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Background To assess the safety and efficacy of dabigatran-based triple antithrombotic (TAT) regimen in patients after percutaneous coronary intervention (PCI) with atrial fibrillation (AF). Methods A multicenter, open-label, randomized controlled trial across 50 Chinese hospitals enrolled nonvalvular AF patients after coronary stenting. Participants were randomly assigned to receive dabigatran (110 mg twice/daily) or warfarin-based TAT regimen (dabigatran or warfarin with aspirin and clopidogrel) for 1 month and then convert to dual antithrombotic therapy (dabigatran or warfarin with clopidogrel) for 6 months. The primary safety endpoint was the first occurrence of clinically relevant bleeding (BARC types 2–5). Secondary endpoints included net adverse clinical events (NACEs) and major or clinically relevant non-major bleeding (CRNB). And the efficacy endpoint was the major adverse cardiac and cerebral events (MACCEs). Results The study was terminated early due to COVID-19 impacting recruitment. A total of 540 patients were enrolled. BARC types 2–5 bleeding occurred in 8.0% and 4.3% of patients in warfarin and dabigatran groups, respectively (HR 0.54; 95% CI 0.26–1.09; P  = 0.0861). And total bleeding events (BARC 1–5) were 20.5% and 9.4% (HR 0.44; 95% CI 0.27–0.70; P  = 0.0005). Dabigatran showed a lower total bleeding risk than warfarin, with similar risks for BARC types 2–5 bleeding, NACEs, CRNB, major bleeding, and MACCEs. Conclusions Among AF patients underwent PCI, the dabigatran-based TAT regimen did not significantly reduce the rate of BARC types 2–5 bleeding at 6 months compared with warfarin-based regimen, although the power of the study to find a difference was low due to early termination (COACH-PCI, NCT03536611, https://clinicaltrials.gov/show/NCT03536611 ).

Background and objectiveThis study aimed to assess the efficacy and safety of “one-stop” procedures that combined radiofrequency catheter ablation and left atrial appendage closure (LAAC) with the Watchman device under the guidance of intracardiac echocardiography (ICE) vs. transesophageal echocardiography (TEE) in patients with atrial fibrillation.Methods and resultsIn this study, we prospectively enrolled patients who underwent “one-stop” procedures under the guidance of ICE ( n  = 193, 109 men, 65.02 ± 8.47 years) or TEE ( n  = 109, 69 men, 64.23 ± 7.75 years) between January 2021 and October 2022. Intraprocedural thrombus formation in the left atrial appendage (LAA) was observed in 3 (1.46%) patients in the ICE group and 15 (11.63%) patients in the TEE group ( P  < 0.05) before LAAC. Total fluoroscopy time and dose in the ICE group were less than those in the TEE group. The total “one-stop” turnaround time and LAAC procedure time in the ICE group were significantly shorter than those in the TEE group ( P  < 0.05). Postoperative esophagus discomfort, nausea and vomiting, and hypotension were more often seen in the TEE group ( P  < 0.001). There was no significant difference in matched cases between ICE and fluoroscopy measurements ( P  = 0.082). The TEE results related to LAAC and clinical events were similar between the two groups during the follow-up ( P  > 0.05).ConclusionThe ICE-guided “one-stop” procedure was safe and feasible with less radiation exposure, shorter turnaround time, and fewer complications and intraoperative thrombus formations than the TEE group. ICE offered accurate measurements in the LAA dimension during LAAC. Echocardiography during the “one-stop” procedures was necessary to rule out the intraoperative thrombus.

A new catheter (the QDOT-MICRO catheter) is used for high-power short duration (vHPSD) ablation. This study aimed to optimize lesion formation in QMODE+ ablation (using QDOT-MICRO catheter) by clarifying effects of key parameters and developing impedance-adapted strategies. Radio frequency (RF) ablation was performed on excised porcine myocardium with QDOT-MICRO catheter under QMODE+ ablation mode. Parameters included contact force (CF), power, RF duration, interlesion distance, contact angle, and impedance. The optimal parameter was determined, and adjustments for consistent lesion formation across varying impedances were investigated. In QMODE+ ablation mode, lesion size (surface width and depth) increased with higher CF, longer RF duration, and greater power, but decreased as impedance elevated. However, lesions became smaller when CF exceeded 25 g, due to rapid temperature drops from the QMODE+ temperature control system. Perpendicular contact resulted in greater lesion depth compared to parallel contact. An interlesion distance of 5 mm was used as an experimentally evaluated reference condition and produced continuous lesions without excessive overlap. For impedance adjustments, 80 W/3 s, 80 W/4 s, and 90 W/3 s at 90Ω under QMODE+ ablation mode produced lesions comparable to those at 120Ω; when the impedance was high at 150Ω, switching to QMODE ablation mode with AI = 400/420 achieved similar lesion characteristics comparable to those at 120Ω. Routine QMODE+ ablation with 90 W power, 4 s RF duration, catheter CF < 25 g, 5 mm interlesion distance (reference in this model), and perpendicular contact achieves optimal lesion formation. To ensure consistent damage across different impedances, adjust QMODE+ parameters at low impedance and switch to QMODE at high impedance. Parallel contact could be preferred at fragile sites or under low impedance to reduce lesion depth and avoid over-damage.

(1) Background: Atrial scars play an important role in atrial tachycardia (AT). They can not only be found in patients with prior cardiac surgery (PCS) but also in patients without PCS or significant structural heart disease, in which case the scar is called a spontaneous scar (SS). This study aims to compare the characteristics, mechanisms and ablation outcomes of AT in patients with PCS and SS. (2) Methods: We retrospectively reviewed electrophysiological and ablative characteristics of ATs in 46 patients with PCS and 18 patients with SS. (3) Results: There were averages of 1.52 and 2.33 ATs per patient in the PCS group and SS group, respectively (p < 0.01). Cavo-tricuspid isthmus dependent atrial flutter (CTI-AFL) was presented in most patients in both groups (93.50% vs. 77.80%, p = 0.17), whereas the SS group had a higher occurrence of scar-mediated reentrant AT (SMAT) and focal AT (FAT) compared with the PCS group (88.90% vs. 39.10%, p < 0.01; 22.2% vs. 2.2%, p < 0.05). There were no significant differences in acute success rate between the two groups, whereas patients with SS had lower long-term success rate (87.0% vs. 61.1%, p < 0.05) and higher occurrence of sinus node dysfunction (SND) (4.3% vs. 22.2%, p < 0.05). (4) Conclusions: CTI-AFL is common in both patients with PCS and SS, and routine CTI ablation is recommended. Compared with patients with PCS, patients with SS have more ATs, especially with higher occurrence of SMAT and FAT, and had a lower long-term success rate and higher incidence of SND.

The study aims to investigate the impact of key parameters of pulsed field ablation (PFA) on lesion depth, including voltage (V), pulse width (PW), number of pulses (P), and ablation number (N), using potato models. Potatoes are utilized as a display of the irreversible electroporation lesion. The key ablation parameters were varied systematically to explore its influences on lesion depths. The key ablation parameters have varying degrees of influence on lesion depths, following the order of PW>V; V>P; PW>P; N>P. Lesion depths increased with higher values of V and P. However, when the total number of pulses reached 9,600, there was no significant increase in injury depth.

Background. Bachmann’s bundle (BB) is the main pathway of interatrial connection that could be involved in the development of atrial fibrillation (AF). Based on this hypothesis, we raised a novel ablation strategy, BB modification in addition to circumferential pulmonary vein isolation (CPVI-BB) in patients with AF. Methods. A retrospective cohort of patients with AF who underwent CPVI-BB or CPVI alone from March 2018 to July 2021 was enrolled in our study. Propensity score matching was performed in patients with paroxysmal AF and persistent AF, respectively, to reduce the risk of selection bias between the treatment strategies (CPVI-BB or CPVI alone). The primary endpoint was overall freedom from atrial arrhythmia recurrence through 12 months of follow-up. Results. Our propensity score-matched cohort included 82 patients with paroxysmal AF (CPVI group: n = 41; CPVI-BB group: n = 41) and 168 patients with persistent AF (CPVI group: n = 84; CPVI-BB group: n = 84). Among patients with persistent AF, one-year freedom from atrial arrhythmia recurrence rate was 83.3% in the CPVI-BB group and 70.2% in the CPVI group (log-rank P = 0.047). Among patients with paroxysmal AF, no significant difference was found in the primary endpoint between two groups (85.4% in the CPVI-BB group vs. 80.5% in the CPVI group; log-rank P = 0.581). In addition, procedure-related complications and recurrence of atrial tachycardia or atrial flutter were similar between the two treatment groups, regardless of the type of AF. Conclusions. BB modification in addition to CPVI is an effective approach in increasing the maintenance of sinus rhythm in patients with persistent AF, while it does not improve the clinical outcomes of radiofrequency catheter ablation in patients with paroxysmal AF.

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

Background. Catheter ablation failure poses a clinical challenge for epicardial or intramural ventricular arrhythmia (VA); however, guidewire ablation within the coronary venous system (CVS) may be effective and safe for targeting VAs. Methods. The ex vivo phase included four steps. In step 1, the steam pop incidence rates during guidewire ablation at power settings of 5, 10, 15, 20, and 25 W were analyzed using 10 mm- and 20 mm-tip guidewires. In step 2, guidewire ablation was performed for application durations of 10, 20, 30, 40, 50, 60, and 90 s, and the lesion size was measured. In step 3, the effects of saline infusion (0, 1, 2, 3, and 4 mL/min) on lesion dimensions and steam pop formation were examined. In step 4, an orthogonal array was constructed to obtain the optimal guidewire ablation parameters. In the in vivo phase, guidewire ablation within the CVS was performed in three dogs, and the lesion features in 10 days after ablation were observed. Results. In step 1, the steam pop incidence rates at 5, 10, 15, 20, and 25 W were 0%, 0%, 12.5%, 62.5%, and 100% using the 10 mm-tip guidewires and 0%, 0%, 0%, 25%, and 75% using the 20 mm-tip guidewires, respectively. In step 2, we found that the lesion areas increased with an increase in the ablation duration (the maximum lesion diameters at 30, 60, and 90 s were 4.9 ± 0.4, 7.0 ± 0.8, and 9.2 ± 0.7 mm in the 10 mm group and 3.2 ± 0.5, 4.5 ± 0.4, and 5.3 ± 0.7 mm in the 20 mm-tip group, respectively). In step 3, we observed that saline infusion was negatively correlated with ablation lesions but had a lower risk of steam pop. The optimal parameters for the 20 mm-tip guidewire ablation were 15 W, 50 s, and 2 mL/min or 20 W, 70 s, and 2 mL/min. In the in vivo phase, effective ablation lesions with maximum and minimum diameters of 3.2 ± 0.3 and 2.8 ± 0.5 mm, respectively, were created by the guidewires during the 10-day observation period after ablation. Conclusion. This novel radiofrequency guidewire ablation technique can feasibly create effective lesions within the CVS, which may improve the efficacy of catheter ablation for challenging epicardial or intramural VA.

Pulmonary vein isolation with wide antral ablation leads to better clinical outcomes for the treatment of atrial fibrillation, but the isolation lesion is invisible in conventional cryoballoon ablation. In this study, we aim to investigate the efficacy of the wide pulmonary vein isolation technique that includes the intervenous carina region, guided by high-density mapping, compared with pulmonary vein isolation alone without the mapping system. We conducted a propensity score-matched comparison of 74 patients who underwent a wide cryoballoon ablation guided by high-density mapping (mapping group) and 74 controls who underwent conventional cryoballoon ablation in the same period (no-mapping group). The primary outcome was a clinical recurrence of documented atrial arrhythmias for >30 s during the 1-year follow-up. Of 74 patients in the mapping group, residual local potential in the pulmonary vein antrum was found in 30 (40.5%) patients, and additional cryothermal applications were performed to achieve a wide pulmonary vein isolation. Compared with the no-mapping group, the use of the mapping system in the mapping group was associated with a longer fluoroscopic time (26.97 ± 8.07 min vs. 23.76 ± 8.36 min,  = 0.023) and greater fluoroscopic exposure [339 (IQR181-586) mGy vs. 224 (IQR133-409) mGy,  = 0.012]. However, no significant differences between the two groups were found in terms of procedural duration and left atrial dwell time (104.10 ± 18.76 min vs. 102.45 ± 21.01 min,  = 0.619; 83.52 ± 17.01 min vs. 79.59 ± 17.96 min,  = 0.177). The rate of 12-month freedom from clinical atrial arrhythmia recurrence was 85.1% in the mapping group and 70.3% in the no-mapping group (log-rank  = 0.029). Voltage and pulmonary vein potential mapping after cryoballoon pulmonary vein isolation can identify residual potential in the pulmonary vein antrum, and additional cryoablation guided by mapping leads to improved freedom from atrial arrhythmias compared with conventional pulmonary vein isolation without the mapping system. ChiCTR2200064383.