[Lead placement in cardiac implantable electronic devices]. / Elektrodenplatzierung in der kardialen Devicetherapie.

The implantation of electrodes for cardiac implantable electronic devices (CIED) requires profound technical understanding and precise execution. The positioning of electrodes in the right ventricle and atrium has significant implications for patient safety and the effectiveness of CIED therapy. Particular focus is given to the distinction between apical and septal stimulation in ventricular positioning. Based on current data, this article provides a practice-oriented guide that leads implanters through the individual steps of electrode positioning. The implantation of electrodes for physiological stimulation (cardiac resynchronization therapy, CRT, and conduction system pacing, CSP) is not addressed in this article.

Stereotactic arrhythmia radioablation and its implications for modern cardiac electrophysiology: results of an EHRA survey.

Stereotactic arrhythmia radioablation (STAR) is a treatment option for recurrent ventricular tachycardia/fibrillation (VT/VF) in patients with structural heart disease (SHD). The current and future role of STAR as viewed by cardiologists is unknown. The study aimed to assess the current role, barriers to application, and expected future role of STAR. An online survey consisting of 20 questions on baseline demographics, awareness/access, current use, and the future role of STAR was conducted. A total of 129 international participants completed the survey [mean age 43 ± 11 years, 25 (16.4%) female]. Ninety-one (59.9%) participants were electrophysiologists. Nine participants (7%) were unaware of STAR as a therapeutic option. Sixty-four (49.6%) had access to STAR, while 62 (48.1%) had treated/referred a patient for treatment. Common primary indications for STAR were recurrent VT/VF in SHD (45%), recurrent VT/VF without SHD (7.8%), or premature ventricular contraction (3.9%). Reported main advantages of STAR were efficacy in the treatment of arrhythmias not amenable to conventional treatment (49%) and non-invasive treatment approach with overall low expected acute and short-term procedural risk (23%). Most respondents have foreseen a future clinical role of STAR in the treatment of VT/VF with or without underlying SHD (72% and 75%, respectively), although only a minority expected a first-line indication for it (7% and 5%, respectively). Stereotactic arrhythmia radioablation as a novel treatment option of recurrent VT appears to gain acceptance within the cardiology community. Further trials are critical to further define efficacy, patient populations, as well as the appropriate clinical use for the treatment of VT.

Longer and better lives for patients with atrial fibrillation: the 9th AFNET/EHRA consensus conference.

AIMS: Recent trial data demonstrate beneficial effects of active rhythm management in patients with atrial fibrillation (AF) and support the concept that a low arrhythmia burden is associated with a low risk of AF-related complications. The aim of this document is to summarize the key outcomes of the 9th AFNET/EHRA Consensus Conference of the Atrial Fibrillation NETwork (AFNET) and the European Heart Rhythm Association (EHRA). METHODS AND RESULTS: Eighty-three international experts met in Münster for 2 days in September 2023. Key findings are as follows: (i) Active rhythm management should be part of the default initial treatment for all suitable patients with AF. (ii) Patients with device-detected AF have a low burden of AF and a low risk of stroke. Anticoagulation prevents some strokes and also increases major but non-lethal bleeding. (iii) More research is needed to improve stroke risk prediction in patients with AF, especially in those with a low AF burden. Biomolecules, genetics, and imaging can support this. (iv) The presence of AF should trigger systematic workup and comprehensive treatment of concomitant cardiovascular conditions. (v) Machine learning algorithms have been used to improve detection or likely development of AF. Cooperation between clinicians and data scientists is needed to leverage the potential of data science applications for patients with AF. CONCLUSIONS: Patients with AF and a low arrhythmia burden have a lower risk of stroke and other cardiovascular events than those with a high arrhythmia burden. Combining active rhythm control, anticoagulation, rate control, and therapy of concomitant cardiovascular conditions can improve the lives of patients with AF.

Diagnostic Yield and Clinical Implications of Implantable Loop Recorders in Patients with Syncope in Germany: A National Database Analysis.

In patients with unexplained syncope, implantable loop recorders (ILR) are used to detect arrhythmias as a cause of syncope. This study aimed to assess the diagnostic yield and clinical implications arising from ILR implantation in patients with syncope in Germany. Secondary longitudinal data were obtained from a large German research database including anonymized data from nationwide statutory health insurances, representative for the German population. Patients ≥ 18 years with a diagnosis of syncope and ILR implantation between 2017 and 2018 were analyzed, and cardiac diagnoses and therapies during a follow-up period of two years assessed. Of 2,403,301 continuously insured persons in 2017-2018, 1360 (0.1%) received an ILR and 675 patients (45.6% female) were included. During follow-up, arrhythmias were diagnosed in 65.0%. The following antiarrhythmic therapies were established: pacemaker and defibrillator implantations in 20% and 1.5%, respectively, ablation therapy in 3.0%, and antiarrhythmic drug therapy in 4.7%. Aside from the diagnoses typically associated with syncope, atrial fibrillation or flutter was diagnosed in 37.0%, and anticoagulation therapy was initiated in 21.5%. There was a high diagnostic yield of arrhythmias following ILR implantation, leading to a relevant number of syncope-specific treatment. Arrhythmias not necessarily related to syncope were also diagnosed, leading to a high rate of anticoagulation therapy.

The impact of Twitter/X promotion on visibility of research articles: Results of the #TweetTheJournal study.

Aim: Social media (SoMe) are emerging as important tools for research dissemination. Twitter/X promotion has been shown to increase citation rates in well-established journals. We aimed to test the effect of a SoMe promotion strategy on the Mendeley reader counts, the Altmetric Attention Score and the number of citations in an upcoming open-access journal. Methods: The #TweetTheJournal study is a randomized, controlled study. Articles published in seven subsequent issues of the International Journal of Cardiology Heart & Vasculature (April 2021-April 2022) were randomized to a Twitter/X promotion arm (articles were posted four times) and to a control arm (without active posting). Articles with accompanied editorials were excluded. Primary endpoint of the study was Mendeley reader count, secondary endpoints were Altmetric Attention Score and number of citations. Follow-up was one year. Results: SoMe promotion of articles showed no statistically significant difference in Mendeley reader counts or number of citations at one year follow up. SoMe promotion resulted in a statistically significant higher Altmetric Attention Score in the intervention compared to the control group (RR 1.604, 95 % CI 1.024-2.511, p = 0.039). In the overall group, Altmetric Attention Score showed a correlation with Mendeley reader counts (Spearman's ρ = 0.202, p = 0.010) and Mendeley reader counts correlated significantly with number of citations (Spearman's ρ = 0.372, p < 0.001). Conclusion: A dedicated SoMe promotion strategy did not result in statistically significant differences in early impact indicators as the Mendeley reader count in a upcoming journal, but increased the Altmetric Attention Score.

A pilot study for risk stratification of ventricular tachyarrhythmia in hypertrophic cardiomyopathy with routine echocardiography parameters.

Ventricular tachyarrhythmia (VTA) are frequent arrhythmias in patients with hypertrophic cardiomyopathy (HCM). Representing a major risk factor for sudden cardiac death, Holter ECG at first clinical presentation appears insufficient. This study aims to investigate the ability of routinely obtained parameters associated with myocardial remodeling in stratifying for VTA in HCM. In this monocentric analysis, patients with HCM underwent 12-channel electrocardiography and echocardiography, including tissue doppler imaging. The study's primary endpoint was the documentation of non-sustained and sustained ventricular tachycardia-summarized as ventricular tachyarrhythmias (VTA) on Holter ECG or active devices. The occurrence of VTA was exploratory. Based on our collective, we developed a risk model regarding VTA. Of 140 HCM patients, 38 (27.1%) had an episode of VTA. Patients with VTA were likelier to have a history of atrial fibrillation (p < 0.001), a thicker interventricular septum (p < 0.001) and lower peak systolic mitral annular velocity (p < 0.001). The parameters were independently associated with endpoint in univariate and multivariate logistic regression. We created a logistic equation and calculated a cut-off value. The resulting ROC curve revealed a discriminative ability with AUC of 0.80 (sensitivity, 63%; specificity, 88%). Our risk model including these widely available parameters is able to distinguish low and high-risk of VTA in patients with HCM.

[Characterization of atrial fibrillation burden using wearables]. / Charakterisierung der Vorhofflimmerlast mittels Wearables.

The characterization of atrial fibrillation (AF) according to current guidelines categorically refers to the differentiation between paroxysmal, persistent, and permanent AF. A more precise characterization of AF, including the evaluation of AF burden, is playing an increasingly significant role in both scientific research and clinical practice. Digital devices, especially those with the capability of passive (semi-)continuous recording, can contribute to a more accurate quantification of AF burden. Particularly in patients with an already established diagnosis of AF, the evaluation of AF burden can be used to monitor the success of antiarrhythmic therapy including antiarrhythmic drugs or pulmonary vein isolation. However, important questions remain unanswered: In addition to a uniform, evidence-based definition of AF burden, clinically relevant cut-offs for AF burden and resulting therapeutic consequences (e.g., subclinical AF) need to be elaborated. Furthermore, the establishment and evaluation of care structures for assessing and integrating AF burden in clinical care, especially by incorporating data from wearable medical devices, should take place.

Network analysis of the social media activities around the #TeleCheckAF project.

Aims: TeleCheck-AF is a novel remote on-demand mobile health infrastructure around teleconsultations for patients with atrial fibrillation. Social media (SoMe) communication on Twitter contributed to the dissemination of this healthcare innovation by using the hashtag #TeleCheckAF. This study aims to analyse the SoMe network behind #TeleCheckAF and determine the key opinion leaders. Methods and results: Publicly available data on actors and interactions around the hashtag #TeleCheckAF were collected by web scraping from the platform Twitter. With tools based on social network analysis, a social network was created, different communities were identified, and key opinion leaders were determined by their centrality in the network. The SoMe network consisted of 413 086 accounts with 636 502 ties in 22 different communities. A total of 287 accounts that diffused information and/or used the TeleCheck-AF infrastructure were analysed in depth. Those accounts involved users from >15 different countries and multidisciplinary professions. Further, 20 opinion leaders were identified, including four official accounts of societies and associated journals among key opinion leaders. Peaks in #TeleCheckAF tweets were seen after (virtual) conferences and other activities involving national and international cardiology societies. Social network analysis of the TeleCheck-AF Twitter hashtag revealed a wide, multidisciplinary potential reach for the diffusion of a healthcare innovation. Conclusion: Official society SoMe accounts can amplify the dissemination of research findings by featuring abstract presentations during conferences and published manuscripts. This underlines the synergistic effects between traditional and SoMe-based research dissemination strategies for novel healthcare approaches, such as the TeleCheck-AF project.

[Perioperative management for cardiovascular implantable electronic devices]. / Perioperatives Management bei der Versorgung mit aktiven Rhythmusimplantaten.

Cardiovascular implantable electronic devices (CIED) are an important part of modern cardiology and careful perioperative planning of these procedures is necessary. All information relevant to the indication, the procedure, and the education of the patient must be available prior to surgery. This provides the basis for appropriate device selection. Preoperative antibiotic prophylaxis and perioperative anticoagulation management are essential to prevent infection. After surgery, postoperative monitoring, telemetric control, and device-based diagnostics are required before discharge. These processes need to be adapted to the increasing trend towards outpatient care. This review summarises perioperative management based on practical considerations.

Utilization of and perceived need for simulators in clinical electrophysiology: results from an EHRA physician survey.

AIMS: Simulator training has been recently introduced in electrophysiology (EP) programmes in order to improve catheter manipulation skills without complication risks. The aim of this study is to survey the current use of EP simulators and the perceived need for these tools in clinical training and practice. METHODS AND RESULTS: A 20-item online questionnaire developed by the Scientific Initiatives Committee of the European Heart Rhythm Association (EHRA) in collaboration with EHRA Digital Committee was disseminated through the EHRA Scientific Research Network members, national EP groups, and social media platforms. Seventy-four respondents from 22 countries (73% males; 50% under 40 years old) completed the survey. Despite being perceived as useful among EP professionals (81%), EP simulators are rarely a part of the institutional cardiology training programme (20%) and only 18% of the respondents have an EP simulator at their institution. When available, simulators are mainly used in EP to train transseptal puncture, ablation, and mapping, followed by device implantation (cardiac resynchronization therapy [CRT], leadless, and conduction system pacing [CSP]). Almost all respondents (96%) believe that simulator programmes should be a part of the routine institutional EP training, hopefully developed by EHRA, in order to improve the efficacy and safety of EP procedures and in particular CSP 58%, CRT 42%, leadless pacing 38%, or complex arrhythmia ablations (VT 58%, PVI 45%, and PVC 42%). CONCLUSION: This current EHRA survey identified a perceived need but a lack of institutional simulator programme access for electrophysiologists who could benefit from it in order to speed up the learning curve process and reduce complications of complex EP procedures.

Accuracy and comprehensibility of chat-based artificial intelligence for patient information on atrial fibrillation and cardiac implantable electronic devices.

AIMS: Natural language processing chatbots (NLPC) can be used to gather information for medical content. However, these tools contain a potential risk of misinformation. This study aims to evaluate different aspects of responses given by different NLPCs on questions about atrial fibrillation (AF) and clinical implantable electronic devices (CIED). METHODS AND RESULTS: Questions were entered into three different NLPC interfaces. Responses were evaluated with regard to appropriateness, comprehensibility, appearance of confabulation, absence of relevant content, and recommendations given for clinically relevant decisions. Moreover, readability was assessed by calculating word count and Flesch Reading Ease score. 52, 60, and 84% of responses on AF and 16, 72, and 88% on CIEDs were evaluated to be appropriate for all responses given by Google Bard, (GB) Bing Chat (BC) and ChatGPT Plus (CGP), respectively. Assessment of comprehensibility showed that 96, 88, and 92% of responses on AF and 92 and 88%, and 100% on CIEDs were comprehensible for all responses created by GB, BC, and CGP, respectively. Readability varied between different NLPCs. Relevant aspects were missing in 52% (GB), 60% (BC), and 24% (CGP) for AF, and in 92% (GB), 88% (BC), and 52% (CGP) for CIEDs. CONCLUSION: Responses generated by an NLPC are mostly easy to understand with varying readability between the different NLPCs. The appropriateness of responses is limited and varies between different NLPCs. Important aspects are often missed to be mentioned. Thus, chatbots should be used with caution to gather medical information about cardiac arrhythmias and devices.

[Lead extraction in cardiac implantable electronic devices]. / Sondenextraktionen bei implantierbaren kardialen Devices.

Lead extraction due to infection or lead dysfunction has become more important in recent years. Patients with high risk of severe and life-threatening complications should only undergo surgery in experienced centers where appropriate personnel and equipment are available. In this review, different techniques and methods to safely and successfully perform transvenous lead extraction are summarized.

Antiarrhythmic effects of baroreceptor activation therapy in chronic heart failure: a case report.

Background: Autonomic imbalance represents a keystone of chronic heart failure (HF) with substantial clinical and prognostic implications. Baroreceptor activation therapy (BAT) is a new therapeutic strategy to target the autonomic dysbalance by electrical stimulation of carotid baroreceptors. Besides its known beneficial effects on HF parameters, BAT is also supposed to trigger potential antiarrhythmic effects, which may additionally contribute to HF improvement. Case summary: We report on a 70-year-old male with progredient shortness of breath and advanced HF in the context of an extensive cardiovascular history. After optimization of pharmacologic and device-related therapy, the decision was made to implant a BAT system (Barostim Neo, CVRx) to improve functional cardiac parameters and support symptomatic improvement. Implantation was associated with an overall clinical improvement assessed during outpatient visits every 6 months. Frequency of ventricular arrhythmic events declined, and atrial fibrillation ceased spontaneously. Echocardiography revealed an amelioration in left ventricular systolic function. Numbers of HF hospitalization decreased after Barostim implantation. Discussion: We present a patient with an extensive cardiovascular history and fully exploited pharmacologic and device-related therapy, who showed improvement in New York Heart Association (NYHA) functional classification, left ventricular systolic function, and reduction of arrhythmic events following implantation of the BAT device. This case presents an additional positive potential of BAT for HF patients in terms of reduction of arrhythmia burden. These results should be confirmed by further clinical trials.

Improving mental well-being in psychocardiology-a feasibility trial for a non-blended web application as a brief metacognitive-based intervention in cardiovascular disease patients.

Background: Many patients with cardiovascular disease also show a high comorbidity of mental disorders, especially such as anxiety and depression. This is, in turn, associated with a decrease in the quality of life. Psychocardiological treatment options are currently limited. Hence, there is a need for novel and accessible psychological help. Recently, we demonstrated that a brief face-to-face metacognitive therapy (MCT) based intervention is promising in treating anxiety and depression. Here, we aim to translate the face-to-face approach into digital application and explore the feasibility of this approach. Methods: We translated a validated brief psychocardiological intervention into a novel non-blended web app. The data of 18 patients suffering from various cardiac conditions but without diagnosed mental illness were analyzed after using the web app over a two-week period in a feasibility trial. The aim was whether a non-blended web app based MCT approach is feasible in the group of cardiovascular patients with cardiovascular disease. Results: Overall, patients were able to use the web app and rated it as satisfactory and beneficial. In addition, there was first indication that using the app improved the cardiac patients' subjectively perceived health and reduced their anxiety. Therefore, the approach seems feasible for a future randomized controlled trial. Conclusion: Applying a metacognitive-based brief intervention via a non-blended web app seems to show good acceptance and feasibility in a small target group of patients with CVD. Future studies should further develop, improve and validate digital psychotherapy approaches, especially in patient groups with a lack of access to standard psychotherapeutic care.

Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association.

AIMS: Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era. METHODS AND RESULTS: An online survey consisting of 27 multiple-choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of pacemakers (PMs), 10.4% of implantable cardioverter defibrillators (ICDs), and 10.2% of cardiac resynchronization therapy (CRT) devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs, and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% of left-sided ablations, and 17.5% of right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs, and 56.9% of CRT devices and for 54.5% of AF ablations, 42.2% of right-sided ablations, and 46.1% of left-sided ablations. Reimbursement (43-56%) and bed availability (20-47%) were reported to have no consistent impact on the organization of elective procedures. CONCLUSION: There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement nor bed availability consistently influenced LOS.

Antiplatelet and Anti-Coagulation Therapy for Left-Sided Catheter Ablations: What Is beyond Atrial Fibrillation?

Aim: International guidelines on the use of anti-thrombotic therapies in left-sided ablations other than atrial fibrillation (AF) are lacking. The data regarding antiplatelet or anticoagulation strategies after catheter ablation (CA) procedures mainly derive from AF, whereas for the other arrhythmic substrates, the anti-thrombotic approach remains unclear. This survey aims to explore the current practices regarding antithrombotic management before, during, and after left-sided endocardial ablation, not including atrial fibrillation (AF), in patients without other indications for anti-thrombotic therapy. Material and Methods: Electrophysiologists were asked to answer a questionnaire containing questions on antiplatelet (APT) and anticoagulation therapy for the following left-sided procedures: accessory pathway (AP), atrial (AT), and ventricular tachycardia (VT) with and without structural heart disease (SHD). Results: We obtained 41 answers from 41 centers in 15 countries. For AP, before ablation, only four respondents (9.7%) used antiplatelets and two (4.9%) used anticoagulants. At discharge, APT therapy was prescribed by 22 respondents (53.7%), and oral anticoagulant therapy (OAC) only by one (2.4%). In patients with atrial tachycardia (AT), before ablation, APT prophylaxis was prescribed by only four respondents (9.7%) and OAC by eleven (26.8%). At discharge, APT was recommended by 12 respondents (29.3%) and OAC by 24 (58.5%). For VT without SHD, before CA, only six respondents (14.6%) suggested APT and three (7.3%) suggested OAC prophylaxis. At discharge, APT was recommended by fifteen respondents (36.6%) and OAC by five (12.2%). Regarding VT in SHD, before the procedure, eight respondents (19.5%) prescribed APT and five (12.2%) prescribed OAC prophylaxis. At discharge, the administration of anti-thrombotic therapy depended on the LV ejection fraction for eleven respondents (26.8%), on the procedure time for ten (24.4%), and on the radiofrequency time for four (9.8%), with a cut-off value from 1 to 30 min. Conclusions: Our survey indicates that the management of anti-thrombotic therapy surrounding left-sided endocardial ablation of patients without other indications for anti-thrombotic therapy is highly variable. Further studies are necessary to evaluate the safest approach to these procedures.

Electrophysiology fellowship experience and requirements: an EHRA survey.

AIMS: This study aims to survey current educational experience and the individual requirements for electrophysiologists in training. METHODS AND RESULTS: The European Heart Rhythm Association (EHRA) e-Communication Committee and the Scientific Initiatives Committee prepared a questionnaire and distributed it via newsletters, Twitter, LinkedIn, and Facebook. The survey consisted of 22 questions collected on an individual basis anonymously. Two hundred and forty-three responders from 35 countries (32% female, age 38 ± 6 years old) completed the survey. This EHRA electrophysiology (EP) fellowship survey showed that (i) hands-on participation and observation of EP procedures are very important; (ii) the main motivations to choose the EP fellowship institution are centre reputation and volume as well as the availability of a structured EP fellowship programme; (iii) 59% passed the EHRA exam and 46% took a national certification exam; (iv) respondents are overall satisfied with their own fellowships, but there are areas of less confidence such as conduction system pacing implantation and cardiac resynchronization therapy implantation; (v) 78% of respondents performed research during their fellowship, (vi) the optimal duration of an EP fellowship should be at least 2 years; and (viii) doing fellowships abroad is beneficial, but significant obstacles exist. CONCLUSION: The results of this EHRA survey may help to refine current EP fellowship programmes to improve the quality of EP training and early career building of young electrophysiologists.

Performance and feasibility of three different approaches for computer based semi-automated analysis of ventricular arrhythmias in telemetric long-term ECG in cynomolgus monkeys.

Computer-based analysis of long-term electrocardiogram (ECG) monitoring in animal models represents a cost and time-consuming process as manual supervision is often performed to ensure accuracy in arrhythmia detection. Here, we investigate the performance and feasibility of three ECG interval analysis approaches A) attribute-based, B) attribute- and pattern recognition-based and C) combined approach with additional manual beat-to-beat analysis (gold standard) with regard to subsequent detection of ventricular arrhythmias (VA) and time consumption. ECG analysis was performed on ECG raw data of 5 male cynomolgus monkeys (1000 h total, 2 × 100 h per animal). Both approaches A and B overestimated the total number of arrhythmias compared to gold standard (+8.92% vs. +6.47%). With regard to correct classification of detected VA event numbers (accelerated idioventricular rhythms [AIVR], ventricular tachycardia [VT]) approach B revealed higher accuracy compared to approach A. Importantly, VA burden (% of time) was precisely depicted when using approach B (-1.13%), whereas approach A resulted in relevant undersensing of ventricular arrhythmias (-11.76%). Of note, approach A and B could be performed with significant less working time (-95% and - 91% working time) compared to gold standard. In sum, we show that a combination of attribute-based and pattern recognition analysis (approach B) can reproduce VA burden with acceptable accuracy without using manual supervision. Since this approach allowed analyses to be performed with distinct time saving it represents a valuable approach for cost and time efficient analysis of large preclinical ECG datasets.

The digital journey: 25 years of digital development in electrophysiology from an Europace perspective.

AIMS: Over the past 25 years there has been a substantial development in the field of digital electrophysiology (EP) and in parallel a substantial increase in publications on digital cardiology.In this celebratory paper, we provide an overview of the digital field by highlighting publications from the field focusing on the EP Europace journal. RESULTS: In this journey across the past quarter of a century we follow the development of digital tools commonly used in the clinic spanning from the initiation of digital clinics through the early days of telemonitoring, to wearables, mobile applications, and the use of fully virtual clinics. We then provide a chronicle of the field of artificial intelligence, a regulatory perspective, and at the end of our journey provide a future outlook for digital EP. CONCLUSION: Over the past 25 years Europace has published a substantial number of papers on digital EP, with a marked expansion in digital publications in recent years.

Utilization of 3D mapping systems in interventional electrophysiology and its impact on procedure time and fluoroscopy-Insights from the "Go for Zero Fluoroscopy" project.

AIM: The implementation of 3D mapping systems plays an important role in interventional electrophysiology (EP) in recent years. The aim of the present study was to evaluate use of 3D mapping systems regarding fluoroscopy and procedure duration. METHOD: In the "Go for Zero Fluoroscopy" project 25 European centers provided data of consecutive EP procedures. Data on use of 3D mapping systems as well as utilization of contact force catheters and multipolar mapping catheters were associated with fluoroscopy time, dose area product (DAP), and procedure duration. RESULT: A 3D mapping system was used in 966 (54%) cases. Use of 3D mapping for atrioventricular nodal reentry tachycardia (AVNRT) was associated with reduced fluoroscopy time (p < 0.001), DAP (p = 0.04) but increased procedure time (p = 0.029). Moreover, fluoroscopy time (p < 0.001) and DAP (p = 0.005) were significantly lower in the 3D mapping group in ablation of typical atrial flutter. However, the procedure time (p < 0.001) increased. Use of 3D mapping in the ablation of accessory pathway (AP) was associated with reduced fluoroscopy time (p < 0.001) and DAP (p < 0.001) with no significant increase in procedure time (p = 0.066). In the case of atrial fibrillation, a 3D mapping system was used in 485 patients (75.8%). Additional use of a contact force catheter was associated with lower fluoroscopy time (p < 0.001) and DAP (p < 0.001). Use of a multipolar mapping catheter was associated with lower fluoroscopy time (p = 0.002). The implementation of 3D mapping systems in the ablation of ventricular tachycardias resulted in a significant increase in the procedure time (p = 0.001) without significant differences regarding the DAP (p = 0.773) and fluoroscopy time (p = 0.249). CONCLUSION: Use of 3D mapping systems in ablation of supraventricular tachycardias is associated with lower radiation exposure. Nevertheless, the procedure time often increases, except in the case of ablation for AP. Use of contact force catheters and multipolar mapping catheters is associated with yet lower radiation exposure values. Prospective randomized studies are needed to further elucidate potential benefit of these technological tools.