Very long term outcomes of atrial fibrillation ablation

Long-term outcomes of catheter ablation compared with medical therapy in atrial fibrillation

BACKGROUND

The long-term effects of catheter ablation (CA) compared with medical therapy on cardiovascular outcomes for atrial fibrillation (AF) remain undetermined.

OBJECTIVE

Using a population-based cohort, we sought to determine what the association between CA and medical therapy was on these outcomes.

METHODS

By use of Alberta administrative data, patients with AF as the primary diagnosis during hospitalization, emergency department visit, or physician visit were included between October 1, 2008, and March 31, 2018. Based on therapy received, patients were assigned to categories of CA, rate control, or rhythm control with medication. The association of treatment with the primary composite outcome of all-cause death, hospitalization for heart failure, or stroke was examined after adjustment for age, sex, comorbidities, and baseline medications.

RESULTS

Of 39,966 treated AF patients, 2077 (5.2%), 29,467 (73.7%), and 8422 (21.1%) were treated with CA, rate control, and rhythm control with medication, respectively. Patients in the CA group had a lower incidence of the primary outcome (4.0/100 person-years) compared with the rate control group (8.7/100 person-years) or the rhythm control with medication group (6.8/100 person-years) during a median follow-up of 6.3 years. In multivariable analysis, compared with CA, both rate control (hazard ratio, 1.28; 95% confidence interval, 1.09-1.50) and rhythm control with medication (hazard ratio, 1.21; 95% confidence interval, 1.03-1.43) were associated with a higher risk of the primary outcome.

CONCLUSION

In this cohort study, patients who received CA demonstrated a reduction in the risk of long-term adverse cardiovascular outcomes compared with medical therapy in patients with AF, providing some data to indicate the effects of CA in the long-term.

Association between the preprocedural serum potassium level and atrial fibrillation recurrence after catheter ablation

BACKGROUND

The association between serum potassium and atrial fibrillation (AF) recurrence after catheter ablation remains unclear.

OBJECTIVE

The purpose of this study was to investigate whether preprocedural serum potassium level influences AF recurrence in patients who underwent catheter ablation.

METHODS

We used data of patients with AF who underwent de novo catheter ablation from the prospective Chinese Atrial Fibrillation Registry Study. Patients with prior ablation and without baseline serum potassium were excluded. The primary outcome was 1-year AF recurrence after a 3-month blanking period from the ablation procedure. Restricted cubic spline and Cox proportional models were used to compare outcomes across serum potassium groups.

RESULTS

A total of 4838 patients with AF who underwent de novo catheter ablation was enrolled. At 1 year, AF recurrence occurred in 1347 patients (27.8%). The relationship between preprocedural serum potassium levels and 1-year AF recurrence after ablation presented as U shape (P for nonlinear = .048). Compared with the group of serum potassium within 4.41-4.60 mmol/L, the risk of AF recurrence increased significantly in the lowest serum potassium group (≤4.00 mmol/L) after multivariable analysis (hazard ratio [HR] 1.26; 95% confidence interval 1.06-1.51; P = .010). Other groups with lower or higher serum potassium levels including 4.01-4.20 mmol/L (HR 1.18), 4.21-4.40 mmol/L (HR 1.16), 4.61-4.80 mmol/L (HR 1.07), and ≥4.81 mmol/L (HR 1.11) showed nonsignificant higher recurrence risk.

CONCLUSION

The relationship between preprocedural potassium and AF recurrence was U shaped, with an optimal potassium range (4.41-4.60 mmol/L). Lower potassium level is associated with increased AF recurrence risk after catheter ablation.

Ethanol marshall bundle elimination, pulmonary vein isolation, and linear ablation for atrial fibrillation with or without heart failure

Background

In medical practice, atrial fibrillation (AF) is intricately associated with heart failure (HF). Currently, ethanol infusion of vein of Marshall (EIVOM) for AF ablation in HF patients remains significantly limited.

Method

This was a non-randomized, single-center, retrospective observational study. AF patients received 4-step ablation composed of EIVOM, pulmonary vein isolation (PVI) and linear ablation. The primary composite endpoint was defined as recurrence of atrial tachycardia over 30 s. Propensity score matching (PSM) was performed to reduce selection bias.

Results

From April 2020 to May 2022, 362 patients were included, comprising of 182 HF patients and 180 non-HF patients. EIVOM success rate was lower in HF patients than non-HF patients (86.8% vs. 93.9%). Cardiac effusion was more common in HF patients (44.0% vs. 37.2%), and 2 cases of atrial-esophageal fistula were observed in the HF group. During a median follow-up of 12 months, no significant difference in the primary endpoint was observed between HF and non-HF group. Different HF subgroups had similar AF recurrence. After PSM, AF recurrence rate remained statistically equivalent between the HF and non-HF groups.

Conclusion

EVIOM combining catheter ablation can be completed with comparable success rate in AF patients with or without HF. However, peri-procedural safety is a concern for HF patients undergoing EIVOM combing AF catheter ablation. During the follow-up, HF status before ablation is not related with increased AF recurrence.

L-shaped association of plasma low-density lipoprotein cholesterol with atrial fibrillation recurrence after catheter ablation: a prospective cohort study

The association between plasma low-density lipoprotein cholesterol (LDL-C) and atrial fibrillation (AF) recurrence after catheter ablation remains unclear. We aimed to assess the relationship between preprocedural LDL-C and the AF recurrence in patients undergoing catheter ablation. The cohort study consecutively included AF patients who underwent de novo catheter ablation between April 2021 and January 2023 in the Second Affiliated Hospital of Nanchang University in Jiangxi Province, China. Patients were divided into quartiles based on their baseline fasting LDL-C level (Q1-Q4). Multivariable Cox proportional hazards models were used to evaluate the relationship between LDL-C and AF recurrence. Our analysis included the use of a generalized additive model and smooth curve fitting (penalized spline method), and two-piecewise Cox proportional hazards models, to address the nonlinearity between preprocedural LDL-C and AF recurrence. A total of 482 AF patients with de novo catheter ablation were enrolled, with a median follow-up period of 15.00 months, AF recurrence occurred in 96 (19.92%) patients. The relationship between preprocedural LDL-C and AF recurrence after ablation presented as an L-shape, and the inflection point for the curve was found at the LDL-C level of 3.20 mmol/L (Log likelihood ratio P = 0.031). The hazard ratios (HR) [(95% confidence intervals (CI)] for AF recurrence were 0.50 (0.33-0.74) and 2.11 (0.76-5.89) to the left and right of the inflection point, respectively. Lower LDL-C level is associated with increased AF recurrence risk after catheter ablation were consistent across all subgroups.

A Cost Analysis of Catheter Ablation for Atrial Fibrillation: A Canadian Pre-Post Study

Background

There is a paucity of Canadian studies using patient-level data to analyze the costs of catheter ablation (CA) for atrial fibrillation (AF). We sought to identify the health care resource use, costs, and cost predictors of CA.

Methods

A cost analysis was performed in a population of AF patients treated with CA in Central Zone Nova Scotia from 2010 to 2018. Costs were compared 2 years before ablation (pre-CA) with costs 2 years after (post-CA); the 3-month period post-CA was defined as the treatment window. Costs were also compared according to CA technology defined as before 2015 for patients treated with non-contact force sensing CA and after 2015 for patients treated with contact force sensing CA.

Results

Heart failure hospitalizations, AF-related emergency department visits, acute inpatient admissions, and cardioversions all decreased after ablation. The cost difference post-CA vs pre-CA was CAD$18,869 (95% confidence interval [CI], $15,570-$22,168). This increase in costs was driven by costs incurred during the treatment window, which was $21,439 (95% CI, $20,468-$22,409). After excluding treatment window costs, the mean year 1 post-CA cost was $11,223 (95% CI, $9113-$13,334) and year 2 post-CA cost was $4555 (95% CI, $3145-$5965); both were lower than the pre-CA costs. Costs remained stable over the time frame of the study period, with no influence from new technologies on cost. The post-CA cost difference between the post-2015 and pre-2015 groups was $2573 (95% CI, -$2336 to $7481).

Conclusions

We showed that although CA is expensive, it might be a cost-effective treatment modality for AF because of the associated reduction in costs and health care resource use.

The Relationship Between Cardiac CT-based Left Atrial Structure and Epicardial Adipose Tissue and Postablation Atrial Fibrillation Recurrence Within 2 Years

PURPOSE

The aim of this study was to explore the association of cardiac CT-based left atrium (LA) structural and functional parameters and left atrial epicardial adipose tissue (LA-EAT) parameters with postablation atrial fibrillation (AF) recurrence within 2 years.

MATERIALS AND METHODS

Contrast-enhanced cardiac CT images of 286 consecutive AF patients (median age: 65 y; 97 females) who underwent initial ablation between June 2018 and June 2020 were retrospectively analyzed. Structural and functional parameters of LA, including maximum and minimum volume and ejection fraction of LA and left atrial appendage (LAA), and LA-EAT volume, were measured. The body surface area indexed maximum and minimum volume of LA (LAVI max , LAVI min ) and LAA (LAAVI max , LAAVI min ), and LA-EAT volume index (LA-EATVI) were calculated. Independent predictors of AF recurrence were determined using Cox regression analysis. The clinical predictors were added to the imaging predictors to build a combined model (clinical+imaging). The predictive performance of the clinical, imaging, and combined models was assessed using the area under the receiver operating characteristics curve (AUC).

RESULTS

A total of 108 (37.8%) patients recurred AF within 2 years after ablation at a median follow-up of 24 months (IQR=11, 32). LA and LAA size and LA-EAT volume were significantly increased in patients with AF recurrence ( P <0.05). After the multivariable regression analysis, LA-EATVI, LAAVI max , female sex, AF duration, and stroke history were independent predictors for AF recurrence. The combined model exhibited superior predictive performance compare to the clinical model (AUC=0.712 vs. 0.641, P =0.023) and the imaging model (AUC=0.712 vs. 0.663, P =0.018).

CONCLUSION

Cardiac CT-based LA-EATVI and LAAVI max are independent predictors for postablation AF recurrence within 2 years and may provide a complementary value for AF recurrence risk assessment.

Lesion characteristics using high-frequency low-tidal volume ventilation versus standard ventilation during ablation of paroxysmal atrial fibrillation

INTRODUCTION

High-frequency low-tidal-volume (HFLTV) ventilation during radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) has been shown to be superior to standard ventilation (SV) in terms of procedural efficiency, acute and long-term clinical outcomes. Our study aimed to compare ablation lesions characteristics utilizing HFLTV ventilation versus SV during RFCA of PAF.

METHODS

A retrospective analysis was conducted on patients who underwent pulmonary vein isolation (PVI) for PAF between August 2022 and March 2023, using high-power short-duration ablation. Thirty-five patients underwent RFCA with HFLTV ventilation and were matched with another cohort of 35 patients who underwent RFCA with SV. Parameters including ablation duration, contact force (CF), impedance drop, and ablation index were extracted from the CARTONET database for each ablation lesion.

RESULTS

A total of 70 patients were included (HFLTV = 35/2484 lesions, SV = 35/2830 lesions) in the analysis. There were no differences in baseline characteristics between the groups. While targeting the same ablation index, the HFLTV ventilation group demonstrated shorter average ablation duration per lesion (12.3 ± 5.0 vs. 15.4 ± 8.4 s, p < .001), higher average CF (17.0 ± 8.5 vs. 10.5 ± 4.6 g, p < .001), and greater impedance reduction (9.5 ± 4.6 vs. 7.7 ± 4.1 ohms, p < .001). HFLTV ventilation group also demonstrated shorter total procedural time (61.3 ± 25.5 vs. 90.8 ± 22.8 min, p < .001), ablation time (40.5 ± 18.6 vs. 65.8 ± 22.5 min, p < .001), and RF time (15.3 ± 4.8 vs. 22.9 ± 9.7 min, p < .001).

CONCLUSION

HFLTV ventilation during PVI for PAF was associated with improved ablation lesion parameters and procedural efficiency compared to SV.

Regional conduction velocities determined by noninvasive mapping are associated with arrhythmia-free survival after atrial fibrillation ablation

BACKGROUND

Atrial arrhythmogenic substrate is a key determinant of atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI), and reduced conduction velocities have been linked to adverse outcome. However, a noninvasive method to assess such electrophysiologic substrate is not available to date.

OBJECTIVE

This study aimed to noninvasively assess regional conduction velocities and their association with arrhythmia-free survival after PVI.

METHODS

A consecutive 52 patients scheduled for AF ablation (PVI only) and 19 healthy controls were prospectively included and received electrocardiographic imaging (ECGi) to noninvasively determine regional atrial conduction velocities in sinus rhythm. A novel ECGi technology obviating the need of additional computed tomography or cardiac magnetic resonance imaging was applied and validated by invasive mapping.

RESULTS

Mean ECGi-determined atrial conduction velocities were significantly lower in AF patients than in healthy controls (1.45 ± 0.15 m/s vs 1.64 ± 0.15 m/s; P < .0001). Differences were particularly pronounced in a regional analysis considering only the segment with the lowest average conduction velocity in each patient (0.8 ± 0.22 m/s vs 1.08 ± 0.26 m/s; P < .0001). This average conduction velocity of the "slowest" segment was independently associated with arrhythmia recurrence and better discriminated between PVI responders and nonresponders than previously proposed predictors, including left atrial size and late gadolinium enhancement (magnetic resonance imaging). Patients without slow-conduction areas (mean conduction velocity <0.78 m/s) showed significantly higher 12-month arrhythmia-free survival than those with 1 or more slow-conduction areas (88.9% vs 48.0%; P = .002).

CONCLUSION

This is the first study to investigate regional atrial conduction velocities noninvasively. The absence of ECGi-determined slow-conduction areas well discriminates PVI responders from nonresponders. Such noninvasive assessment of electrical arrhythmogenic substrate may guide treatment strategies and be a step toward personalized AF therapy.

Long-term clinical outcomes and cost-effectiveness of catheter vs thoracoscopic surgical ablation in long-standing persistent atrial fibrillation using continuous cardiac monitoring: CASA-AF randomized controlled trial

BACKGROUND

Long-term clinical outcomes of catheter ablation (CA) compared to thoracoscopic surgical ablation (SA) to treat patients with long-standing persistent atrial fibrillation (LSPAF) are not known.

OBJECTIVE

The purpose of this study was to compare the long-term (36-month) clinical efficacy, quality of life, and cost-effectiveness of SA and CA in LSPAF.

METHODS

Participants were followed up for 3 years using implantable loop recorders and questionnaires to assess the change in quality of life. Intention-to-treat analyses were used to report the findings.

RESULTS

Of the 115 patients with LSPAF treated, 104 (90.4%) completed 36-month follow-up [CA: n = 57 (95%); SA: n = 47 (85%)]. After a single procedure without antiarrhythmic drugs, 7 patients (12%) in the CA arm and 5 (11%) in the SA arm [hazard ratio 1.22; 95% confidence interval (CI) 0.81-1.83; P = .41] were free from atrial fibrillation/tachycardia (AF/AT) ≥30 seconds at 36 months. Thirty-three patients (58%) in the CA arm and 26 (55%) in the SA arm (hazard ratio 1.04; 95% CI 0.57-1.88; P = .91) had their AF/AT burden reduced by ≥75%. The overall impact on health-related quality of life was similar, with mean quality-adjusted life year estimates of 2.45 (95% CI 2.31-2.59) for CA and 2.32 (95% CI 2.13-2.52) for SA. Estimated costs were higher for SA (mean £24,682; 95% CI £21,746-£27,618) than for CA (mean £18,002; 95% CI £15,422-£20,581).

CONCLUSION

In symptomatic LSPAF, CA and SA were equally effective at achieving arrhythmia outcomes (freedom from AF/AT ≥30 seconds and ≥75% burden reduction) after a single procedure without antiarrhythmic drugs. However, SA is significantly more costly than CA.

Treatment of atrial fibrillation with second-generation cryoballoon followed by contact-sensing radiofrequency catheter ablation for arrhythmia recurrences-results of a 5-year follow-up

INTRODUCTION

The aim of this study was to report the long-term follow-up results of cryoballoon (CB) ablation in patients with atrial fibrillation.

METHODS

All consecutive patients who underwent second-generation CB ablation from February 2015 to December 2017 were included in our study. In all procedures, we used a 28-mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20-mm octapolar intraluminal circular catheter was used for intracardiac recordings. A single 180-s freeze strategy was employed. Repeated procedures were performed with a 3D mapping system and radiofrequency catheters.

RESULTS

A total of 126 patients (69.8% male, mean age 57 ± 11 years), of which 77.0% had paroxysmal atrial fibrillation (PAF), were included in the study. After a 5-year period, 52.4% of patients were in sinus rhythm without AF recurrence, off antiarrhythmic drugs. A total of 61.9% of patients were free of AF recurrence when redo PVI procedures were performed. When accounting for redo pulmonary vein isolation and antiarrhythmic drugs, a total of 73.8% of the patients were without AF recurrence in long-term follow-up. The patients who underwent redo pulmonary vein isolation procedures had statistically significant lower rates of AF recurrence (p = 0.006). In patients with PAF, long-term success rates improved from 62.9 to 79.4% for patients who underwent the redo procedure (p = 0.020). In patients with persistent atrial fibrillation (PersAF), success rates went up from 41.4 to 55.1% for patients with single or repeated PVI procedure (p = 0.071). In the whole cohort, a total of 3 (2.4%) procedure-related major complications occurred which included persistent PNP, arterial pseudoaneurysm, and arteriovenous fistula.

CONCLUSION

Our data suggest a favorable long-term safety and efficacy profile of second-generation CB ablation. In the mixed paroxysmal and persistent population, up to 73.8% of patients remained free of AF recurrence in the 5-year follow-up, when accounting for redo procedures and AADs. Only 2.4% of patients experienced major complications of the ablation procedure, none with permanent sequelae.

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter

BACKGROUND

Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear.

METHODS

This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups.

RESULTS

Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group.

CONCLUSION

In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

Eicosapentaenoic Acid and the Outcomes in Older Patients Undergoing Atrial Fibrillation Ablation

BACKGROUND

A lower serum eicosapentaenoic acid (EPA) to arachidonic acid (AA) ratio (EPA/AA) level correlates with cardiovascular events. Nevertheless, elevated serum EPA levels increase the risk of new-onset atrial fibrillation (AF) in older patients. The relationship between the EPA/AA and outcomes post-AF ablation remains unclear. This study investigated the impact of the EPA/AA on AF recurrence and cardiovascular events after AF ablation in older patients.

METHODS AND RESULTS

This retrospective cohort study examined consecutive patients with AF aged ≥65 years who underwent a first-time AF ablation. We compared the 3-year AF recurrence and 5-year major adverse cardiovascular event (MACE) rates between patients divided into high and low EPA/AA levels defined as above and below the median EPA/AA value before ablation. MACE was defined as heart failure hospitalizations, strokes, coronary artery disease, major bleeding, and cardiovascular death. Among the 673 included patients, the median EPA/AA value was 0.35. Compared with the low EPA/AA group, the high EPA/AA group had a significantly higher cumulative incidence of AF recurrence (39.3% versus 27.6%; log-rank P=0.004) and lower cumulative incidence of MACE (13.8% versus 25.5%, log-rank P=0.021). A high EPA/AA level was determined as an independent predictor of AF recurrence (hazard ratio [HR], 1.75 95% CI, 1.24-2.49; P=0.002) and MACE (HR, 0.60 [95% CI, 0.36-0.99]; P=0.046).

CONCLUSIONS

The EPA/AA was associated with AF recurrence and MACE after ablation in patients with AF aged ≥65 years.

Concurrent vs Staged Hybrid Ablation for Long-Standing Persistent Atrial Fibrillation: A Propensity-Matched Cohort Study

BACKGROUND

Long-term success rates of catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) are less than satisfactory. Further improvement of ablation methods is crucial for enhancing the treatment of LSPAF.

OBJECTIVES

This study sought to compare the outcomes of concurrent vs staged minimally invasive surgical-catheter hybrid ablation for LSPAF.

METHODS

From December 2015 to December 2021, 104 matched patients (concurrent and staged, 1:1) were included in study. In the concurrent group, both left unilateral thoracoscopic epicardial ablation (EA) and CA were performed simultaneously in one procedure. In the staged group, EA was performed at the first hospitalization. If the patients experienced atrial fibrillation (AF) recurrence, CA was performed between 3 months and 1 year after EA.

RESULTS

In the concurrent group, 4 patients were restored to sinus rhythm after EA, and 41 were patients restored to sinus rhythm during CA; 86.5% (45 of 52) achieved intraprocedural AF termination during concurrent hybrid ablation. In the staged group, all 52 patients underwent staged CA because of the recurrence of AF or atrial tachycardia (AT). Forty-seven (90.4%) patients achieved intraprocedural AF or AT termination during CA. Freedom from AF or AT off antiarrhythmic drugs at 2 years after hybrid ablation was 79.9% ± 5.7% in the concurrent group and 86.0% ± 4.9% in the staged group (P = 0.390). Failure of intraprocedural AF termination (HR: 14.378) was an independent risk factor for AF recurrence after hybrid ablation.

CONCLUSIONS

Both concurrent and staged hybrid ablation could be safely and effectively applied to treat LSPAF. Improving the intraprocedural AF termination rate predicted better outcomes.

Chinese guidelines for the diagnosis and management of atrial fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of the guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice timely and fully, the Chinese Society of Cardiology of Chinese Medical Association and the Heart Rhythm Committee of Chinese Society of Biomedical Engineering jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2‑VASc‑60 stroke risk score based on the characteristics of the Asian AF population. The guidelines also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Left atrial low-voltage areas, but not volume, predict the recurrence of atrial fibrillation in repeat ablation procedures

INTRODUCTION

Left atrial (LA) low voltage areas (LVA) are a controversial target in atrial fibrillation ablation procedures. However, LVA and LA volume are good predictors of arrhythmia recurrence in ablation-naïve patients. Their predictive value in progressively diseased pre-ablated atria is uncertain.

METHODS

Consecutive patients with recurrent atrial fibrillation (AF) or atrial tachycardia (AT), who were scheduled for repeat LA ablation, were enrolled in the prospective Bernau ablation registry between 2016 and 2020. All patients received a complete LA ultrahigh-density map before ablation. Maps were analyzed for LA size, LVA percentage and distribution. The predictive value of demographic, anatomic, and mapping variables on AF recurrence was analyzed.

RESULTS

160 patients (50.6% male, 1.3 pre-ablations, 60% persistent AF) with complete LA voltage maps were included. Mean follow-up time was 16 ± 11 months. Mean recorded electrograms (EGMs) per map were 9754 ± 5808, mean LA volume was 176.1 ± 35.9 ml and mean rate of LVAs <0.5 mV was 30.6% ± 23.1%. During follow-up recurrence rate of AF or AT >30 s was 55.6%. Patients with recurrence had a significant higher percentage of LVAs (40.0% vs. 18.8%, p < .001) but no relevant difference in LA volume (172 vs. 178 mL, p = .299). ROC curves revealed LVA as a good predictor for recurrence (AUC = 0.79, p < .001) and a cut-off of 22% LVAs with highest sensitivity (73.0%) and specificity (71.8%). Based on this cut off, event free survival was significantly higher in the Low LVA group (p < .01).

CONCLUSION

Total LVA percentage has a good predictive power on arrhythmia recurrence in a cohort of advanced scarred left atria in repeat procedures independent of the applied ablation strategy. Left atrial volume seems to have minor impact on the rhythm outcome in our study cohort.

Early ablation of newly diagnosed paroxysmal atrial fibrillation (NEWPaAF) versus newly diagnosed persistent atrial fibrillation (NEWPeAF): Comparison of patient populations and ablation outcomes

INTRODUCTION

Little is known about very early atrial fibrillation (AF) ablation after first AF detection.

METHODS

We evaluated patients with AF ablation <4 months from newly diagnosed paroxysmal AF (NEWPaAF) and newly diagnosed persistent AF (NEWPeAF). We compared the two patient populations and compared ablation outcomes to those undergoing later ablation.

RESULTS

Ablation was done <4 months from AF diagnosis in 353 patients (135 = paroxysmal, 218 = persistent). Early ablation outcome was best for NEWPaAF versus NEWPeAF for initial (p = 0.030) but not final (p = 0.102) ablation. Despite recent AF diagnosis in both groups, they were clinically quite different. NEWPaAF patients were younger (64.3 ± 13.0 vs. 67.3 ± 10.9, p = 0.0020), failed fewer drugs (0.39 vs. 0.60, p = 0.007), had smaller LA size (4.12 ± 0.58 vs. 4.48 ± 0.59 cm, p < 0.0001), lower BMI (28.8 ± 5.0 vs. 30.3 ± 6.0, p = 0.016), and less CAD (3.7% vs. 11.5%, p = 0.007), cardiomyopathies (2.2% vs. 22.9%, p = 0.0001), hypertension (46.7% vs. 67.4%, p < 0.0001), diabetes (8.1% vs. 17.4%, p = 0.011) and sleep apnea (20.0% vs. 30.3%, p = 0.031). For NEWPaAF, early ablation AF-free outcome was no better than later ablation (p = 0.314). For NEWPeAF, AF-free outcomes were better for early ablation than later ablation (p < 0.0001). Delaying ablation allowed more strokes/TIAs in both AF types (paroxysmal p = 0.014, persistent p < 0.0001).

CONCLUSIONS

Patients presenting for early ablation after newly diagnosed persistent AF have more pre-existing comorbidities and worse initial ablation outcomes than patients with NEWPaAF. For NEWPaAF, there was no advantage to early ablation, as long as the AF remained paroxysmal. For NEWPeAF, early ablation gave better outcomes than later ablation and they should undergo early ablation. For both AF types, waiting was associated with more neurologic events, suggesting all patients should consider earlier ablation.

Statewide data on surgical ablation for atrial fibrillation: The data provide a path forward

OBJECTIVE

Atrial fibrillation (AF), if left untreated, is associated with increased intermediate and long-term morbidity/mortality. Surgical treatment for AF is lacking standardization in patient selection and lesion set, despite clear support from multi-society guidelines. The aim of this study was to analyze a statewide cardiac surgery registry to establish whether or not there is an association between center volume and type of index procedure with performance of surgical ablation (SA) for AF, the lesion set chosen, and ablation technology used.

METHODS

Adult, first-time, nonemergency patients with preoperative AF between 2014 and 2022 excluding standalone SA procedures from a statewide registry of Society of Thoracic Surgeons data were included (N = 4320). AF treatment variability by hospital volume (ordered from smallest to largest) and surgery type were examined with χ2 analyses. Hospital-level Spearman correlations compared hospital volume with proportion of AF patients treated with SA.

RESULTS

Overall, 37% of patients with AF were ablated at the time of surgery (63% of mitral procedures, 26% of non-mitrals) and 15% had left atrial appendage management only. There was a significant temporal trend of increasing performance of SA for AF over time (Cochran-Armitage = 27.8; P < .001). Hospital cardiac surgery volume did not correlate with the proportion of AF patients treated with SA (rs = 0.19; P = .603) with a rate of SA below the state average for academic centers. Of cases with SA (n = 1582), only 43% had a biatrial lesion set. Procedures that involved mitral surgery were more likely to include a biatrial lesion set (χ2 = 392.3; P < .001) for both paroxysmal and persistent AF. Similarly, ablation technology use was variable by type of concomitant operation (χ2 = 219.0; P < .001) such that radiofrequency energy was more likely to be used in non-mitral procedures.

CONCLUSIONS

These results indicate an increase in adoption of SA for AF over time. No association between greater hospital volume or academic status and performance of SA for AF was established. Similar to national data, the type of index procedure remains the most consistent factor in the decision to perform SA with a disconnect between AF pathophysiology and decision making on the type of SA performed. This analysis demonstrates a gap between evidence-based guidelines and real-world practice, highlighting an opportunity to confer the benefits of concomitant SA to more patients.

Efficacy of Shensong Yangxin capsule combined with dronedarone in paroxysmal atrial fibrillation after ablation

OBJECTIVE

To investigate whether postoperative administration of Shensong Yangxin capsules (SSYX) and dronedarone for atrial fibrillation (AF) can reduce the recurrence of paroxysmal AF after radiofrequency ablation, thus providing a more optimal choice of antiarrhythmic medication during the blank period.

METHODS

We included 120 patients with paroxysmal AF who underwent radiofrequency ablation at our hospital between July 2020 and July 2022. They underwent routine circumferential pulmonary vein ablation and, subsequently, left and right atrial pressure monitoring to assess sinoatrial node recovery time under burst 400/300 ms stimulation. Postoperatively, the patients were randomly divided into 2 groups (60 patients each). The control group was administered dronedarone orally for 3 months and the study group was treated with SSYX combined with dronedarone. This study aimed to compare differences in clinical efficacy of the treatment between the 2 groups.

RESULTS

The left and right atrial pressures in both groups were higher than those in the preoperative period (P < .05), with no statistically significant differences between the 2 groups (P > .05). Sinoatrial node recovery time under burst 400/300 ms stimulation showed no statistical difference between the 2 groups (P > .05). At 3 months and 1 year postoperatively, the AFEQT scale scores for both groups were lower than those before treatment (P < .05), with the study group scoring lower than the control group at 3 months (P < .05). However, no statistically significant difference was observed between the 2 groups at 1 year postoperatively (P > .05). At 3 months postoperatively, the sinus rhythm maintenance rate and heart rate were higher in the intervention group than in the control group (P < .05); however, these differences between the 2 groups were not statistically significant at 1 year postoperatively (P > .05).

CONCLUSION SUBSECTIONS

The combination of SSYX and dronedarone could effectively reduce the early recurrence of paroxysmal AF after radiofrequency ablation, increase heart rate, and improve the quality of life.

Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, significantly impacting patients' quality of life and increasing the risk of death, stroke, heart failure, and dementia. Over the past two decades, there have been significant breakthroughs in AF risk prediction and screening, stroke prevention, rhythm control, catheter ablation, and integrated management. During this period, the scale, quality, and experience of AF management in China have greatly improved, providing a solid foundation for the development of guidelines for the diagnosis and management of AF. To further promote standardized AF management, and apply new technologies and concepts to clinical practice in a timely and comprehensive manner, the Chinese Society of Cardiology of the Chinese Medical Association and the Heart Rhythm Committee of the Chinese Society of Biomedical Engineering have jointly developed the Chinese Guidelines for the Diagnosis and Management of Atrial Fibrillation. The guidelines have comprehensively elaborated on various aspects of AF management and proposed the CHA2DS2-VASc-60 stroke risk score based on the characteristics of AF in the Asian population. The guidelines have also reevaluated the clinical application of AF screening, emphasized the significance of early rhythm control, and highlighted the central role of catheter ablation in rhythm control.

Hybrid atrial fibrillation ablation: long-term outcomes from a single-centre 10-year experience

AIMS

Hybrid atrial fibrillation (AF) ablation is a promising approach in non-paroxysmal AF. The aim of this study is to assess the long-term outcomes of hybrid ablation in a large cohort of patients after both an initial and as a redo procedure.

METHODS AND RESULTS

All consecutive patients undergoing hybrid AF ablation at UZ Brussel from 2010 to 2020 were retrospectively evaluated. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation. Additional lesions were performed based on clinical indication and physician judgement. Primary endpoint was freedom from atrial tachyarrhythmias (ATas). A total of 120 consecutive patients were included, 85 patients (70.8%) underwent hybrid AF ablation as first procedure (non-paroxysmal AF 100%), 20 patients (16.7%) as second procedure (non-paroxysmal AF 30%), and 15 patients (12.5%) as third procedure (non-paroxysmal AF 33.3%). After a mean follow-up of 62.3 months ± 20.3, a total of 63 patients (52.5%) experienced ATas recurrence. Complications occurred in 12.5% of patients. There was no difference in ATas between patients undergoing hybrid as first vs. redo procedure (P = 0.53). Left atrial volume index and recurrence during blanking period were independent predictors of ATas recurrence.

CONCLUSION

In a large cohort of patients undergoing hybrid AF ablation, the survival from ATas recurrence was 47.5% at ≈5 years follow-up. There was no difference in clinical outcomes between patients undergoing hybrid AF ablation as first procedure or as a redo.