Intracardiac echocardiography (ICE) is an alternative to transesophageal echocardiography for imaging guidance during left atrial appendage occlusion (LAAO) in patients with atrial fibrillation with intolerance to long-term oral anticoagulation. This narrative review synthesizes contemporary evidence on ICE-guided LAAO. Across observational studies, ICE provides real-time high-resolution imaging enabling accurate trans-septal puncture, device sizing, and deployment under conscious sedation. Procedural success, peri-device leak, and device-related thrombus rates appear comparable between ICE- and TEE-guided LAAO, while ICE may also shorten fluoroscopy time and avoid general anesthesia. Challenges with ICE include operator learning curve, need for additional venous access and intracardiac catheter manipulation, that may add to risks like pericardial effusions, vascular complications and higher costs. Emerging 3D/4D ICE and artificial-intelligence-integrated computed tomographic planning may improve efficiency and allow for combined ablation and LAAO procedures. Further randomized controlled trials and cost-effectiveness studies are needed to define the role of ICE-first approach.
C. Gahona, R. Vempati, Quang Dat Ha et al.· Pacing and clinical electrop...· 0 citations
BACKGROUND
Obesity is a prevalent risk factor for recurrent atrial fibrillation (AF) after catheter ablation. Experimental and observational studies suggest that metformin may reduce the risk of AF.
OBJECTIVE
To determine the effect of metformin on recurrent atrial arrhythmias after catheter ablation for AF.
METHODS
In this single-center, randomized, open-label trial, patients undergoing AF ablation with body mass index (BMI) > 25 kg/m2 and without diabetes were randomized (1:1) to metformin or usual care before ablation. Metformin was titrated to the maximum tolerated dose and continued for 1 year after ablation. All patients received handheld electrocardiogram monitors in addition to usual clinical monitoring. The primary endpoint was freedom from recurrent atrial arrhythmia assessed at 12 months after ablation with a 3-month blanking period.
RESULTS
Of 99 participants (mean age 63 ± 9.5 years, 70% men, BMI 32 ± 5.4 kg/m2, A1c 5.7 ± 0.5, 46% paroxysmal, and 22% prior ablation), 49 were randomized to metformin and 50 to usual care. At 12 months, the primary endpoint occurred in 38 (78%) of the metformin group and 29 (58%) of the usual care group (HR: 0.5; 95% CI: 0.2-0.9; P = 0.04). In the year after ablation, AF burden was lower in the metformin group (IQR: 0%-0%; median 0%) compared with usual care (IQR: 0%-25%; median 0%) (P = 0.03). Antiarrhythmic drugs were used in 4 of 49 patients (8%) in the metformin group and in 9 of 50 patients (18%) in the control group after ablation.
CONCLUSIONS
In patients with AF, elevated BMI, and without diabetes, treatment with metformin may reduce recurrent atrial arrhythmias after ablation. These findings require confirmation in larger trials.
A. Deshmukh, Muazzum M Shah, Paul Kozlowski et al.· JACC Clinical Electrophysiol...· 0 citations
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