Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry

BACKGROUND

The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.

METHODS

REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.

RESULTS

Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.

CONCLUSIONS

REAL-AF operators were high volume low fluoroscopy "real world" operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

Simplified risk-prediction for benchmarking and quality improvement in emergency general surgery. Prospective, multicenter, observational cohort study

BACKGROUND AND AIMS

Emergency General Surgery (EGS) conditions account for millions of deaths worldwide, yet it is practiced without benchmarking-based quality improvement programs. The aim of this observational, prospective, multicenter, nationwide study was to determine the best benchmark cutoff points in EGS, as a reference to guide improvement measures.

METHODS

Over a 6-month period, 38 centers (5% of all public hospitals) attending EGS patients on a 24-h, 7-days a week basis, enrolled consecutive patients requiring an emergent/urgent surgical procedure. Patients were stratified into cohorts of low (i.e., expected morbidity risk <33%), middle and high risk using the novel m-LUCENTUM calculator.

RESULTS

A total of 7258 patients were included; age (mean ± SD) was 51.1 ± 21.5 years, 43.2% were female. Benchmark cutoffs in the low-risk cohort (5639 patients, 77.7% of total) were: use of laparoscopy ≥40.9%, length of hospital stays ≤3 days, any complication within 30 days ≤ 17.7%, and 30-day mortality ≤1.1%. The variables with the greatest impact were septicemia on length of hospital stay (21 days; adjusted beta coefficient 16.8; 95% CI: 15.3 to 18.3; P < .001), and respiratory failure on mortality (risk-adjusted population attributable fraction 44.6%, 95% CI 29.6 to 59.6, P < .001). Use of laparoscopy (odds ratio 0.764, 95% CI 0.678 to 0.861; P < .001), and intraoperative blood loss (101-500 mL: odds ratio 2.699, 95% CI 2.152 to 3.380; P < .001; and 500-1000 mL: odds ratio 2.875, 95% CI 1.403 to 5.858; P = .013) were associated with increased morbidity.

CONCLUSIONS

This study offers, for the first time, clinically-based benchmark values in EGS and identifies measures for improvement.

Procedural and short-term results of electroanatomic-mapping-guided ganglionated plexus ablation by first-time operators: A multicenter study

INTRODUCTION

Single-center observational studies have shown promising results with fragmented electrogram (FE)-guided ganglionated plexus (GP) ablation in patients with vagally mediated bradyarrhythmia (VMB). We aimed to compare the acute procedural characteristics during FE-guided GP ablation in patients with VMB performed by first-time operators and those of a single high-volume operator.

METHODS AND RESULTS

This international multicenter cohort study included data collected over 2 years from 16 cardiac hospitals. The primary operators were classified according to their prior GP ablation experience: a single high-volume operator who had performed > 50 GP ablation procedures (Group 1), and operators performing their first GP ablation cases (Group 2). Acute procedural characteristics and syncope recurrence were compared between groups. Forty-seven consecutive patients with VMB who underwent FE-guided GP ablation were enrolled, n = 31 in Group 1 and n = 16 in Group 2. The mean number of ablation points in each GP was comparable between groups. The ratio of positive vagal response during ablation on the left superior GP was higher in Group 1 (90.3% vs. 62.5%, p = .022). Ablation of the right superior GP increased heart rate acutely without any vagal response in 45 (95.7%) cases. The procedure time was longer in group 2 (83.4 ± 21 vs. 118.0 ± 21 min, respectively, p < .001). Over a mean follow-up duration of 8.0 ± 3 months (range 2-24 months), none of the patients suffered from syncope.

CONCLUSION

This multi-center pilot study shows for the first time the feasibility of FE-guided GP ablation across a large group of procedure-naïve operators.

Analysis of outcomes of emergency general and gastrointestinal surgery during the COVID-19 pandemic

BACKGROUND

Few surgical studies have provided adjusted comparative postoperative outcome data among contemporary patients with and without COVID-19 infection and patients treated before the pandemic. The aim of this study was to determine the impact of performing emergency surgery in patients with concomitant COVID-19 infection.

METHODS

Patients who underwent emergency general and gastrointestinal surgery from March to June 2020, and from March to June 2019 in 25 Spanish hospitals were included in a retrospective study (COVID-CIR). The main outcome was 30-day mortality. Secondary outcomes included postoperative complications and failure to rescue (mortality among patients who developed complications). Propensity score-matched comparisons were performed between patients who were positive and those who were negative for COVID-19; and between COVID-19-negative cohorts before and during the pandemic.

RESULTS

Some 5307 patients were included in the study (183 COVID-19-positive and 2132 COVID-19-negative during pandemic; 2992 treated before pandemic). During the pandemic, patients with COVID-19 infection had greater 30-day mortality than those without (12.6 versus 4.6 per cent), but this difference was not statistically significant after propensity score matching (odds ratio (OR) 1.58, 95 per cent c.i. 0.88 to 2.74). Those positive for COVID-19 had more complications (41.5 versus 23.9 per cent; OR 1.61, 1.11 to 2.33) and a higher likelihood of failure to rescue (30.3 versus 19.3 per cent; OR 1.10, 0.57 to 2.12). Patients who were negative for COVID-19 during the pandemic had similar rates of 30-day mortality (4.6 versus 3.2 per cent; OR 1.35, 0.98 to 1.86) and complications (23.9 versus 25.2 per cent; OR 0.89, 0.77 to 1.02), but a greater likelihood of failure to rescue (19.3 versus 12.9 per cent; OR 1.56, 95 per cent 1.10 to 2.19) than prepandemic controls.

CONCLUSION

Patients with COVID-19 infection undergoing emergency general and gastrointestinal surgery had worse postoperative outcomes than contemporary patients without COVID-19. COVID-19-negative patients operated on during the COVID-19 pandemic had a likelihood of greater failure-to-rescue than prepandemic controls.

Effect of conscious sedation and deep sedation on the vagal response characteristics during ganglionated plexus ablation

INTRODUCTION

We aimed to determine the effects of conscious and deep sedation on vagal response (VR) characteristics during ganglionated plexus (GP) ablation.

METHODS

Forty consecutive patients undergoing GP ablation for vasovagal syncope were divided to receive conscious sedation with midazolam (Group 1, n = 29) or deep sedation with the midazolam-propofol combination (Group 2, n = 11). VR was defined on three levels. R-R interval increase of >50% (Level 1); R-R interval increase of 20%-50% (Level 2); and R-R interval increase of <20% (Level 3).

RESULTS

The ratio of Level 1 VR during ablation on left superior and inferior GPs was significantly lower in Group 2 (p < .0001 and p = .034, respectively). Once the cut-off for VR was decreased to Level 2, the ratio of (+) VR was similar between groups during ablation of left-sided GPs. Positive VR in any level was lower than 20% during ablation of right-sided GPs.

CONCLUSIONS

The autonomic tone might be affected in different ways by the level or type of intravenous sedation. Awareness of anesthesia-related differences may be important if GP ablation will be performed by using VR characteristics during ablation.

A prospective multi-site registry of real-world experience of catheter ablation for treatment of symptomatic paroxysmal and persistent atrial fibrillation (Real-AF): design and objectives

Purpose

Catheter ablation has become a mainstay therapy for atrial fibrillation (AF) with rapid innovation over the past decade. Variability in ablation techniques may impact efficiency, safety, and efficacy; and the ideal strategy is unknown. Real-world evidence assessing the impact of procedural variations across multiple operators may provide insight into these questions. The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal (PAF) and Persistent (PsAF) Atrial Fibrillation registry (Real-AF) is a multicenter prospective registry that will enroll patients at high volume centers, including academic institutions and private practices, with operators performing ablations primarily with low fluoroscopy when possible. The study will also evaluate the contribution of advent in technologies and workflows to real-world clinical outcomes.

Methods

Patients presenting at participating centers are screened for enrollment. Data are collected at the time of procedure, 10–12 weeks, and 12 months post procedure and include patient and detailed procedural characteristics, with short and long-term outcomes. Arrhythmia recurrences are monitored through standard of care practice which includes continuous rhythm monitoring at 6 and 12 months, event monitors as needed for routine care or symptoms suggestive of recurrence, EKG performed at every visit, and interrogation of implanted device or ILR when applicable.

Results

Enrollment began in January 2018 with a single site. Additional sites began enrollment in October 2019. Through May 2021, 1,243 patients underwent 1,269 procedures at 13 institutions. Our goal is to enroll 4000 patients.

Discussion

Real-AF’s multiple data sources and detailed procedural information, emphasis on high volume operators, inclusion of low fluoroscopy operators, and use of rigorous standardized follow-up methodology allow systematic documentation of clinical outcomes associated with changes in ablation workflow and technologies over time. Timely data sharing may enable real-time quality improvements in patient care and delivery.

Trial registration

Clinicaltrials.gov: NCT04088071 (registration date: September 12, 2019)

Supplementary Information

The online version contains supplementary material available at 10.1007/s10840-021-01031-w.

Effect of general and local anesthesia on the vagal response characteristics during ganglionated plexus ablation

Funding Acknowledgements

Type of funding sources: None.

Background

The effect of different anesthetics on the function of the autonomic nervous system (ANS) is not well known. As a relatively new treatment option, ganglionated plexus (GP) ablation aims to modify the behavior of the cardiac ANS to prevent some/all of the autonomic processes occurring in vasovagal syncope (VVS) by using endocardial ablation techniques.

Purpose

The purpose of this study was to determine the effects midazolam and propofol on the vagal response (VR) characteristics during GP ablation in patients with vasovagal syncope (VVS).

Methods

Forty consecutive patients undergoing GP ablation for VVS were divided to receive local anesthesia with midazolam (group 1, n = 29) or general anesthesia with propofol (group EA, n = 11). All GP sites were detected by using previously defined fragmented electrogram based strategy. VR was defined on 3 levels: 1) R-R interval increased by 50% (level 1); 2) R-R interval increased by 20-50% (level 2); and 3) R-R interval increase lower than 20% (level 3).

Results

Baseline characteristics and mean follow-up times were comparable between groups. In both groups, the left superior GP (LSGP) was the most common GP site at which a VR was observed. However, there was a significant difference between groups for level of VR. While ablation on the LSGP caused a level 1 VR in 89.6% of cases in group 1, level 1 VR was seen in 22.2% of cases in group 2 (p &lt; 0.0001). Similarly, ratio of level 1 VR during ablation on the left inferior GP (LIGP) was significantly lower in group 2 (44.8% vs 9%, p = 0.034). Once cut-off for VR was decreased to level 2, the ratio of (+) VR increased to 90.9% during ablation on the LSGP in group 2. Level 2 VR was detected in 45.4% of cases during ablation on the LIGP. Ratio of positive VRs in any level was lower than 20% during ablation on the right superior and inferior GPs in both groups. During a mean follow-up time of 12.1 ± 7 months, all but 2 (5%) of 40 patients were free of syncope.

Conclusions

The autonomic nervous tone might be affected in different ways by local and general anesthesia. Propofol may reveal a shift in the sympathovagal balance toward sympathetic predominance which may cause a blunting on VR during GP ablation. Further randomized, controlled and multicenter studies should be performed to confirm these findings.

Left atrial appendage closure in patients with prohibitive anatomy: Insights from PINNACLE FLX

BACKGROUND

Watchman 2.5 (Boston Scientific Inc, Marlborough, MA) implant success approaches 95% in registries, yet many patients are not attempted because of complex left atrial appendage (LAA) anatomy. Watchman FLX can expand the range of ostium width (14-31.5 mm) and depth available for LAA closure.

OBJECTIVE

The purpose of this study was to evaluate the safety and efficacy of Watchman FLX in patients with a failed Watchman 2.5 attempt or prohibitive LAA anatomy.

METHODS

The roll-in (n = 58) and primary effectiveness (n = 400) cohorts of the PINNACLE FLX trial comprised the study population. Subjects were identified who previously failed implantation of Watchman 2.5 (n = 11) or were not attempted because of prohibitive LAA anatomy (n = 88). Demographic characteristics, implant procedure details, and TEE follow-up data were compared to controls composed of enrollees not meeting these criteria (n = 359).

RESULTS

Watchman FLX LAA closure was successfully implanted in all subjects with a prior failed Watchman 2.5 attempt (n = 11 of 11). Subjects with previously failed Watchman 2.5 were more likely to receive a 35 mm FLX device than controls (27.3% vs 7.3%; P = .047). Patients with prohibitive anatomy had smaller LAA dimensions than did controls (diameter 18.0 ± 4 mm vs 20.4 ± 3 mm; P < .001 and length 23.7 ± 5 mm vs 28.9 ± 5 mm; P < .001). There was no difference in age, sex, CHA₂DS₂-VASc score, HAS-BLED score, or primary efficacy between cohorts. Transesophageal echocardiography (TEE) at 12 months showed zero leak in 90.9% in the failed Watchman 2.5 cohort, 91.3% in the prohibitive anatomy cohort, and 89.5% in the control cohort (P = .84). Overall and cardiovascular mortality was lower in the prohibitive anatomy cohort (1.2% vs 8.8% in controls; P = .02).

CONCLUSION

Watchman FLX implantation in patients with a prior failed Watchman 2.5 attempt or prohibitive LAA anatomy remained safe and highly effective. The association of reduced overall mortality with smaller LAA dimension warrants future study.

Predictors of clinical success after paroxysmal atrial fibrillation catheter ablation

INTRODUCTION

Contact force (CF) guided ablation of paroxysmal atrial fibrillation (PAF) with stable catheter-tissue contact optimizes clinical success and may increase an operator's ability to achieve pulmonary vein isolation (PVI) in a single encirclement. First pass PVI reduces procedure time but the relationship with long term clinical success is not well understood. This study evaluated patient characteristics and procedural details as predictors of 1-year clinical success after PAF ablation, including first pass isolation.

METHODS

Consecutive de novo PAF ablations were performed with a porous tip CF catheter in 2017 and 2018. All ablations used wide-area circumferential ablation, with first pass isolation captured separately for the left and right pulmonary veins (PVs). CF was held between 10 and 20 g and the catheter was moved every 10-20 s. Radiofrequency energy was set at 40-45 W throughout the atrium. Patient characteristics and procedural details were tested for association with clinical success, defined as freedom from recurrent atrial tachyarrhythmia through 1 year.

RESULTS

A total of 404 patients were included in the study. Clinical success at 1 year was 86.6%. Achieving first pass isolation on at least one ipsilateral PV pair was the most significant predictor of clinical success (p = .0126). After controlling for first pass isolation, only recurrence within the 90-day blanking period was independently predictive (p = .0015). First pass isolation was not associated with early recurrence (p = .2454).

CONCLUSION

In a real-world setting, first pass isolation was highly predictive of 12-month clinical success after CF-guided ablation in a PAF population.

Primary Outcome Evaluation of a Next-Generation Left Atrial Appendage Closure Device: Results From the PINNACLE FLX Trial

BACKGROUND

Left atrial appendage (LAA) occlusion provides an alternative to oral anticoagulation for thromboembolic risk reduction in patients with nonvalvular atrial fibrillation. Since regulatory approval in 2015, the WATCHMAN device has been the only LAA closure device available for clinical use in the United States. The PINNACLE FLX study (Protection Against Embolism for Nonvalvular AF Patients: Investigational Device Evaluation of the Watchman FLX LAA Closure Technology) evaluated the safety and effectiveness of the next-generation WATCHMAN FLX LAA closure device in patients with nonvalvular atrial fibrillation in whom oral anticoagulation is indicated, but who have an appropriate rationale to seek a nonpharmaceutical alternative.

METHODS

This was a prospective, nonrandomized, multicenter US Food and Drug Administration study. The primary safety end point was the occurrence of one of the following events within 7 days after the procedure or by hospital discharge, whichever was later: death, ischemic stroke, systemic embolism, or device- or procedure-related events requiring cardiac surgery. The primary effectiveness end point was the incidence of effective LAA closure (peri-device flow ≤5 mm), as assessed by the echocardiography core laboratory at 12-month follow-up.

RESULTS

A total of 400 patients were enrolled. The mean age was 73.8±8.6 years and the mean CHA₂DS₂-VASc score was 4.2±1.5. The incidence of the primary safety end point was 0.5% with a 1-sided 95% upper CI of 1.6%, meeting the performance goal of 4.2% (P<0.0001). The incidence of the primary effectiveness end point was 100%, with a 1-sided 95% lower CI of 99.1%, again meeting the performance goal of 97.0% (P<0.0001). Device-related thrombus was reported in 7 patients, no patients experienced pericardial effusion requiring open cardiac surgery, and there were no device embolizations.

CONCLUSIONS

LAA closure with this next-generation LAA closure device was associated with a low incidence of adverse events and a high incidence of anatomic closure. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02702271.

Comparative clinical prognosis of massive and non-massive pulmonary embolism: A registry-based cohort study

AIMS

Little is known about the prognosis of patients with massive pulmonary embolism (PE) and its risk of recurrent venous thromboembolism (VTE) compared with non-massive PE, which may inform clinical decisions. Our aim was to compare the risk of recurrent VTE, bleeding, and mortality after massive and non-massive PE during anticoagulation and after its discontinuation.

METHODS AND RESULTS

We included all participants in the RIETE registry who suffered a symptomatic, objectively confirmed segmental or more central PE. Massive PE was defined by a systolic hypotension at clinical presentation (<90 mm Hg). We compared the risks of recurrent VTE, major bleeding, and mortality using time-to-event multivariable competing risk modeling. There were 3.5% of massive PE among 38 996 patients with PE. During the anticoagulation period, massive PE was associated with a greater risk of major bleeding (subhazard ratio [sHR] 1.72, 95% confidence interval [CI] 1.28-2.32), but not of recurrent VTE (sHR 1.15, 95% CI 0.75-1.74) than non-massive PE. An increased risk of mortality was only observed in the first month after PE. After discontinuation of anticoagulation, among 11 579 patients, massive PE and non-massive PE had similar risks of mortality, bleeding, and recurrent VTE (sHR 0.85, 95% CI 0.51-1.40), but with different case fatality of recurrent PE (11.1% versus 2.4%, P = .03) and possibly different risk of recurrent fatal PE (sHR 3.65, 95% CI 0.82-16.24).

CONCLUSION

In this large prospective registry, the baseline hemodynamic status of the incident PE did not influence the risk of recurrent VTE, during and after the anticoagulation periods, but was possibly associated with recurrent PE of greater severity.

Positive Clinical Benefit on Patient Care, Quality of Life, and Symptoms After Contact Force-Guided Radiofrequency Ablation in Persistent Atrial Fibrillation: Analyses From the PRECEPT Prospective Multicenter Study

BACKGROUND

There is limited evidence on the long-term clinical benefits of catheter ablation in patients with persistent atrial fibrillation.

METHODS

PRECEPT was a prospective, multicenter, single-arm Food and Drug Administration-regulated investigational device exemption clinical study. Patients were followed up to 15 months after ablation. Outcomes included use of antiarrhythmic drugs, rate of cardioversions and cardiovascular hospitalization, Atrial Fibrillation Effect on Quality-of-Life score, and Canadian Cardiovascular Society Severity of Atrial Fibrillation score.

RESULTS

A total of 333 enrolled persistent atrial fibrillation patients underwent ablation. The cardioversion rate decreased by 83% at the 9- to 15-month follow-up. Antiarrhythmic drug utilization decreased by 69% at 12 to 15 months post-ablation. The Kaplan-Meier estimate of freedom from cardiovascular hospitalization was 84.2% (95% CI, 80.2%-88.2%) at 15 months. Consistent improvements in mean Atrial Fibrillation Effect on Quality-of-Life composite (+50.0) were seen at 6 months, sustained at 15 months, and exceeded the minimum clinically important difference. Improvements in Atrial Fibrillation Effect on Quality-of-Life scores were significantly better among participants without documented atrial arrhythmia recurrences. By Canadian Cardiovascular Society Severity of Atrial Fibrillation symptom classification, >80% of patients were asymptomatic (class 0) at 15 months post-ablation compared with only 0.7% at baseline.

CONCLUSIONS

Contact force-guided radiofrequency ablation of persistent atrial fibrillation was associated with a significant decrease in antiarrhythmic drug use, cardioversion rate, and hospitalization. Clinically meaningful improvements in quality of life were observed in all patients. The majority of the patients (>80%) were asymptomatic at 15 months post-ablation. The positive clinical impact of improved quality of life and reduced health care utilization may help with shared decision-making in persistent atrial fibrillation treatment. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02817776.

Prospective implementation of a same-day discharge protocol for catheter ablation of paroxysmal atrial fibrillation

PURPOSE

Overnight stays associated with catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) account for a significant proportion of treatment cost. Same-day discharge (SDD) after CA may be attractive to both patients and hospitals, especially in light of current restrictions on overnight stays due to COVID-19. This study reports on the selection criteria, protocol, and safety of SDD after CA of PAF.

METHODS

Patients undergoing CA for PAF were evaluated to assess the risk of groin, respiratory, cardiac, or bleeding complications. SDD eligibility criteria were stable anticoagulation with no bleeding history, systolic heart failure, respiratory conditions, or interventional procedures within 60 days, and recommended BMI < 35. Patient proximity to the hospital was also considered. Anesthesia with propofol was used, and ablations were performed with a contact force catheter. Patients rested for 6 h post-procedure and then ambulated over 1-2 h. Discharge followed if they were stable without evidence of complications. A nurse called all patients the following morning to elicit evidence of complications.

RESULTS

Of 44 planned SDD procedures between April 2017 and June 2018, 41 resulted in SDD after 7.2 ± 1.0 h, 2 patients stayed overnight for observation, and one by choice. Average age was 59 ± 10 years with CHA₂DS₂-VASc of 1.6 ± 1.1. No SDD-related complications occurred, and no return visits resulted from the follow-up calls.

CONCLUSION

Appropriate low-risk patients identified by well-defined clinical criteria can be safely discharged the same day after CA for PAF. Evaluation in a larger population across different centers is required for generalizability of this SDD protocol.

Durable pulmonary vein (PV) isolation at repeat atrial fibrillation (AF) ablation procedure: a comparison between 4 ablation technologies

Background

Durable PV isolation is the sought-after endpoint to obtain long term success after AF catheter ablation. Evolution in technology improves efficiency, safety and effectiveness in AF catheter ablation.

Purpose

To investigate the effectiveness of different catheter technologies in obtaining durable PV isolation in a real-world practice.

Methods

Retrospective analysis of prospectively collected data of patients undergoing repeat procedures for recurrence of AF or atrial flutter at our institution was performed. Incidence of all PVs being isolated at repeat procedure was recorded and patients 4 groups created based on catheter technology used during index AF ablation procedure (SF: multipored, irrigated catheter; ST: contact force sensor catheter; Cryo: 2nd generation cryobaloon; and STSF: multipored, irrigated, contact force sensing catheter).

Results

We identified 269 subjects undergoing repeat ablation from May 2014 to September 2019. Mean age was 67±9.7 years, 54.6% were males, 74.4% non-paroxysmal AF at the index procedure. The mean CHA2DS2Vasc score was 2.5±0.26, LA size 4.2±0.6 cm, EF 55.3±10%. The mean time from index to redo procedure was 374±331 days. At repeat procedure all veins were isolated in 24% (6/25) who were initially ablated using SF; 36% (8/22) with Cryo; 44% (47/108) with ST; and 74% (84/114) with STSF catheter. (Figure)

Conclusion

Patients undergoing index ablation with STSF catheter technology were significantly more likely to have all 4 PVs isolated at repeat procedure compared to previous generation technology.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Biosense Webster

Positive clinical benefit on patient care, quality of life and symptoms after radiofrequency ablation with contact force in persistent atrial fibrillation: analyses from PRECEPT

Background

The management of persistent (PsAF) aims to prevent AF recurrence and associated disabilities while reducing side effects from treatment. Contact force (CF)-guided RF catheters have proven efficacious and safe for pulmonary vein isolation (PVI) to treat paroxysmal AF; however, there is limited evidence on clinical benefits with ablation of PsAF.

Purpose

To assess long-term clinical effects on patients care, symptoms and QOL after CF-guided RF ablation in PsAF.

Methods

PRECEPT was a multicenter study evaluating the safety and efficacy of CF RF catheters in the treatment of symptomatic PsAF (NCT02817776). PVI was performed with or without substrate modification. Patients were followed at 6, 9, 12 and 15 mos to collect the following data: Atrial Fibrillation Effect on Quality-of-Life (AFEQT) score, Canadian Cardiovascular Society Severity of Atrial Fibrillation (CCS-SAF) score, Class I/III AAD use, and incidence of cardioversion and cardiovascular hospitalization.

Results

A total of 333 enrolled patients (65.4±8.8 yrs, 71.2% male, CHA2DS2-VASC score 2.3±1.5) underwent PVI. Compared to baseline, 1) improvements in the AFEQT composite and subscores were seen from 6–15 mos, exceeding Clinical Important Difference (±5 points) in majority of subjects (Figure), 2) proportion of CCS-SAF Class 0 patients (asymptomatic with respect to AF) rose from 0.7% to 81.0%, 3) class I/III AAD use was reduced from 97.0% to 24.7%, and 4) incidence of cardioversion decreased from 62.0% to 10.7%. Moreover, the 1-yr Kaplan-Meier estimate of freedom from hospitalization was 84.2% [95% CI: 80.2%, 88.2%].

Conclusion

CF-guided RF ablation in PsAF patients led to a clinically meaningful improvement in QOL, as well as a reduction in AAD use, cardioversion, and hospitalization.

Figure 1. Mean AFEQT composite and subscore

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): This study was funded by Biosense Webster, Inc.