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Atrial Fibrillation (AF) is the most common arrhythmia in adults, and the rapid increase in AF prevalence has been classified by experts as an epidemic. The mechanisms of AF are complex and incompletely understood. While many aspects of management are now based on high quality evidence, other clinical decisions are based on experience and judgment. This article provides an up to date review relating to lifestyle modification and its effect on AF to inform clinical treatment. This comprehensive review used PubMed and Google Scholar to perform keyword searches of articles published between 1998 and the present, with the exception of the 1978 “Holiday Heart” article. Robust data has emerged identifying multiple risk factors for development of AF, including age, sex, hypertension, diabetes mellitus, obesity, alcohol consumption, exercise, and obstructive sleep apnea. Recent evidence indicates that lifestyle modification has a significant role in mitigating the risk and burden of AF. In conclusion, based on the available evidence, an interdisciplinary approach to lifestyle modification will likely reduce risk and/or symptom burden of AF.

Purpose of review This review discusses the role of radiofrequency (RF) catheter ablation for the treatment of cardiac arrhythmias and how recent advances in the understanding of RF biophysics have increased procedural safety and efficacy. Recent findings For the treatment of atrial arrhythmias, strategies that can achieve transmural lesions while avoiding collateral injury to neighboring structures are essential. Advancements such as contact force sensing, high-power short-duration RF application, ablation lesion indices, and esophageal protection have improved the safety and efficacy of catheter ablation in the atrium. In contrast to atrial arrhythmias, substrate in ventricular myocardium is often deep and may be surrounded by fibrosis, fat, and calcified scar, which can impair delivery of RF and prevent adequate lesion formation. Understanding RF biophysics allows the operator to optimize energy delivery to create deeper and larger lesions. Strategies such as RF delivery with careful power titration, high impedance irrigants, bipolar ablation, and needle intramyocardial ablation with the SERF system allow successful treatment of ventricular arrhythmias that are refractory to conventional approaches. Summary Advancements in the understanding of RF biophysics continue to be fundamental to the evolution of the treatment of cardiac arrhythmias.

In vitro models to evaluate cardiac pulsed field ablation (PFA) have not been well established. We sought to create a standardized vegetable model and staining protocol for assessing unipolar PFA using a surface electrode. We exposed potato slabs to unipolar PFA in a saline bath using a 3.5 mm electrode catheter and grounding pad connected to a custom-built high-voltage generator. Lesions were clearly visualized after staining with 2,3,5-triphenyltetrazolium chloride (TTC) using a timed protocol to reveal a necrotic center and a periphery of electroporated cells with intact mitochondria. Lesion volume increased linearly with increasing voltage and logarithmically with repetitive PFA applications. The findings observed in this vegetable model using a TTC staining protocol are consistent with findings observed with cardiomyocytes.

Background Left bundle branch area pacing (LBBAP) has emerged as a physiological alternative pacing strategy to biventricular pacing (BIVP) in cardiac resynchronization therapy (CRT). We aimed to assess the impact of LBBAP vs. BIVP on all-cause mortality and heart failure (HF)-related hospitalization in patients undergoing CRT. Methods Studies comparing LBBAP and BIVP for CRT in patients with HF with reduced left ventricular ejection fraction (LVEF) were included. The coprimary outcomes were all-cause mortality and HF-related hospitalization. Secondary outcomes included procedural and fluoroscopy time, change in QRS duration, and change in LVEF. Results Thirteen studies (12 observational and 1 RCT, n  = 3239; LBBAP = 1338 and BIVP = 1901) with a mean follow-up duration of 25.8 months were included. Compared to BIVP, LBBAP was associated with a significant absolute risk reduction of 3.2% in all-cause mortality (9.3% vs 12.5%, RR 0.7, 95% CI 0.57–0.86, p  < 0.001) and an 8.2% reduction in HF-related hospitalization (11.3% vs 19.5%, RR 0.6, 95% CI 0.5–0.71, p  < 0.00001). LBBAP also resulted in reductions in procedural time (mean weighted difference− 23.2 min, 95% CI − 42.9 to − 3.6, p  = 0.02) and fluoroscopy time (− 8.6 min, 95% CI − 12.5 to − 4.7, p  < 0.001) as well as a significant reduction in QRS duration (mean weighted difference:− 25.3 ms, 95% CI − 30.9 to − 19.8, p  < 0.00001) and a greater improvement in LVEF of 5.1% (95% CI 4.4–5.8, p  < 0.001) compared to BIVP in the studies that reported these outcomes. Conclusion In this meta-analysis, LBBAP was associated with a significant reduction in all-cause mortality as well as HF-related hospitalization when compared to BIVP. Additional data from large RCTs is warranted to corroborate these promising findings. Graphical abstract LBBP, left bundle branch area pacing; BIVP, biventricular pacing; RRR, relative risk reduction; ARR, absolute risk reduction; ms, milliseconds; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; min, minutes

Cardiac implantable electronic device (CIED) infections represent one of the most threatening complications associated with device implantation, due to an increase in morbidity and mortality rates, as well as healthcare costs. Besides, it is important to highlight that when compared to the initial implantation of a device, the risks associated with procedures like generator changes, lead and pocket revisions, or device upgrades double. Consequently, to address this issue, various scoring systems, like the PADIT (Prior Procedures, Age, Depressed Renal Function, Immunocompromised Status, Type of Procedure), the RI-AIAC (Ricerca Sulle Infezioni Associate a ImpiAnto o Sostituzione di CIED), and the Shariff score, along with predictive models, have been developed to identify patients at a greater risk of infection. Moreover, several interventions have been assessed to evaluate their role in infection prevention ranging from improving skin preparation and surgical techniques to considering alternative strategies such as the subcutaneous Implantable Cardioverter-Defibrillator (ICD). Methods like antimicrobial prophylaxis, pocket irrigation, chlorhexidine gluconate pocket lavage, capsulectomy, and the use of antibacterial envelopes have been also explored as preventive measures. In this review, we provide a comprehensive assessment of CIED infections in patients undergoing repeat procedures and the strategies designed to reduce the risk of these infections.

Background Focal atrial tachycardias (ATs) represent 5–15% of sustained supraventricular tachycardias (SVTs). Characteristic distribution of sites of origin and detailed electrophysiologic characterization of AT from specific sites of origin (SOO) have been described. Acute success and recurrence are less favorable than for other SVTs. In this series, we present our experience of focal AT ablation over a 10-year period. Methods We undertook a retrospective review of an electronically maintained database of all patients undergoing AT ablation at our institution between January 2011 and December 2020. Demographic, procedural, and outcomes data were reviewed. Results A total of 293 distinct atrial tachycardias were treated during 279 procedures in 256 patients, including 207 first AT ablations. Acutely successful AT suppression was achieved in 91% of first-time ablations. Acute success was dependent on SOO of AT with lowest rates of acute suppression in the para-Hisian region and the crista terminalis (CT). The most common reason for failure to acutely suppress the AT was proximity to a critical structure (phrenic nerve, sinus node, and AV node). 8.9% of patients in this series presented with a tachycardia-mediated cardiomyopathy (TCM). 48% of TCM patients underwent an ablation attempt during an acute medical admission. Among the TCM group, median LV ejection fraction increased from 25% (range 10–50%) to 55% (range 35–65%) with successful treatment of AT. Five patients undergoing a repeat procedure had planned pericardial access for displacement of the phrenic nerve to permit ablation of the AT, which was successful in all cases. Among patients without a pre-existing diagnosis of AF, peri-procedural AF was not associated with a higher incidence of a subsequent diagnosis of AF (odds ratio 1.169, 95% CI 0.4058–3.475, p  = 0.7628). Median duration of follow-up was 832 days. By Kaplan–Meier estimate, recurrence-free survival was 78% (95% CI 67–88%). Conclusions In this series, focal AT ablation is associated with good acute results and a low rate of complications, but outcomes remain less favorable than previously reported for other forms of SVT.

Pulmonary arterial hypertension (PAH) is a rare, progressively worsening disease characterized by dysfunction among endothelial and smooth muscle cells within the pulmonary vasculature with a resultant increase in pulmonary vascular resistance, right ventricular maladaptation and failure, and ultimately early death. The three major therapeutic classes of medications available to treat PAH act as either prostacyclin analogs or endothelin receptor antagonists (ERAs) or by increasing local nitric oxide (NO) levels by means of phosphodiesterase type 5 inhibitors. Several recent trials have investigated the use of oral prostanoid therapy, next-generation ERAs, and soluble guanylate cyclase stimulators (to increase NO levels) as well as novel formulations of pre-existing therapies. The goal of this manuscript is to briefly review established therapies and then discuss recent developments and practical considerations in each of the major drug classes.