAB) has been associated with atrial fibrillation (AF) and stroke in broader cardiovascular populations. Whether these associations extend to hypertrophic cardiomyopathy (HCM), and how IAB relates to underlying left atrial (LA) remodeling, remain unknown.

Objective: This study aims to investigate the prevalence, morpho-functional correlates, and prognostic value of IAB in HCM patients.

Methods: This multicenter study included 259 HCM patients without prior history of AF/stroke. IAB was defined by P-wave duration >120 milliseconds. Associations between morphological and functional parameters of the LA and IAB were assessed using cardiac magnetic resonance imaging. The primary composite endpoint was new-onset AF, transient ischemic attack, or ischemic stroke.

Results: IAB was present in 10% of the cohort. Patients with IAB exhibited larger LA diameter (median 47.4 vs. 43.2mm; p=0.022), indexed maximum LA volume (median 52.5 vs. 46.9 ml/m²; p=0.043), and with impaired LA ejection fraction (median 48% vs. 51%; p=0.043), reduced LA reservoir strain (median 22.0% vs. 29.3%; p=0.018) and reduced LA conduit strain (median 8.3% vs. 12.1%; p=0.012). During a median 5.8-year follow-up, IAB was independently associated with a twofold increased risk of the composite endpoint (HR 2.11; 95%CI: 1.13-3.95; p=0.019) and new-onset AF (HR 2.10; 95%CI: 1.07-4.16; p=0.031).

Conclusion: In HCM patients, IAB is associated with significant LA structural and functional impairments, indicative of advanced atrial cardiomyopathy. Its presence was independently associated with an increased risk of incident AF and stroke, suggesting its value as a simple, accessible electrocardiographic marker for enhanced risk stratification.

Background: Pulmonary vein isolation (PVI) is a well-established treatment for atrial fibrillation (AF), however, strategies for patients with recurrent AF and isolated pulmonary veins remains elusive.

Objective: To evaluate the effectiveness of a personalized artificial intelligence (AI)-guided spatio-temporal dispersion mapping and ablation in patients undergoing a repeat ablation and whose PVs remain isolated from prior ablation procedures.

Methods: The RESTART trial (NCT05477147) was an interventional, prospective, single-arm, multicenter clinical trial. Patients with previous catheter or surgical ablation for paroxysmal, persistent or long-standing persistent AF and with documented symptomatic AF recurrences were enrolled. Patients with documented reconnected PVs during the procedure were prospectively withdrawn from the trial. Follow-up included 3- 6- and 12-month visits with 12-lead ECG and 24-hour Holter. The primary endpoint of the study was freedom from documented AF at 12-month after a single AI-guided repeat ablation procedure.

Results: Of the 213 patients enrolled, the main causes for premature study exit were PV reconnection (n=80) or non-inducibility of AF (n=14). The primary endpoint was achieved in 83% [77/93] of patients and freedom from any atrial arrhythmia after a single procedure was 70% [65/93]. Notably, AF termination during ablation was achieved in 54% of patients, and right atrial dispersion was identified in 59%. The procedure was associated with improvements in quality of life metrics (AFEQT and SF-36 scores).

Conclusion: In patients with documented isolated PVs, AI-guided dispersion ablation is safe, effective and represents an alternative to other ablative strategies.

Background: Although pulsed field ablation (PFA) is generally considered safe, the mechanisms underlying both symptomatic and silent embolic events remain unclear.

Objectives: This study aimed to investigate the timing, number, size, and characteristics of microembolic signals (MES) during each step of the pentaspline PFA procedure using real-time carotid Doppler monitoring.

Methods: MES were assessed during ablation procedures in 32 patients, including 27 who underwent pulmonary vein isolation (PVI) with the pentaspline PFA system and 5 control patients who received radiofrequency ablation limited to the right atrium.

Results: The PFA group showed significantly more MES than the control group. MES were detected throughout the PFA procedure, with the highest counts observed during PFA delivery to the right pulmonary veins (RPVs). Bubble signals were seen in all procedural steps. In contrast, high-intensity transient signals, which are mainly composed of solid components, were more common during PFA energy delivery. All 303 overcurrent errors-events in which energy delivery is stopped due to overcurrent detection-occurred during basket-type PFA applications and were associated with a marked increase in MES. Basket-configuration energy delivery resulted in a significantly higher number of MES than the flower-configuration, particularly in the RPVs. The size of MES was significantly larger during PFA energy delivery than during catheter or sheath manipulation.

Conclusions: This study demonstrated the characteristic timing, frequency, and morphology of MES during pentaspline PFA procedures, providing insights that may help reduce embolic risks in future practice.