Background Provide a brief overview of recent technological advances that can potentially give information for treatment of different kind of arrhythmias. Methods In this report, we describe the features of Omnipolar technology (OT) using high density mapping catheter and we report five different scenario in which this new tool can give some important information to understand arrhythmia’s substrate and guide the treatment. OT combine three unipolar and two bipolar signals and provides maximum voltage regardless of electrode-wavefront orientation, local wavefront activation direction and local measurements of wave speed: it allow to create a velocity map. Results OT has been used to study different types of supraventricular tachycardias. Regarding reentry tachycardias, velocity map has allowed the characterization and definition of the impulse velocity along the dual nodal pathway and the accessory pathways (AP). As regards atrial flutter, it has successfully allowed the definition of the slowest zone of the critical isthmus and radiofrequency (RF) delivery at that point resulted in termination of the arrhythmia. During mapping of the left atrium in sinus rhythm, the velocity map allowed the identification of the course of the Bachmann’s bundle, which could potentially play a role during the ablation of persistent atrial fibrillation (AF). Conclusion OT and velocity map offer significant advantages in the management of challenging arrhythmias, and can potentially improve the efficacy of the treatment of some arrhythmias such as atrial flutter and AF.

Introduction: Recently, a novel non-thermal ablation modality, Pulse Field Ablation (PFA), has been introduced in clinical practice. Case report: Because there were multiple recurrences of ischemic stroke despite adequate anticoagulant therapy , a 64-year-old male was admitted to AF PFA and concomitant left atrial appendage (LAA) closure. An intense smoke effect was detected in the LAA and a cerebral protection device (CPD) was positioned. Catheter AF PFA and LAA closure were performed. One little thrombus had been collected into the CPD at the end of procedure. Conclusion: Combined procedure seems to be safe and feasible.

Letter to the editor

Background: Outcomes of catheter ablation (CA) among patients with non-paroxysmal atrial fibrillation (AF) are largely disappointing. Objective: We sought to evaluate the feasibility, effectiveness, and safety of a single-stage stepwise endo-/epicardial approach in patients with persistent/longstanding-persistent AF. Methods: We enrolled 25 consecutive patients with symptomatic persistent (n=4) or longstanding-persistent (n=21) AF and at least one prior endocardial procedure, who underwent CA using an endo-/epicardial approach. Our anatomical stepwise protocol included multiple endocardial as well as epicardial (Bachmann’s bundle [BB] and ligament of Marshall ablations) components, and entailed ablation of atrial tachycardias emerging during the procedure. The primary outcome was freedom from any AF/atrial tachycardia episode after a 3-month blanking period. The secondary outcome was patients’ symptom status during follow-up. Results: The stepwise endo-/epicardial approach allowed sinus rhythm restoration in 72% of patients, either directly (n=6, 24%) or after AF organization into atrial tachycardia (n=12, 48%). BB’s ablation was commonly implicated in arrhythmia termination. After a median follow-up of 266 days (interquartile range, 96 days), survival free from AF/atrial tachycardia was 88%. Antiarrhythmic drugs could be discontinued in 22 patients (88%). As compared to baseline, more patients were asymptomatic at 9-month follow-up (0% vs- 56%, p=0.02). Five patients (20%) developed mild medical complications, whereas one subject (4%) had severe kidney injury requiring dialysis. Conclusion: a single-stage endo-/epicardial CA resulted in favorable rhythm and symptom outcomes in a cohort of patients with symptomatic persistent/longstanding-persistent AF and one or more prior endocardial procedures. Epicardial ablation of BB was commonly implicated in procedural success.

Introduction. Few data exist about effectiveness of atrial fibrillation (AF) catheter ablation (CA) in athletes and feasibility of resuming vigorous exercise afterwards. Aims of our study were to analyze the efficacy and safety of AF CA in athletes, to compare AF CA outcomes in athletes vs Non-Athletes (NA) and to evaluate the feasibility of resuming vigorous exercise. We additionally analyze the outcome of patients that underwent concomitant cavo-tricuspid isthmus (CTI) CA. Methods and results. From January 2015 to October 2019, 38 athletes were retrospectively matched with 38 NA that underwent first time AF CA. After a median follow-up of 787 days, 62.5% of athletes were free from recurrences after one CA procedure and mostly without antiarrhythmic drugs (87%). Seven athletes underwent a redo procedure and all of them were then free of recurrences with an overall freedom from recurrences of 84%. No major complications were observed. After the first year of follow-up, athletes had a 48% reduced risk of recurrences than NA [adjusted hazard ratio (HR) on antiarrhythmic drugs, LA volume and AF subtype, HR 0.52]. Athletes that underwent also CTI ablation showed a positive trend in terms of freedom from recurrences (50% vs 21%). Most (72%) of the athletes resumed vigorous exercise after at least 3 months from the CA. Conclusion. AF CA is a safe and efficient therapeutic option in athletes and it should be considered instead of drugs to early resume competitive sport activity. Concomitant CTI ablation may have a favorable role.