Early prediction of the efficacy of local epicardial radiofrequency ablation (LERFA) is crucial for optimizing the robotic treatment of persistent atrial fibrillation.
Objective
This study aimed to develop a machine learning model that accurately predicts LERFA efficacy within the first 5 seconds of the procedure, to stop ineffective procedures and reduce unnecessary cardiac tissue damage.
Methods
Impedance data from 92 patients who underwent robotic LERFA were analyzed, with a total of 2486 LERFAs included in the final dataset. LERFA efficacy predictors, including zero-time impedance value, slope, and harmonic components, were extracted from the first 5 seconds of each time-impedance curve. Several supervised machine learning approaches were then tested to predict LERFA efficacy.
Results
Random Forest demonstrated the highest performance, achieving 94.5% accuracy, 88.3% sensibility, and 97.2% specificity. This Random Forest model significantly outperformed the benchmark approach based on the zero-time impedance value alone, which achieved an accuracy of only 55.6% and a specificity of only 37.7%.
Conclusion
The developed model enables fast and accurate prediction of LERFA efficacy, potentially reducing the number of completed LERFAs by 56.8%. This reduction results in minimal damage to cardiac tissue, a lower risk of complications, a reduction in operating time, and greater precision and safety in the ablation process.
{"title":"Early prediction of the efficacy of local epicardial radiofrequency ablation for the robotic treatment of persistent atrial fibrillation","authors":"Daniele Salvi MS , Eduardo Celentano MD, FHRS , Ernesto Cristiano MD , Stefano Schena MD , Alfonso Agnino MD , Ettore Lanzarone MS, PhD","doi":"10.1016/j.hroo.2025.10.003","DOIUrl":"10.1016/j.hroo.2025.10.003","url":null,"abstract":"<div><h3>Background</h3><div>Early prediction of the efficacy of local epicardial radiofrequency ablation (LERFA) is crucial for optimizing the robotic treatment of persistent atrial fibrillation.</div></div><div><h3>Objective</h3><div>This study aimed to develop a machine learning model that accurately predicts LERFA efficacy within the first 5 seconds of the procedure, to stop ineffective procedures and reduce unnecessary cardiac tissue damage.</div></div><div><h3>Methods</h3><div>Impedance data from 92 patients who underwent robotic LERFA were analyzed, with a total of 2486 LERFAs included in the final dataset. LERFA efficacy predictors, including zero-time impedance value, slope, and harmonic components, were extracted from the first 5 seconds of each time-impedance curve. Several supervised machine learning approaches were then tested to predict LERFA efficacy.</div></div><div><h3>Results</h3><div>Random Forest demonstrated the highest performance, achieving 94.5% accuracy, 88.3% sensibility, and 97.2% specificity. This Random Forest model significantly outperformed the benchmark approach based on the zero-time impedance value alone, which achieved an accuracy of only 55.6% and a specificity of only 37.7%.</div></div><div><h3>Conclusion</h3><div>The developed model enables fast and accurate prediction of LERFA efficacy, potentially reducing the number of completed LERFAs by 56.8%. This reduction results in minimal damage to cardiac tissue, a lower risk of complications, a reduction in operating time, and greater precision and safety in the ablation process.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"7 1","pages":"Pages 2-8"},"PeriodicalIF":2.9,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145969326","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01DOI: 10.1016/j.hroo.2025.10.021
Ulrika Birgersdotter-Green MD, FHRS , Willibaldo Ojeda MD , Harish Manyam MD , Alvaro Manrique Garcia MD , George E. Manoukian MD , Mohammad-Ali Jazayeri MD , Frank Cuoco MD, MBA, MS , Frederick Han MD, FACC, FHRS , Michael Katcher MD, FHRS , Rakesh Gopinathannair MD, MA, FAHA, FHRS , Dale Yoo MD , Lin Feng PhD , Fujian Qu DSc , Wenjiao Lin MS , Kwangdeok Lee PhD , Vishnu Charan MS, MBA , Suneet Mittal MD, FACC, FHRS , Dhanunjaya Lakkireddy MD, MBA, FHRS
Background
Accurate atrial fibrillation (AF) detection and burden assessment are critical features of modern insertable cardiac monitors (ICMs), enabling precise determination of AF episode patterns, frequency, duration, and total burden to guide treatments.
Objective
This study aimed to evaluate the AF detection performance of the Assert-IQ ICM and assess the impact of an artificial intelligence (AI) algorithm designed for reducing false-positive AF episodes.
Methods
This prospective, single-arm, multicenter study enrolled 151 subjects with symptomatic, drug-refractory paroxysmal or persistent AF. A Holter assessment was conducted after ICM insertion. AF detection metrics—sensitivity, specificity, positive predictive value (PPV), and negative predictive value—were evaluated by comparing ICM detections with core laboratory–annotated Holter AF events. The impact of an AI algorithm on AF detection performance was then assessed.
Results
Among 135 analyzable patients, 39 had Holter-confirmed AF with 522 episodes lasting ≥2 minutes. Assert-IQ ICM correctly identified all patients with true AF. Duration-based sensitivity, specificity, PPV, negative predictive value, and accuracy were 93.0%, 99.3%, 97.4%, 98.0%, and 97.9%, respectively. Episode detection sensitivity was 99.4% (gross) and 99.9% (patient average). AF burden correlation between ICM and Holter was excellent (r = 0.99). The AI algorithm retained all true positives and reduced 72.6% of false positives, improving PPV from 79.9% to 93.6%.
Conclusion
Assert-IQ ICM accurately detects AF and quantifies burden for long-term monitoring. The AI algorithm effectively reduces false positives while maintaining high sensitivity.
准确的心房颤动（AF）检测和负担评估是现代可插入式心脏监护仪（ICMs）的关键特征，能够精确确定AF发作模式、频率、持续时间和总负担，以指导治疗。目的本研究旨在评估Assert-IQ ICM的AF检测性能，并评估人工智能（AI）算法对减少AF假阳性发作的影响。方法：本前瞻性、单臂、多中心研究纳入151例有症状、药物难治性阵发性或持续性房颤患者。置入ICM后进行动态心电图评估。通过比较ICM检测与核心实验室注释的Holter AF事件，评估AF检测指标-敏感性，特异性，阳性预测值（PPV）和阴性预测值。然后评估人工智能算法对自动对焦检测性能的影响。结果135例可分析患者中，39例为霍尔特确诊房颤，522例发作时间≥2分钟。Assert-IQ ICM正确识别出所有真正的房颤患者。基于病程的敏感性、特异性、PPV、阴性预测值和准确性分别为93.0%、99.3%、97.4%、98.0%和97.9%。发作检测灵敏度为99.4%（总）和99.9%（患者平均）。ICM与Holter的心房颤动负荷相关性极好（r = 0.99）。人工智能算法保留了所有真阳性，减少了72.6%的假阳性，将PPV从79.9%提高到93.6%。结论assert - iq ICM能准确检测房颤，量化长期监测负担。人工智能算法在保持高灵敏度的同时，有效地减少了误报。
{"title":"Atrial fibrillation detection performance of an insertable cardiac monitor: Results from an Assert-IQ post-market clinical study and a novel artificial intelligence algorithm","authors":"Ulrika Birgersdotter-Green MD, FHRS , Willibaldo Ojeda MD , Harish Manyam MD , Alvaro Manrique Garcia MD , George E. Manoukian MD , Mohammad-Ali Jazayeri MD , Frank Cuoco MD, MBA, MS , Frederick Han MD, FACC, FHRS , Michael Katcher MD, FHRS , Rakesh Gopinathannair MD, MA, FAHA, FHRS , Dale Yoo MD , Lin Feng PhD , Fujian Qu DSc , Wenjiao Lin MS , Kwangdeok Lee PhD , Vishnu Charan MS, MBA , Suneet Mittal MD, FACC, FHRS , Dhanunjaya Lakkireddy MD, MBA, FHRS","doi":"10.1016/j.hroo.2025.10.021","DOIUrl":"10.1016/j.hroo.2025.10.021","url":null,"abstract":"<div><h3>Background</h3><div>Accurate atrial fibrillation (AF) detection and burden assessment are critical features of modern insertable cardiac monitors (ICMs), enabling precise determination of AF episode patterns, frequency, duration, and total burden to guide treatments.</div></div><div><h3>Objective</h3><div>This study aimed to evaluate the AF detection performance of the Assert-IQ ICM and assess the impact of an artificial intelligence (AI) algorithm designed for reducing false-positive AF episodes.</div></div><div><h3>Methods</h3><div>This prospective, single-arm, multicenter study enrolled 151 subjects with symptomatic, drug-refractory paroxysmal or persistent AF. A Holter assessment was conducted after ICM insertion. AF detection metrics—sensitivity, specificity, positive predictive value (PPV), and negative predictive value—were evaluated by comparing ICM detections with core laboratory–annotated Holter AF events. The impact of an AI algorithm on AF detection performance was then assessed.</div></div><div><h3>Results</h3><div>Among 135 analyzable patients, 39 had Holter-confirmed AF with 522 episodes lasting ≥2 minutes. Assert-IQ ICM correctly identified all patients with true AF. Duration-based sensitivity, specificity, PPV, negative predictive value, and accuracy were 93.0%, 99.3%, 97.4%, 98.0%, and 97.9%, respectively. Episode detection sensitivity was 99.4% (gross) and 99.9% (patient average). AF burden correlation between ICM and Holter was excellent (r = 0.99). The AI algorithm retained all true positives and reduced 72.6% of false positives, improving PPV from 79.9% to 93.6%.</div></div><div><h3>Conclusion</h3><div>Assert-IQ ICM accurately detects AF and quantifies burden for long-term monitoring. The AI algorithm effectively reduces false positives while maintaining high sensitivity.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"7 1","pages":"Pages 61-69"},"PeriodicalIF":2.9,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145969355","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01DOI: 10.1016/j.hroo.2025.09.027
Iris van der Schaaf MD , Manon Kloosterman MSc , Machteld J. Boonstra PhD , Rob W. Roudijk MD, PhD , Anneline S.J.M. te Riele MD, PhD , Peter M. van Dam PhD , Peter Loh MD, PhD
Background
Pathogenic variants in plakophilin-2 (PKP2) and phospholamban (PLN) are associated with arrhythmogenic cardiomyopathy. Early disease detection is important to prevent adverse events. Body surface potential mapping (BSPM) may detect local electrical abnormalities earlier than the 12-lead electrocardiogram.
Objective
This study aimed to determine abnormalities in R-, S-, and T-wave amplitudes in PKP2- and PLN-pathogenic variant carriers using BSPM.
Methods
67 lead BSPM was performed in controls and PKP2 and PLN carriers. R-, S-, and T-wave amplitudes across all leads in controls were used as reference. Amplitudes of carriers exceeding these ranges were considered abnormal and assessed across disease stages (presymptomatic, electrical, and structural, as done previously). Follow-up BSPM (≥2 years) was performed in a subset of carriers.
Results
152 subjects (40 [27;54] years; 51% women) (40 controls and 112 carriers [53 PKP2 and 59 PLN]) were included. Amplitude abnormalities were most frequent in structural disease, predominantly in T waves (PKP2 20 [10;29]; PLN 25 [22;30] leads). Abnormalities in electrical disease were more prevalent in PLN carriers than PKP2 carriers (R wave 4 [1;7] vs 13 [8;16] leads, P = .002; S wave 2 [1;3] vs 4 [3;12] leads, P < .001; T wave 1 [0;3] vs 20 [16;28] leads, P < .001). Presymptomatic carriers typically had abnormalities outside the 12-lead configuration. As the disease progressed, abnormalities became more frequent and extended toward V1–V6. Follow-up BSPM (23 PKP2 and 16 PLN) showed consistency in locations of abnormalities with increased frequency (maximal increase 31%).
Conclusion
BSPM detected abnormal amplitudes within and beyond the 12-lead electrocardiogram, even in presymptomatic carriers. Follow-up BSPM suggests that these abnormalities are associated with disease progression, highlighting the potential benefit of BSPM in early disease detection.
{"title":"Body surface potential mapping of ventricular depolarization and repolarization in phospholamban and plakophilin-2 cardiomyopathy","authors":"Iris van der Schaaf MD , Manon Kloosterman MSc , Machteld J. Boonstra PhD , Rob W. Roudijk MD, PhD , Anneline S.J.M. te Riele MD, PhD , Peter M. van Dam PhD , Peter Loh MD, PhD","doi":"10.1016/j.hroo.2025.09.027","DOIUrl":"10.1016/j.hroo.2025.09.027","url":null,"abstract":"<div><h3>Background</h3><div>Pathogenic variants in plakophilin<em>-</em>2 (<em>PKP2</em>) and phospholamban (<em>PLN</em>) are associated with arrhythmogenic cardiomyopathy. Early disease detection is important to prevent adverse events. Body surface potential mapping (BSPM) may detect local electrical abnormalities earlier than the 12-lead electrocardiogram.</div></div><div><h3>Objective</h3><div>This study aimed to determine abnormalities in R-, S-, and T-wave amplitudes in <em>PKP2-</em> and <em>PLN-</em>pathogenic variant carriers using BSPM.</div></div><div><h3>Methods</h3><div>67 lead BSPM was performed in controls and <em>PKP2</em> and <em>PLN</em> carriers. R-, S-, and T-wave amplitudes across all leads in controls were used as reference. Amplitudes of carriers exceeding these ranges were considered abnormal and assessed across disease stages (presymptomatic, electrical, and structural, as done previously). Follow-up BSPM (≥2 years) was performed in a subset of carriers.</div></div><div><h3>Results</h3><div>152 subjects (40 [27;54] years; 51% women) (40 controls and 112 carriers [53 <em>PKP2</em> and 59 <em>PLN</em>]) were included. Amplitude abnormalities were most frequent in structural disease, predominantly in T waves (<em>PKP2</em> 20 [10;29]; <em>PLN</em> 25 [22;30] leads). Abnormalities in electrical disease were more prevalent in <em>PLN</em> carriers than <em>PKP2</em> carriers (R wave 4 [1;7] vs 13 [8;16] leads, <em>P</em> = .002; S wave 2 [1;3] vs 4 [3;12] leads, <em>P</em> < .001; T wave 1 [0;3] vs 20 [16;28] leads, <em>P</em> < .001). Presymptomatic carriers typically had abnormalities outside the 12-lead configuration. As the disease progressed, abnormalities became more frequent and extended toward V1–V6. Follow-up BSPM (23 <em>PKP2</em> and 16 <em>PLN</em>) showed consistency in locations of abnormalities with increased frequency (maximal increase 31%).</div></div><div><h3>Conclusion</h3><div>BSPM detected abnormal amplitudes within and beyond the 12-lead electrocardiogram, even in presymptomatic carriers. Follow-up BSPM suggests that these abnormalities are associated with disease progression, highlighting the potential benefit of BSPM in early disease detection.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"7 1","pages":"Pages 130-142"},"PeriodicalIF":2.9,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145969366","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01DOI: 10.1016/j.hroo.2025.12.001
Jeanne E. Poole MD, FHRS
{"title":"State of the Journal 2026","authors":"Jeanne E. Poole MD, FHRS","doi":"10.1016/j.hroo.2025.12.001","DOIUrl":"10.1016/j.hroo.2025.12.001","url":null,"abstract":"","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"7 1","pages":"Page 1"},"PeriodicalIF":2.9,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145969325","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2026-01-01DOI: 10.1016/j.hroo.2025.11.009
Moon-Hyun Kim MD , Oh-Seok Kwon PhD , Daehoon Kim MD , Hae-Min Lee BS , Kyeung-Se Im BS , Hee Tae Yu MD, PhD , Tae-Hoon Kim MD , Jae-Sun Uhm MD, PhD , Boyoung Joung MD, PhD , Moon-Hyoung Lee MD, PhD , Hui-Nam Pak MD, PhD, FHRS
Background
Cryoballoon (CB) pulmonary vein isolation (PVI) offers outcomes comparable to radiofrequency PVI (RF-PVI) in patients with atrial fibrillation (AF) but has limitations for wide circumferential PVI and extra-pulmonary vein (PV) trigger (ExPVT) ablations.
Objective
This study aimed to compare long-term outcomes of CB-PVI vs RF-PVI in patients without ExPVT and explore underlying electroanatomical mechanisms.
Methods
We identified 1902 patients undergoing de novo AF ablation without ExPVT. After propensity matching for age, sex, AF type, and left atrium anteroposterior (LAAP) diameter in patients, we compared AF recurrence in 403 CB-PVI and 403 RF-PVI cases, considering AF type and LAAP diameter. Using a Cox model, we identified the optimal LAAP diameter cutoff for differentiating outcomes and examined the relationship between PVI modality and reduction in electrically active LA area via computational modeling.
Results
During a median follow-up of 24 months, CB-PVI had poorer rhythm outcomes than RF-PVI in propensity-matched patients (log-rank P = .009). Outcomes were comparable in those with an LAAP diameter <40 mm or paroxysmal AF. However, CB-PVI was associated with higher AF recurrence in patients with a LAAP diameter ≥40 mm (hazard ratio [HR] 1.54 [1.01–2.36]; log-rank P = .047) or persistent AF (HR 2.17 [1.36–3.45]; log-rank P = .001). In computational modeling, a larger non-ablated LA area post-PVI was independently related to a higher AF recurrence risk. RF-PVI reduced LA surface area more than CB-PVI, especially in patients with a large LA or persistent AF.
Conclusion
CB-PVI showed inferior rhythm outcomes compared with RF-PVI in patients with a LAAP diameter ≥40 mm or persistent AF, possibly because of a smaller reduction in LA critical mass.
低温球囊（CB）肺静脉隔离（PVI）在房颤（AF）患者中提供与射频PVI （RF-PVI）相当的结果，但对于宽周PVI和肺静脉外（PV）触发（ExPVT）消融有局限性。目的本研究旨在比较CB-PVI与RF-PVI在无ExPVT患者中的长期预后，并探讨潜在的电解剖学机制。方法我们收集了1902例无ExPVT的房颤消融患者。在对患者的年龄、性别、房颤类型和左心房前后方（LAAP）直径进行倾向匹配后，考虑房颤类型和LAAP直径，我们比较了403例CB-PVI和403例RF-PVI的房颤复发情况。使用Cox模型，我们确定了区分结果的最佳LAAP直径截止点，并通过计算建模检查了PVI模式与电活性LA面积减少之间的关系。结果在中位随访24个月期间，倾向匹配患者的CB-PVI节律结局比RF-PVI差（log-rank P = 0.009）。LAAP直径为40 mm或阵发性房颤患者的结果具有可比性。然而，LAAP直径≥40 mm的患者（风险比[HR] 1.54 [1.01-2.36]; log-rank P = 0.047）或持续性房颤患者（风险比[HR] 2.17 [1.36-3.45]; log-rank P = .001）， CB-PVI与房颤复发率较高相关。在计算模型中，pvi后较大的未消融的LA面积与较高的房颤复发风险独立相关。RF-PVI比CB-PVI更能减少LA表面积，尤其是在LAAP直径≥40 mm或持续性AF患者中。结论与RF-PVI相比，CB-PVI在LAAP直径≥40 mm或持续性AF患者中表现出更差的心律结果，可能是因为LA临界质量的减少较小。
{"title":"Association between non-ablated left atrial surface area and rhythm outcome in patients treated with cryoballoon and radiofrequency ablation","authors":"Moon-Hyun Kim MD , Oh-Seok Kwon PhD , Daehoon Kim MD , Hae-Min Lee BS , Kyeung-Se Im BS , Hee Tae Yu MD, PhD , Tae-Hoon Kim MD , Jae-Sun Uhm MD, PhD , Boyoung Joung MD, PhD , Moon-Hyoung Lee MD, PhD , Hui-Nam Pak MD, PhD, FHRS","doi":"10.1016/j.hroo.2025.11.009","DOIUrl":"10.1016/j.hroo.2025.11.009","url":null,"abstract":"<div><h3>Background</h3><div>Cryoballoon (CB) pulmonary vein isolation (PVI) offers outcomes comparable to radiofrequency PVI (RF-PVI) in patients with atrial fibrillation (AF) but has limitations for wide circumferential PVI and extra-pulmonary vein (PV) trigger (ExPVT) ablations.</div></div><div><h3>Objective</h3><div>This study aimed to compare long-term outcomes of CB-PVI vs RF-PVI in patients without ExPVT and explore underlying electroanatomical mechanisms.</div></div><div><h3>Methods</h3><div>We identified 1902 patients undergoing de novo AF ablation without ExPVT. After propensity matching for age, sex, AF type, and left atrium anteroposterior (LAAP) diameter in patients, we compared AF recurrence in 403 CB-PVI and 403 RF-PVI cases, considering AF type and LAAP diameter. Using a Cox model, we identified the optimal LAAP diameter cutoff for differentiating outcomes and examined the relationship between PVI modality and reduction in electrically active LA area via computational modeling.</div></div><div><h3>Results</h3><div>During a median follow-up of 24 months, CB-PVI had poorer rhythm outcomes than RF-PVI in propensity-matched patients (log-rank <em>P =</em> .009). Outcomes were comparable in those with an LAAP diameter <40 mm or paroxysmal AF. However, CB-PVI was associated with higher AF recurrence in patients with a LAAP diameter ≥40 mm (hazard ratio [HR] 1.54 [1.01–2.36]; log-rank <em>P =</em> .047) or persistent AF (HR 2.17 [1.36–3.45]; log-rank <em>P =</em> .001). In computational modeling, a larger non-ablated LA area post-PVI was independently related to a higher AF recurrence risk. RF-PVI reduced LA surface area more than CB-PVI, especially in patients with a large LA or persistent AF.</div></div><div><h3>Conclusion</h3><div>CB-PVI showed inferior rhythm outcomes compared with RF-PVI in patients with a LAAP diameter ≥40 mm or persistent AF, possibly because of a smaller reduction in LA critical mass.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"7 1","pages":"Pages 18-26"},"PeriodicalIF":2.9,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145969369","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Posterior wall isolation (PWI) is a supplemental modality to pulmonary vein isolation in radiofrequency ablation for persistent atrial fibrillation. Residual epicardial connections may contribute to nondurable PWI and increased atrial fibrillation recurrence.
Objective
The study aimed to investigate the use of a novel high-amplitude pacing (HAP) technique to unmask epicardial connections after PWI.
Methods
100 consecutive patients underwent pulmonary vein isolation/PWI radiofrequency ablation with roof and floor lines and segmental ablation for posterior wall (PW) entrance block. The PW was divided into 4 quadrants, each subdivided into 4 segments, labeled 1–16. After the PW entrance block, bipolar pacing was performed in each segment with standard pacing (10 mA at 2 ms) and HAP (20 mA at 2 ms). Exit block was defined as a lack of atrial capture from within PW.
Results
Patients were divided into groups 1 (unable to achieve complete PWI) and 2 (PWI achieved). We categorized patients into subgroups based on the presence/absence of entrance blocks, captures, and exit blocks. PW entrance block was not achieved in 2 patients (2%); 17 patients (17%) demonstrated bidirectional PW block with standard pacing. HAP-only capture was seen in 74 of the remaining 81 patients. Mid-PW had the highest frequency of HAP-only capture. Additional ablation was performed in 63 HAP patients without PW exit block, with final PWI achieved in 51 of 63 patients (80.9%) compared with 18 of 18 (100%) in the cohort with HAP noncapture/exit block (P = .045).
Conclusion
Our novel protocol of HAP unmasked possible epicardial capture in 63% of patients, with true PWI with additional ablation in 80.9% patients. HAP may help unmask epicardial connections and facilitate durable PWI to improve long-term procedural success.
{"title":"High-amplitude pacing can identify epicardial connections in the posterior wall during ablation for atrial fibrillation","authors":"Arshad Muhammad Iqbal MD , Suhaib Bajwa MD , Cory Smith MD , Supraja Thunuguntla MD , Sandeep Gautam MD, FHRS","doi":"10.1016/j.hroo.2025.09.023","DOIUrl":"10.1016/j.hroo.2025.09.023","url":null,"abstract":"<div><h3>Background</h3><div>Posterior wall isolation (PWI) is a supplemental modality to pulmonary vein isolation in radiofrequency ablation for persistent atrial fibrillation. Residual epicardial connections may contribute to nondurable PWI and increased atrial fibrillation recurrence.</div></div><div><h3>Objective</h3><div>The study aimed to investigate the use of a novel high-amplitude pacing (HAP) technique to unmask epicardial connections after PWI.</div></div><div><h3>Methods</h3><div>100 consecutive patients underwent pulmonary vein isolation/PWI radiofrequency ablation with roof and floor lines and segmental ablation for posterior wall (PW) entrance block. The PW was divided into 4 quadrants, each subdivided into 4 segments, labeled 1–16. After the PW entrance block, bipolar pacing was performed in each segment with standard pacing (10 mA at 2 ms) and HAP (20 mA at 2 ms). Exit block was defined as a lack of atrial capture from within PW.</div></div><div><h3>Results</h3><div>Patients were divided into groups 1 (unable to achieve complete PWI) and 2 (PWI achieved). We categorized patients into subgroups based on the presence/absence of entrance blocks, captures, and exit blocks. PW entrance block was not achieved in 2 patients (2%); 17 patients (17%) demonstrated bidirectional PW block with standard pacing. HAP-only capture was seen in 74 of the remaining 81 patients. Mid-PW had the highest frequency of HAP-only capture. Additional ablation was performed in 63 HAP patients without PW exit block, with final PWI achieved in 51 of 63 patients (80.9%) compared with 18 of 18 (100%) in the cohort with HAP noncapture/exit block (<em>P</em> = .045).</div></div><div><h3>Conclusion</h3><div>Our novel protocol of HAP unmasked possible epicardial capture in 63% of patients, with true PWI with additional ablation in 80.9% patients. HAP may help unmask epicardial connections and facilitate durable PWI to improve long-term procedural success.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 12","pages":"Pages 1928-1935"},"PeriodicalIF":2.9,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771846","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.hroo.2025.09.024
Qing Zhang MD, PhD , Guohao Wang PhD , Zhangpu Yan BS , Weiling Xu MD , Shaofeng Zhang BS , Jun Li MD , Ling Liang MD, PhD , Changqing Sun MD, PhD , Rong Tang MD , Joachim Pircher MD, PhD , Qiang Xie MD, PhD, FHRS , Wuyang Zheng MD, PhD
Background
Clonal hematopoiesis of indeterminate potential (CHIP) has emerged as an independent cardiovascular risk factor, with recent studies suggesting a link to atrial fibrillation (AF). However, the causal nature of this relationship, particularly the role of DNMT3a and TET2 mutations, remains unclear.
Objective
This study aimed to assess the causal relationship between CHIP and AF and identify potential mediating pathways.
Methods
We conducted a bidirectional Mendelian randomization (MR) analysis using genome-wide association study data for CHIP from the UK Biobank (n = 368,526) and AF data from 2 large, independent cohorts (287,805 individuals from FinnGen and 1,030,836 from 6 additional AF studies). A 2-step MR mediation analysis was used to explore potential intermediate risk factors.
Results
Inverse variance weighted MR analysis demonstrated a causal effect of CHIP on increased AF risk (meta-inverse variance weighted, odds ratio [OR] 1.057; P = .001), including both DNMT3a- and TET2-related CHIP (DNMT3a, OR 1.048, P = 4.56 × 10-4; TET2, OR 1.038, P = .025). Causal associations between overall CHIP, including DNMT3a-CHIP, and AF were validated by a 2-sample MR study in 2 independent cohorts. Reverse MR showed no evidence of AF causing CHIP. The mediation analysis identified elevated systolic blood pressure as a key mediator in the DNMT3a-CHIP–AF pathway, accounting for 7.8% of the effect (P = .034).
Conclusion
Our findings provide genetic evidence that CHIP, particularly DNMT3a-related mutations, causally but modestly increases AF risk. There is no support for reverse causation. Elevated systolic blood pressure was identified as a significant mediator linking DNMT3a-CHIP to AF.
克隆造血不确定电位（CHIP）已成为一个独立的心血管危险因素，最近的研究表明其与心房颤动（AF）有关。然而，这种关系的因果性质，特别是DNMT3a和TET2突变的作用仍不清楚。目的探讨CHIP与房颤之间的因果关系，并确定可能的介导途径。方法：我们使用来自UK Biobank的CHIP全基因组关联研究数据（n = 368,526）和来自2个大型独立队列的AF数据（来自FinnGen的287,805名个体和来自另外6项AF研究的1,030,836名个体）进行了双向孟德尔随机化（MR）分析。采用两步MR中介分析探讨潜在的中间危险因素。结果反向方差加权MR分析显示CHIP与AF风险增加有因果关系（meta-inverse方差加权，优势比[OR] 1.057; P = .001），包括DNMT3a和TET2相关CHIP （DNMT3a, OR 1.048, P = 4.56 × 10-4; TET2, OR 1.038, P = 0.025）。包括DNMT3a-CHIP在内的总体CHIP与房颤之间的因果关系通过2个独立队列的2样本MR研究得到验证。反向MR未显示AF引起CHIP的证据。中介分析发现收缩压升高是DNMT3a-CHIP-AF通路的关键中介，占7.8%的效应（P = 0.034）。结论：我们的研究结果提供了遗传证据，证明CHIP，特别是dnmt3a相关突变，会导致但适度地增加房颤风险。没有证据支持反向因果关系。收缩压升高被确定为DNMT3a-CHIP与房颤之间的重要中介。
{"title":"Clonal hematopoiesis of indeterminate potential as a risk factor for atrial fibrillation: Evidence of a causal relationship by Mendelian randomization study","authors":"Qing Zhang MD, PhD , Guohao Wang PhD , Zhangpu Yan BS , Weiling Xu MD , Shaofeng Zhang BS , Jun Li MD , Ling Liang MD, PhD , Changqing Sun MD, PhD , Rong Tang MD , Joachim Pircher MD, PhD , Qiang Xie MD, PhD, FHRS , Wuyang Zheng MD, PhD","doi":"10.1016/j.hroo.2025.09.024","DOIUrl":"10.1016/j.hroo.2025.09.024","url":null,"abstract":"<div><h3>Background</h3><div>Clonal hematopoiesis of indeterminate potential (CHIP) has emerged as an independent cardiovascular risk factor, with recent studies suggesting a link to atrial fibrillation (AF). However, the causal nature of this relationship, particularly the role of DNMT3a and TET2 mutations, remains unclear.</div></div><div><h3>Objective</h3><div>This study aimed to assess the causal relationship between CHIP and AF and identify potential mediating pathways.</div></div><div><h3>Methods</h3><div>We conducted a bidirectional Mendelian randomization (MR) analysis using genome-wide association study data for CHIP from the UK Biobank (n = 368,526) and AF data from 2 large, independent cohorts (287,805 individuals from FinnGen and 1,030,836 from 6 additional AF studies). A 2-step MR mediation analysis was used to explore potential intermediate risk factors.</div></div><div><h3>Results</h3><div>Inverse variance weighted MR analysis demonstrated a causal effect of CHIP on increased AF risk (meta-inverse variance weighted, odds ratio [OR] 1.057; <em>P</em> = .001), including both DNMT3a- and TET2-related CHIP (DNMT3a, OR 1.048, <em>P</em> = 4.56 × 10<sup>-4</sup>; TET2, OR 1.038, <em>P</em> = .025). Causal associations between overall CHIP, including DNMT3a-CHIP, and AF were validated by a 2-sample MR study in 2 independent cohorts. Reverse MR showed no evidence of AF causing CHIP. The mediation analysis identified elevated systolic blood pressure as a key mediator in the DNMT3a-CHIP–AF pathway, accounting for 7.8% of the effect (<em>P</em> = .034).</div></div><div><h3>Conclusion</h3><div>Our findings provide genetic evidence that CHIP, particularly DNMT3a-related mutations, causally but modestly increases AF risk. There is no support for reverse causation. Elevated systolic blood pressure was identified as a significant mediator linking DNMT3a-CHIP to AF.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 12","pages":"Pages 1949-1959"},"PeriodicalIF":2.9,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771848","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2025-12-01DOI: 10.1016/j.hroo.2025.09.026
Leonardo J. Uribe-Cavero MD , Fabian A. Chavez-Ecos MD , Kiara Camacho-Caballero MD , José Carlos Grados-Pintos MD , Patricia Vera-Maccha MD , Anthony Siguas-Huasasquiche MD , Dinesh Sharma MD , Carlos J. Toro-Huamanchumo MD MMed
Background
Bioelectrical impedance analysis (BIA) is widely used to assess body composition. However, its safety in patients with cardiac implantable electronic devices (CIEDs) remains uncertain owing to potential electromagnetic interference (EMI).
Objective
This study aimed to evaluate potential complications associated with clinical-grade BIA use in patients with CIEDs, based on currently available evidence.
Methods
We conducted a systematic review of studies published up to December 26, 2024, identified through PubMed, Embase, Scopus, and the Cochrane Library. The primary outcome was the occurrence of adverse events, including EMI, device malfunction, or arrhythmias.
Results
Of 3668 records, 6 cohort studies (n = 531 patients) met the inclusion criteria. These included patients with pacemakers (n = 175), implantable cardioverter-defibrillators (n = 268), and cardiac resynchronization therapy defibrillators (n = 154). BIA protocols varied in frequency (5–500 kHz) and current intensity (typically ≤0.8 mA). No study reported clinically significant EMI, device malfunctions, or BIA-induced arrhythmias. Device parameters (eg, lead impedance, pacing thresholds) remained stable before and after BIA exposure. Risk of bias was rated as good in 1 study and fair in 5.
Conclusion
Current evidence suggests that clinical-grade BIA is safe in patients with CIEDs, with no reported adverse effects or device interferences. These findings contribute to informing and potentially updating previous recommendations that discouraged BIA in this population. However, further high-quality studies are needed to confirm safety across different BIA protocols and device types. Importantly, these findings apply to clinical-grade BIA and should not be extrapolated to consumer-grade wearables, which may present a theoretical risk of CIED interference.
{"title":"Safety of bioelectrical impedance analysis in patients with cardiac implantable electronic devices: A systematic review","authors":"Leonardo J. Uribe-Cavero MD , Fabian A. Chavez-Ecos MD , Kiara Camacho-Caballero MD , José Carlos Grados-Pintos MD , Patricia Vera-Maccha MD , Anthony Siguas-Huasasquiche MD , Dinesh Sharma MD , Carlos J. Toro-Huamanchumo MD MMed","doi":"10.1016/j.hroo.2025.09.026","DOIUrl":"10.1016/j.hroo.2025.09.026","url":null,"abstract":"<div><h3>Background</h3><div>Bioelectrical impedance analysis (BIA) is widely used to assess body composition. However, its safety in patients with cardiac implantable electronic devices (CIEDs) remains uncertain owing to potential electromagnetic interference (EMI).</div></div><div><h3>Objective</h3><div>This study aimed to evaluate potential complications associated with clinical-grade BIA use in patients with CIEDs, based on currently available evidence.</div></div><div><h3>Methods</h3><div>We conducted a systematic review of studies published up to December 26, 2024, identified through PubMed, Embase, Scopus, and the Cochrane Library. The primary outcome was the occurrence of adverse events, including EMI, device malfunction, or arrhythmias.</div></div><div><h3>Results</h3><div>Of 3668 records, 6 cohort studies (n = 531 patients) met the inclusion criteria. These included patients with pacemakers (n = 175), implantable cardioverter-defibrillators (n = 268), and cardiac resynchronization therapy defibrillators (n = 154). BIA protocols varied in frequency (5–500 kHz) and current intensity (typically ≤0.8 mA). No study reported clinically significant EMI, device malfunctions, or BIA-induced arrhythmias. Device parameters (eg, lead impedance, pacing thresholds) remained stable before and after BIA exposure. Risk of bias was rated as good in 1 study and fair in 5.</div></div><div><h3>Conclusion</h3><div>Current evidence suggests that clinical-grade BIA is safe in patients with CIEDs, with no reported adverse effects or device interferences. These findings contribute to informing and potentially updating previous recommendations that discouraged BIA in this population. However, further high-quality studies are needed to confirm safety across different BIA protocols and device types. Importantly, these findings apply to clinical-grade BIA and should not be extrapolated to consumer-grade wearables, which may present a theoretical risk of CIED interference.</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 12","pages":"Pages 1985-1992"},"PeriodicalIF":2.9,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771988","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Preclinical studies showed inconsistent results regarding the influence of adipose tissue on effective pulsed field ablation (PFA), raising questions about its efficacy in patients with elevated epicardial adipose tissue (EAT) levels.
Objective
Elevated EAT levels may lead to higher atrial fibrillation (AF) recurrence rates after pulmonary vein isolation using PFA than high-power, short-duration radiofrequency (RF) ablation.
Methods
103 patients with body mass index of >29 kg/m2 with paroxysmal or short-term persistent AF who underwent first-time AF ablation were prospectively enrolled (PFA n = 41; RF n = 62). All patients received preablation photon-counting computed tomography imaging to volumetrically quantify left and right atrial EAT levels. PFA was performed using a pentaspline catheter, and RF ablation was performed using high-power, short-duration energy.
Results
Median EAT volumes were 71.85 mL (interquartile range 50.35–93.35 mL) in the RF group and 65.61 mL (interquartile range 40.45–90.8 mL) in the PFA group (P = .1352). Median follow-up was 367 days, excluding a 6-week blanking period. Atrial arrhythmia recurrence at 1 year was 33.87% in the RF group vs 17.07% in the PFA group (P = .077). Cox regression showed that, in the PFA group, left atrial EAT was the only significant predictor of recurrence (hazard ratio 1.06; 95% confidence interval 1.01–1.12; P = .022), corresponding to a 6.2% increased risk per mL. In the RF group, left atrial EAT was not significantly associated with recurrence (hazard ratio 1.00; 95% confidence interval 0.97–1.03; P = .846).
Conclusion
PFA showed good 1-year results after pulmonary vein isolation in patients with a body mass index of >29 kg/m2. However, EAT may have a more significant impact on AF recurrences after PFA than RF ablation.
{"title":"Epicardial adipose tissue and ablation outcomes in obese patients with paroxysmal atrial fibrillation: A comparison of pulsed field and radiofrequency ablation","authors":"Florian Englert MD , Theresa Obermeyer , Fabian Bahlke MD , Miruna Popa MD , Hannah Krafft MD , Alex Tunsch Martinez MD , Jan Syväri MD , Madeleine Tydecks MD , Dominic Dischel MD , Eva Koops MD , Theresa Reiter MD , Marta Telishevska MD , Sarah Lengauer MD , Kenno Bressem MD , Martin Hadamitzky MD , Gabriele Hessling MD , Isabel Deisenhofer MD, FHRS , Nico Erhard MD","doi":"10.1016/j.hroo.2025.09.020","DOIUrl":"10.1016/j.hroo.2025.09.020","url":null,"abstract":"<div><h3>Background</h3><div>Preclinical studies showed inconsistent results regarding the influence of adipose tissue on effective pulsed field ablation (PFA), raising questions about its efficacy in patients with elevated epicardial adipose tissue (EAT) levels.</div></div><div><h3>Objective</h3><div>Elevated EAT levels may lead to higher atrial fibrillation (AF) recurrence rates after pulmonary vein isolation using PFA than high-power, short-duration radiofrequency (RF) ablation.</div></div><div><h3>Methods</h3><div>103 patients with body mass index of >29 kg/m<sup>2</sup> with paroxysmal or short-term persistent AF who underwent first-time AF ablation were prospectively enrolled (PFA n = 41; RF n = 62). All patients received preablation photon-counting computed tomography imaging to volumetrically quantify left and right atrial EAT levels. PFA was performed using a pentaspline catheter, and RF ablation was performed using high-power, short-duration energy.</div></div><div><h3>Results</h3><div>Median EAT volumes were 71.85 mL (interquartile range 50.35–93.35 mL) in the RF group and 65.61 mL (interquartile range 40.45–90.8 mL) in the PFA group (<em>P</em> = .1352). Median follow-up was 367 days, excluding a 6-week blanking period. Atrial arrhythmia recurrence at 1 year was 33.87% in the RF group vs 17.07% in the PFA group (<em>P</em> = .077). Cox regression showed that, in the PFA group, left atrial EAT was the only significant predictor of recurrence (hazard ratio 1.06; 95% confidence interval 1.01–1.12; <em>P</em> = .022), corresponding to a 6.2% increased risk per mL. In the RF group, left atrial EAT was not significantly associated with recurrence (hazard ratio 1.00; 95% confidence interval 0.97–1.03; <em>P</em> = .846).</div></div><div><h3>Conclusion</h3><div>PFA showed good 1-year results after pulmonary vein isolation in patients with a body mass index of >29 kg/m<sup>2</sup>. However, EAT may have a more significant impact on AF recurrences after PFA than RF ablation.</div></div><div><h3>Trial Registration Number</h3><div>NCT06559787</div></div>","PeriodicalId":29772,"journal":{"name":"Heart Rhythm O2","volume":"6 12","pages":"Pages 1901-1910"},"PeriodicalIF":2.9,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145771998","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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