Prevention of atrial fibrillation recurrence with corticosteroids after radiofrequency catheter ablation: a randomized controlled trial

Atrial arrhythmias after lung transplantation

Atrial arrhythmias are a common complication after lung transplant (LT), occurring in about 16-46% of LT patients early postoperatively, and in about 14% during longer-term follow-up. They have a significant impact on postoperative in-hospital length of stay and may have an impact on overall mortality. In this report, we review the incidence and risk factors of post lung transplant AA, their pathogenesis and their impact on short- and long-term outcomes. Pharmacological management options are reviewed. In brief, early atrial arrhythmias tend to be mostly atrial fibrillation and are treated acutely with a rate control strategy followed if needed by rhythm control for 4-6 weeks. Late atrial arrhythmias >6 months after LT tend to be more frequently organized atrial flutters amenable to ablation therapy. Long-term anticoagulation is controversial especially in patients with bilateral lung transplant who received surgical pulmonic vein isolation, however anticoagulation is still favored especially in single LT patients. More studies are needed to further document the pathophysiology of early versus late atrial arrhythmias and whether long-term anticoagulation is needed.

Catheter Ablation of Atrial Fibrillation: An Overview for Clinicians

Catheter ablation (CA) of atrial fibrillation (AF) is currently one of the most commonly performed electrophysiology procedures. Ablation of paroxysmal AF is based on the elimination of triggers by pulmonary vein isolation (PVI), while different strategies for additional AF substrate modification on top of PVI have been proposed for ablation of persistent AF. Nowadays, various technologies for AF ablation are available. The radiofrequency point-by-point ablation navigated by electro-anatomical mapping system and cryo-balloon technology are comparable in terms of the efficacy and safety of the PVI procedure. Long-term success of AF ablation including multiple procedures varies from 50 to 80%. Arrhythmia recurrences commonly occur, mostly due to PV reconnection. The recurrences are particularly common in patients with non-paroxysmal AF, dilated left atrium and the "early recurrence" of AF within the first 2-3 post-procedural months. In addition, this complex procedure can be accompanied by serious complications, such as cardiac tamponade, stroke, atrio-esophageal fistula and PV stenosis. Therefore, CA represents a second-line treatment option after a trial of antiarrhythmic drug(s). Good candidates for the procedure are relatively younger patients with symptomatic and frequent episodes of AF, with no significant structural heart disease and no significant left atrial enlargement. Randomized trials demonstrated the superiority of ablation compared to antiarrhythmic drugs in terms of improving the quality of life and symptoms in AF patients. However, nonrandomized studies reported additional clinical benefits from ablation over drug therapy in selected AF patients, such as the reduction of the mortality and stroke rates and the recovery of tachyarrhythmia-induced cardiomyopathy. Future research should enable the creation of more durable ablative lesions and the selection of the optimal lesion set in each patient according to the degree of atrial remodeling. This could provide better long-term CA success and expand indications for the procedure, especially among the patients with non-paroxysmal AF.

Radiofrequency catheter ablation is effective for atrial fibrillation patients with hypertrophic cardiomyopathy by decreasing left atrial pressure

Background

Radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) refractory to medical therapy remains controversial in patients with hypertrophic cardiomyopathy (HCM); the acute effects on the direct left atrial (LA) pressure are not completely understood.

Methods

We consecutively studied patients with HCM (n=15) and without HCM (NHCM, n=106) who underwent extensive encircling pulmonary vein isolation for drug-refractory AF. We compared clinical parameters, echocardiographic parameters, electrophysiological parameters, LA pressures using hemodynamic catheterization and recurrence rate in both groups.

Results

The LA volume index was significantly higher (51.9±13.6 mL/m² vs. 41.6±12.7 mL/m², p=0.02) in the HCM group than the NHCM group. The pre-ablation mean LA pressure was significantly higher in the HCM group than the NHCM group. Among the AF patients, the mean LA pressure decreased more significantly in the HCM group than the NHCM group (post-ablation minus pre-ablation pressures: 4.2±3.7 mmHg vs. 0.9±4.1 mmHg, p=0.03). The early recurrence rate (within 30 days after ablation) tended to be higher in the HCM group than the NHCM group (20% vs. 5.7%, p=0.08), but the rates of late recurrences (>30 days after ablation) were similar (13.3% vs. 7.6%, p=0.83). Discontinuation of antiarrhythmic drugs occurred at rates of 13% and 62% in the HCM and NHCM groups, respectively (p<0.001).

Conclusions

The LA pressure in the HCM group decreased immediately after AF RFCA. Patients with HCM and drug-refractory AF may benefit from RFCA.

A Potential Role of Esophageal Cancer Related Gene-4 for Atrial Fibrillation

Epidemiological studies have shown a strong correlation between tumor and AF. However, the molecular link between tumor and AF remains unknown. ECRG4, a tumor suppressor gene that is expressed in the A-V node and in sporadic ventricular myocytes, inhibits tumorigenesis and monitors tissue homeostasis by functioning as a ‘sentinel’ molecule gauging inflammatory and cell proliferative responses. To explore the potential physiological function of Ecrg4 in heart, we evaluated its distribution in heart, analyzed its expression in patients with persistent AF and in a canine AF model, and dissected the molecular events downstream of Ecrg4. The results showed that the level of Ecrg4 expression is homogenously high in atria and the conduction systems and in sporadic ventricular myocytes. Importantly, the expression of Ecrg4 was significantly decreased in atrial appendages of AF patients than patients with SR. Moreover, in rapid pacing canine AF models, the expression of ECRG4 in atria was significantly decreased compared to that of the controls. Mechanistically, knockdown ECRG4 in atrial myocytes significantly shortened the APDs, inhibited the expression of Gja1, and activated pro-inflammatory cascades and genes involved in cardiac remodeling. These results suggest that Ecrg4 may play a critical role in the pathogenesis of AF.

Systemic Inflammation and Arrhythmogenesis: A Review of Mechanistic and Clinical Perspectives

In the recent decades, systemic inflammation, as a clinical phenomenon, has been the focus of extensive research particularly with regard to its potential association with a variety of cardiovascular diseases including atherogenesis and acute coronary syndromes. Within this context, there also exists a potential link between systemic inflammation and cardiac arrhythmogenesis in various aspects. Accordingly, systemic inflammation response as measured with inflammation markers (cytokines, etc) has been investigated in the setting of well-known cardiac arrhythmias including atrial fibrillation and ventricular tachycardia. Based on current literature, clinical utility of these markers might potentially yield important prognostic implications in the setting of certain arrhythmogenic conditions. On the other hand, there exists limited data regarding therapeutic implications including clinical benefit of primary anti-inflammatory agents (corticosteroids, colchicine, etc) in the setting of arrhythmia management. The present review primarily aims to discuss potential triggers and fundamental mechanisms of inflammation-related arrhythmias along with a particular emphasis on clinical implications of systemic inflammation in the setting of cardiac arrhythmogenesis.

Effects of Alpha Lipoic Acid on Multiple Cytokines and Biomarkers and Recurrence of Atrial Fibrillation Within 1 Year of Catheter Ablation

Catheter ablation (CA) is a procedure commonly used to restore sinus rhythm in patients with atrial fibrillation (AF). However, AF recurrence after CA remains a relevant clinical issue. We tested the effects of an oral antioxidant treatment (alpha lipoic acid [ALA]) on AF recurrence post-CA. Patients with paroxysmal AF have been enrolled in a randomized, prospective, double-blind, controlled placebo trial. After CA, patients have been randomly assigned to receive ALA oral supplementation (ALA group) or placebo (control group) and evaluated at baseline and after a 12-month follow-up: 73 patients completed the 12-month follow-up (ALA: 33 and control: 40). No significant difference has been detected between the 2 groups at baseline. Strikingly, 1 year after CA, ALA therapy significantly reduced serum markers of inflammation. However, there was no significant difference in AF recurrence events at follow-up comparing ALA with placebo group. Multivariate analysis revealed that the only independent prognostic risk factor for AF recurrence after CA is age. In conclusion, ALA therapy reduces serum levels of common markers of inflammation in ablated patients. Nevertheless, ALA does not prevent AF recurrence after an ablative treatment.

Use of Oral Steroid and its Effects on Atrial Fibrillation Recurrence and Inflammatory Cytokines Post Ablation - The Steroid AF Study

Background

Use of corticosteroids before and after atrial fibrillation (AF) ablation can decrease acute inflammation and reduce AF recurrence.

Purpose

To assess the efficacy of oral prednisone in improving the outcomes of pulmonary vein isolation with radiofrequency ablation and its effect on inflammatory cytokine.

Methods

A total of 60 patients with paroxysmal AF undergoing radiofrequency ablation were randomized (1:1) to receive either 3 doses of 60 mg daily of oral prednisone or a placebo. Inflammatory cytokine levels (TNF-α, IL-1, IL6, IL-8) were measured at baseline, prior to ablation, immediately after ablation, and 24 hours post ablation. Patients underwent 30 day event monitoring at 3 months, 6 months and 12 months post procedure.

Results

Immediate post ablation levels of inflammatory cytokines were lower in the steroid group when compared to the placebo group; IL-6: 9.0 ±7 vs 15.8 ±13 p=0.031; IL-8: 10.5 ±9 vs 15.3 ±8; p=0.047 respectively. Acute PV reconnection rates during the procedure (7/23% vs 10/36%; p = 0.39), and RF ablation time (51±13 vs 56±11 min, p = 0.11) trended to be lower in the placebo group than the steroid group. There was no difference in the incidence of early recurrence of AF during the blanking period and freedom from AF off AAD at 12 months between both groups (5/17% vs 8/27%; p = 0.347 and 21/70% vs 18/60%; p=0.417 in placebo and steroid groups respectively).

Conclusion

Although oral corticosteroids have significant effect in lowering certain cytokines, it did not impact the clinical outcomes of AF ablation.

Plasma oxidative stress and inflammatory biomarkers are associated with the sizes of the left atrium and pulmonary vein in atrial fibrillation patients

BACKGROUND

Oxidative stress and inflammatory processes are responsible for the pathogenesis of AF, but their relationship with the sizes of the LA and PVs in AF patients remains unclear.

HYPOTHESIS

Oxidative stress and inflammatory processes are associated with the sizes of the LA and PVs in AF patients.

METHODS

82 AF patients were compared to 30 control patients by using a case-control study design. Oxidative stress, inflammatory biomarkers and the sizes of the LA and PVs were detected.

RESULTS

(1) Hs-CRP, IL-6, IL-8, TNF-α, MDA and ox-LDL were higher, and SOD was lower in AF patients than in control patients. Hs-CRP, MDA and ox-LDL were higher in permanent AF patients than in paroxysmal and persistent AF patients. (2) CsA of LSPV, RSPV, RIPV, LAA and LAV were statistically higher in AF patients than in control patients. CsA of RSPV, LSPV, LIPV and LAV were higher in permanent AF patients than in paroxysmal and persistent AF patients. (3) In the AF group, hs-CRP and TNF-α were positively correlated with LAV; MDA was positively correlated with CsA of LAA, LSPV and LAV; SOD was passively correlated with CsA of LAA and LAV; ox-LDL was positively correlated with CsA of LAA and LAV. Multivariate logistic regression analysis showed hs-CRP, ox-LDL, RSPV CsA, LIPV CsA and LAV were associated with AF.

CONCLUSIONS

Oxidative stress, inflammatory biomarkers and the sizes of the LA and PVs were significantly increased in AF patients. Hs-CRP, ox-LDL, RSPV CsA, LIPV CsA and LAV were associated with AF persistence.

What Does The Blanking Period Blank?

In the management of paroxysmal, drug-refractory atrial fibrillation, pulmonary vein isolation has become a widely accepted treatment option. Currently, the arrhythmias following any form of myocardial ablation are not considered within a period of three months, known as "the blanking period". Although this period is authority- rather than evidence-based, it has become universally recognized. Indeed, several mechanisms play a role to determine the transient increased risk of post-procedural atrial tachyarrhythmias, occurring early after the procedure. Acute inflammatory changes may be responsible for immediate recurrence, since application of ablative energy on atrial tissue has a pro-inflammatory- and potentially arrhythmogenic effect. Atrial arrhythmias within the first 3 months after ablation are very common (35% to 65% of cases) and their significance as predictor of late recurrences is more significant during the first month. Furthermore, the current biological evidences indicate that the edema of the surrounding and ablated tissue is no longer present after 1 month. In our letter we advocate the reasons why a blanking period of four weeks should appear more reasonable, fostering its clinical importance and utility.

Mechanisms and clinical significance of early recurrences of atrial arrhythmias after catheter ablation for atrial fibrillation

Early recurrence of atrial arrhythmias (ERAA) after ablation is common and strongly predicts late recurrences and ablation failure. However, since arrhythmia may eventually resolve in up to half of patients with ERAA, guidelines do not recommend immediate reintervention for ERAA episodes occurring during a 3-mo post-ablation blanking period. Certain clinical demographic, electrophysiologic, procedural, and ERAA-related characteristics may predict a higher likelihood of long-term ablation failure. In this review, we aim to discuss potential mechanisms of ERAA, and to summarize the clinical significance, prognostic implications, and treatment options for ERAA.

New-onset ventricular arrhythmias post radiofrequency catheter ablation for atrial fibrillation

As a new complication, new-onset ventricular arrhythmias (VAs) post atrial fibrillation (AF) ablation have not been well defined. This prospective study aimed to describe the details of new-onset VAs post AF ablation in a large study cohort.One thousand fifty-three consecutive patients who underwent the first radiofrequency catheter ablation for AF were enrolled. All patients had no evidence of pre-ablation VAs. New-onset VAs were defined as new-onset ventricular tachycardia (VT) or premature ventricular contractions (PVC) ≥1000/24 h within 1 month post ablation.There were 46 patients (4.4%) who had 62 different new-onset VAs, among whom 42 were PVC alone, and 4 were PVC coexisting with nonsustained VT. Multivariate analysis showed that increased serum leukocyte counts ≥50% post ablation were independently associated with new-onset VAs (OR: 1.9; 95% CI: 1.0-3.5; P = 0.043). The median number of PVC was 3161 (1001-27,407) times/24 h. Outflow tract VAs were recorded in 35 (76.1%) patients. No significant differences were found in origin of VAs (P = 0.187). VAs disappeared without any treatment in 6 patients (13.0%). No VAs-related adverse cardiac event occurred.The study revealed a noticeable prevalence but relatively benign prognosis of new-onset VAs post AF ablation. Increased serum leukocyte counts ≥50% post ablation appeared to be associated with new-onset VAs, implying that inflammatory response caused by ablation might be the mechanism.

Effect of remote ischemic preconditioning on myocardial injury and inflammatory response induced by ablation for atrial fibrillation: A randomized controlled trial

BACKGROUND

Remote ischemic preconditioning (RIPC) has been suggested to reduce postoperative release of cardiac and inflammatory markers in patients undergoing cardiac surgery. This study aimed to evaluate the effect of RIPC on nonischemic myocardial damage and inflammatory response in patients undergoing radiofrequency catheter ablation for paroxysmal atrial fibrillation (AF).

METHODS

Seventy-two patients with drug-refractory paroxysmal AF undergoing radiofrequency catheter ablation were randomized into RIPC or control groups. RIPC (intermittent arm ischemia through four cycles of 5-min inflation and 5-min deflation of a blood-pressure cuff) was performed once daily on 2 consecutive days before the ablation and immediately before ablation. Cardiac troponin-I (cTnI), high-sensitive C-reactive protein (hs-CRP), and interleukin (IL)-6 levels were measured before RIPC/sham RIPC, after the ablation, and 24 and 72h later. The early recurrence of atrial fibrillation (ERAF) in the two groups was observed over the subsequent 3months.

RESULTS

Radiofrequency ablation resulted in a significant rise in cTnI, hs-CRP, and IL-6 in both groups, which persisted for 72h. The RIPC group showed a lower increase in cTnI (P<0.001), hs-CRP (P=0.003), and IL-6 (P=0.008) than the control and tended to have a lower risk of ERAF (hazard ratio [HR]=0.77, 95% confidence interval [CI]: 0.32-1.88).

CONCLUSIONS

These results show that RIPC before ablation for paroxysmal AF significantly reduces the increase in cTnI, hs-CRP, and IL-6 associated with the procedure and results in a lower risk of ERAF. These findings suggest that RIPC could provide cardioprotection against nonischemic myocardial damage.

Efficacy of Short-Term Antiarrhythmic Drugs Use after Catheter Ablation of Atrial Fibrillation-A Systematic Review with Meta-Analyses and Trial Sequential Analyses of Randomized Controlled Trials

Background

The efficacy of short-term antiarrhythmic drugs (AADs) use compared with no-AADs prescription after catheter ablation of atrial fibrillation (AF) in preventing atrial arrhythmia recurrence is uncertain.

Methods

We searched PubMed, Embase, and the Cochrane Library through December 2015 to identify randomized controlled trials (RCTs) which evaluated the efficacy of short-term AADs use compared with no-AADs prescription after AF ablation in preventing atrial arrhythmia recurrence. The primary outcome was labeled as early atrial arrhythmia recurrence within 3 months after ablation. Secondary outcome was defined as late recurrence after 3 months of ablation. Random-effects model or fixed-effects model was used to estimate relative risks (RRs) with 95% confidence intervals (CIs).

Results

Six RCTs with 2,667 patients were included into this meta-analysis. Compared with no-AADs administration after AF ablation, short-term AADs use was associated with significant reduction of early atrial arrhythmia recurrence (RR, 0.68; 95% CI, 0.52–0.87; p = 0.003). Trial sequential analysis (TSA) showed that the cumulative Z-curve crossed the trial sequential monitoring boundary for benefit, establishing sufficient and conclusive evidence. However, compared with no-AADs prescription, short-term AADs use after AF ablation didn’t significantly reduce the risk of late atrial arrhythmia recurrence (RR, 0.92; 95% CI, 0.83–1.03; p = 0.15). TSA supported this result; meanwhile the estimated required information size (1,486 patients) was also met.

Conclusion

Short-term use of AADs after AF ablation can significantly decrease the risk of early atrial arrhythmia recurrence but not lead to corresponding reduction in risk of late atrial arrhythmia recurrence.

Early Recurrence After Pulmonary Vein Isolation of Paroxysmal Atrial Fibrillation With Different Ablation Technologies - Prospective Comparison of Radiofrequency vs. Second-Generation Cryoballoon Ablation

BACKGROUND

Inflammation plays a prominent role in the etiology of the early recurrence of atrial fibrillation (ERAF). We prospectively compared the proportion of ERAF and time-course patterns of biomarkers between radiofrequency (RF) and cryoballoon (CB) ablation.

METHODS AND RESULTS

We enrolled 82 consecutive paroxysmal AF patients undergoing pulmonary vein (PV) isolation, performed with either a 28-mm 2nd-generation CB and 3-min freeze technique or point-by-point RF ablation. Each group had 41 patients. In the RF group, all PVs were successfully isolated with 28.9 ± 6.5 min of RF delivery. In the CB group, a mean of 5.3 ± 1.4 applications/patient was delivered. The proportion of ERAF was similar between the groups. The time-course patterns significantly differed between the groups for high-sensitivity C-reactive protein (hs-CRP) value (P=0.006) and myocardial injury markers (P<0.0001). Greater myocardial injury was observed in the CB than in the RF group (P<0.0001), whereas the peak hs-CRP value was comparable between the groups. The 2-day post-procedure hs-CRP value was the sole factor correlating with ERAF as identified by the multivariable analysis (hazard ratio 1.697; 95% confidence interval, 1.005-2.865; P=0.048) in the RF, but not the CB group.

CONCLUSIONS

The proportion of ERAF was comparable after RF and 2nd-generation CB ablation. Despite CB ablation exhibiting greater myocardial injury than RF ablation, the inflammatory responses were comparable between the groups. The inflammatory response extent predicted ERAF post-RF ablation but not post-CB ablation.

Target-Based Drug Repositioning Using Large-Scale Chemical-Protein Interactome Data

Drug repositioning, or the identification of new indications for known drugs, is a useful strategy for drug discovery. In this study, we developed novel computational methods to predict potential drug targets and new drug indications for systematic drug repositioning using large-scale chemical-protein interactome data. We explored the target space of drugs (including primary targets and off-targets) based on chemical structure similarity and phenotypic effect similarity by making optimal use of millions of compound-protein interactions. On the basis of the target profiles of drugs, we constructed statistical models to predict new drug indications for a wide range of diseases with various molecular features. The proposed method outperformed previous methods in terms of interpretability, applicability, and accuracy. Finally, we conducted a comprehensive prediction of the drug-target-disease association network for 8270 drugs and 1401 diseases and showed biologically meaningful examples of newly predicted drug targets and drug indications. The predictive model is useful to understand the mechanisms of the predicted drug indications.

Effect of Short-Term Steroid Therapy on Early Recurrence During the Blanking Period After Catheter Ablation of Atrial Fibrillation

BACKGROUND

Early recurrence (ER) of atrial tachyarrhythmias during the first 3 months (blanking period) after atrial fibrillation ablation can be highly symptomatic, often requiring emergency treatment. Short-term steroid therapy may suppress ER during the blanking period.

METHODS AND RESULTS

We prospectively enrolled 138 patients who were randomly assigned to 2 groups (steroid group and control group). An intravenous bolus of 0.5 mg/kg of methylprednisolone for 2 days followed by 12 mg daily of oral methylprednisolone for 4 days was given to the steroid group patients. The primary end point was ER during the blanking period (3 months post ablation). During the blanking period, 51 of the 138 (37.0%) patients experienced ER after atrial fibrillation ablation. The steroid group had a lower rate of ER than the control group (15/64 [23.4%] versus 36/74 [48.6%], P=0.003). There was no difference between the 2 groups about late recurrence during a 24-month follow-up (log-rank test, P=0.918). In a multivariate analysis, short-term steroid therapy was independently associated with a lower rate of ER during the blanking period (adjusted OR, 0.45; 95% confidence interval, 0.25-0.83; P=0.01).

CONCLUSIONS

Periprocedural short-term moderate intensity steroid therapy reduces ER (≈3 months) after catheter ablation of atrial fibrillation. It is not effective in preventing late (3≈24 m) atrial fibrillation recurrence.

CLINICAL TRIAL REGISTRATION

URL: www.who.int/ictrp; Unique identifier: KCT0000107.

Prevention of immediate recurrence of atrial fibrillation with low-dose landiolol after radiofrequency catheter ablation

BACKGROUND

Immediate recurrence of atrial fibrillation (AF) after radiofrequency (RF) catheter ablation is commonly observed within 3 d after the procedure. The mechanism and pharmacological management of immediate AF recurrence remain unclear.

METHODS

A total of 50 consecutive patients with paroxysmal AF were randomized to receive either low-dose landiolol (landiolol group) or a placebo (placebo group). In the landiolol group, intravenous landiolol (0.5 μg kg(-1) min(-1)) was administered for 3 d after AF ablation.

RESULTS

No serious adverse event associated with RF catheter ablation or landiolol administration was observed. The prevalence of immediate AF recurrence (≤3 d after RF catheter ablation) was significantly lower in the landiolol group than in the placebo group (16% vs. 48%, p=0.015). Although the postprocedural change in heart rate was significantly lower in the landiolol group compared to that in the placebo group, the changes in blood pressure and body temperature were not different between the two groups. Multiple logistic regression analysis revealed that landiolol treatment was the only independent predictor of immediate AF recurrence after ablation (odds ratio: 0.180; 95% confidence interval: 0.044-0.729; p=0.016).

CONCLUSIONS

Prophylactic administration of low-dose landiolol after AF ablation may be effective and safe for preventing immediate AF recurrence within 3 d after AF ablation.

eNOS3 Genetic Polymorphism Is Related to Post-Ablation Early Recurrence of Atrial Fibrillation

PURPOSE

Previous studies have demonstrated an association between eNOS polymorphisms and atrial fibrillation (AF). We sought to determine whether eNOS polymorphisms are associated with AF recurrence after a radiofrequency catheter ablation (RFCA).

MATERIALS AND METHODS

A total of 500 consecutive patients (56±11 years, 77% male) with paroxysmal (68%) or persistent (32%) AF who underwent RFCA and 500 age, gender-matched controls were genotyped for the eNOS3 single nucleotide polymorphism (rs1799983). AF recurrence was monitored according to 2012 ACC/AHA/ESC guidelines.

RESULTS

The frequencies of the rs1799983 variant alleles (T) in the case and control group were not significantly different (OR 1.05, 95% CI 0.75-1.46, p=0.798). AF patients with rs1799983 variants were more likely to have coronary artery disease or stroke than those without genetic variant at this gene (31.0% vs. 17.3%, p=0.004). During mean 17 months follow-up, early recurrence of AF (ERAF; within 3 months) and clinical recurrence (CR) of AF were 31.8% and 24.8%, respectively. The rs1799983 variant was associated with higher risk of ERAF (OR 1.71, 95% CI 1.06-2.79, p=0.028), but not with CR. ERAF occurred earlier (11±16 days) in variant group than those without variant allele (20±25 days, p=0.016). A multiple logistic regression analysis showed that presence of the rs1799983 variant (OR 1.75, 95% CI 1.07-2.86, p=0.026) and persistent AF were independent predictors for ERAF after AF ablation.

CONCLUSION

The rs1799983 variant of the eNOS3 gene was associated with ERAF, but not with CR, after RFCA. eNOS3 gene variants may have a potential role for stratification of post-ablation management.

Risk of incident atrial fibrillation in gout: a cohort study

OBJECTIVE

Atrial fibrillation (AF) is the most common arrhythmia associated with cardiovascular disease and mortality. Recent studies suggest an association between inflammation, hyperuricaemia and AF, but little is known whether gout is associated with AF risk.

METHODS

Using data from a US commercial insurance plan (2004-2013), we conducted a cohort study to evaluate the risk of incident AF in patients with gout versus osteoarthritis. Patients with gout or osteoarthritis were identified with ≥2 diagnoses and ≥1 dispensing for gout or osteoarthritis medications. Incident AF was defined as a new AF diagnosis and a new dispensing for anticoagulants or antiarrhythmics. The risk of incident AF in gout was also compared with the non-gout group.

RESULTS

We identified 70 015 patients with gout and 210 045 with osteoarthritis, matched on age, sex and index date. The mean age was 57 years, and 81% were men. Over the mean 2-year follow-up, the incidence rate of AF per 1000 person-years was 7.19 in gout and 5.87 in osteoarthritis. The age, sex and index date-matched HR of AF was 1.23 (95% CI 1.14 to 1.32) in gout versus osteoarthritis. In a multivariable Cox regression, adjusting for age, sex, comorbidities, medications and healthcare usage, the HR of AF in gout was 1.13 (95% CI 1.04 to 1.23). When compared with non-gout, the multivariable HR of AF in gout was also increased (HR 1.21, 95% CI 1.11 to 1.33).

CONCLUSIONS

In this large population-based cohort study, gout was associated with a modestly increased risk of incident AF compared with osteoarthritis and non-gout after adjusting for other risk factors.

Early recurrence of atrial arrhythmias following pulmonary vein antral isolation: Timing and frequency of early recurrences predicts long-term ablation success

BACKGROUND

Early recurrence of atrial arrhythmia (ERAA) is common after atrial fibrillation (AF) ablation and is associated with long-term recurrence. However, the association between timing or frequency of ERAA and long-term ablation success remains unclear.

OBJECTIVE

We aimed to examine whether timing or frequency of ERAA after pulmonary vein antral isolation (PVAI) affects long-term ablation success.

METHODS

Three hundred AF patients (100 paroxysmal, 100 persistent, 100 long-standing persistent; mean age 59.5 ± 9.6 years, 79% male) undergoing PVAI were included. All patients underwent 30-day monitoring with mobile continuous outpatient telemetry after PVAI and were followed for >1 year. ERAA was defined as AF or organized atrial tachycardia (OAT) in the first 6 weeks, and was categorized as early (weeks 1-2), intermediate (weeks 3-4), or late (weeks 5-6). Long-term ablation success was defined as the absence of AF/OAT lasting >30 seconds off antiarrhythmic drugs 1 year after a single ablation (excluding first 6 weeks).

RESULTS

ERAA occurred in 169 patients (53%); of those, 79 (46.7%) had single ERAA and 90 (53.3%) had multiple ERAAs. ERAA occurred less commonly with paroxysmal versus persistent or long-standing persistent AF (46% vs 57% and 66%; P = .017). ERAA was associated with worse ablation success at 1 year (38.1% vs 79.5% [no ERAA]; P < .001). Multiple (vs single) ERAA more strongly predicted long-term ablation failure (OR: 4.5; 95% CI [2.3-8.8]).

CONCLUSIONS

ERAA after PVAI is associated with decreased long-term ablation success. Patients experiencing multiple ERAA events are at greatest risk for long-term arrhythmia recurrence and represent a subgroup in whom early reablation may be considered.

Comparison of two different doses of single bolus steroid injection to prevent atrial fibrillation recurrence after radiofrequency catheter ablation

PURPOSE

Steroids may play a role in preventing the early recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA). However, optimal doses and route of steroid delivery have not yet been determined. This study evaluated the effect of two different doses of a single bolus injection of steroids on AF recurrence after RFCA.

MATERIALS AND METHODS

Of 448 consecutive AF patients who underwent RFCA, a single steroid bolus was injected into 291 patients. A low-dose steroid group (n=113) received 100 mg of hydrocortisone and a moderate-dose steroid group (n=174) received 125 mg of methylprednisolone. We used propensity-score matching to select patients as follows: control (n=95), low-dose (n=95), and moderate-dose steroid groups (n=97).

RESULTS

Pericarditis developed in 1 (1.1%) control patient, 2 (2.1%) low-dose patients and 0 moderate-dose patients. Maximum body temperature and C-reactive protein were significantly decreased in the moderate-dose steroid group compared to the other groups (p<0.01). The number of patients of early AF recurrence (≤3 months) did not differ among three groups. Early recurrence was 24 (25%) in the control, 24 (25%) in the low-dose and 25 (26%) in the medium-dose groups (p=0.99). Compared with control group, low-dose or moderate-dose steroid treatment did not effectively decrease mid-term (3-12 months) AF recurrence [22 (23%) vs. 23 (24%) vs. 18 (19%); p=0.12].

CONCLUSION

A single injection of moderate-dose steroid decreased inflammation. However, single bolus injections of low-dose or moderate-dose steroids were not effective in preventing immediate, early or midterm AF recurrence after RFCA.

Role of inflammation in atrial fibrillation pathophysiology and management

Atrial fibrillation (AF) is the most common clinically relevant arrhythmia, but the methods available for treating AF and its complications (of which the most important is thrombogenesis), as well as for assessing AF risk and underlying pathophysiology, are largely limited. Emerging evidence suggests a significant role of inflammation in the pathogenesis of AF. That evidence includes elevated serum levels of inflammatory biomarkers in AF subjects, the expression of inflammatory markers in cardiac tissues of AF patients and animal models of AF, and beneficial effects of anti-inflammatory drugs in experimental AF paradigms. Inflammation is suggested to be linked to various pathological processes, such as oxidative stress, apoptosis, and fibrosis, that promote AF substrate formation. Inflammation has also been associated with endothelial dysfunction, platelet activation, and coagulation cascade activation, leading to thrombogenesis. Thus, inflammation may contribute to both the occurrence/maintenance of AF and its thromboembolic complications. Here, we review the evidence for a role of inflammation and inflammatory biomarkers in the risk management and treatment of AF. We also summarize the current knowledge of inflammation-dependent cellular and molecular mechanisms in AF pathophysiology and their potential as therapeutic targets.

Inflammation and the pathogenesis of atrial fibrillation

Atrial fibrillation (AF) is the most common cardiac arrhythmia. However, the development of preventative therapies for AF has been disappointing. The infiltration of immune cells and proteins that mediate the inflammatory response in cardiac tissue and circulatory processes is associated with AF. Furthermore, the presence of inflammation in the heart or systemic circulation can predict the onset of AF and recurrence in the general population, as well as in patients after cardiac surgery, cardioversion, and catheter ablation. Mediators of the inflammatory response can alter atrial electrophysiology and structural substrates, thereby leading to increased vulnerability to AF. Inflammation also modulates calcium homeostasis and connexins, which are associated with triggers of AF and heterogeneous atrial conduction. Myolysis, cardiomyocyte apoptosis, and the activation of fibrotic pathways via fibroblasts, transforming growth factor-β and matrix metalloproteases are also mediated by inflammatory pathways, which can all contribute to structural remodelling of the atria. The development of thromboembolism, a detrimental complication of AF, is also associated with inflammatory activity. Understanding the complex pathophysiological processes and dynamic changes of AF-associated inflammation might help to identify specific anti-inflammatory strategies for the prevention of AF.

Hybrid therapy in the management of atrial fibrillation

Atrial fibrillation is the most common sustained arrhythmia. Because of the sub-optimal outcomes and associated risks of medical therapy as well as the recent advances in non-pharmacologic strategies, a multitude of combined (hybrid) algorithms have been introduced that improve efficacy of standalone therapies while maintaining a high safety profile. Antiarrhythmic administration enhances success rate of electrical cardioversion. Catheter ablation of antiarrhythmic drug-induced typical atrial flutter may prevent recurrent atrial fibrillation. Through simple ablation in the right atrium, suppression of atrial fibrillation may be achieved in patients with previously ineffective antiarrhythmic therapy. Efficacy of complex catheter ablation in the left atrium is improved with antiarrhythmic drugs. Catheter ablation followed by permanent pacemaker implantation is an effective and safe treatment option for selected patients. Additional strategies include pacing therapies such as atrial pacing with permanent pacemakers, preventive pacing algorithms, and/or implantable dual-chamber defibrillators are available. Modern hybrid strategies combining both epicardial and endocardial approaches in order to create a complex set of radiofrequency lesions in the left atrium have demonstrated a high rate of success and warrant further research. Hybrid therapy for atrial fibrillation reviews history of development of non-pharmacological treatment strategies and outlines avenues of ongoing research in this field.

Pericardial fat volume is associated with clinical recurrence after catheter ablation for persistent atrial fibrillation, but not paroxysmal atrial fibrillation: an analysis of over 600-patients

BACKGROUND

Although pericardial fat volume (PFV) has been suggested to be associated with atrial fibrillation (AF), only a few studies have reported the association between pericardial fat and clinical outcome after radiofrequency catheter ablation (RFCA). The purpose of this study was to explore the factors associated with PFV and its prognostic significance after catheter ablation for AF, depending on the types of AF.

METHODS

We included 665 patients (76.7% male, 57.3±11.1 years of age, 67.7% with paroxysmal AF [PAF] and 32.3% with persistent AF [PeAF]) who underwent RFCA for AF, and compared PFV with clinical variables. The factors associated with clinical recurrence of AF were evaluated.

RESULTS

1. PFV (10 cm3) was independently correlated with age (B=0.09, 95% CI 0.06-0.13, p<0.001), body mass index (BMI) (B=0.25, 95% CI 0.12-0.38, p<0.001), body surface area (BSA) (B=10.51, 95% CI 7.64-13.39, p<0.001), and left atrial (LA) dimension (B=0.09, 95% CI 0.03-0.14, p=0.003). 2. During the 19.3±8.5 month follow-up period, the clinical recurrence rate was 26.5%. PFV (HR 1.06; 95% CI 1.02-1.10, p= 0.004) and PeAF (HR 1.86; 95% CI 1.31-2.62, p<0.001) were independent predictors of clinical recurrence after RFCA. 3. PFV was significantly greater in PeAF patients with recurrence compared to those without (p=0.001), but, not in the PAF group (p=0.212). 4. PFV was independently associated with post-ablation recurrence only in PeAF (HR 1.10; 95% CI 1.05-1.16, p<0.001).

CONCLUSIONS

PFV was independently associated with old age, greater LA dimension, and high BMI and BSA, and a significant predictor for AF recurrence after catheter ablation for PeAF.

Relation of chronic obstructive pulmonary disease to atrial and ventricular arrhythmias

Chronic obstructive pulmonary disease (COPD) is associated with increased cardiovascular morbidity and mortality, yet the exact pathophysiological links remain unclear. Whether the presence and severity of COPD are associated with atrial or ventricular arrhythmias recorded on continuous electrocardiographic monitoring is unknown. We identified consecutive adult patients who underwent clinically indicated pulmonary function testing as well as 24-hour Holter monitoring at the Mayo Clinic, Rochester, from 2000 to 2009. Demographic data and relevant co-morbidities were gathered from the electronic medical record; severity of COPD was classified according to the GOLD classification, and arrhythmias were classified in concordance with the current clinical guidelines. From 7,441 patients who were included (age 64±16 years, 49% woman, 92% Caucasian), COPD was diagnosed in 3,121 (41.9%). Compared with those without COPD, the presence and severity of COPD were associated with increased likelihood of atrial fibrillation/atrial flutter (AF/AFL; 23.3% vs 11.0%, respectively, p<0.0001), nonsustained ventricular tachycardia (NSVT; 13.0% vs 5.9%, respectively, p<0.0001), and sustained ventricular tachycardia (0.9% vs 1.6%, respectively, p<0.0001). COPD remained a significant predictor of AF/AFL and NSVT (p<0.0001 and p<0.0001, respectively) after adjusting for age, gender, tobacco use, obesity, hypertension, coronary artery disease, heart failure, diabetes, anemia, cancer, chronic kidney disease, and rate/rhythm control medications. In conclusion, the independent association between the presence and severity of COPD and arrhythmias (AF/AFL and NSVT) provides further insight into the markedly increased cardiovascular mortality of patients with COPD. Further studies should explore which anti-arrhythmic strategies would best apply to the patients with COPD.

Targeting inflammation and oxidative stress in atrial fibrillation: role of 3-hydroxy-3-methylglutaryl-coenzyme a reductase inhibition with statins

SIGNIFICANCE

Atrial fibrillation (AF) is a burgeoning health-care problem, and the currently available therapeutic armamentarium is barely efficient. Experimental and clinical evidence implicates inflammation and myocardial oxidative stress in the pathogenesis of AF.

RECENT ADVANCES

Local and systemic inflammation has been found to both precede and follow the new onset of AF, and NOX2-dependent generation of reactive oxygen species in human right atrial samples has been independently associated with the occurrence of AF in the postoperative period in patients undergoing cardiac surgery. Anti-inflammatory and antioxidant agents can prevent atrial electrical remodeling in animal models of atrial tachypacing and the new onset of AF after cardiac surgery, suggesting a causal relationship between inflammation/oxidative stress and the atrial substrate that supports AF.

CRITICAL ISSUES

Statin therapy, by redressing the myocardial nitroso-redox balance and reducing inflammation, has emerged as a potentially effective strategy for the prevention of AF. Evidence indicates that statins prevent AF-induced electrical remodeling in animal models of atrial tachypacing and may reduce the new onset of AF after cardiac surgery. However, whether statins have antiarrhythmic properties in humans has yet to be conclusively demonstrated, as data from randomized controlled trials specifically addressing the relevance of statin therapy for the primary and secondary prevention of AF remain scanty.

FUTURE DIRECTIONS

A better understanding of the mechanisms underpinning the putative antiarrhythmic effects of statins may afford tailoring AF treatment to specific clinical settings and patient's subgroups. Large-scale randomized clinical trials are needed to support the indication of statin therapy solely on the basis of AF prevention.

Antiarrhythmic therapy following ablation of atrial fibrillation

Antiarrhythmic drugs (AADs) are often used after ablation for atrial fibrillation (AF); the drugs employed vary, but most common are the drugs that were unsuccessful prior to ablation since it seems that the efficacy of AADs might substantially increase after catheter ablation of AF. AADs reduce early recurrences of atrial tachyarrhythmias after AF catheter ablation, whereas they did not prevent arrhythmia recurrences occurring later. Several upstream therapies (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, corticosteroids and colchicine) have been tested with conflicting results. To date, there is no sufficient evidence to support the use of any upstream therapy after AF catheter ablation. Larger registries and controlled clinical trials in well-defined patient groups and with well-defined outcome parameters are required to further elucidate the role of AADs after AF ablation.

Colchicine for prevention of atrial fibrillation recurrence after pulmonary vein isolation: mid-term efficacy and effect on quality of life

BACKGROUND

Our group previously showed that colchicine treatment is associated with decreased early recurrence rate after ablation for atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to test the mid-term efficacy of colchicine in reducing AF recurrences after a single procedure of pulmonary vein isolation in patients with paroxysmal AF. Assessment of quality-of-life (QOL) changes was a secondary objective.

METHODS

Patients with paroxysmal AF who were scheduled for ablation were randomized to a 3-month course of colchicine 0.5 mg twice daily or placebo and were followed for a median of 15 months (with a 3-month blanking period). QOL was assessed with a general-purpose health-related QOL tool (26-item World Health Organization QOL questionnaire) at baseline and after 3 and 12 months.

RESULTS

Two hundred twenty-three randomized patients underwent ablation, and 206 patients were available for analysis (144 male, age 62.2 ± 5.8 years). AF recurrence rate in the colchicine group was 31.1% (32/103) vs 49.5% (51/103) in the control group (P = .010), translated in a relative risk reduction of 37% (odds ratio 0.46, 95% confidence interval 0.26-0.81). The number needed to treat was 6 (95% confidence interval 3.2-19.8). Physical domain QOL scores at 12 months were 63.6 ± 13.8 in the colchicine group and 52.5 ± 18.1 in controls, whereas psychological domain scores were 56.1 ± 13.7 vs 44.7 ± 17.3, respectively (P <.001, for both).

CONCLUSION

Colchicine treatment after pulmonary vein isolation for paroxysmal AF is associated with lower AF recurrence rates after a single procedure. This reduction is accompanied by corresponding improvements in physical and psychological health-related QOL scores.

Time course of inflammation, myocardial injury, and prothrombotic response after radiofrequency catheter ablation for atrial fibrillation

BACKGROUND

Inflammation has been linked to the genesis of stroke in atrial fibrillation (AF) and is implicated in early recurrent arrhythmia after AF ablation. We aimed to define the time course of inflammation, myocardial injury, and prothrombotic markers after radiofrequency ablation for AF and its relation to AF recurrence.

METHODS AND RESULTS

Ninety consecutive AF patients (53% paroxysmal) undergoing radiofrequency ablation were recruited. High-sensitivity C-reactive protein (hs-CRP), Troponin-T, creatine kinase-MB, fibrinogen, and D-Dimer concentrations were measured at baseline, at 1, 2, 3, 7 days, and at 1 month after ablation. AF recurrence was documented at 3 days and at 1, 3, and 6 months follow-up. Troponin-T and creatine kinase-MB peaked at day 1 after procedure (both P<0.05). Hs-CRP peaked at day 3 after procedure (P<0.05). Fibrinogen (P<0.05) and D-Dimer (P<0.05) concentrations were significantly elevated at 1 week after procedure. Ln hs-CRP elevation correlated with Ln Troponin-T and fibrinogen elevation. The extent of Ln hs-CRP, Ln Troponin-T, and fibrinogen elevation predicted early AF recurrence within 3 days after procedure (P<0.05, respectively), but not at 3 and 6 months.

CONCLUSIONS

Patients undergoing radiofrequency ablation for AF exhibit an inflammatory response within 3 days. The extent of inflammatory response predicts early AF recurrence but not late recurrence. Prothrombotic markers are elevated at 1 week after ablation and may contribute to increased risk of early thrombotic events after AF ablation.

Atrial fibrillation

Atrial fibrillation is the most common arrhythmia affecting patients today. Disease prevalence is increasing at an alarming rate worldwide, and is associated with often catastrophic and costly consequences, including heart failure, syncope, dementia, and stroke. Therapies including anticoagulants, anti-arrhythmic medications, devices, and non-pharmacologic procedures in the last 30 years have improved patients' functionality with the disease. Nonetheless, it remains imperative that further research into AF epidemiology, genetics, detection, and treatments continues to push forward rapidly as the worldwide population ages dramatically over the next 20 years.

Structural and Functional Remodeling of the Left Atrium: Clinical and Therapeutic Implications for Atrial Fibrillation

Atrial fibrillation (AF) is the most commonly encountered arrhythmia in clinical practice. Despite advances in our understanding of the pathophysiology of this complex arrhythmia, current therapeutic options remain suboptimal. This review aimed to delineate the atrial structural and functional remodeling leading to the perpetuation of AF. We explored the complex changes seen in the atria in various substrates for AF and the therapeutic options available to prevent these changes or for reverse remodeling. Here we also highlighted the emerging role of aggressive risk factor management aimed at the arrhythmogenic atrial substrate to prevent or retard AF progression.

Atrial fibrillation from the pathologist's perspective

Atrial fibrillation (AF), the most common sustained cardiac arrhythmia encountered in clinical practice, is associated with increased morbidity and mortality. Electrophysiologically, it is characterized by a high rate of asynchronous atrial cell depolarization causing a loss of atrial contractile function and irregular ventricular rates. For a long time, AF was considered as a pure functional disorder without any structural background. Only in recent years, have new mapping and imaging techniques identified atrial locations, which are very often involved in the initiation and maintenance of this supraventricular arrhythmia (i.e. the distal portion of the pulmonary veins and the surrounding atrial myocardium). Morphological analysis of these myocardial sites has demonstrated significant structural remodeling as well as paved the way for further knowledge of AF natural history, pathogenesis, and treatment. This architectural myocardial disarrangement is induced by the arrhythmia itself and the very frequently associated cardiovascular disorders. At the same time, the structural remodeling is also capable of sustaining AF, thereby creating a sort of pathogenetic vicious circle. This review focuses on current understanding about the structural and genetic bases of AF with reference to their classification, pathogenesis, and clinical implications.

Corticosteroid use during pulmonary vein isolation is associated with a higher prevalence of dormant pulmonary vein conduction

BACKGROUND

Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is associated with PV to left atrium reconduction.

OBJECTIVE

The purpose of this study was to prospectively determine if the use of intraprocedural corticosteroids to limit the extent of tissue edema and/or inflammation alters the prevalence of spontaneous and adenosine-induced acute PV reconnection after PVI.

METHODS

Prior to wide circumferential PVI, 45 patients received a single intravenous (IV) bolus of hydrocortisone 250 mg immediately after transseptal access (steroid group). Another 45 consecutive patients underwent standard PVI without IV hydrocortisone (nonsteroid group). After PVI, all patients underwent adenosine testing to unmask dormant conduction. Patients were followed at 3, 6, and 12 months.

RESULTS

Dormant conduction was unmasked in a significantly higher proportion of PVs in the steroid group compared with the nonsteroid group (32.8% of PVs [60/183] vs 21.1% of PVs [37/175], P = .03). On multivariate generalized estimating equation analysis, steroid use remained independently associated with dormant PV conduction (P = .03). There was no difference in the segmental distribution of reconnection between the 2 groups. The 1-year freedom from recurrent AF did not differ between groups (P = .37). Radiofrequency time was significantly longer in the steroid group (58 ± 21 minutes vs 48 ± 18 minutes, P <.01), whereas procedure duration and fluoroscopy time were comparable (P = .55 and P = .44, respectively).

CONCLUSION

A single bolus of hydrocortisone 250 mg IV prior to PVI results in greater radiofrequency requirements for PVI and a higher prevalence of dormant PV conduction unmasked by adenosine. The utility of these approaches requires evaluation in a long-term prospective randomized study.

Human atrial fibrillation substrate: towards a specific fibrotic atrial cardiomyopathy

The atrial structure/substrate of patients with atrial fibrillation (AF) and clinically similar characteristics can present very differently, and also the 'phenotype' (i.e. paroxysmal, persistent, and long standing persistent) of the arrhythmia cannot comprehensively explain these differences. It was unclear why some patients stay in paroxysmal AF for decades, whereas other patients with the same characteristics progress to persistent AF within a few months. In this review, evidence is described that AF patients without apparent structural heart disease have a chronic fibrotic bi-atrial substrate. There is also evidence from intraoperatively obtained specimen analysis, post-mortem autopsy findings, electroanatomic mapping studies, and delayed enhancement-MRI investigations that a higher mean value of fibrosis is detected in patients with persistent vs. paroxysmal AF but that the variability in the extend of fibrosis is always very high with part of paroxysmal AF patients having massive fibrosis and part of persistent AF patients showing mild fibrosis. In addition, patients undergoing ablation very early after the first AF episodes show already significant fibrosis. These data do not support a causal relationship that AF (significantly) produces fibrosis in the sense of 'AF begets AF' instead of being a consequence of the fibrotic process. In patients with mitral stenosis, evidence for reverse atrial remodelling after commissurotomy was reported, however, in patients with 'lone' AF, the atrial substrate progressed after successful AF elimination indicating towards the independent/progressive disease process of an underlying structural atrial disease called fibrotic atrial cardiomyopathy. Other 'conventional wisdoms' also need to be re-considered including the aetiological role of age and arterial hypertension for human structural atrial remodelling.

Effect of eplerenone on maintenance of sinus rhythm after catheter ablation in patients with long-standing persistent atrial fibrillation

Several studies have demonstrated a relation between the rennin-angiotensin-aldosterone system and atrial fibrillation (AF), but there are no reports on the effect of eplerenone, a selective aldosterone blocker, on the prevention of AF recurrence after radiofrequency catheter ablation (RFCA). The aim of this study was to evaluate the effects of eplerenone on clinical outcomes after RFCA in patients with long-standing persistent AF. A total of 161 consecutive patients with long-standing persistent AF (sustained AF duration 1 to 20 years, mean 3.4 ± 3.8) who underwent RFCA were investigated. Eplerenone was used in 55 patients and not used in the remaining 106 patients. Other conventional pharmacologic agents, including angiotensin-converting enzyme inhibitors or angiotensin type 1 receptor blockers, were used equally in the 2 groups. After 24 months of follow-up, 47% of the patients were free from AF recurrence. The rate of freedom from AF recurrence was significantly greater in the eplerenone group (60%) than in the noneplerenone group (40%) (p = 0.011). By univariate analysis, the duration of sustained AF (p <0.001), left atrial diameter (p = 0.010), left atrial volume index (p = 0.017), and early AF recurrence (p <0.001) were significantly associated with AF recurrence, and the use of eplerenone was associated with maintenance of sinus rhythm after RFCA (p = 0.022). Multivariate Cox regression analysis showed that longer duration of sustained AF (>3 years) (p <0.001) and early AF recurrence (p <0.001) were significantly associated with AF recurrence, and only eplerenone therapy significantly improved maintenance of sinus rhythm (p = 0.017). In conclusion, eplerenone significantly improved maintenance of sinus rhythm after RFCA in patients with long-standing persistent AF.