Catheter ablation of tachyarrhythmias in children: state of the art and future directions.

Introduction: Paediatric catheter ablation procedures have traditionally relied heavily on fluoroscopic guidance, exposing children to ionizing radiation and the associated long-term cancer risks ranging from 0.4 to 6.0% of total lifetime cancer risk. This necessitates technological innovations to minimize radiation dependency while maintaining therapeutic effectiveness.

Objectives: To review current state-of-the-art technologies and emerging innovations in paediatric catheter ablation.

Materials and methods: This review examines advanced three-dimensional (3D) mapping algorithms, including low voltage bridge mapping, late annotation electrograms, open window mapping, and omnipolar technology for substrate characterization. Intracardiac echocardiography and digital twin frameworks utilizing cardiac magnetic resonance imaging, computed tomography, and electrocardiogram data for personalized procedural planning are also analyzed.

Results: The implementation of advanced 3D mapping systems demonstrates a marked reduction in radiation exposure while optimizing procedural outcomes across structurally normal and complex congenital heart disease patients. Intracardiac echocardiography provides high-resolution real-time imaging, eliminating fluoroscopic dependence and enabling dynamic clinical decision-making during complex procedures. Focal pulsed field ablation may have a role in paediatric ablations, as it potentially reduces the risk of damaging the conduction tissue and other nearby structures.

Conclusions: The integration of advanced imaging technologies represents transformative progress in paediatric electrophysiology, enabling safer, more precise interventions with significantly reduced radiation exposure. These innovations establish new paradigms for personalized paediatric cardiac care, promising improved long-term outcomes for vulnerable populations requiring catheter ablation procedures.