The growing popularity of minimally invasive treatment of atrial fibrillation (AF) has shown increasing interest in concomitant left atrial appendage occlusion (LAAO). Surgical robotic technology adds advantages such as magnified visualization, enhanced dexterity of movement and decreased invasiveness. The aim of this study is to evaluate the effectiveness and early outcomes of robotic-assisted LAAO.

This is an observational, multicentre, retrospective study of patients with AF who underwent robotic-assisted LAAO. In-hospital mortality, perioperative complications, length of stay (LOS) and imaging-driven (cardiac CT scan, transesophageal echocardiography [TEE]) efficacy at 3-month follow-up were analysed.

Between August 2019 and June 2024, 194 patients with documented AF (70.4% male, mean age 67.7 ± 10.1) underwent robotic-assisted epicardial LAAO. The procedure was performed under TEE guidance in 193 patients without complications. In one patient with previous sternotomy, LAAO was not feasible. Blood product transfusion was necessary in one patient, due to significant chest wall bleeding requiring thoracoscopic re-exploration. No stroke or thromboembolic events were observed. Left hemidiaphragm paralysis requiring plication occurred in 3 patients (1.5%). Hospital mortality was 0%. Mean LOS time was 2.2 days (range 1-10 days) and all patients were discharged home. Imaging follow-up was complete in 157 cases (81%) and was achieved by TEE in 91 patients while the remaining 66 underwent cardiac CT scan. Two patients had residual flow in the left atrial appendage and oral anticoagulant was continued at follow-up.

Robotic-assisted LAAO is safe with satisfactory outcome both in an isolated setting and with concomitant hybrid ablating procedures for patients with AF.

Hybrid ablation can manage persistent atrial fibrillation (PsAF) and long-standing persistent atrial fibrillation (LSPAF). Robotic-enhanced hybrid ablation (RE-HA) offers greater precision and stability. However, biophysical predictors of effective local epicardial radiofrequency ablation (ELRF) during epicardial ablation are unknown.

The purpose of this study was to compare the time course of biophysical predictors of ELRF and no-ELRF during the first stage of RE-HA in patients with PsAF and LSPAF.

We conducted a dual-center retrospective cohort study involving 92 consecutive patients with PsAF or LSPAF who underwent RE-HA between January 2021 and May 2024. Epicardial electrogram disappearance, defined as a reduction of bipolar voltages to <0.05 mV, baseline impedance (BI), and impedance drop (ID), were compared between ELRF and no-ELRF cases. Univariate and multivariate logistic regression models were used to identify predictive variables. Optimal cutoff values were determined using receiver operating characteristic curves.

Among 2474 radiofrequency (RF) applications, significant predictors of ELRF included BI and ID at 1 and 8 seconds, with optimal cutoff values of <107, 0-7, and 5-17 Ω. The composite predictive model had an area under the receiver operating characteristic of 0.775, with 94% sensitivity, 53% specificity, and 65% accuracy. Our predictive ELRF score ranged from 0-4, and the Youden J test identifying a cutoff value of 3 as optimal.

BI and progressive ID were strong predictors of local epicardial RE-HA efficacy. The composite model was a reliable tool for early identification of ELRF, potentially reducing RF delivery and enhancing procedural efficiency. Larger prospective studies are needed to validate these findings.

Clinical outcomes of catheter ablation remain suboptimal in patients with atrial fibrillation (AF), particularly in those with persistent AF, despite decades of research, clinical trials, and technological advancements. Recently, pulsed-field ablation (PFA), a promising non-thermal technology, has been introduced to improve procedural outcomes. Its unique feature of myocardial selectivity offers safety advantages by avoiding potential harm to vulnerable adjacent structures during AF ablation. However, despite the global enthusiasm within the electrophysiology community, recent data indicate that PFA is still far from being a "magic wand" for addressing such a complex and challenging arrhythmia as AF. More progress is needed in mapping processes rather than in ablation technology. This editorial reviews relevant available data and explores future research directions for PFA.