Etiologies, Mechanisms, Management, and Outcomes of Electrical Storm.

Electrical storm (ES) is characterized by three or more discrete sustained ventricular tachyarrhythmia episodes occurring within a limited time frame (generally ≤ 24 h) or an incessant ventricular tachyarrhythmia lasting > 12 h. In patients with an implantable cardioverterdefibrillator (ICD), ES is defined as three or more appropriate device therapies, separated from each other by at least 5 min, which occur within a 24-h period. ES may constitute a medical emergency, depending on the number arrhythmic episodes, their duration, the type, and the cycle length of the ventricular arrhythmias, as well as the underlying ventricular function. This narrative review was facilitated by a search of MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, and other clinically relevant studies. The search was limited to English-language reports published between 1999 and 2023. ES was searched using the terms mechanisms, genetics, channelopathies, management, pharmacological therapy, sedation, neuraxial modulation, cardiac sympathetic denervation, ICDs, and structural heart disease. Google and Google scholar as well as bibliographies of identified articles were reviewed for additional references. This manuscript examines the current strategies available to treat ES and compares pharmacological and invasive treatment strategies to diminish ES recurrence, morbidity, and mortality.

Mortality benefit of catheter ablation versus medical therapy in atrial fibrillation: An RCT only meta-analysis.

INTRODUCTION: Catheter ablation for atrial fibrillation (AF) in comparison to medical therapy alone is known to improve freedom from arrhythmia and quality of life, but the benefit regarding mortality is unclear. The publication of several recent large randomized controlled trials (RCT) comparing ablation with medical therapy has warranted an updated meta-analysis. METHODS: We sought to compare the effectiveness of catheter ablation versus medical therapy only in patients with AF. MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched from inception until 04/30/2021. Relevant RCTs comparing catheter ablation versus medical therapy in patients with AF were selected. RESULTS: A total of 24 RCTs involving 5730 adult patients were included (2992 in catheter ablation and 2738 in medical therapy). There was a reduction in all-cause mortality with catheter ablation compared with medical therapy only (risk ratio (RR) 0.70 [95% confidence interval (CI) 0.55-0.89]; p = .003). Catheter ablation also demonstrated a reduction in hospitalizations (RR 0.50 [95% CI 0.36-0.70]; p < .001), improvement in left ventricular ejection fraction (LVEF) (mean difference [MD] + 5.94% [95% CI 0.40-11.48] p = .04), greater freedom from atrial arrhythmia (RR 2.23 [95% CI 1.79-2.76]; p < .001), and AF (RR 1.95 [95% CI 1.44-2.66]; p < .001). In subgroup analysis, catheter ablation demonstrated a significant reduction in mortality and hospitalizations among patients with reduced LVEF, and when ablation was compared with antiarrhythmic drug use. CONCLUSIONS: In comparison to medical therapy only, catheter ablation for atrial fibrillation reduces mortality, hospitalizations, and increases freedom from arrhythmia.

Comparison of radiofrequency ablation from the coronary cusps and endocardial left ventricular outflow tract for left ventricular summit ventricular arrhythmias in a porcine and infrared thermal model.

INTRODUCTION: The coronary cusps (CCs) are utilized as an alternative vantage point for radiofrequency catheter ablation (RFCA) of left ventricular summit ventricular arrhythmias but are sometimes a challenge despite favorable activation timing and pace mapping. METHODS: Ex vivo experiments were performed in 12 intact porcine hearts submerged in a 37°C saline bath. Radiofrequency (RF) applications were delivered with an irrigated contact force sensing catheter oriented 45° to the endocardial left ventricular outflow tract (LVOT) surface and nadir of the CCs using different dosing parameters. Sections were stained in 2% triphenyltetrazolium chloride and lesion dimensions were measured. Thermal infrared imaging analysis was used to compare time-to-lethal tissue temperature and depth/area of lethal isotherms. RESULTS: A total of 60 RF applications were performed under different dosing parameters for (1) 30, 40, and 50 Watts (W) × 30 s and (2) 40 W × 30, 45, and 60 s. Lesion depth was greater with RFCA from LVOT than from the CCs (maximum depth 6.11 vs. 2.68 mm). Longer RF duration led to larger lesion volume in the CC group (40 W × 30 s: 8.1 ± 0.4 vs. 40 W × 60 s: 10.1 ± 0.96 mm; p = .002). One steam pop occurred in both the LVOT (50 W × 30 s) and CC groups (40 W × 60 s). Time-to-reach lethal temperature of 58°C was longer in the CC group than in the LVOT group (4.7 vs. 11.3 s; p = .02) CONCLUSIONS: RFCA from the CC led comparatively to shallower lesion depth than from the LVOT. Longer RF duration led to an increase in lesion volume during ablation from CCs.

Comparison of ablation index versus time-guided radiofrequency energy dosing using normal and half-normal saline irrigation in a porcine left ventricular model.

BACKGROUND: Ablation Index (AI) is a multiparametric quality marker to assess the durability of radiofrequency (RF) lesions. The comparative effectiveness and safety of AI versus time-based energy dosing for ablation of ventricular arrhythmias are unknown. OBJECTIVE: We compared AI and time-based RF dosing strategies in the left ventricles (LVs) of freshly harvested porcine hearts. METHODS: Ablation was performed in vitro with an open-irrigated ablation catheter (Thermocool ST/SF), 40 W, contact force 10-15 g. Tissue samples were stained in triphenyltetrazolium chloride for the measurement of lesion dimensions. RESULTS: A total of 560 lesions were performed (AI-group: [n = 360]; time-group: [n = 200]). Using normal saline (NS) (n = 280), growth in lesion depth slowed after 30 s and AI > 550 in comparison to width, volume, and magnitude of impedance drops which continued to increase with longer RF duration. Risk of steam pop (SP) was higher for RF > 30 s (RF < 30 s:1 SP [2.5%] vs. RF > 30 s: 15 SP [25%]; p = .002) or AI targets >550 (AI: 350-550: 2 SP [2%] vs. AI 600-750: 15 SP [19%]; p = .001). Using half-normal saline (HNS) (n = 280), lesion dimension and impedance drops were larger and growth in lesion depth slowed earlier (AI: 500). Risk of SPs was higher above AI 550 (AI: 350-550: 7 [7%] SPs vs. AI 600-750: 28 [35%] SPs; p < .00001). While codependent variables, correlation between AI and time was modest-to-strong but decreased with longer RF duration. CONCLUSION: In this ex vivo study, AI was a better predictor of lesion dimensions than ablation time and magnitude of impedance drop in the LV using NS and HNS irrigation. AI targets above 550 led to a higher risk of SPs. Future trials are required to verify these findings.

Use of infrared thermography to delineate temperature gradients and critical isotherms during catheter ablation with normal and half normal saline: Implications for safety and efficacy.

BACKGROUND: Radiofrequency (RF) ablation with half-normal saline (HNS) has shown promise as a bail-out strategy following failed ventricular tachycardia ablation using standard approaches. OBJECTIVE: To use a novel infrared thermal imaging (ITI) model to evaluate biophysical and lesion characteristics during RF ablation using normal saline (NS) and HNS irrigation. METHODS: Left ventricular strips of myocardium were excised from fresh porcine hearts. RF ablation was performed using an open-irrigated ablation catheter (Thermocool ST/SF) with NS (n = 75) and HNS (n = 75) irrigation using different power settings (40/50 W), RF durations (30/60 s), contact force of 10-15 g, and flow rate of 15 ml/min. RF lesions were recorded using an infrared thermal camera and border zone, lethal, 100° isotherms were matched with necrotic borders after 2% triphenyltetrazolium chloride staining. Lesion dimensions and isotherms (mm2 ) were measured. RESULTS: In total, 150 lesions were delivered. HNS lesions were deeper (6.4 ± 1.1 vs. 5.7 ±0.8 mm; p = .03), and larger in volume (633 ± 153 vs. 468 ± 107 mm3 ; p = .007) than NS lesions. Steam pops (SPs) occurred during 19/75 lesions (25%) in the NS group and 32/75 lesions (43%) in the HNS group (p = .34). Lethal (57.8 ± 6.5 vs. 36.0 ± 3.9 mm2 ; p = .001) and 100°C isotherm areas (16.9 ± 6.9 vs. 3.8 ± 4.2 mm2 ; p = .003) areas were larger and were reached earlier in the HNS group. CONCLUSIONS: RFA using HNS created larger lesions than NS irrigation but led to more frequent SPs. The presence of earlier lethal isotherms and temperature rises above 100°C on ITI suggest a potentially narrower therapeutic-safety window with HNS.

High-power short duration vs. conventional radiofrequency ablation of atrial fibrillation: a systematic review and meta-analysis.

AIMS: We sought to compare the effectiveness and safety of high-power short-duration (HPSD) radiofrequency ablation (RFA) with conventional RFA in patients with atrial fibrillation (AF). METHODS AND RESULTS: MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 15 May 2020 for relevant studies comparing HPSD vs. conventional RFA in patients undergoing initial catheter ablation for AF. A total of 15 studies involving 3718 adult patients were included in our meta-analysis (2357 in HPSD RFA and 1361 in conventional RFA). Freedom from atrial arrhythmia was higher in HPSD RFA when compared with conventional RFA [odds ratio (OR) 1.44, 95% confidence interval (CI) 1.10-1.90; P = 0.009]. Acute PV reconnection was lower (OR 0.56, P = 0.005) and first-pass isolation was higher (OR 3.58, P < 0.001) with HPSD RFA. There was no difference in total complications between the two groups (P = 0.19). Total procedure duration [mean difference (MD) -37.35 min, P < 0.001], fluoroscopy duration (MD -5.23 min, P = 0.001), and RF ablation time (MD -16.26 min, P < 0.001) were all significantly lower in HPSD RFA. High-power short-duration RFA also demonstrated higher freedom from atrial arrhythmia in the subgroup analysis of patients with paroxysmal AF (OR 1.80, 95% CI 1.29-2.50; P < 0.001), studies with ≥50 W protocol in the HPSD RFA group (OR 1.53, 95% CI 1.08-2.18; P = 0.02] and studies with contact force sensing catheter use (OR 1.65, 95% CI 1.21-2.25; P = 0.002). CONCLUSION: High-power short-duration RFA was associated with better procedural effectiveness when compared with conventional RFA with comparable safety and shorter procedural duration.

Three-dimensional echocardiography definitively delineates a malpositioned permanent pacing lead in a patient with chronic chest pain.

Inadvertent malpositioning of a cardiac pacing lead into the left heart chambers is a rare complication of transvenous pacing. We report a patient with a history of a transient ischemic attack and chronic chest pain whose left atrial pacing lead location was revealed by transesophageal three-dimensional (3D) echocardiography during evaluation of an inter-atrial shunt.

Sensors for rate-adaptive pacing: How they work, strengths, and limitations.

Chronotropic incompetence is the inability of the sinus node to increase heart rate commensurate with increased metabolic demand. Cardiac pacing alone may be insufficient to address exercise intolerance, fatigue, dyspnea on exertion, and other symptoms of chronotropic incompetence. Rate-responsive (adaptive) pacing employs sensors to detect physical or physiological indices and mimic the response of the normal sinus node. This review describes the development, strengths, and limitations of a variety of sensors that have been employed to address chronotropic incompetence. A mini-tutorial on programming rate-adaptive parameters is included along with emphasis that patients' lifestyles and underlying medical conditions require careful consideration. In addition, special sensor applications used to respond prophylactically to physiologic signals are detailed and an in-depth discussion of sensors as a potential aid in heart failure management is provided.

Meta-analysis of pulmonary vein isolation ablation for atrial fibrillation conventional vs low- and zero-fluoroscopy approaches.

INTRODUCTION: Radiation exposure during catheter ablation procedures is a significant hazard for both patients and operators. Atrial fibrillation (AF) ablation procedures have been historically associated with higher fluoroscopy usage than other electrophysiology procedures. Recent efforts have been made to reduce dependence on fluoroscopy during pulmonary vein isolation (PVI) ablation procedures using alternative techniques. METHODS: We performed a meta-analysis of studies comparing zero or low fluoroscopy (LF) vs conventional fluoroscopy (CF) approaches for AF ablation. Outcomes of interest included acute and 12-month procedural efficacy, safety, procedure duration, fluoroscopy time, and dose area product. Aggregated data were analyzed with random-effects models, using a Bayesian hierarchical approach. RESULTS: A total of 2228 participants (LF, n = 1190 vs CF, n = 1038) from 15 studies were included in the meta-analysis. Risk of AF recurrence in 12 months (odds ratio [OR], 95% confidence interval [95% CI] = 1.343 [0.771-2.340]; P = .297), redo-ablation procedures (OR [95% CI] = 0.521 [0.198-1.323]; P = .186), and procedural complications (OR [95% CI] = 0.99 [0.485-2.204]; P = .979) were similar between LF- and CF-ablation groups. In comparison to CF ablation, LF ablation led to shorter procedure duration (weighted mean differences [WMDs] [95% CI] = -14.6 minutes [-22.5 to -6.8]; P < .001), fluoroscopy time (WMD [95% CI] = -8.8 minutes [-11.9 to -5.9]; P < .001), and dose area product (WMD [95% CI] = -1946 mGy/cm2 [-2685 to 1207]; P < .001). CONCLUSION: LF approaches have similar clinical efficacy and safety as CF approaches for PVI. LF approaches are associated with shorter procedure time, fluoroscopy usage, and dose area product during PVI.

A systematic review and meta-analysis comparing second-generation cryoballoon and contact force radiofrequency ablation for initial ablation of paroxysmal and persistent atrial fibrillation.

INTRODUCTION: Cryoballoon ablation (CBA) and radiofrequency ablation (RFA) are the preferred modalities for catheter ablation of atrial fibrillation (AF). Technological advances have improved procedural outcomes, warranting an updated comparison. We sought to evaluate the efficacy and safety of CBA-2nd generation (CBA-2G) in comparison to RFA-contact force (RFA-CF) in patients with AF. METHODS: MEDLINE, Cochrane, and ClinicalTrials.gov databases were searched until 03/01/2020 for relevant studies comparing CBA-2G versus RFA-CF in patients undergoing initial catheter ablation for AF. RESULTS: A total of 17 studies, involving 11 793 patients were included. There was no difference between the two groups in the outcomes of freedom from atrial arrhythmia (p = .67) and total procedural complications (p = .65). There was a higher incidence of phrenic nerve palsy in CBA-2G (odds ratio: 10.7; 95% confidence interval [CI]: 5.85 to 19.55; p < .001). Procedure duration was shorter (mean difference: -31.32 min; 95% CI: -40.73 to -21.92; p < .001) and fluoroscopy duration was longer (+3.21 min; 95% CI: 1.09 to 5.33; p = .003) in CBA-2G compared to RFA-CF. In the subgroup analyses of patients with persistent AF and >1 freeze lesion delivered per vein, there was no difference in freedom from atrial arrhythmia. CONCLUSIONS: In AF patients undergoing initial ablation, CBA-2G and RFA-CF were equally efficacious. The procedure duration was shorter, but with a higher incidence of phrenic nerve palsy in CBA-2G. In patients with persistent AF, there was no difference in the efficacy between CBA-2G or RFA-CF techniques.

Comparison between minimal fluoroscopy and conventional approaches for visually guided laser balloon pulmonary vein isolation ablation.

INTRODUCTION: Although balloon-based techniques, such as the laser balloon (LB) ablation have simplified pulmonary vein isolation (PVI), procedural fluoroscopy usage remains higher in comparison to radiofrequency PVI approaches due to limited 3-dimensional mapping system integration. METHODS: In this prospective study, 50 consecutive patients were randomly assigned in alternating fashion to a low fluoroscopy group (LFG; n = 25) or conventional fluoroscopy group (CFG; n = 25) and underwent de novo PVI procedures using visually guided LB technique. RESULTS: There was no statistical difference in baseline characteristics or cross-overs between treatment groups. Acute PVI was accomplished in all patients. Mean follow up was 318 ± 69 days. Clinical recurrence of atrial fibrillation after PVI was similar between groups (CFG: 19% vs LFG: 15%; P = .72). Total fluoroscopy time was significantly lower in the LFG than the CFG (1.7 ± 1.4  vs 16.9 ± 5.9 minutes; P < .001) despite similar total procedure duration (143 ± 22 vs 148 ± 22 minutes; P = .42) and mean LA dwell time (63 ± 15 vs 59 ± 10 minutes; P = .28). Mean dose area product was significantly lower in the LFG (181 ± 125 vs 1980 ± 750 µGym2 ; P < .001). Fluoroscopy usage after transseptal access was substantially lower in the LFG (0.63 ± 0.43 vs 11.70 ± 4.32 minutes; P < .001). Complications rates were similar between both groups (4% vs 2%; P = .57). CONCLUSIONS: This study demonstrates that LB PVI can be safely achieved using a novel low fluoroscopy protocol while also substantially reducing fluoroscopy usage and radiation exposure in comparison to conventional approaches for LB ablation.

Permanent His Bundle Pacing: A programming and troubleshooting guide.

Permanent His Bundle Pacing (HBP) has recently gained popularity. However, implanting physicians and those who perform the device checks must invest in additional education in order to accurately program these devices, identify changes in morphology and perform troubleshooting to help achieve the best outcomes for the patients. This paper reviews key aspects of HBP and provides the educational tools for successful HBP follow-up and troubleshooting.

How to perform electroanatomic mapping-guided cardiac resynchronization therapy using Carto 3 and ESI NavX three-dimensional mapping systems.

AIMS: To examine the feasibility and safety of a novel protocol for low fluoroscopy, electroanatomic mapping (EAM)-guided Cardiac resynchronization therapy with a defibrillator (CRT-D) implantation and using both EnSite NavX (St. Jude Medical, St. Paul, MN, USA) and Carto 3 (Biosense Webster, Irvine, CA, USA) mapping systems. METHODS AND RESULTS: Twenty consecutive patients underwent CRT implantation using either a conventional fluoroscopic approach (CFA) or EAM-guided lead placement with Carto 3 and EnSite NavX mapping systems. We compared fluoroscopy and procedural times, radiopaque contrast dose, change in QRS duration pre- and post-procedure, and complications in all patients. Fluoroscopy time was 86% lower in the EAM group compared to the conventional group [mean 37.2 min (CFA) vs. 5.5 min (EAM), P = 0.00003]. There was no significant difference in total procedural time [mean 183 min (CFA) vs. 161 min (EAM), P = 0.33] but radiopaque contrast usage was lower in the EAM group [mean 16 mL (CFA) vs. 4 mL (EAM), P = 0.006]. Likewise, there was no significant change in QRS duration with BiV pacing between the groups [mean -13 (CFA) vs. -25 ms (EAM), P = 0.09]. CONCLUSION: Electroanatomic mapping-guided lead placement using either Carto or ESI NavX mapping systems is a feasible alternative to conventional fluoroscopic methods for CRT-D implantation utilizing the protocol described in this study.

An Unusual Electrocardiogram.

A 56-year-old female was hospitalized and her admission ECG differed from previous tracings. Knowledge of variant cardiac anatomy along with awareness of common pitfalls in ECG recording reveals the clinical diagnosis and explains the difference.

Permanent His Bundle Pacing: The Past, Present, and Future.

Long-term right ventricular (RV) apical pacing has been associated with an increased risk of death, heart failure, and atrial fibrillation (AF). Alternative sites for RV pacing have not proven to be superior to RV apical pacing. Cardiac resynchronization therapy (CRT) using a biventricular (BiV) lead system is indicated for patients with a low left ventricular ejection fraction and QRS prolongation, but there remains about a 25-30% nonresponse rate. CRT has been less effective for nonleft bundle branch block conduction delay and with normal/low normal left ventricular function. Over the past decade, there have been more data on the feasibility and advantages of pacing at the His Bundle (HB) region. We review the anatomy and physiology of the HB, the available data on permanent HB pacing, its current and potential future applications.

Reassessing Risk Factors for High Defibrillation Threshold: The EF-SAGA Risk Score and Implications for Device Testing.

OBJECTIVES: To reevaluate risk factors for high defibrillation threshold (DFT) and propose a risk assessment tool. BACKGROUND: Controversy exists over routine DFT testing during implantable cardioverter defibrillator (ICD) placement. METHODS: We retrospectively analyzed 1,642 consecutive patients who received an ICD and underwent DFT testing. RESULTS: The incidence of high DFT requiring addition of a subcutaneous array was 2.3%. Five significant independent variables predictive of high DFT were identified, including younger age, male gender (hazard ratio 1.99), left ventricular (LV) dysfunction, secondary prevention (hazard ratio 2.33), and amiodarone use (hazard ratio 2.39). Each 10-year increase in age was indicative of a 0.35-times lower chance of high DFT. Each 10% increase of LV ejection fraction (EF) was indicative of a 0.52-times lower chance of high DFT. These five variables form the EF-SAGA risk score (LVEF < 20%, Secondary prevention ICD indication, Age < 60 years, male Gender, Amiodarone use). Cumulative risk of high DFT increased incrementally; patients with four or more variables had an 8.9% likelihood of high DFT. Importantly, primary prevention patients with LVEF > 20% had a negative predictive value for high DFT of 99.3%. CONCLUSION: We identified five independent predictors of high DFT. We propose the EF-SAGA risk score to help decision making. Primary prevention patients with an LVEF > 20% had an exceedingly low incidence of high DFT suggesting that testing could be avoided in these patients. Careful assessment of the risk-benefit ratio of testing is important in high-risk patients.

Single-lead portable ECG devices: Perceptions and clinical accuracy compared to conventional cardiac monitoring.

INTRODUCTION: Portable ECG devices are widely available yet there are limited data on their accuracy, physician and patient perceptions, and ease of use. The purpose of this study was to evaluate the accuracy of 4 single-lead portable ECG devices compared to a conventional 3-lead hospital cardiac monitor and to assess physician and patient perceptions of portable ECG devices. METHODS: Twenty consecutive hospitalized patients were provided 4 portable ECG devices for 30 second cardiac rhythm recording. ECG rhythm strips from the portable ECG devices were interpreted by a group of 5 physician reviewers. The reviewers then compared the portable ECG device rhythm strips to simultaneously recorded hospital cardiac monitor rhythm strips to determine physician preference. A cardiac electrophysiologist interpreted ECG rhythm strips from the hospital cardiac monitor as the "gold standard." Rhythm interpretations of the portable ECG devices and the hospital cardiac monitor were analyzed to evaluate clinical accuracy. Patient perceptions were evaluated by a 20-item questionnaire. RESULTS: There was less than 50% concordance of portable ECG device rhythm strips with the hospital cardiac monitor (when uninterpretable rhythm strips were included). Physicians usually preferred interpreting ECGs from hospital cardiac monitors compared to portable ECG devices. Manufacturer instructions were insufficient to allow patients to operate portable ECG devices in a limited time. Most patients felt comfortable using a portable ECG device if prescribed by a physician. CONCLUSION: Portable ECG devices may be a reasonable option for long-term rhythm surveillance in select patients. Widespread use of these devices cannot be endorsed unless improvements in their accuracy are properly addressed.

The value of diastolic function parameters in the prediction of left atrial appendage thrombus in patients with nonvalvular atrial fibrillation.

BACKGROUND: Left ventricular diastolic impairment and consequently elevated filling pressure may contribute to stasis leading to left atrial appendage thrombus (LAAT) in nonvalvular atrial fibrillation (AF). We investigated whether transthoracic echocardiographic parameters can predict LAAT independent of traditional clinical predictors. METHODS: We conducted a retrospective cohort study of 297 consecutive nonvalvular AF patients who underwent transthoracic echocardiogram followed by a transesophageal echocardiogram within one year. Multivariate logistic regression analysis models were used to determine factors independently associated with LAAT. RESULTS: Nineteen subjects (6.4%) were demonstrated to have LAAT by transesophageal echocardiography. These patients had higher mean CHADS2 scores [2.6 ± 1.2 vs. 1.9 ± 1.3, P = 0.009], higher E:e' ratios [16.6 ± 6.1 vs. 12.0 ± 5.4, P = 0.001], and lower mean e' velocities [6.5 ± 2.1 cm/sec vs. 9.1 ± 3.2 cm/sec, P = 0.001]. Both E:e' and e' velocity were associated with LAAT formation independent of the CHADS2 score, warfarin therapy, left ventricular ejection fraction (LVEF), and left atrial volume index (LAVI) [E:e' odds-ratio = 1.14 (95% confidence interval = 1.03 - 1.3), P = 0.009; e' velocity odds-ratio = 0.68 (95% confidence interval = 0.5 - 0.9), P = 0.007]. Similarly, diastolic function parameters were independently associated with spontaneous echo contrast. CONCLUSION: The diastolic function indices E:e' and e' velocity are independently associated with LAAT in nonvalvular AF patients and may help identify patients at risk for LAAT.

Narrative Review: Surgical and Hybrid Management of Atrial Fibrillation.

Although significant strides have been made in non-pharmacologic management of atrial fibrillation (AF), these treatments remain a work in progress. While catheter ablation is often effective for management of paroxysmal AF, it is less successful in patients with persistent or longstanding persistent AF. This review was undertaken to clarify the risks, benefits, and alternatives to catheter ablation for non-pharmacologic AF management. In order to clarify the roles of surgical and hybrid ablation, this narrative review was undertaken by searching MEDLINE to identify peer-reviewed clinical trials, randomized controlled trials, meta-analyses, review articles, and other clinically relevant studies. The search was limited to English-language reports published between 1960 and 2023. Atrial fibrillation was searched using the terms surgical ablation, catheter ablation, hybrid ablation, stroke prevention, left atrial occlusion, and atrial excision. Google and Google Scholar, as well as bibliographies of identified articles, were also reviewed for additional references. The Cox-maze surgical approach is still the most efficacious non-pharmacological treatment for AF. Hybrid ablation, combining cardiac surgical and catheter ablation techniques, has become an attractive option for persistent or longstanding persistent AF.