Very long-term clinical outcomes after radiofrequency catheter ablation for atrial fibrillation: A large single-center experience

Long-term outcomes of cryoballoon versus robotic magnetic navigation guided radiofrequency ablation in patients with persistent atrial fibrillation

This study aimed to evaluate the long-term efficacy and clinical outcomes of catheter ablation performed with cryoballoon (CRYO) in comparison with robotic magnetic navigation (RMN) in patients with persistent atrial fibrillation (PersAF). A total of 200 patients with symptomatic PersAF were prospectively enrolled and non-randomly assigned (1:1) to the CRYO or RMN guided-ablation group undergoing pulmonary vein isolation (PVI) and additional linear ablation if necessary and then followed up over 5 years. The primary endpoint was freedom from atrial tachyarrhythmias (ATs) recurrence following a 3-month blanking period after the initial procedure. The secondary endpoints consisted of all-cause and cardiovascular rehospitalizations, rates of electrical cardioversion (EC) and re-do ablation, new-onset neurological event, major bleeding event and the difference in CHA2DS2-VASc score at 5-year compared with baseline. After a median follow-up period of 60 months, 184 patients (93 in RMN, 91 in CRYO) completed the follow-up. Freedom from recurrent ATs was achieved in 44 out of 93 patients in the RMN group and 37 out of 91 patients in the CRYO group (47.3% vs. 40.7%, P = 0.32). There were no significant differences in the risk of all-cause and cardiovascular rehospitalizations, rates of EC and re-do ablation, new-onset neurological event, and major bleeding event at 5 years. Anticoagulation (OAC) discontinuation was relatively common after ablation, since 48.4% of patients with a CHA2DS2-VASc score ≥ 2 were not on OAC therapy. CRYO is comparable to RMN-guided ablation with respect to long-term freedom from ATs in patients with PersAF. Discontinuation of OAC after ablation is not rare even in patients at risk of stroke for continued OAC therapy.

Associations Among Sleep Apnea, Objective or Subjective Sleep Duration, and Recurrence of Atrial Fibrillation in Patients Who Undergo Radiofrequency Catheter Ablation for Persistent Atrial Fibrillation - A Prospective Observational Study

BACKGROUND

Sleep apnea (SA), subjective sleep duration (SSD), and objective sleep duration (OSD) were reported as risk factors for atrial fibrillation (AF). However, the association between AF and the combination of SA and OSD has not been clarified. Nor has a mismatch between SSD and OSD been investigated.

METHODS AND RESULTS

We assessed SA with polysomnography, OSD with actigraphy, and SSD in patients who underwent radiofrequency catheter ablation for persistent AF. We investigated associations among SA, OSD, OSD×3% oxygen desaturation index (3%ODI), and AF recurrence, considering SSD-OSD (i.e., the difference between SSD and OSD) and OSD. Seventy of 94 (74.4%) participants had moderate-to-severe SA (apnea-hypopnea index [AHI] ≥15). Participants were classified into OSD tertiles. Participants in Tertile 3 (mean OSD: 7.3 h) had decreased SSD-OSD (0.0 h) with increased Stage N1 sleep. Over 27.6 months, 10 AF recurrences occurred in 51 participants without treatment for SA. AHI ≥20 and OSD Tertile 3 were associated with AF recurrence (hazard ratios 5.7 [95% confidence interval 1.1-24.7] and 10.3 [95% confidence interval 1.2-88.4], respectively). Participants with AF recurrence had a higher OSD×3%ODI.

CONCLUSIONS

SA and long OSD were predictors of recurrent AF through long exposure to intermittent hypoxia during sleep. SSD-OSD was low in patients with long OSD, possibly because of decreased sleep quality.

Comparing simultaneous hybrid ablation with stand-alone thoracoscopic surgical ablation for the treatment of non-paroxysmal atrial fibrillation: a prospective randomized controlled trial

AIMS

Advanced atrial fibrillation (AF) is currently a dilemma for electrophysiologists when choosing a minimally invasive treatment strategy. Previous studies have demonstrated the outcome of either catheter ablation or thoracoscopic surgical ablation (SA) is unsatisfactory in these patients. Whether hybrid ablation (HA) could improve outcomes in these patients is unknown. The purpose of this study was to evaluate the clinical efficacy of HA for the treatment of advanced AF.

METHODS AND RESULTS

A randomized controlled trial was designed to enrol patients with persistent AF (PerAF) and enlarged left atrium or long-standing persistent AF (LSPAF) who were randomized to HA or thoracoscopic SA at a 1:1 ratio. The primary endpoint was freedom from any recurrence of AF off antiarrhythmic drugs (AADs) 12 months after operation. The primary endpoint was monitored by 7-day electrocardiogram monitoring devices. One hundred patients were enrolled. The mean age was 58.5 ± 7.6 years, and the mean left atrial diameter (LAD) was 50.1 ± 6.1 mm. At 12 months, freedom from AF off AADs was recorded in 71.4% (35/49) of patients in HA group and 45.8% (22/48) in SA group [odds ratio 2.955, 95% confidence interval (1.275-6.848), P = 0.014]. HA significantly reduced patients' AF burden (30.2% in SA group and 14.8% in HA group, P = 0.048) and the LAD (mean differences: -5.53 ± 4.97 mm in HA group and -3.27 ± 5.20 mm in SA group, P = 0.037) at 12 months after operation.

CONCLUSION

In patients with PerAF and enlarged left atrium or LSPAF, HA achieved better freedom from AF after 1 year of follow-up compared with thoracoscopic SA.

A meta-analysis and cost-minimization analysis of cryoballoon ablation versus radiofrequency ablation for paroxysmal atrial fibrillation

Background

Previous studies have shown inconsistent results in clinical effectiveness between cryoballoon ablation (CBA) and radiofrequency ablation (RFA), and cost assessment between the procedures is important. The aim of this study was to evaluate the clinical effectiveness and cost-effectiveness between the procedures in patients with paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drug therapy.

Methods

A systematic review and meta-analysis were performed. The primary outcome for the meta-analysis was long-term AF recurrence. Following the results of the meta-analysis, the cost-effectiveness of CBA versus RFA in Japan was assessed.

Results

The meta-analysis included 12 randomized controlled trials and six propensity-score matching cohort studies. AF recurrence was slightly lower in patients referred for CBA than for RFA, with an integrated risk ratio of 0.93 (95% confidence interval: 0.81-1.07) and an integrated hazard ratio of 0.96 (95% confidence interval: 0.77-1.19), but no significant difference was found. A cost-minimization analysis was conducted to compare the medical costs of CBA versus RFA because there was no significant difference in the risk of AF recurrence between the procedures. The estimated costs for CBA and RFA were JPY 4 858 544 (USD 32 390) and JPY 4 505 255 (USD 30 035), respectively, with cost savings for RFA of JPY 353 289 (USD 2355).

Conclusion

Our meta-analysis suggests that CBA provides comparable benefits with regard to AF recurrence compared with RFA, as shown in previous studies. Although the choice of treatment should be based on patient and treatment characteristics, RFA was shown that it might be cost saving as compared to CBA.

Prognostic Importance of B-Type Natriuretic Peptide Level in Patients Undergoing Catheter Ablation for Atrial Fibrillation

BACKGROUND

This study assessed the prognostic importance of B-type natriuretic peptide (BNP) concentrations for clinical events after catheter ablation for atrial fibrillation (AF).

METHODS AND RESULTS

We enrolled 1,750 consecutive patients undergoing initial AF ablation whose baseline BNP data were available from a large-scale multicenter observational cohort (TRANQUILIZE-AF Registry). The prognostic impact of BNP concentration on clinical outcomes, including recurrent tachyarrhythmias and a composite of heart failure (HF) hospitalization or cardiac death, was evaluated. Median baseline BNP was 94.2 pg/mL. During a median follow-up of 2.4 years, low BNP (<38.3 pg/mL) was associated with lower rates of recurrent atrial tachyarrhythmias than BNP concentrations ≥38.3 pg/mL (19.9% vs. 30.6% at 3 years; P<0.001) and HF (0.8% vs. 5.3% at 3 years; P<0.001). Multivariable Cox regression analyses revealed that low BNP was independently associated with lower risks of arrhythmia recurrence (hazard ratio [HR] 0.63; 95% confidence interval [CI] 0.47-0.82; P<0.001) and HF (HR 0.17; 95% CI 0.04-0.71; P=0.002). The favorable impact of low BNP on arrhythmia recurrence was prominent in patients with paroxysmal, but not non-paroxysmal, AF, particularly among those with long-standing AF.

CONCLUSIONS

Low BNP concentrations had a favorable impact on clinical outcomes after AF ablation. The heterogeneous impact of baseline BNP concentrations on arrhythmia recurrence for the subgroups of patients divided by AF type warrants future larger studies with longer follow-up periods.

Freedom from atrial arrhythmia and other clinical outcomes at 5 years and beyond after catheter ablation of atrial fibrillation: a systematic review and meta-analysis

AIMS

Catheter ablation of atrial fibrillation (AF) is now a mainstream procedure although long-term outcomes are uncertain. We performed a systematic review and meta-analysis of procedural outcomes at 5 years and beyond.

METHODS AND RESULTS

We searched PubMed and Embase and after the screening, identified 73 studies (67 159 patients) reporting freedom from atrial arrhythmia, all-cause death, stroke, and major bleeding at ≥5 years after AF ablation. The pooled mean age was 59.7y, 71.5% male, 62.2% paroxysmal AF, and radiofrequency was used in 78.1% of studies. Pooled incidence of freedom from atrial arrhythmia at 5 years was 50.6% (95%CI 45.5-55.7%) after a single ablation and 69.7% [95%CI (confidence interval) 63.8-75.3%) after multiple procedures. The incidence was higher among patients with paroxysmal compared with non-paroxysmal AF after single (59.7% vs. 33.3%, p = 0.002) and multiple (80.8% vs. 60.6%, p < 0.001) ablations but was comparable between radiofrequency and cryoablation. Pooled incidences of other outcomes were 6.0% (95%CI 3.2-9.7%) for death, 2.4% (95%CI 1.4-3.7%) for stroke, and 1.2% (95%CI 0.8-2.0%) for major bleeding at 5 years. Beyond 5 years, freedom from arrhythmia recurrence remained largely stable (52.3% and 64.7% after single and multiple procedures at 10 years), while the risk of stroke and bleeding increased over time.

CONCLUSION

Nearly 70% of patients having multiple ablations remained free from atrial arrhythmia at 5 years, with the incidence slightly decreasing beyond this period. Risk of death, stroke, and major bleeding at 5 years were low but increased over time, emphasizing the importance of long-term thromboembolism prevention and bleeding risk management.

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.

Very long term outcomes of atrial fibrillation ablation

BACKGROUND

Little is known about the very long term durability of atrial fibrillation (AF) ablation.

OBJECTIVE

The purpose of this study was to evaluate very long term AF ablation outcomes.

METHODS

We followed 5200 patients undergoing 7145 ablation procedures. We evaluated outcomes after single and multiple ablation procedures for paroxysmal (PAF; 33.6%), persistent (PeAF; 56.4%), and long-standing (LsAF; 9.9%) AF. We compared 3 ablation eras by initial ablation catheter: early (101 patients) using solid big tip (SBT) catheters (October 2003 to December 2005), intermediate (2143 patients) using open irrigated tip (OIT) catheters (December 2005 to August 2016), and contemporary (2956 patients) using contact force (CF) catheters (March 2014 to December 2021).

RESULTS

AF freedom at 5, 10, and 15 years was as follows: initial ablation: PAF 67.8%, 56.3%, 47.6%; PeAF 46.6%, 35.6%, 26.5%; and LsAF 30.4%, 18.0%, 3.4%; final ablation: PAF 80.3%, 72.6%, 62.5%; PeAF 60.1%, 50.2%, 42.5%; and LsAF 43.4%, 32.0%, 20.6%. For PAF and PeAF, CF ablation procedures were better than OIT ablation procedures (P < .0001) and both were better than SBT ablation procedures (P < .001). LsAF had no outcome improvement over the eras. The 8-year success rate after final ablation for CF, OIT, and SBT catheter eras was as follows: PAF 79.1%, 71.8%, 60.0%; PeAF 55.9%, 50.7%, 38.0%; and LsAF 42.7%, 36.2%, 31.8%. Highest AF recurrence was in the first 2 years, with a 2- to 15-year recurrence of 2%/yr. Success predictors after initial and final ablation procedures were younger age, smaller left atrium, shorter AF duration, male sex, less persistent AF, lower CHA₂DS₂-VASc score, fewer drugs failed, and more recent catheter era.

CONCLUSION

After year 2, there is 2%/yr recurrence rate for all AF types. Ablation success is best in the CF catheter era, intermediate in the OIT era, and worst in the SBT era. Over the ablation eras, outcomes improved for PAF and PeAF but not for LsAF. We should follow patients indefinitely after ablation. We need an understanding of how to better ablate more persistent AF.

Prognostic impact of catheter ablation in patients with asymptomatic atrial fibrillation

BACKGROUND

Catheter ablation for asymptomatic atrial fibrillation (AF) remains controversial. The aim of the present study was to explore the prognostic impact of catheter ablation in asymptomatic AF patients.

METHODS

We performed a post-hoc analysis of 537 risk-matched pairs of AF patients receiving first-time catheter ablation or conservative management. The primary outcome measure was a composite of cardiovascular death, heart failure (HF) hospitalization, ischemic stroke, or major bleeding. The study patients were divided into asymptomatic and symptomatic patients, and were further divided according to the presence or absence of previous AF-related complications (ischemic stroke or HF hospitalization).

RESULTS

Most baseline characteristics were well balanced between the catheter ablation versus conservative management groups. The median follow-up period was 5.3 years. Catheter ablation as compared to conservative management was associated with significantly lower incidence of the primary outcome measure in the asymptomatic AF patients (14.7% versus 25.4% at 8-year, log-rank P = 0.008). However, the advantage of catheter ablation was significant only in the high-risk subset of patients with the previous AF-related complications (19.2% versus 55.6% at 8-year, log-rank P = 0.006), but not in those without (13.9% and 17.3%, P = 0.08). On the other hand, among the symptomatic AF patients, catheter ablation was associated with significantly lower incidence of the primary outcome measure regardless of the previous AF-related complications.

CONCLUSIONS

In the post-hoc analysis of the matched AF cohort, catheter ablation as compared with conservative management was associated with better long-term clinical outcomes among asymptomatic AF patients only when the previous AF-related complications were present.

Relation of a Filling Defect of Left Atrial Appendage by Contrast Computed Tomography Image With Subsequent Clinical Events in Patients With Atrial Fibrillation Receiving Catheter Ablation Procedures

Filling defect (FD) in left atrial appendage (LAA) is commonly observed in contrast computed tomography (CT) among patients with atrial fibrillation (AF), although its prognostic impact has not been well explored. We enrolled 1,019 consecutive patients who underwent AF ablation with baseline contrast CT images. FD in LAA was graded into 3 groups: grade 0 for complete filling (79.7%), grade 1 for incomplete filling (12.6%), and grade 2 for complete FD (7.8%). We evaluated the impact of the FD grade on the long-term clinical outcomes during the mean follow-up of 4.4 ± 2.0 years. Patients with grade 2 FD had higher prevalence of nonparoxysmal AF, higher brain natriuretic peptide level, and larger left atrial volume than those with grade 0 or 1 FD. The 5-year cumulative incidence of recurrent atrial tachyarrhythmias was higher in patients with grade 2 FD than those with grade 0 or 1 FD (74.0% vs 38.8% and 62.1%, log-rank p <0.001). The 5-year cumulative incidence of major adverse cardiovascular events (MACEs), defined as a composite of all-cause death, heart failure hospitalization, and ischemic stroke, was also significantly higher in patients with grade 2 FD (19.4% vs 5.6% and 9.5%, log-rank p <0.001). Follow-up CT images acquired in 87.1% of patients at median interval of 98 days showed significantly decreased FD (grade 1 in 4.5% and grade 2 in 2.1%, p <0.001). The residual grade 2 FD at follow-up was associated with significantly higher risk for subsequent MACEs. In conclusion, among patients with AF receiving catheter ablation, severe FD in LAA in contrast CT was associated with higher incidence of arrhythmia recurrence and MACEs during follow-up.

Follow-up study of depressive state on patients with atrial fibrillation 1 year after radio-frequency ablation

OBJECTIVE

To analyze the effect of depression on the recurrence of atrial fibrillation (AF) 1 year after radio-frequency ablation.

METHODS

A total of 91 patients with AF admitted to our hospital from January 2020 to July 2021 were studied. All patients were followed up 1 year after radio-frequency ablation. A total of 91 subjects were divided into recurrence group (n = 30) and no recurrence group (n = 61) according to the recurrence situation 1 year after radio-frequency ablation. Age, disease course, body mass index (BMI), gender, echocardiography (left atrial diameter), blood inflammatory indicators (neutrophil count, lymphocyte count, and monocyte count), and Self-rating Depression Scale (SDS) scores were compared between the two groups. Logistic multivariate regression analysis was used to analyze the effect of SDS score and other indexes on the recurrence of AF 1 year after radio-frequency ablation.

RESULTS

The age of patients in relapse group was higher than that in no relapse group (P < 0.05) and the course of disease was longer than that of the no recurrence group (P < 0.05). The BMI was higher than that of the no recurrence group (P < 0.05) and the left atrial diameter was greater than that of the no recurrence group (P < 0.05). Neutrophil count and monocyte count were significantly higher than those in no recurrence group (P < 0.05) and the lymphocyte count was significantly lower than that in the no recurrence group (P < 0.05). There were significant differences in SDS score composition between the two groups (P < 0.05) and the composition ratio of patients with moderate and major depression in the relapsing group was significantly higher than that in the non-relapsing group. The composition ratio of patients without depression in the relapsing group was significantly lower than that in the non-relapsing group. Multivariate analysis showed that age, disease course, BMI, left atrial diameter, neutrophil count, lymphocyte count, monocyte count, and SDS score were all independent factors affecting the recurrence of AF patients 1 year after radio frequency ablation (P < 0.05). Compared with patients without depression, patients with mild, moderate and major depression had an increased risk of recurrence by 74.0, 98.2, and 151.2% 1 year after radio-frequency ablation, respectively (OR = 1.740, 1.982, and 2.512).

CONCLUSION

There is a high rate of depression in patients with AF. Depression is an important factor affecting the early recurrence of patients with AF after radio-frequency ablation.

Esophageal Thermal Injury after Catheter Ablation for Atrial Fibrillation with High-Power (50 Watts) Radiofrequency Energy

Background and Objectives

Data regarding the safety of atrial fibrillation (AF) ablation using high-power (50 W) radiofrequency (RF) energy in Asian populations are limited. This study was conducted to evaluate the incidence and pattern of esophageal injury after high-power AF ablation in an Asian cohort.

Methods

We searched the prospective AF ablation registry to identify patients who underwent AF ablation with 50 W RF energy using the smart touch surround flow catheter (Biosense Webster, Diamond Bar, CA, USA). Visitag™ (Biosense Webster) was used for lesion annotation with predefined settings of catheter stability (3 mm for 5 seconds) and minimum contact force (50% of time >5 g). All patients underwent upper gastrointestinal endoscopy at 1 or 3 days after the ablation.

Results

A total of 159 patients (mean age: 63±9 years, male: 69%, paroxysmal AF: 45.3%, persistent AF: 27.7%, long-standing persistent AF: 27.0%) were analyzed. Initially, 26 patients underwent pulmonary vein isolation with 50 W for 5 seconds at each point. The remaining 133 patients underwent prolonged RF duration (anterior 10 seconds and posterior 6 seconds). The incidence rates of esophageal erythema/erosion and superficial ulceration were 1.3% for each type of the lesion. Food stasis, a suggestive finding of gastroparesis, was observed in 25 (15.7%) patients. There were no cases of cardiac tamponade, stroke, or death.

Conclusions

In Asian patients, AF ablations using 50 W resulted in very low rates of mild esophageal complications.

Impact of catheter ablation for atrial fibrillation on cardiac disorders in patients with coexisting heart failure

Aims

We sought to investigate the time course of cardiac disorders after catheter ablation for atrial fibrillation (AF) in patients with coexisting heart failure (HF) during long‐term follow‐up.

Methods and results

We analysed consecutive 280 patients undergoing first‐time catheter ablation for AF who had coexisting HF, which was defined as prior HF hospitalization, estimated right ventricular systolic pressure ≥45 mmHg, or B‐type natriuretic peptide (BNP) ≥200 pg/dL before the procedure. The primary endpoints were improvements in left ventricular ejection fraction (LVEF), E/e′, BNP, left atrial dimension (LAD), and mitral regurgitation (MR) at 1 year. The secondary endpoints were serial changes of LVEF, E/e′, BNP, LAD, and MR at 6 months, 1 year, and 5 years and cumulative incidence of HF hospitalization. During the mean follow‐up of 5.1 ± 3.0 years, 70.7% of patients were free from recurrent AF. Among patients with LVEF < 50%, E/e′ ≥ 15, BNP ≥ 200 pg/dL, LAD ≥ 40 mm, and moderate‐to‐severe MR, changes in those parameters from baseline to 1 year were 34.5 ± 9.9% to 43.2 ± 14.4% (P < 0.001), 19.7 ± 3.9 to 12.5 ± 6.6 (P < 0.001), 290 to 85 pg/dL (P < 0.001), and 100% to 37.8% (P < 0.001), respectively. The improvements in the cardiac disorders were maintained up to 5 years except for E/e′. In patients with LVEF < 40%, significant delayed improvement of LVEF beyond 1 year was observed (ΔLVEF = 10.5 ± 18.5, P = 0.001), but not in patients with LVEF of 40–49%. The cumulative incidence of HF hospitalization was 12.6% at 5 years. Baseline diastolic dysfunction was the only independent predictor for subsequent HF hospitalization.

Conclusions

In patients undergoing AF ablation with coexisting HF, all cardiac disorders significantly improved after the procedure, which was mostly maintained during 5 year follow‐up.

Renal function and outcomes in atrial fibrillation patients after catheter ablation

BACKGROUND

Atrial fibrillation (AF) and renal failure coexist and interact. However, scarce data about association between renal function and clinical outcomes in patients undergoing catheter ablation for AF are available. We sought to evaluate long-term renal function and clinical outcomes after AF ablation.

METHODS

We enrolled 791 non-dialysis patients undergoing catheter ablation for AF, and evaluated the incidence of worsening renal function (WRF) after the procedure, defined as >30% decline in estimate glomerular filtration rate.

RESULTS

Mean follow-up duration was 5.1±2.5 years. Five hundreds and twenty-six patients (66.5%) were free from recurrent atrial arrhythmias without any antiarrhythmic drugs at the time of final follow-up. Cumulative incidence of WRF was 13.2% at 5-year after procedure, which was significantly higher in patients with recurrent AF compared to those without (21.6% versus 8.7%, P<0.001). In the multivariable analysis, recurrent AF was an independent risk factor for WRF (adjusted hazard ratio [HR] 1.89, 95% confidence interval 1.27-2.81, P = 0.002), along with congestive heart failure, diabetes, and eGFR <60 ml/min/1.73m2 at baseline. Patients with WRF had significantly higher 5-year incidences of all-cause death, cardiovascular death, heart failure hospitalization, ischemic stroke, and major bleeding compared to those without WRF. After adjustment of baseline differences in the multivariate Cox model, the excessive risks of WRF for all-cause death and heart failure hospitalization remained significant (adjusted HR 3.46, P = 0.002; adjusted HR 3.67, P<0.001).

CONCLUSIONS

In AF patients undergoing catheter ablation for AF, arrhythmia recurrence was associated with WRF during follow-up, which was a strong predictor of adverse clinical outcomes.

Simultaneous hybrid maze procedure for long-standing persistent atrial fibrillation with dilated atrium

Background

The efficacy of catheter-based or thoracoscopic ablation for treating long-standing persistent atrial fibrillation (AF) with a dilated atrium remains suboptimal. This study aimed to assess the feasibility and initial results of simultaneous hybrid ablation with a new biatrial lesion set in these patients.

Methods

Twenty-seven consecutive patients with long-standing persistent AF and dilated atrium underwent simultaneous hybrid ablation with a new biatrial lesion set consistent with the principle of the Cox maze procedure at our institution. Patients were followed up at 3, 6, and 12 months after the procedure and annually thereafter.

Results

After thoracoscopic epicardial ablation, endocardial mapping confirmed complete bilateral pulmonary vein isolation in 25 patients (96.2%). All patients were followed for a mean of 18.7 ± 8.9 months. Freedom from atrial tachyarrhythmia at 1 year after the single hybrid procedure was 64% with antiarrhythmic drugs and 60% without antiarrhythmic drugs. Freedom from atrial tachyarrhythmia at latest follow-up after the hybrid procedure and redo catheter ablation was 77.8% with antiarrhythmic drugs and 74.1% without antiarrhythmic drugs. In patients with sinus rhythm restoration, mean left atrial diameter decreased from 54.4 ± 4.3 mm to 45.2 ± 4.1 mm (P < .001), and mean right atrial diameter decreased from 59.4 ± 3.9 mm to 54.9 ± 4.4 mm (P < .001). Postoperative pleural effusion was observed in 3 patients (11.1%), and no adverse events occurred during follow-up.

Conclusions

In patients with long-standing persistent AF and a dilated atrium, simultaneous hybrid ablation with the new biatrial lesion set, in combination with touch-up catheter ablation when necessary, can achieve promising results. More studies are needed to confirm these findings.

Cost-Effectiveness of Obstructive Sleep Apnea Screening and Treatment Before Catheter Ablation for Symptomatic Atrial Fibrillation

Background: Although management of obstructive sleep apnea (OSA) has been recommended to improve outcomes of catheter ablation (CA) in patients with symptomatic atrial fibrillation (AF), the most cost-effective way of preprocedural OSA screening is undetermined. This study assessed the cost-effectiveness of OSA management before CA for symptomatic AF.

Methods and Results: A Markov model was developed to assess the cost-effectiveness of 3 OSA detection strategies before CA: no screening; Type 3 portable monitor (PM)-guided screening; and polysomnography (PSG)-guided screening. The target population consisted of a hypothetical cohort of patients aged 65 years with symptomatic AF, with 50% prevalence of OSA. We used a 5-year horizon, with sensitivity analyses for significant variables and scenario analyses for lower and higher OSA prevalence (30% and 70%, respectively). In the base-case, both types of OSA screening were dominant (less costly and more effective) relative to no screening. Although PSG-guided management was more effective than PM-guided management, it was more costly and therefore did not show clear benefit. These findings were replicated in cohorts with lower and higher OSA risks.

Conclusions: OSA screening before CA is cost-effective in patients with symptomatic AF, with PM screening being the most cost-effective. Physicians should consider OSA management using this simple tool in the decision making for treatment of symptomatic AF.

Atrial Fibrillation Ablation with Multipolar Phased-Radiofrequency Catheter: The Learning Curve Effect for Procedural Parameters, but not for the Long-Term Outcome

BACKGROUND

Pulmonary vein isolation (PVI) is a routine treatment in atrial fibrillation (AF). Single-shot techniques were introduced to simplify the procedure. We analyzed time-dependent changes in procedural parameters, acute success, complication rates, and long-term outcomes during our initial experience with multipolar phased-radiofrequency (RF) ablation. Methods and Results: The first 126 consecutive patients (98 male; age: 58.8 ± 8.7 years) who underwent PVI with phased-RF ablation at our center were included in the study. Procedural parameters, complication rate, acute success and 12-month efficacy were compared in the first, second and third group of 42 consecutive patients. In all patients, 516/526 PVs were effectively isolated (98.1%), with no differences between the tierces (p = 0.67). Procedure (169.8 vs. 132.9 vs. 105.8 min, p < 0.0001), fluoroscopy (32.9 vs. 24.3 vs. 14.1 min, p < 0.0001) and left atrial dwell (83.0 vs. 61.9 vs. 51.4 min, p < 0.0001) times were significantly reduced with experience in tierces 1-3, respectively. In the 12-month follow-up, 60.3% of patients were arrhythmia-free with no differences between the tierces (p = 0.88). In multivariate analysis, the relapse in the blanking period (p < 0.0001), time from AF diagnosis (p = 0.004) and left atrial diameter (p = 0.012) were the only independent predictors of AF recurrence.

CONCLUSIONS

The learning curve effect was demonstrated in procedural parameters, but not in the complication rate nor the long-term success of PVI with phased-RF technique. The relapse in the blanking period was the strongest predictor of treatment failure in long-time observation.

Second-generation cryoballoon ablation for recurrent atrial fibrillation after an index procedure with radiofrequency versus cryo: Different pulmonary vein reconnection patterns but similar long-term outcome-Results of a multicenter analysis

INTRODUCTION

Repeated procedures are often needed for long-term success of atrial fibrillation ablation. There are scarce data regarding cryoballoon use for such procedure.

METHODS AND RESULTS

We analyzed acute effect and long-term follow-up of second-generation cryoballoon ablation, performed as a repeat procedure after an index radiofrequency vs cryoballoon ablation. Sixty-one patients from three centers were included. In 36 cases radiofrequency (RF-I) and in 25 cryoballoon ablation (CB-I) was the index procedure. During redo procedure, pulmonary vein reconnection was less frequent in CB-I vs RF-I (51.5% vs 66.9%; P = 0.017). After cryoballoon, left inferior (P =  0.027) and right superior (P = 0.06) pulmonary veins were less likely to exhibit reconnection. Moreover, patients after initial RF ablation frequently presented multiple-vein reconnection (P = 0.018), while patients after cryoablation more often had only one vein reconnected (P = 0.008). During reablation procedures, all 149 reconnected veins in both groups were isolated, with no differences in procedural parameters, except for procedure time, shorter in CB-I group (65.5 vs 71.1 minutes; P = 0.04). Transient phrenic nerve palsy was the only complication in both groups (5.6% and 8.0%; ns). After mean follow-up of 15 ± 9 months, 70.3% of patients were free from atrial fibrillation (AF), with no differences between the groups (P = 0.71). In multivariate Cox-regression analysis, the persistent form of arrhythmia (P = 0.009) and relapse in the blanking period (P = 0.0004) were the only independent predictors of AF recurrence.

CONCLUSIONS

The use of second-generation cryoballoon is associated with less frequent pulmonary vein reconnection compared with RF ablation. Cryoballoon is safe and effective for repeated AF ablation, regardless of the technique used for the initial procedure.

Early choice for catheter ablation reduced readmission in management of atrial fibrillation: Impact of diagnosis-to-ablation time

BACKGROUND

The impact of delays in the treatment with radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) has not been well evaluated. The aim of this study was to investigate the impact of diagnosis-to-ablation time (DAT) on the long-term clinical outcomes after AF-RFCA.

METHODS

We enrolled 1206 consecutive patients undergoing first-time RFCA for AF. The study population was divided into 2 groups based on DAT: short (<3 years) (N = 675) and long (>3 years) (N = 531) DAT groups.

RESULTS

Mean follow-up duration was 5.0 ± 2.5 years. The 5-year event-free rates from recurrent atrial tachyarrhythmias after the first and second RFCAs were significantly higher in short DAT group than in long DAT group (60.2% versus 48.3%, log-rank P < 0.001; 83.2% versus 75.2%, log-rank P = 0.02, respectively), leading to reduced cardiovascular hospitalization in short DAT group. After adjusting baseline differences, short DAT was independently associated with lower arrhythmia recurrence rates after the first and second RFCAs (hazard ratio [HR] 0.72, 95% confidence interval [CI] 0.60-0.86 and HR 0.72, 95%CI 0.55-0.95, respectively). There were no significant differences between the 2 groups in the event-free rates from all-cause and cardiovascular deaths, heart failure hospitalization, and ischemic stroke. However, among patients with a history of heart failure or reduced left ventricular function, the event-free rate from heart failure readmission was significantly higher in short DAT group (85.0% versus 61.0%, P = 0.004).

CONCLUSIONS

In the management of AF, early RFCA was associated with significantly lower arrhythmia recurrence compared with delayed RFCA, leading to reduced cardiovascular hospitalization, especially in heart failure patients.

Impact of Pre-Existing Bradycardia on Subsequent Need for Pacemaker Implantation After Radiofrequency Catheter Ablation for Atrial Fibrillation

BACKGROUND

The incidence of subsequent need for permanent pacemaker implantation (PMI) after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) in real world patients with and without pre-existing bradycardia has not yet been fully evaluated.

METHODS AND RESULTS

A total of 1,131 consecutive patients undergoing first-time RFCA for AF who had no previous or planned device implantation, were enrolled in the present study. Of 799 paroxysmal AF (PAF) patients, 121 (15.1%) had sinus node dysfunction (SND). Of 332 non-PAF patients, 73 (22.0%) had slow ventricular response (VR), defined as heart rate <80 beats/min at rest without any rate-control drugs. The 5-year cumulative incidence of PMI after RFCA in PAF patients with and without SND was 14.8% and 1.7%, respectively (P<0.001). The 5-year cumulative incidence of PMI after RFCA in non-PAF patients with and without slow VR was 14.8% and 4.7%, respectively (P<0.001). SND and female gender in PAF patients, as well as slow VR and age ≥75 years in non-PAF patients, were independent and additive predictors of PMI. The 5-year cumulative incidence of PMI was 26.3% in female PAF patients with SND and 33.3% in elderly non-PAF patients with slow VR.

CONCLUSIONS

PMI was avoided in >85% of patients undergoing RFCA for PAF with pre-existing SND, although care should be taken for female patients. Decision-making regarding RFCA for non-PAF patients with slow VR, especially in the elderly, should be cautious.