Background: Intracardiac echocardiography (ICE) is increasingly used during left atrial appendage occlusion (LAAO) as an alternative to transesophageal echocardiography (TEE) Aim: To evaluate the impact of ICE vs. TEE guidance during LAAO on procedural characteristics and acute outcomes, as well the presence of peri-device leaks and residual septal defects during follow-up. Methods: All studies comparing ICE-guided vs. TEE-guided LAAO were identified. The primary outcomes were procedural efficacy and occurrence of procedure-related complications. Secondary outcomes included lab efficiency (defined as a reduction in in-room time), procedural time, fluoroscopy time, and presence of peri-device leaks and residual interatrial septal defects (IASD) during follow-up. Results: Twelve studies (n=5637) were included. There were no differences in procedural success group (98.3% vs. 97.8%; OR 0.73, 95% CI 0.42-1.27, p=0.27; I2=0%) or adverse events (4.5% vs. 4.4%; OR 0.81 95% CI 0.56-1.16, p=0.25; I2=0%) between the ICE-guided and TEE-guided groups. ICE guidance reduced in in-room time (mean-weighted 28.6-minute reduction in in-room time) without differences in procedural time or fluoroscopy time. There were no differences in peri-device leak (OR 0.93, 95% CI 0.68-1.27, p=0.64); however, an increased prevalence of residual IASD was observed with ICE-guided vs. TEE-guided LAAO (46.3% vs. 34.2%; OR 2.23, 95% CI 1.05-4.75, p=0.04). Conclusion: ICE guidance is associated with similar procedural efficacy and safety, but could result in improved lab efficiency (as established by a significant reduction in in-room time). No differences in the rate of periprocedural leaks were found. A higher prevalence of residual interatrial septal defects was observed with ICE guidance.

Introduction: Some patients suffer recurrent syncope following cardioneuroablation (CNA) for vasovagal syncope (VVS), yet no cases of repeat CNA have been described in detail. Methods and Results: Our present patient suffered a recurrence seven months following successful CNA and wished for a repeat CNA. Pre-procedurally, she lacked an atropine response. During CNA, high-frequency stimulation (HFS) at ganglionated plexi (GP) would not trigger cardioinhibitory events. Ablation was delivered based on anatomy and fractionation mapping, producing characteristic tachycardia at 2 GP sites. Conclusion: Repeat CNA is feasible and safe, and characterized by unique physiology.

Lamin Cardiomyopathy (LC) is associated with refractory ventricular arrhythmias. Catheter ablation success rate is low due to presence of multiple circuits and intramural substrate. We present a LC case presented with electrical storm. During catheter ablation, arrhythmia was easily inducible but activation mapping, including full epicardial and endocardial mapping, failed to demonstrate the full tachycardia cycle length (70% only) suggesting intramural activation. Critical isthmus was not identified even with successful concealed entrainment on both Endo/epicardial surfaces. This case shows that even combined endocardial and epicardial catheter approach can be ineffective in identifying the full arrhythmogenic substrate in LC.

Background: Atrial fibrillation (AF) genetics studies have focused on a linear genotype- phenotype relationship, i.e. genetic predisposition to the arrhythmia. Genome wide association studies have implicated numerous upstream mechanisms responsible for AF. Objective: We hypothesized that the genetic predisposing factors for AF might be associated with non-AF clinical phenotypes and sought to characterize electrophysiology parameters as a function of AF genetic risk. Methods:. Biosamples were obtained from 405 subjects for classification of carrier status at 12 single nucleotide polymorphisms with a known association to AF allowing calculation of a validated AF genetic risk score. We then analyzed subgroups within the total population; in order to understand the effect on (a) sinus node function and cardiac conduction (b) primary atrial flutter (c) left atrial appendage morphology. Results: We evaluated 405 patients consisting of a range of genetic risk scores from −1.016 to +2.178. Within this, we identified 86 patients without prescribed chronotropic pharmacotherapy with a 24-hour Holter recording to investigate sinus node function; 181 patients with invasive H-V measurement at the time of electrophysiologic study to investigate cardiac conduction; 78 undergoing cavotricuspid isthmus ablation for typical atrial flutter without prior diagnosis of AF; and 284 patients with cardiac imaging of the left atrial appendage. Conclusions: A common AF genetic risk score is associated with a number of non-AF electrophysiologic relevant phenotypes. Sinus node function, AV node physiology, post flutter ablation AF risk, atrial appendage morphology all appear to be associated with the common genetic AF risk.