HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical ablation of atrial fibrillation: recommendations for personnel, policy, procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force on catheter and surgical ablation of atrial fibrillation

Pulsed Field vs Conventional Thermal Ablation for Paroxysmal Atrial Fibrillation: Recurrent Atrial Arrhythmia Burden

BACKGROUND

The ADVENT randomized trial revealed no significant difference in 1-year freedom from atrial arrhythmias (AA) between thermal (radiofrequency/cryoballoon) and pulsed field ablation (PFA). However, recent studies indicate that the postablation AA burden is a better predictor of clinical outcomes than the dichotomous endpoint of 30-second AA recurrence.

OBJECTIVES

The goal of this study was to determine: 1) the impact of postablation AA burden on outcomes; and 2) the effect of ablation modality on AA burden.

METHODS

In ADVENT, symptomatic drug-refractory patients with paroxysmal atrial fibrillation underwent PFA or thermal ablation. Postablation transtelephonic electrocardiogram monitor recordings were collected weekly or for symptoms, and 72-hour Holters were at 6 and 12 months. AA burden was calculated from percentage AA on Holters and transtelephonic electrocardiogram monitors. Quality-of-life assessments were at baseline and 12 months.

RESULTS

From 593 randomized patients (299 PFA, 294 thermal), using aggregate PFA/thermal data, an AA burden exceeding 0.1% was associated with a significantly reduced quality of life and an increase in clinical interventions: redo ablation, cardioversion, and hospitalization. There were more patients with residual AA burden <0.1% with PFA than thermal ablation (OR: 1.5; 95% CI: 1.0-2.3; P = 0.04). Evaluation of outcomes by baseline demographics revealed that patients with prior failed class I/III antiarrhythmic drugs had less residual AA burden after PFA compared to thermal ablation (OR: 2.5; 95% CI: 1.4-4.3; P = 0.002); patients receiving only class II/IV antiarrhythmic drugs pre-ablation had no difference in AA burden between ablation groups.

CONCLUSIONS

Compared with thermal ablation, PFA more often resulted in an AA burden less than the clinically significant threshold of 0.1% burden. (The FARAPULSE ADVENT PIVOTAL Trial PFA System vs SOC Ablation for Paroxysmal Atrial Fibrillation [ADVENT]; NCT04612244).

Use of wearable technology in cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source: a systematic review

INTRODUCTION

Prolonged cardiac monitoring after cryptogenic stroke or embolic stroke of undetermined source (ESUS) is necessary to identify atrial fibrillation (AF) that requires anticoagulation. Wearable devices may improve AF detection compared to conventional management. We aimed to review the evidence for the use of wearable devices in post-cryptogenic stroke and post-ESUS monitoring.

METHODS

We performed a systematic search of PubMed, EMBASE, Scopus and clinicaltrials.gov on 21 July 2022, identifying all studies that investigated the use of wearable devices in patients with cryptogenic stroke or ESUS. The outcomes of AF detection were analysed. Literature reports on electrocardiogram (ECG)-based (external wearable, handheld, patch, mobile cardiac telemetry [MCT], smartwatch) and photoplethysmography (PPG)-based (smartwatch, smartphone) devices were summarised.

RESULTS

A total of 27 relevant studies were included (two randomised controlled trials, seven prospective trials, 10 cohort studies, six case series and two case reports). Only four studies compared wearable technology to Holter monitoring or implantable loop recorder, and these studies showed no significant differences on meta-analysis (odds ratio 2.35, 95% confidence interval [CI] 0.74-7.48, I 2 = 70%). External wearable devices detected AF in 20.7% (95% CI 14.9-27.2, I 2 = 76%) of patients and MCT detected new AF in 9.6% (95% CI 7.4%-11.9%, I 2 = 56%) of patients. Other devices investigated included patch sensors, handheld ECG recorders and PPG-based smartphone apps, which demonstrated feasibility in the post-cryptogenic stroke and post-ESUS setting.

CONCLUSION

Wearable devices that are ECG or PPG based are effective for paroxysmal AF detection after cryptogenic stroke and ESUS, but further studies are needed to establish how they compare with Holter monitors and implantable loop recorder.

Potential Role of Left Atrial Strain to Predict Atrial Fibrillation Recurrence after Catheter Ablation Therapy: A Clinical and Systematic Review

Pulmonary vein isolation (PVI) with catheter ablation (CA) represents an effective therapy for atrial fibrillation (AF). Unfortunately, it is still not exempt from severe complications. The balance of risks and benefits should be assessed, and a patient-tailored approach is desirable. So far, several clinical and cardiac imaging parameters have been evaluated to investigate pre- and post-procedural features that could help clinicians in the selection of patients at high risk of a poor outcome after CA. This clinical and systematic review analyses the potential role of new LA parameters, such as LA reservoir strain, to predict AF recurrence after CA therapy. Notably, LA reservoir strain gains substantial clinical importance in patients with paroxysmal AF and when a low CHADS2-VASc score is retrieved. LA reservoir strain provides data concerning the risk of AF recurrence after PVI and, thus, in the management of long-term medical therapy in this patient's group.

Association of Left Atrial Appendage Morphology and Function With Stroke and Transient Ischemic Attack in Atrial Fibrillation Patients

We aimed to correlate left atrial appendage (LAA) structure and function with the history of stroke/transient ischemic attack (TIA) in patients with atrial fibrillation (AF). We analyzed the data of 649 patients with AF who were scheduled for catheter ablation. Patients underwent cardiac computed tomography and transesophageal echocardiography before ablation. The LAA morphologies depicted by cardiac computed tomography were categorized into 4 groups: cauliflower, chicken wing, swan, and windsock shapes. The mean age was 61.3 ± 10.5 years, 33.9% were women. The prevalence of stroke/TIA was 7.1%. After adjustment for the main risk factors, the LAA flow velocity ≤35.3 cm/s (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.09 to 4.61, p = 0.033) and the swan LAA shape (OR 2.69, 95% CI 0.96 to 6.86, p = 0.047) independently associated with a higher risk of stroke/TIA, whereas the windsock LAA morphology proved to be protective (OR 0.32, 95% CI 0.12 to 0.77, p = 0.017) compared with the cauliflower LAA shape. Comparing the differences between the LAA morphology groups, we measured a significantly smaller LAA orifice area (389.3 ± 137.7 mm2 in windsock vs 428.3 ± 158.9 ml in cauliflower, p = 0.021) and LAA volume (7.4 ± 3.0 mm2 in windsock vs 8.5 ± 4.8 mm2 in cauliflower, p = 0.012) in patients with windsock LAA morphology, whereas the LAA flow velocity did not differ significantly. Reduced LAA function and swan LAA morphology were independently associated with a higher prevalence of stroke/TIA, whereas the windsock LAA shape proved to be protective. Comparing the differences between the various LAA morphology types, significantly lower LAA volume and LAA orifice area were measured in the windsock LAA shape than in the cauliflower LAA shape.

Global research progress on radiofrequency ablation in cardiology: A bibliometric analysis (2004-2023)

In recent years, significant advancements in radiofrequency ablation technology have notably enhanced arrhythmia treatment in cardiology. Technological advancements and increasing clinical adoption have made radiofrequency ablation a key therapy in improving life quality for patients with conditions like atrial fibrillation (AF). Consequently, there has been a marked increase in research output, underscoring the technology's significance and its potential in cardiology. Aims to comprehensively analyze cardiology's radiofrequency ablation research trends, identifying leading countries and institutions in international collaborations, key researchers' contributions, and evolving research hotspots. The study, based on the Web of Science Core Collection database, reviewed the literatures from 2004 to 2023. CiteSpace 6.2.R7 Basic was used for bibliometric analysis, which examined annual publication trends, international collaboration networks, key authors, leading research institutions, major journals, keyword co-occurrence and clustering trends. Analyzing 3423 relevant articles, this study reveals a consistent growth in cardiology radiofrequency ablation research since 2004. The analysis shows that the United States, Germany, and France hold central roles in the international collaboration network, with leading authors from premier US and European institutions. Keyword cluster analysis identifies "atrial flutter" and "ventricular tachycardia" as current research focal points. Cardiology radiofrequency ablation research shows a growth trend, led by the United States and European countries. Research hotspots are concentrated on the diverse applications of radiofrequency ablation technology and the treatment of AF. Future studies may increasingly focus on technological innovation and the deepening of clinical applications.

Impact of Comorbid Sleep-Disordered Breathing and Atrial Fibrillation on the Long-Term Outcome After Ischemic Stroke

BACKGROUND

Sleep-disordered breathing (SDB) and atrial fibrillation (AF) are highly prevalent in patients with stroke and are recognized as independent risk factors for stroke. Little is known about the impact of comorbid SDB and AF on long-term outcomes after stroke.

METHODS

In this prospective cohort study, 353 patients with acute ischemic stroke or transient ischemic attacks were analyzed. Patients were screened for SDB by respiratory polygraphy during acute hospitalization. Screening for AF was performed using a 7-day ECG up to 3× in the first 6 months. Follow-up visits were scheduled at 1, 3, 12, 24, and 36 months poststroke. Cox regression models adjusted for various factors (age, sex, body mass index, hypertension, diabetes, dyslipidemia, and heart failure) were used to assess the impact of comorbid SDB and AF on subsequent death or cerebro-cardiovascular events.

RESULTS

Among 353 patients (299 ischemic stroke and 54 transient ischemic attacks), median age, 67 (interquartile range, 57-74) years with 63% males. Moderate-to-severe SDB (apnea-hypopnea index score, ≥15/h) was present in 118 (33.4%) patients. Among the 56 (15.9%) patients with AF, 28 had comorbid moderate-to-severe SDB and AF. Over 36 months, there were 12 deaths and 67 recurrent cerebro-cardiovascular events. Patients with comorbid moderate-to-severe SDB and AF had a higher risk of subsequent death or cerebro-cardiovascular events compared with those with only moderate-to-severe SDB without AF (hazard ratio, 2.49 [95% CI, 1.18-5.24]) and to those without moderate-to-severe SDB or AF (hazard ratio, 2.25 [95% CI, 1.12-4.50]). However, no significant difference was found between the comorbid moderate-to-severe SDB and AF group and the group with only AF without moderate-to-severe SDB (hazard ratio, 1.64 [95% CI, 0.62-4.36]).

CONCLUSIONS

Comorbid moderate-to-severe SDB and AF significantly increase the risk of long-term mortality or recurrent cerebro-cardiovascular events after acute ischemic stroke. Considering both conditions as cumulative and modifiable cerebro-cardiovascular risk factors is of interest for the management of acute stroke.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02559739.

High sensitivity C reactive protein levels and atrial fibrillation recurrence after catheter ablation for atrial fibrillation: A systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) recurrence after AF ablation is not uncommon. High sensitivity C reactive protein (hs-CRP) is a widely used inflammatory marker with a potential property to predict AF recurrence. We conducted a systematic review and a meta-analysis to find an association between hs-CRP levels and AF recurrence after ablation.

METHODS

We searched PubMed, Embase, and Wiley-Cochrane Library from inception to January 2022 for studies that reported hs-CRP levels in patients who underwent AF ablation. Weighted mean difference (WMD) was used to evaluate the difference between hs-CRP levels in post-ablation AF recurrent and non-recurrent group. Also, the difference between hs-CRP levels in pre- and post-ablation was determined.

RESULTS

We identified 10 studies, and a total of 789 patients were included (299 recurrent vs. 490 non-recurrent patients). The mean age was 57.7 years (76.4% male). There was no difference in baseline hs-CRP levels between AF recurrent and non-recurrent group (WMD = 0.05, 95% CI = -0.04 to 0.15, p = 0.045). However, higher hs-CRP levels post-ablation were found in AF recurrent group (WMD = 0.09, 95% CI = 0.03-0.15, p < 0.001).

CONCLUSION

There is no significant difference in baseline hs-CRP levels between AF recurrent and non-recurrent patients after AF ablation. However, higher post-ablation hs-CRP level was found in AF recurrent group. High Sensitivity C reactive protein may play a role as a predictor of AF recurrence.

High-Frequency Low-Tidal Volume Ventilation Improves Long-Term Outcomes in AF Ablation: A Multicenter Prospective Study

BACKGROUND

High-frequency, low-tidal-volume (HFLTV) ventilation is a safe and simple strategy to improve catheter stability and first-pass isolation during pulmonary vein (PV) isolation. However, the impact of this technique on long-term clinical outcomes has not been determined.

OBJECTIVES

This study sought to assess acute and long-term outcomes of HFLTV ventilation compared with standard ventilation (SV) during radiofrequency (RF) ablation of paroxysmal atrial fibrillation (PAF).

METHODS

In this prospective multicenter registry (REAL-AF), patients undergoing PAF ablation using either HFLTV or SV were included. The primary outcome was freedom from all-atrial arrhythmia at 12 months. Secondary outcomes included procedural characteristics, AF-related symptoms, and hospitalizations at 12 months.

RESULTS

A total of 661 patients were included. Compared with those in the SV group, patients in the HFLTV group had shorter procedural (66 [IQR: 51-88] minutes vs 80 [IQR: 61-110] minutes; P < 0.001), total RF (13.5 [IQR: 10-19] minutes vs 19.9 [IQR: 14.7-26.9] minutes; P < 0.001), and PV RF (11.1 [IQR: 8.8-14] minutes vs 15.3 [IQR: 12.4-20.4] minutes; P < 0.001) times. First-pass PV isolation was higher in the HFLTV group (66.6% vs 63.8%; P = 0.036). At 12 months, 185 of 216 (85.6%) in the HFLTV group were free from all-atrial arrhythmia, compared with 353 of 445 (79.3%) patients in the SV group (P = 0.041). HLTV was associated with a 6.3% absolute reduction in all-atrial arrhythmia recurrence, lower rate of AF-related symptoms (12.5% vs 18.9%; P = 0.046), and hospitalizations (1.4% vs 4.7%; P = 0.043). There was no significant difference in the rate of complications.

CONCLUSIONS

HFLTV ventilation during catheter ablation of PAF improved freedom from all-atrial arrhythmia recurrence, AF-related symptoms, and AF-related hospitalizations with shorter procedural times.

Association of Shunt Size and Long-Term Clinical Outcomes in Patients with Cryptogenic Ischemic Stroke and Patent Foramen Ovale on Medical Management

INTRODUCTION

Patent foramen ovale (PFO) is a potential source of cardiac embolism in cryptogenic ischemic stroke, but it may also be incidental. Right-to-left shunt (RLS) size may predict PFO-related stroke, but results have been controversial. In this cohort study of medically-managed PFO patients with cryptogenic stroke, we aimed to investigate the association of shunt size with recurrent stroke, mortality, newly detected atrial fibrillation (AF), and to identify predictors of recurrent stroke.

METHODS

Patients with cryptogenic stroke who screened positive for a RLS using a transcranial Doppler bubble study were included. Patients who underwent PFO closure were excluded. Subjects were divided into two groups: small (Spencer Grade 1, 2, or 3; n = 135) and large (Spencer Grade 4 or 5; n = 99) shunts. The primary outcome was risk of recurrent stroke, and the secondary outcomes were all-cause mortality and newly detected AF.

RESULTS

The study cohort included 234 cryptogenic stroke patients with medically-managed PFO. The mean age was 50.5 years, and 31.2% were female. The median period of follow-up was 348 (IQR 147-1096) days. The rate of recurrent ischemic stroke was higher in patients with large shunts than in those with small shunts (8.1% vs. 2.2%, p = 0.036). Multivariate analyses revealed that a large shunt was significantly associated with an increased risk of recurrent ischemic stroke [aOR 4.09 (95% CI 1.04-16.0), p = 0.043].

CONCLUSIONS

In our cohort of cryptogenic stroke patients with medically managed PFOs, those with large shunts were at a higher risk of recurrent stroke events, independently of RoPE score and left atrium diameter.

Alarmins as a Possible Target of Future Therapies for Atrial Fibrillation

To date, worldwide, atrial fibrillation is the most common cardiovascular disease in adults, with a prevalence of 2% to 4%. The trigger of the pathophysiological mechanism of arrhythmia includes several factors that sustain and exacerbate the disease. Ectopic electrical conductivity, associated with the resulting atrial mechanical dysfunction, atrial remodeling, and fibrosis, promotes hypo-contractility and blood stasis, involving micro endothelial damage. This causes a significant local inflammatory reaction that feeds and sustains the arrhythmia. In our literature review, we evaluate the role of HMGB1 proteins, heat shock proteins, and S100 in the pathophysiology of atrial fibrillation, offering suggestions for possible new therapeutic strategies. We selected scientific publications on the specific topics "alarmins" and "atrial fibrillation" from PubMed. The nonsystematic review confirms the pivotal role of molecules such as S100 proteins, high-mobility group box-1, and heat shock proteins in the molecular pattern of atrial fibrillation. These results could be considered for new therapeutic opportunities, including inhibition of oxidative stress, evaluation of new anticoagulant drugs with novel therapeutic targets, molecular and genetic studies, and consideration of these alarmins as predictive or prognostic biomarkers of disease onset and severity.

European Stroke Organisation (ESO) guideline on screening for subclinical atrial fibrillation after stroke or transient ischaemic attack of undetermined origin

We aimed to provide practical recommendations for the screening of subclinical atrial fibrillation (AF) in patients with ischaemic stroke or transient ischaemic attack (TIA) of undetermined origin. These guidelines are based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. Five relevant Population, Intervention, Comparator, Outcome questions were defined by a multidisciplinary module working group (MWG).

Longer duration of cardiac rhythm monitoring increases the detection of subclinical AF, but the optimal monitoring length is yet to be defined. We advise longer monitoring to increase the rate of anticoagulation, but whether longer monitoring improves clinical outcomes needs to be addressed. AF detection does not differ from in- or out-patient ECG-monitoring with similar monitoring duration, so we consider it reasonable to initiate in-hospital monitoring as soon as possible and continue with outpatient monitoring for more than 48h. Although insertable loop recorders (ILR) increase AF detection based on their longer monitoring duration, comparison with non-implantable ECG devices for similar monitoring time is lacking. We suggest the use of implantable devices, if feasible, for AF detection instead of non- implantable devices to increase the detection of subclinical AF. There is weak evidence of a useful role for blood, ECG, and brain imaging biomarkers for the identification of patients at high risk of AF. In patients with patent foramen ovale, we found insufficient evidence from RCT, but prolonged cardiac monitoring in patients >55 years is advisable for subclinical AF detection. To conclude, in adult patients with ischaemic stroke or TIA of undetermined origin, we recommend longer duration of cardiac rhythm monitoring of more than 48h and if feasible with IRL to increase the detection of subclinical AF.

Contactless facial video recording with deep learning models for the detection of atrial fibrillation

Atrial fibrillation (AF) is often asymptomatic and paroxysmal. Screening and monitoring are needed especially for people at high risk. This study sought to use camera-based remote photoplethysmography (rPPG) with a deep convolutional neural network (DCNN) learning model for AF detection. All participants were classified into groups of AF, normal sinus rhythm (NSR) and other abnormality based on 12-lead ECG. They then underwent facial video recording for 10 min with rPPG signals extracted and segmented into 30-s clips as inputs of the training of DCNN models. Using voting algorithm, the participant would be predicted as AF if > 50% of their rPPG segments were determined as AF rhythm by the model. Of the 453 participants (mean age, 69.3 ± 13.0 years, women, 46%), a total of 7320 segments (1969 AF, 1604 NSR & 3747others) were analyzed by DCNN models. The accuracy rate of rPPG with deep learning model for discriminating AF from NSR and other abnormalities was 90.0% and 97.1% in 30-s and 10-min recording, respectively. This contactless, camera-based rPPG technique with a deep-learning model achieved significantly high accuracy to discriminate AF from non-AF and may enable a feasible way for a large-scale screening or monitoring in the future.

The Association Between Recurrence of Atrial Fibrillation and Revascularization in Patients With Coronary Artery Disease After Catheter Ablation

Aim: The connection between revascularization for coronary artery disease (CAD) and the incidence of recurrent events of atrial fibrillation (AF) after ablation is unclear. This study aimed to explore the relationship between coronary revascularization and AF recurrence in patients who underwent radiofrequency catheter ablation (RFCA). Methods: Four hundred and nineteen patients who underwent performed coronary angiography at the same time as RFCA were enrolled in this study. Obstructive CAD was defined as at least one coronary artery vessel stenosis of ≥75% and percutaneous coronary intervention (PCI) was recommended. Non-obstructive CAD was defined as coronary artery vessel stenosis of <75%. The endpoint was freedom from recurrence from AF after RFCA during the 24-month follow-up. Results: In total, 102, 95, and 212 patients were undergone coronary angiography and diagnosed as having obstructive CAD, Non-obstructive CAD, and Non-CAD, respectively. During the 24-month follow-up period, patients without obstructive CAD were significantly more likely to achieve freedom from AF than patients with obstructive CAD (hazard ratio [HR]: 1.72; 95% confidence interval [CI]: 1.23-2.41; P = 0.001). The recurrence rate of AF was significantly lower in patients who underwent PCI than in those who did not (HR: 0.45; 95% CI: 0.25-0.80; P = 0.007). The multivariate regression analysis showed that the other predictors of AF recurrence for obstructive CAD were multivessel stenosis (HR: 1.92; 95% CI: 1.04-3.54; P = 0.036) and left atrial diameter (HR: 2.56; 95% CI: 1.31-5.00; P = 0.006). Conclusions: This study suggests that obstructive CAD is associated with a higher rate of AF recurrence. Additionally, For patients with CAD, coronary revascularization is related to a lower recurrence rate of AF after RFCA.

Five-year follow-up report: Box lesion radiofrequency ablation procedure for atrial fibrillation under video-assisted thoracoscope

We report the initial 5-year follow-up of a novel mini-invasive procedure for epicardial ablation for the treatment of atrial fibrillation. The initial 5-year survival rate is acceptable and comparable with that of hybrid ablation. And this shared procedure has the advantages of shorter operation time and less surgical trauma.

Left atrial appendage size is a marker of atrial fibrillation recurrence after radiofrequency catheter ablation in patients with persistent atrial fibrillation

Introduction

There are no consistently confirmed predictors of atrial fibrillation (AF) recurrence after catheter ablation. Therefore, we aimed to study whether left atrial appendage volume (LAAV) and function influence the long‐term recurrence of AF after catheter ablation, depending on AF type.

Methods

AF patients who underwent point‐by‐point radiofrequency catheter ablation after cardiac computed tomography (CT) were included in this analysis. LAAV and LAA orifice area were measured by CT. Uni‐ and multivariable Cox proportional hazard regression models were performed to determine the predictors of AF recurrence.

Results

In total, 561 AF patients (61.9 ± 10.2 years, 34.9% females) were included in the study. Recurrence of AF was detected in 40.8% of the cases (34.6% in patients with paroxysmal and 53.5% in those with persistent AF) with a median recurrence‐free time of 22.7 (9.3–43.1) months. Patients with persistent AF had significantly higher body surface area‐indexed LAV, LAAV, and LAA orifice area and lower LAA flow velocity, than those with paroxysmal AF. After adjustment left ventricular ejection fraction (LVEF) <50% (HR = 2.17; 95% CI = 1.38–3.43; p < .001) and LAAV (HR = 1.06; 95% CI = 1.01–1.12; p = .029) were independently associated with AF recurrence in persistent AF, while no independent predictors could be identified in paroxysmal AF.

Conclusion

The current study demonstrates that beyond left ventricular systolic dysfunction, LAA enlargement is associated with higher rate of AF recurrence after catheter ablation in persistent AF, but not in patients with paroxysmal AF.

Real-time visualization of the esophagus and left atrial posterior wall by intra-left atrial echocardiography

PURPOSE

Localization of the esophagus and the left atrium (LA) posterior wall thickness (LAPWT) should be taken into account when delivering radiofrequency energy. To validate the visualization of the esophagus and analyze LAPWT by ICE advanced into the LA in patients with atrial fibrillation (AF) undergoing ablation index (AI)-guided pulmonary vein (PV) isolation.

METHODS

In 73 patients (mean age, 68 ± 12; paroxysmal AF in 45), a 3-dimensional (3D) esophagus image was created with CARTO Soundstar^Ⓡ and its location was compared with contrast esophagography saved in Carto UNIVU™. LAPWT adjacent to the esophagus was measured at 4 levels: left superior PV (LSPV), intervenous carina (IC), left inferior PV (LIPV), and LIPV bottom. A target AI value was 260 (25 W power) on the esophagus demonstrated by ICE.

RESULTS

All patients had the esophagus posterior to the left PV antrum. Creating a 3D esophagus and measurement of LAPWT with ICE was done without any complications. ICE esophagus image was completely overlapped with contrast esophagography. LAPWT (mm) was 2.8 (interquartile range, 2.5-3.2), 2.2 (1.9-2.5), 1.9 (1.8-2.1), and 2.1 (1.9-2.4) for LSPV, IC, LIPV, and LIPV bottom, respectively, while LA roof thickness was 3.2 (2.9-3.6) (P < 0.0001 by ANOVA). No residual conduction gap on the esophagus after the first circumferential PV isolation was found in 64 of 73 (88%) patients.

CONCLUSIONS

ICE inserted into the LA can reliably locate and display the esophagus and its relationship to the LA. LAPWT was the thinnest at the LIPV level. AI-guided ablation targeting at AI value 260 on the esophagus seemed to be effective.

Decreased estimated glomerular filtration rate predicts long-term recurrence after catheter ablation of atrial fibrillation in mild to moderate renal insufficiency

BACKGROUND

Catheter ablation is an established therapy for atrial fibrillation (AF), but recurrence after ablation remains a great challenge. Additionally, little is known about the effect of renal function on the efficiency of AF ablation. This study aimed to evaluate the predictors of the prognosis of catheter ablation for AF, especially the effect of renal function.

METHODS

A total of 306 drug-refractory symptomatic patients with AF who underwent first-time catheter ablation were enrolled in the present study. Individuals underwent circumferential pulmonary vein isolation for paroxysmal AF and stepwise ablation for persistent AF.

RESULTS

The follow-up time was 27.2 ± 19.5 months, 202 patients (66.01%) were free of atrial tachyarrhythmia (non-recurrence group), and the other 104 patients experienced recurrence (recurrence group). The recurrence group had a larger left atrial diameter (LAD) and left atrial volume (LAV), a higher LAV index (LAVI) (both, p < 0.01), and a lower estimated glomerular filtration rate (eGFR) (53.5 ± 14.4 vs. 65.5 ± 13.3 ml/min/1.732, p < 0.001) and creatinine clearance rate (CCr) (85.2 ± 26.1 vs. 101.5 ± 29.4 ml/min, p < 0.05). Multivariate logistic regression indicated both eGFR (p = 0.002) and LAVI (p < 0.001) as independent associated factors for long-term recurrence after single catheter ablation; multivariate Cox proportional hazard regression with backward feature selection identified both eGFR (HR: 0.93, 95% CI: 0.91-0.95, p < 0.001) and LAVI (HR: 1.32, 95% CI: 1.25-1.40, p < 0.001) as independent prognostic factors for recurrence when adjusting other clinical variables.

CONCLUSIONS

Decreased eGFR and elevated LAVI may facilitate the long-term recurrence of atrial tachyarrhythmia after catheter ablation for AF.

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.

A randomized ablation-based atrial fibrillation rhythm control versus rate control trial in patients with heart failure and high burden atrial fibrillation: The RAFT-AF trial rationale and design

Heart failure (HF) and atrial fibrillation (AF) are 2 cardiac conditions that are increasing in prevalence and incidence. The 2 conditions frequently coexist, and are associated with increased morbidity and mortality. Catheter ablation of AF has been successfully performed in patients with HF, with an improvement in HF and AF, when compared to amiodarone, but further data is required to compare this to rate control. OBJECTIVES: The primary objective is to determine whether AF treated by catheter ablation, with or without antiarrhythmic drugs reduces all-cause mortality and hospitalizations for HF as compared with rate control in patients with HF and a high burden AF. METHODS: This is a multi-center prospective randomized open blinded endpoint (PROBE) study. Patients with NYHA class II-III HF (HF with reduced ejection fraction (<35%) or HF with preserved ejection fraction), and high burden AF are included in the trial. Patients are randomized to either rate control or catheter ablation-based AF rhythm control in a 1:1 ratio. Patients in the rate control group receive optimal HF therapy and rate control measures to achieve a resting hazard ratio (HR) < 80 bpm and 6-minute walk HR < 110 bpm. Patients randomized to catheter ablation-based AF rhythm control group receive optimal HF therapy and one or more aggressive catheter ablation, which include PV antral ablation and LA substrate ablation with or without adjunctive antiarrhythmic drug. The primary outcome is a composite of all-cause mortality and hospitalization for heart failure defined as an admission to a health care facility. The sample size is 600. Enrolment has been completed.

Inducibility of atrial fibrillation after catheter ablation predicts recurrences of atrial fibrillation: a meta-analysis

BACKGROUND

Pulmonary vein isolation (PVI) is a component of standard care for patients with symptomatic atrial fibrillation (AF). Procedural inducibility of AF following PVI has been suggested as predictor of AF recurrence but is discussed controversially. This meta-analysis aimed at evaluating the relevance of electrophysiological inducibility of AF following PVI for future AF recurrences.

METHODS

A literature search of MEDLINE and Web of Science was performed until April 2020. Prospective trials of PVI in patients with AF and post-procedural atrial stimulation to test for inducibility of AF as well as adequate follow-up for AF recurrence (defined as AF >10 s to >10 min at follow-up) were included. Odds ratios (ORs) were analyzed using random-effects models.

RESULTS

A total of 11 trials with 1544 patients (follow-up 7-39 months, age 56 ± 6 years, predominantly male 74 ± 6%) were included. Inducibility of AF post-PVI was predictive for AF recurrence during follow-up (OR 2.08; 95% CI 1.25 to 3.46). Prediction for AF recurrence at follow-up was better for patients with paroxysmal AF (OR 4.06; 95% CI 1.39 to 11.91), stimulation in the CS (OR 2.82, 95% CI 1.17 to 6.79). A trend towards higher ORs was seen without the use of isoproterenol (OR 2.43; 95% CI 1.17 to 5.07), as well as few stimulations during induction and a short definition of AF in meta-regression analyses.

CONCLUSIONS

Electrophysiological inducibility of AF following PVI was predictive for future recurrence of AF, in particular in patients with paroxysmal AF, stimulation in only CS and no use of isoproterenol.

The crosstalk between cardiomyocyte calcium and inflammasome signaling pathways in atrial fibrillation

Atrial fibrillation (AF) is the most frequent arrhythmia in adults. The prevalence and incidence of AF is going to increase substantially over the next few decades. Because AF increases the risk of stroke, heart failure, dementia, and others, it severely impacts the quality of life, morbidity, and mortality. Although the pathogenesis of AF is multifaceted and complex, focal ectopic activity and reentry are considered as the fundamental proarrhythmic mechanisms underlying AF development. Over the past 2 decades, large amount of evidence points to the key role of intracellular Ca²⁺ dysregulation in both initiation and maintenance of AF. More recently, emerging evidence reveal that NLRP3 (NACHT, LRR, PYD domain-containing 3) inflammasome pathway contributes to the substrate of both triggered activity and reentry, ultimately promoting AF. In this article, we review the current state of knowledge on Ca²⁺ signaling and NLRP3 inflammasome activity in AF. We also discuss the potential crosstalk between these two quintessential contributors to AF promotion.

New Biparietal Bipolar Catheter Prototype for Hybrid Atrial Fibrillation Ablation

Objective

To evaluate the size and depth of linear lesions by in vitro testing with a custom-made radio frequency biparietal bipolar ablation catheter in a single-stage setting.

Methods

A custom-made catheter was created to generate linear lesions around the left atrium and pulmonary veins of an ex vivo pig. Two frames were made, 1 epicardial and 1 endocardial. A continuous copper braid electrode and an alignment system consisting of 2 parallel rows of neodymium magnets were embedded in a flexible plastic support. After 24 hours of formalin conservation, samples of the left atrium of a freshly slaughtered pig were sliced in a cryotome, thus obtaining a sequence of 100-µm thick layers extending from the endocardial to the epicardial side. After being digitized through a scanner, these layers were evaluated using morphometric computer software. For each slice, we evaluated the maximum length of the lesions, the maximum epicardial length, the maximum endocardial length, the total area of the lesion, and the total volume.

Results

Forty transmural lesions from 40 specimens were obtained. The results were the following (the number in parenthesis is the interquartile range in mm): lesion maximum length (L_MAX) was 7.297 mm (0.006), epicardial maximum length (L_EPI) was 7.291 mm (0.014), and endocardial maximum length was 7.291 mm (0.018). The total area and total volume were 1018.50 ± 36.51 mm² and 101.85 ± 3.65 mm³, respectively.

Conclusions

Our prototype showed very promising results. The next step will be to enhance the design for clinical application.

Anesthetic Choice for Atrial Fibrillation Ablation: A National Anesthesia Clinical Outcomes Registry Analysis

OBJECTIVE

The authors evaluated the type of anesthesia administered in atrial fibrillation ablation, hypothesizing that monitored anesthesia care is used less frequently than general anesthesia.

DESIGN

A retrospective study.

SETTING

National Anesthesia Clinical Outcomes Registry data, which are multi-institutional from across the United States.

PARTICIPANTS

Adult patients who underwent elective atrial fibrillation ablation between 2013 and 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

National Anesthesia Clinical Outcomes Registry data were evaluated, and covariates were selected a priori within multivariate models to assess for predictors of anesthetic type. A total of 54,321 patients underwent atrial fibrillation ablation; 3,251 (6.0%) received monitored anesthesia care. Patients who received monitored anesthesia care were more likely to be >80 years old (12.4% v 4.9%; p < 0.0001), female (36.1% v 34.3%; p < 0.0001), have American Society of Anesthesiologists physical status >III (17.28% v 10.48%; p < 0.0001), and reside in urban areas (62.23% v 53.37%; p < 0.0001). They received care in the Northeast (17.6% v 10.1%; p < 0.0001) at low-volume centers (median 224 v 284 procedures; p < 0.0001). Multivariate analysis revealed that each five-year increase in age, being female, and having an American Society of Anesthesiologists physical status >III resulted in a 7% (p < 0.0001), 9% (p = 0.032), and 200% (p < 0.0001) increased odds of receiving monitored anesthesia care, respectively. Requiring additional ablation of atria or of a second arrhythmia and residing outside the Northeast resulted in a decreased odds of monitored anesthesia care (adjusted odds ratio 0.24 [p=0.002] and < 0.5 [p < 0.03], respectively). For each 50 cases performed annually at a center, the odds decreased by 5% (p = 0.005).

CONCLUSIONS

General anesthesia is the most common type of anesthesia administered for atrial fibrillation ablation. The type of anesthesia administered, however, varies with patient, procedural, and hospital characteristics.

Comparative occurrence of ischemic stroke with the rhythm versus rate control strategy in a national prospective cohort of atrial fibrillation

BACKGROUND/AIMS

Comparative occurrence of ischemic stroke for rhythm versus rate control strategy in patients with non-valvular atrial fibrillation (NVAF) is still inconclusive. The purpose of this study was to investigate whether the rhythm control strategy is associated with a lower risk of ischemic stroke compared to the rate control strategy in NVAF patients.

METHODS

The CODE-AF registry prospectively enrolled 6,280 consecutive patients who were treated for NVAF at 10 tertiary referral centers in South Korea. Of these, 2,513 NVAF patients (age, 67 ± 10 years; male, 61.8%) were clinically followed up for over 1-year and divided into rate and rhythm control groups.

RESULTS

Those treated with the rhythm control strategy were younger and had less proportions of underlying disease compared to those treated with the rate control strategy. After the propensity matching analysis, those treated with the rhythm control strategy had similar baseline characteristics including the CHA2DS2-VASC score compared to those treated with the rate control strategy. The rate of oral anticoagulation, all bleeding, and hospitalization were also similarly between the two groups. The incidence rate of ischemic stroke in the rhythm control group was significantly lower than in the rate control group (0.7 vs. 6.9 per 1,000 person-years, p = 0.011).

CONCLUSION

The rhythm control strategy demonstrated a beneficial effect to lower the risk of ischemic stroke during a 1-year follow-up compared to the rate control strategy.

Predictive value of atrial fibrillation during the postradiofrequency ablation blanking period

BACKGROUND

Recurrent arrhythmia following catheter ablation of atrial fibrillation (AF) may present early, during a standard 3-month blanking period. Early recurrence has been correlated to late recurrence, but the degree to which its absence predicts longer-term success has not been quantified.

OBJECTIVE

The purpose of this study was to explore and quantify the relationship between early and late arrhythmia recurrence, specifically the negative predictive value, that is, the degree to which absence of blanking period recurrence predicts absence of late recurrence.

METHODS

A systematic literature review and meta-analysis were conducted using statistical methods of a diagnostic test accuracy review. Studies of AF ablation using point-by-point radiofrequency, with repeated monitoring of arrhythmia recurrence including asymptomatic recurrence, and with separate data by AF type, were eligible.

RESULTS

Nine studies met the prespecified eligibility criteria. For paroxysmal AF, 89% (confidence interval [CI] 82%-94%) of patients free from early recurrence remained free from late recurrence. The estimate for persistent AF was similar (91%; CI 75%-97%). This finding was robust in sensitivity analyses. Patients with early recurrence had a wider range of likely outcomes with longer-term follow-up.

CONCLUSION

Freedom from AF recurrence during the blanking period is highly predictive of longer-term success in catheter ablation. Clinical trials in this area may be able to leverage these findings to more quickly assess the potential utility of new ablation technologies and methods, for example, by using early surrogate measures of success.

The Effect of Renin-Angiotensin System Inhibitors on the Recurrence of Atrial Fibrillation After Catheter Ablation

Atrial fibrillation (AF) is the most common sustained arrhythmia. Renin-angiotensin system (RAS) inhibitors were reported to modify the arrhythmia substrate and reverse atrial remodeling. However, the role of RAS inhibitors on AF recurrence after catheter ablation remains much more controversial. In this study, a meta-analysis was performed to explore the effect of RAS inhibitors on AF recurrence after catheter ablation.We searched PubMed, Cochrane Library, EMBASE, and Web of Science for all articles published up to July 2019 on the effect of RAS inhibitors on AF recurrence rate after ablation. We used the random-effects model to estimate the odds ratios (ORs) and confidence intervals (CI). The I2 statistic was used to evaluate statistical heterogeneity. A two-tailed P value of <0.05 was considered statistically significant. Results were further analyzed by subgroup according to the type of study design.We included 13 studies, including 3661 patients with AF, in this analysis, of which 4 were randomized controlled trials (RCTs) and the others were cohort studies. Overall, treatment with RAS inhibitors showed a significant reduction of AF recurrence after catheter ablation (OR, 0.61; 95% CI, 0.45-0.82). Additionally, both the RCT (OR, 0.35; 95% CI, 0.24-0.49) and non-RCT (OR, 0.76; 95% CI, 0.57-1.00) groups demonstrated that RAS inhibitors could reduce the AF recurrence rate after catheter ablation in the subgroup analysis.Our meta-analysis suggests that RAS inhibitors had significant benefit in reducing the recurrence rate of AF after catheter ablation.

Revisiting Antiarrhythmic Drug Therapy for Atrial Fibrillation: Reviewing Lessons Learned and Redefining Therapeutic Paradigms

Since the clinical use of digitalis as the first pharmacological therapy for atrial fibrillation (AF) 235 years ago in 1785, antiarrhythmic drug therapy has advanced considerably and become a cornerstone of AF clinical management. Yet, a preventive or curative panacea for sustained AF does not exist despite the rise of AF global prevalence to epidemiological proportions. While multiple elevated risk factors for AF have been established, the natural history and etiology of AF remain incompletely understood. In the present article, the first section selectively highlights some disappointing shortcomings and current efforts in antiarrhythmic drug therapy to uncover reasons why AF is such a clinical challenge. The second section discusses some modern takes on the natural history of AF as a relentless, progressive fibro-inflammatory "atriomyopathy." The final section emphasizes the need to redefine therapeutic strategies on par with new insights of AF pathophysiology.

Anatomical changes in the pulmonary veins and left atrium after cryoballoon ablation

BACKGROUND

The anatomical changes in pulmonary veins (PVs) after cryoballoon ablation (CBA) are unclear. We aimed to determine the morphological changes in the PVs and left atrium (LA) along with the predictive factors for clinical PV stenosis.

METHODS

We analyzed data of 320 PVs from 80 patients who underwent CBA for atrial fibrillation (age: 62 ± 10 years, 59 males). All patients underwent pre- and post-procedural cardiac computed tomography. We defined clinical PV stenosis when the cross-sectional area decreased by more than 50%.

RESULTS

The average ostial PV area and LA volume decreased significantly after CBA (pre- vs post-CBA; 2.4 ± 1.0 cm² vs 2.3±1.1 cm² , P < .001, 75.0 ± 23.2 cm³ vs 70.7 ± 21.9 cm³ , P < .001, respectively). There was a significant correlation between the reduction rates of the PV area and those of LA volume (R = 0.411, P < .001). The larger preoperative PV area and greater reduction in LA volume were associated with advanced PV narrowing. Clinical PV stenosis was observed in six PVs, was more common in females (male vs female; 0.8% vs 4.8%, P = .043), and tended to be more frequent in left PVs (left PVs vs right PVs; 3.1% vs 0.6%: P = .107), irrespective of the LA volume reduction.

CONCLUSIONS

The significant reduction of the ostial PV area occurred after CBA, which correlated with the reduction rate of LA volume. The narrowing of the PV was partly produced by the LA volume reduction. Clinical PV stenosis was more common in females and tended to be more frequent in left PVs.

Three-year outcomes of the postapproval study of the AtriCure Bipolar Radiofrequency Ablation of Permanent Atrial Fibrillation Trial

OBJECTIVES

The Cox Maze IV operation is commonly performed concomitant with other cardiac operations and effectively reduces the burden of atrial fibrillation. Prospective randomized trials have reported outcomes early and at 12 months, but only single-center late durability results are available. As part of the postapproval process for a bipolar radiofrequency ablation system, we sought to determine early and midterm outcomes of patients undergoing the Cox Maze IV operation.

METHODS

A prospective, multicenter, single-arm study of 363 patients (mean age, 70 years, 82% valve surgery) with nonparoxysmal atrial fibrillation (mean duration, 60 months, 94% Congestive heart failure, Hypertension, Age ≥ 75, Diabetes, Stroke, VAScular disease, Age 65-74, Sex category ≥2) undergoing concomitant Maze IV atrial fibrillation ablation at 40 sites with 70 surgeons was performed between June 2010 and October 2014. Compliance with the study lesion set was 94.5%, and 99% had left atrial appendage closure. Freedom from atrial fibrillation was determined by extended monitoring, with a 48-hour Holter monitor minimum.

RESULTS

There were no device-related complications. Freedom from atrial fibrillation off antiarrhythmic medications at 1, 2, and 3 years was 66%, 65%, and 64%, respectively, and including those using antiarrhythmics was 80%, 78%, and 76%, respectively. Warfarin was used in 49%, 44%, and 40%, respectively.

CONCLUSIONS

In patients with nonparoxysmal atrial fibrillation, compliance with the protocol was high, and freedom from atrial fibrillation off antiarrhythmics was high and sustained to 3 years. The safety and effectiveness of the system and Cox Maze IV procedure support the Class I guideline recommendation for concomitant atrial fibrillation ablation in patients undergoing cardiac surgery.

5-Year Experience of In-Hospital Outcomes After Percutaneous Left Atrial Appendage Closure in Germany

OBJECTIVES

The aim of this study was to evaluate 5-year in-hospital trends and safety outcomes of left atrial appendage (LAA) closure in the German nationwide inpatient sample.

BACKGROUND

The safety and efficacy of percutaneous LAA closure have been demonstrated in randomized trials and prospective cohort studies, but results from large samples are missing.

METHODS

Data on patient characteristics and in-hospital safety outcomes for all percutaneous LAA closures performed in Germany between 2011 and 2015 were analyzed. Overall, 15,895 inpatients were included.

RESULTS

The annual number of LAA occlusions increased from 1,347 in 2011 to 4,932 in 2015 (β = 1.00; 95% confidence interval [CI]: 0.95 to 1.01; p < 0.001), with a nonsignificant uptrend of in-hospital mortality (from 0.5% in 2011 to 0.9% in 2015; β = 0.01; 95% CI: -0.09 to 0.32; p = 0.271). Patient characteristics shifted toward older age and higher prevalence of comorbidities such as heart failure, chronic obstructive pulmonary disease, and chronic renal insufficiency over time. Important independent predictors of in-hospital mortality were cancer (odds ratio [OR]: 2.49; 95% CI: 1.00 to 6.12; p = 0.050), heart failure (OR: 2.42; 95% CI: 1.72 to 3.41; p < 0.001), stroke (OR: 5.39; 95% CI: 2.76 to 10.53; p < 0.001), acute renal failure (OR: 13.28; 95% CI: 9.08 to 19.42; p < 0.001), pericardial effusion (OR: 5.65; 95% CI: 3.76 to 8.48; p < 0.001), and shock (OR: 45.11; 95% CI: 31.01 to 65.58; p < 0.001).

CONCLUSIONS

The use of percutaneous LAA closure increased 3.6-fold from 2011 to 2015, with a nonsignificant uptrend of in-hospital mortality rate in this real-world setting. Important predictors of in-hospital death were acute renal failure, pericardial effusion, and ischemic stroke during hospitalization.

Experiência de um Centro Brasileiro com Crioablação para Isolamento Elétrico das Veias Pulmonares na Fibrilação Atrial Paroxística e Persistente – Resultados Preliminares no Brasil

Fundamento

O isolamento elétrico das veias pulmonares é reconhecidamente base fundamental para o tratamento não farmacológico da fibrilação atrial (FA) e, portanto, tem sido recomendado como passo inicial na ablação de FA em todas as diretrizes. A técnica com balão de crioenergia, embora amplamente utilizada na América do Norte e Europa, ainda se encontra em fase inicial em muitos países em desenvolvimento, como o Brasil.

Objetivo

Avaliar o sucesso e a segurança da técnica de crioablação em nosso serviço, em pacientes com FA paroxística e persistente.

Métodos

Cento e oito pacientes consecutivos com FA sintomática e refratária ao tratamento farmacológico foram submetidos à crioablação para isolamento das veias pulmonares. Os pacientes foram separados em dois grupos, de acordo com a classificação convencional da FA paroxística (duração de até sete dias) e persistente (FA por mais de sete dias). Dados de recorrência e segurança do procedimento foram analisados respectivamente como desfechos primário e secundário. O nível de significância adotado foi de 5%.

Resultados

Cento e oito pacientes, com idade média de 58±13 anos, 84 do sexo masculino (77,8%), foram submetidos ao procedimento de crioablação de FA. Sessenta e cinco pacientes apresentavam FA paroxística (60,2%) e 43, FA persistente (39,2%). O tempo médio do procedimento foi de 96,5±29,3 minutos e o tempo médio de fluoroscopia foi de 29,6±11,1 minutos. Foram observadas cinco (4,6%) complicações, nenhuma fatal. Considerando a evolução após os 3 meses iniciais, foram observadas 21 recorrências (19,4%) em período de um ano de seguimento. As taxas de sobrevivência livre de recorrência nos grupos paroxístico e persistente foram de 89,2% e 67,4%, respectivamente.

Conclusão

A crioablação para isolamento elétrico das veias pulmonares é um método seguro e eficaz para tratamento da FA. Nossos resultados estão consoantes com demais estudos, que sugerem que a tecnologia pode ser utilizada como abordagem inicial, mesmo nos casos de FA persistente. (Arq Bras Cardiol. 2020; 115(3):528-535)

Meta-analysis of efficacy and safety of new oral anticoagulants compared with warfarin in Japanese patients undergoing catheter ablation for atrial fibrillation

OBJECTIVES

This meta-analysis was designed to evaluate the efficacy and safety of new oral anticoagulants (NOACs) for perioperative anticoagulation of atrial fibrillation (AF) catheter ablation (CA) in Japanese patients with non-valvular atrial fibrillation (NVAF).

METHODS

PubMed, Embase, Web of Science, and the Cochrane Library were searched for articles published up to June 30, 2019. Two reviewers independently screened literature, extracted data, and assessed the methodological quality of the included studies according to the inclusion and exclusion criteria. Then, meta-analysis was performed using RevMan 5.3 software.

RESULTS

Nineteen studies with a total of 6827 patients were included in this meta-analysis. The experimental group received dabigatran, rivaroxaban, apixaban, or edoxaban; the control group received warfarin. The safety endpoints were bleeding complications; the efficacy endpoints were thromboembolic complications. Results were as follows: Patients with NOACs had a lower risk of overall bleeding complications (OR = 0.69, 95% CI (0.54, 0.87), P = 0.002), including major bleeding complications (OR = 0.52, 95% CI (0.32, 0.84), P = 0.007) and minor bleeding complications (OR = 0.73, 95% CI (0.56, 0.94), P = 0.02). There was no significant difference in thromboembolic complications between NOACs and warfarin after CA (OR = 0.39, 95% CI (0.14, 1.10), P = 0.08).

CONCLUSIONS

In Japanese NVAF patients undergoing CA, NOACs have similar effects to warfarin in the prevention of stroke and systemic embolism. Moreover, NOACs were associated with a lower incidence of bleeding complications.

Convergent epicardial-endocardial ablation for treatment of long-standing persistent atrial fibrillation: A review of literature

BACKGROUND AND AIM OF STUDY

The convergent procedure (CVP) is a hybrid ablation technique via a subxiphoid incision that has recently emerged as a treatment option for non-paroxysmal atrial fibrillation (npAF). By combining endocardial and epicardial ablation into a simultaneous or staged procedure, the pulmonary vein and posterior left atrium can be isolated with transmural lesion sets while minimizing the risk of proarrhythmic gaps that are a known limitation with endocardial linear lesion sets. We reviewed the 12-month outcomes in patients who underwent CVP compared to those who underwent endocardial catheter ablation (CA) and surgical ablation (SA).

METHODS

A literature search was conducted using the PubMed database for publications related to CVP. Selected studies included detailed 12-month follow-up of patients, patient characteristics, periprocedural complications, use of antiarrhythmic drugs (AADs), and monitoring method.

RESULTS

Five studies with 340 patients who underwent CVP between January 2009 and March 2017 were selected for this review. A total of 8.5% of patients had paroxysmal AF (pAF), 42.2% had persistent AF (peAF), and 49.1% had long-standing persistent AF (lspAF). At 12 months, 81.9% of patients were in sinus rhythm, while 54.1% of patients were in sinus rhythm while not taking AADs. The overall complication rate was 10%.

CONCLUSION

CVP had better 1-year efficacy in eliminating AF when compared to CA. However, SA, specifically the Cox Maze IV, had lower rates of AF recurrence in the npAF patient population. Despite its promising 1-year efficacy rates, the periprocedural complication rate for CVP was significantly higher than both CA and SA.

The predictive value of heart rate variability indices tested in early period after radiofrequency catheter ablation for the recurrence of atrial fibrillation

INTRODUCTION

To explore the relationship between recurrence of atrial fibrillation (AF) and the autonomic nervous activity evaluated by heart rate variability (HRV) indices after radiofrequency catheter ablation (RFCA) in the early period.

METHODS

We enrolled 102 patients with paroxysmal AF and tested the HRV indices by the high-resolution Holter electrocardiogram the next morning after RFCA. The HRV indices were compared between the non-recurrence group (n = 85) and the recurrence group (n = 17).

RESULTS

The HRV indices included standard deviation of normal to normal intervals (SDNN), SDNN index, root-mean square successive differences (RMSSD), the proportion of normal to normal intervals differing by >50 millisecond (ms) (pNN50), high-frequency components (HF), low-frequency components (LF) and very low-frequency components were significantly higher in recurrence group than that in non-recurrence group, while no such difference was found for LF/HF. Based on the median value of the recurrent time (9 months), RMSSD (P = .012), pNN50 (P < .0001) and HF (P = .033) were lower in late recurrence group than that in early recurrence group. The Cox regression analyses indicated that higher values of RMSSD (P = .01), pNN50 (P = .02) and HF (P = .02) were associated with a higher risk of recurrence after adjusted for covariates. The receiver operating characteristic curves showed higher rates of clinical recurrence of AF after RFCA in patients with RMSSD ≥27.5 ms, pNN50 ≥4.5%, and HF ≥178.25 ms² .

CONCLUSIONS

Values of RMSSD, pNN50, and HF tested in the early period after RFCA could independently predict the recurrence of AF.

Comparison of Long-Term Adverse Outcomes in Patients With Atrial Fibrillation Having Ablation Versus Antiarrhythmic Medications

The impact of atrial fibrillation (AF) catheter ablation versus chronic antiarrhythmic therapy alone on clinical outcomes such as death and stroke remains unclear. We compared adverse outcomes for AF ablation versus chronic antiarrhythmic therapy in 1,070 adults with AF treated between 2010 and 2014 in the Kaiser Permanente Northern California and Southern California healthcare delivery systems. Patients who underwent AF catheter ablation were matched to patients treated with only antiarrhythmic medications, based on age, gender, history of heart failure, history of coronary heart disease, history of hypertension, history of diabetes, and high-dimensional propensity score. We compared crude and adjusted rates of death, ischemic stroke or transient ischemic attack, intracranial hemorrhage, and hospitalization. The matched cohort of 535 patients treated with AF ablation and 535 treated with antiarrhythmic therapy had a median follow-up of 2.0 (interquartile range 1.1 to 3.5) years. There was no significant difference in adjusted rates of death (adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.03 to 1.95), intracranial hemorrhage (adjusted HR 0.17, CI 0.02 to 1.71), ischemic stroke or transient ischemic attack (adjusted HR 0.53, CI 0.18 to 1.60), and heart failure hospitalization (adjusted HR 0.85, CI 0.34 to 2.12), although there was a trend toward improvement in these outcomes with ablation. However, there was a significantly increased risk of all-cause hospitalization following ablation (adjusted HR 1.60, CI 1.25 to 2.05). In a contemporary, multicenter, propensity-matched observational cohort, AF ablation was not significantly associated with death, intracranial hemorrhage, ischemic stroke or transient ischemic attack, or heart failure hospitalization, but was associated with a higher rate of all cause-hospitalization.

Effectiveness of catheter ablation of atrial fibrillation according to heart failure etiology

BACKGROUND

Catheter ablation is an important rhythm control therapy in patients with atrial fibrillation (AF) with concomitant heart failure (HF). The objective of this study was to assess the comparative efficacy of AF ablation patients with ischemic vs nonischemic heart failure.

METHODS

We conducted a retrospective, observational cohort study of patients with HF who underwent AF ablation. Outcomes were compared based on HF etiology and included in-hospital events, symptoms (Mayo AF Symptom Inventory [MAFSI]), and functional status (New York Heart Association class) and freedom from atrial arrhythmias at 12 months.

RESULTS

Among 242 patients (n = 70 [29%] ischemic, n = 172 [71%] nonischemic), patients with nonischemic cardiomyopathy were younger (mean age 64 ± 11.5 vs 69 ± 9.1, P = .002), more often female (36% vs 17%, P = .004), and had higher mean left-ventricular ejection fraction (47% vs 42%, P = .0007). There were no significant differences in periprocedural characteristics, including mean procedure time (243 ± 74.2 vs 259 ± 81.8 minutes, P = .1) and nonleft atrial ablation (17% vs 20%, P = .6). All-cause adverse events were similar in each group (15% vs 17%, P = .7). NYHA and MAFSI scores improved significantly at follow-up and did not differ according to HF etiology (P = .5; P = .10-1.00 after Bonferroni correction). There were no significant differences in freedom from recurrent atrial arrhythmia at 12-months between ischemic (74%) and nonischemic patients (78%): adjusted RR 0.63, 95% confidence interval 0.33-1.19.

CONCLUSIONS

Catheter ablation in patients with AF and concomitant heart failure leads to significant improvements in functional and symptom status without significant differences between patients with ischemic vs nonischemic HF etiology.

Clinical and electrophysiological characteristics predicting the re-ablation outcome for atrial fibrillation patients

BACKGROUND

Re-ablation has an important role in the control of recurrent atrial fibrillation (AF) post the first ablation. The present study was to report the outcome of AF re-ablation for patients who recurred after initial ablation, and to characterize the clinical and electrophysiological features predicting recurrence after redo ablation.

METHODS

From January 2012 to May 2017, patients undergoing re-ablation for AF in our hospital were consecutively enrolled. Clinical and electrophysiological data for the initial and second procedure were collected retrospectively and prospectively, respectively. All patients were followed up for one year and recurrences during the time were reported.

RESULTS

Totally 259 patients entered into the analysis (age, 58.4 ± 10.5 years; 169 men). At the end of one-year follow-up, 85 patients recurred with atrial arrhythmias (32.8%). In the multivariate analysis, higher CHA₂DS₂-VAS_C score (p = 0.023, 95% CI 1.03-1.53) and shorter time to recurrence after the initial ablation (p = 0.001, 95% CI 0.93-0.98) were clinical factors predictive of one-year recurrence after the repeat ablation. The reconnection of the right pulmonary vein (PV) (p = 0.034, 95% CI 0.31-0.96) and the absence of not eliminated non-PV trigger at the second procedure (p = 0.032, 95% CI 1.25-142.80) independently predicted the better re-ablation outcome.

CONCLUSIONS

About one-third of patients recurred after one year following re-ablation. CHA₂DS₂-VAS_C score and time to recurrence after the initial ablation were independent clinical factors predicting recurrence. Also, electrophysiological findings during the repeat ablation (the right PV reconnection and absence of not eliminated non-PV trigger) were associated with better outcome during one year of follow-up.

Recurrent atrial fibrillation/flutter detection after ablation or cardioversion using the AliveCor KardiaMobile device: iHEART results

OBJECTIVE

This study evaluated the impact of daily ECG (electrocardiogram) self-recordings on time to documented recurrent atrial fibrillation (AF) or atrial flutter (AFL) and time to treatment of recurrent arrhythmia in patients undergoing catheter radiofrequency ablation (RFA) or direct current cardioversion (DCCV) for AF/AFL.

BACKGROUND

AF recurrence rates after RFA and DCCV are 20% to 45% and 60% to 80%, respectively. Randomized trials comparing mobile ECG devices to standard of care have not been performed in an AF/AFL population after treatment.

METHODS

Of 262 patients consented, 238 were randomized to either standard of care (123) or to receive the iHEART intervention (115). Patients in the intervention group were provided with and trained to use an AliveCor KardiaMobile ECG monitor, and were instructed to take and transmit daily ECG recordings. Data were collected from transmitted ECG recordings and patients' electronic health records.

RESULTS

In a multivariate Cox model, the likelihood of recurrence detection was greater in the intervention group (hazard ratio = 1.56, 95% confidence interval [CI]: 1.06-2.30, P = .024). Hazard ratios did not differ significantly for RFA and DCCV procedures. Recurrence during the first month after ablation strongly predicted later recurrence (hazard ratio = 4.53, 95% CI: 2.05-10.00, P = .0006). Time from detection to treatment was shorter for the control group (hazard ratio = 0.33, 95% CI: 0.57-2.92, P < .0001).

CONCLUSIONS

The use of mobile ECG self-recording devices allows for earlier detection of AF/AFL recurrence and may empower patients to engage in shared health decision-making.

New approaches for treating atrial fibrillation: Focus on autonomic modulation

Atrial fibrillation (AF) is a rapidly growing clinical problem in routine practice, both for cardiologists as well as general practitioners. Current therapies aimed at the management of AF include anti-arrhythmic drug therapy and catheter ablation. These therapies have a number of limitations and risks, and have disappointing long-term efficacy in maintaining sinus rhythm and improving hard clinical outcomes. Because of this, there is growing interest in pursuing alternative management strategies in patients with AF. This review seeks to highlight emerging AF therapies, with a specific focus on several modalities aimed at modulation of the autonomic nervous system. These therapies have shown promise in early pre-clinical and clinical trials, and represent exciting alternatives to standard AF treatment.

A Nurse-led Approach to Improving Cardiac Lifestyle Modification in an Atrial Fibrillation Population

Atrial fibrillation (AF) is a major public health problem and the most common cardiac arrhythmia encountered in clinical practice at this time. AF is associated with numerous symptoms such as palpitations, shortness of breath, and fatigue, which can significantly reduce health-related quality of life and result in serious adverse cardiac outcomes. In light of this, the aim of the present pilot study was to test the feasibility of implementing a mobile health (mHealth) lifestyle intervention titled "Atrial Fibrillation and Cardiac Health: Targeting Improving Outcomes via a Nurse-Led Intervention (ACTION)," with the goal of improving cardiac health measures, AF symptom recognition, and self-management. As part of this study, participants self-identified cardiac health goals at enrollment. The nurse used web-based resources from the American Heart Association (Dallas, TX, USA), which included the Life's Simple 7® My Life Check® assessment, to quantify current lifestyle behavior change needs. Furthermore, on the My AFib Experience™ website (American Heart Association, Dallas, TX, USA), the patient used a symptom tracker tool to capture the date, time, frequency, and type of AF symptoms, and these data were subsequently reviewed by the cardiac nurse. Throughout the six-month intervention period, the cardiac nurse used a motivational interviewing approach to support participants' cardiac health goals. Ultimately, the ACTION intervention was tested in 53 individuals with AF (mean age: 59 ± 11 years; 76% male). Participants were predominantly overweight/obese (79%), had a history of hypertension (62%) or hyperlipidemia (61%), and reported being physically inactive/not preforming any type of regular exercise (52%). The majority (88%) of the participants had one or more Life's Simple 7® measures that could be improved. Most of the participants (98%) liked having a dedicated nurse to work with them on a biweekly basis via the mHealth portal. The most commonly self-reported symptoms were palpitations, fatigue/exercise intolerance, and dyspnea. Seventy percent of the participants had an improvement in their weight and blood pressure as documented within the electronic health record as well as a corresponding improvement in their Life's Simple 7® score at six months. On average, there was a three-pound (1.36-kg) decrease in weight and a 5-mmHg decrease in systolic blood pressure between baseline and at six months. In conclusion, this pilot work provides initial evidence regarding the feasibility of implementing the ACTION intervention and supports testing the ACTION intervention in a larger cohort of AF patients to inform existing AF guidelines and build an evidence base for reducing AF burden through lifestyle modification.

Outcomes and Management of Patients With Severe Pulmonary Vein Stenosis From Prior Atrial Fibrillation Ablation

BACKGROUND

Pulmonary vein (PV) stenosis remains a feared complication of atrial fibrillation ablation. Little is known about outcomes in patients with severe PV stenosis, especially about repeat ablations.

METHODS

In 10 368 patients undergoing atrial fibrillation ablation (2000-2015), computed tomography scans were obtained 3 to 6 months after ablation. The clinical outcomes in severe PV stenosis were determined.

RESULTS

Severe PV stenosis was diagnosed in 52 patients (0.5%). This involved mostly the left superior PV (51% of severely stenosed veins). Percutaneous interventions were performed in 43 patients, and complications occurred in 5: 3 PV ruptures, 1 stroke, and 1 phrenic injury. Over a median follow-up of 25 months, 41 (79%) patients remained arrhythmia free. Repeat ablation was performed in 15 patients (7 from the main series and 8 from prior ablation at other institutions); of whom 10 had PV stents in place. Conduction recovery was noted in all but 2 of the stenosed or stented PVs, and areas with recovery were targeted with antral ablation. Lasso entrapment within stents occurred in 2 patients but eventually freed without complications. After redo ablation, preplanned stenting was performed in 3 patients and computed tomographic scans showed progression of concomitant stenoses in 1 patient (moderate to severe). No procedure-related deaths occurred.

CONCLUSIONS

The incidence of severe PV stenosis is low but remains associated with significant morbidity. In patients with recurrent arrhythmia, conduction recovery at the stenosed or stented veins is common. Care must be taken to ablate antrally to avoid stenosis progression. In patients with prior PV stents, we suggest to avoid using Lasso.

Long-Term Clinical Comparison of Procedural End Points After Pulmonary Vein Isolation in Paroxysmal Atrial Fibrillation: Elimination of Nonpulmonary Vein Triggers Versus Noninducibility

BACKGROUND

Pulmonary vein isolation (PVI) is effective for maintenance of sinus rhythm in 50% to 75% of patients with paroxysmal atrial fibrillation, and it is not uncommon for patients to require additional ablation after PVI. We prospectively evaluated the relative effectiveness of 2 post-PVI ablation strategies in paroxysmal atrial fibrillation.

METHODS AND RESULTS

A total of 500 patients (mean age, 55.7±11.0 years; 74.6% male) were randomly assigned to undergo ablation by 2 different strategies after PVI: (1) elimination of non-PV triggers (group A, n=250) or (2) stepwise substrate modification including complex fractionated atrial electrogram or linear ablation until noninducibility of atrial tachyarrhythmia was achieved (group B, n=250). During a median follow-up of 26.0 months, 75 (32.2%) patients experienced at least 1 episode of recurrent atrial tachyarrhythmia after the single procedure in group A compared with 105 (43.8%) patients in group B (P value in log-rank test of Kaplan-Meier analysis: 0.012). Competing risk analysis showed that the cumulative incidence of atrial tachycardia was significantly higher in group B compared with group A (P=0.007). With the exception of total ablation time, there were no significant differences in fluoroscopic time or procedure-related complications between the 2 groups.

CONCLUSIONS

Elimination of triggers as an end point of ablation in patients with paroxysmal atrial fibrillation decreased long-term recurrence of atrial tachyarrhythmia compared with a noninducibility approach achieved by additional empirical ablation. The post-PVI trigger test is thus a better end point of ablation for paroxysmal atrial fibrillation.

A Cost-Utility Analysis of Cryoballoon Ablation versus Radiofrequency Ablation for Paroxysmal Atrial Fibrillation

Introduction

The objective of this study was to evaluate the cost-effectiveness of the treatment with cryoballoon (CB) compared to the standard treatment with traditional irrigated radiofrequency (RF) ablation for pulmonary vein isolation in patients with paroxysmal atrial fibrillation (pAF) refractory to antiarrhythmic drug therapy.

Methods

A decision tree model was developed to graphically depict the probabilities, utilities and costs of CB compared to RF therapy. Data from a conducted systematic literature review and meta-analysis of only RCTs were used to evaluate clinical outcomes of CB and RF treatments, including success rates after one year, complications and recurrence of atrial fibrillation.

Results

The cost-utility analysis estimated that, CB therapy had £1,747 higher cost, and 0.0114 more quality-adjusted life years (QALYs) compared to standard RF treatment over a one-year time horizon. The incremental cost per QALY of CB ablation compared to RF ablation was estimated to be £152,836/QALY.

Conclusions

Based on current evidence, CB ablation for pulmonary vein isolation in patients with pAF is costeffective compared to RF if decision makers are willing to pay £152,836 or higher for a QALY.

Prolonged P-wave duration in sinus rhythm pre-ablation is associated with atrial fibrillation recurrence after pulmonary vein isolation-A systematic review and meta-analysis

INTRODUCTION

A prolonged P-wave duration (PWD) in sinus rhythm pre-ablation has been hypothesized to be a non-invasive ECG marker associated with increased atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). This systematic review and meta-analysis will assess the latest evidence on the association of prolonged PWD pre-ablation with AF recurrence after PVI.

HYPOTHESIS

Prolonged PWD pre-ablation is associated with AF recurrence after PVI.

METHODS

The inclusion criteria for this study are all cohort studies that assess prolonged PWD on ECG during sinus rhythm pre-ablation and its association with AF recurrence in post-PVI patients.

RESULTS

There were 1,482 patients with AF post-PVI from twelve cohort studies. The cut-off points for prolonged PWD ranges from >120 ms to >150 ms. Meta-analysis on six studies showed a pooled mean difference of PWD in subjects with recurrent AF and non-recurring AF was 12.54 ms [8.76-16.31], p < 0.001; I² 78%. Pooled odds ratio was 4.17 [2.10-8.31], p < 0.001; I² 72% and pooled hazard ratio was 1.93 [1.10-3.39], p = 0.02; I² 80%. Upon subgroup analysis, the association between prolonged PWD and AF recurrence was significant in signal-averaged ECG, 12-lead ECG, paroxysmal AF, >120-130 ms, and >140-150 ms PWD cut-off point subgroups.

CONCLUSION

These findings suggest that prolonged PWD with a cutoff of >120 ms to >150 ms in sinus rhythm before ablation may be associated with AF recurrence after PVI regardless of age, gender, left atrial size, and the presence of structural heart disease. We also encouraged further studies that investigate predicting models to include prolonged PWD as one of their parameters.