A worldwide survey on incidence, management and prognosis of oesophageal fistula formation following atrial fibrillation catheter ablation: The POTTER-AF study

Anesthesia management for cardiac catheter ablation: what anesthesiologists should know

Catheter ablation has become a central part of the non-pharmacological treatment of cardiac arrhythmias. It can be performed under conscious sedation, deep sedation, or general anesthesia, but it is getting clear that the incidence of complications during the procedure and the success rate of treatment (with no recurrence of arrhythmia) may be strongly influenced by sedation or anesthesia method. In particular, in sedated patients, ablation procedure may frequently cause severe pain, and the most common adverse events are related to sedation methods. Therefore, anesthesiologists will increasingly be asked to take care of the patients undergoing catheter ablation. In this article, we describe what anesthesiologists should know about ablation procedure and its associated problems, to provide appropriate anesthesia care to patients undergoing catheter ablation.

Pulsed Field or Cryoballoon Ablation for Paroxysmal Atrial Fibrillation

BACKGROUND

Pulmonary-vein isolation is an effective treatment for paroxysmal atrial fibrillation. Pulsed field ablation (PFA) is a nonthermal ablation method with few adverse effects beyond the myocardium. Data are lacking on outcomes after PFA as compared with cryoballoon ablation as assessed with continuous rhythm monitoring.

METHODS

In this randomized noninferiority trial in Switzerland, we randomly assigned patients with symptomatic paroxysmal atrial fibrillation in a 1:1 ratio to undergo PFA or cryoablation. All the patients received an implantable cardiac monitor to detect atrial tachyarrhythmias. The primary end point was the first recurrence of an atrial tachyarrhythmia between day 91 and day 365 after ablation. We assessed noninferiority using a margin of 20 percentage points for the difference in the cumulative incidence of recurrence. The safety end point was a composite of procedure-related complications.

RESULTS

A total of 105 patients were assigned to undergo PFA, and 105 were assigned to undergo cryoablation. A recurrence of atrial tachyarrhythmia was observed between day 91 and day 365 in 39 patients in the PFA group and in 53 patients in the cryoablation group (Kaplan-Meier cumulative incidence, 37.1% and 50.7%, respectively; between-group difference, -13.6 percentage points; 95% confidence interval, -26.9 to -0.3; P<0.001 for noninferiority, P = 0.046 for superiority). The safety end point occurred in 1 patient (1.0%) with PFA and in 2 patients (1.9%) with cryoablation.

CONCLUSIONS

Among patients with symptomatic paroxysmal atrial fibrillation, PFA was noninferior to cryoballoon ablation with respect to the incidence of a first recurrence of atrial tachyarrhythmia, as assessed by continuous rhythm monitoring. (Funded by Inselspital and others; SINGLE SHOT CHAMPION ClinicalTrials.gov number, NCT05534581.).

Catheter Ablation of Atrial Fibrillation: Technique and Future Perspectives

Atrial fibrillation is the most common sustained cardiac arrhythmia with a significant impact on quality of life in terms of symptoms and reduction of functional status. Also, it is associated with an increased risk of mortality, stroke, and peripheral embolism. Catheter ablation for atrial fibrillation has become a well-established treatment, improving arrhythmia outcomes without increasing the risk of serious adverse events compared to antiarrhythmic drug therapy. The field has undergone significant advancements in recent years, yet pulmonary vein isolation continues to be the cornerstone of any atrial fibrillation ablation procedure. The purpose of this review is to provide an overview of the current techniques, emerging technologies, and future directions.

Esophageal Protection Strategies for Ablation of Atrial Fibrillation: Comparative Results of Consecutive Endoscopic Evaluation

BACKGROUND

Atrial-esophageal fistula following AF ablation remains a concern. There is no standardized approach to minimize its risk and morbidity.

OBJECTIVE

To present the seven-year experience of a systematic endoscopic surveillance of esophageal injury after AF catheter ablation.

METHODS

This is a retrospective single center registry of systematic endoscopic evaluation after AF ablation in consecutive procedures performed from 2016 to 2022. A p-value of <0.05 was considered statistically significant.

RESULTS

823 AF ablation with controlled esophagogastroduodenoscopy (EGD) were analyzed. Most patients (n=588, 71.4%) were male, 575 (69.9%) had paroxysmal AF. Esophageal temperature monitoring was performed using a single sensor in 310 patients (40.3%) and a multi-sensor probe in 306 (39.8%). Lesions were presented in 217 EGD (26.5%): hematoma-ecchymosis in 27 (3.3%), erythema in 14 (1.7%), erosion in 78 (9.5%) and ulcer in 67 (8.2%) patients. No esophageal protective strategy was associated with more ulcers, except the use of 8mm tip-catheter (14.7% of ulcers with 8mm tip catheter vs 6.7% with other catheters, p = 0.001). Thermal lesions were early detected and treated. Most lesions were considered healed at endoscopy, but one patient who underwent pulmonary vein isolation with an 8m tip catheter had esophageal fistula, treated successfully with endoscopic metal clip and endoloop technique.

CONCLUSION

The incidence of esophageal lesions at routine EGD following AF ablation is high, although in most of the cases they heal spontaneously. Patients who underwent ablation with the 8mm tip catheter had more severe thermal lesions. Early esophagus endoscopy may help the diagnosis of early-stage lesions and the prevention of fistula formation after AF ablation.

A 71-Year-Old Man With Gas Accumulation in the Left Atrium

CASE PRESENTATION

A 71-year-old man with a history of atrial fibrillation presented to the emergency department with sudden unconsciousness after finishing lunch. Just 4 weeks ago, the patient underwent radiofrequency ablation for atrial fibrillation and regularly took rivaroxaban for anticoagulant therapy. According to the medical history, the patient suffered recurrent chest tightness and heartburn after radiofrequency ablation without other discomforts. During transportation to the hospital, the patient experienced a drop in BP after forceful vomiting.

[Guideline to safe and effective atrial fibrillation ablation with pulsed-field ablation using the pentaspline PFA system as an example]

Atrial fibrillation ablation is an established procedure for the treatment of atrial fibrillation, in which Pulsed Field Ablation (PFA) is a novel method alongside radiofrequency and cryoablation. The article explains the technical basics of PFA, describes different types of catheters and gives detailed instructions on how to perform the procedure, from patient selection to sedation strategies and imaging. Important safety aspects and possible complications are also covered. Finally, the further development of PFA technology for the treatment of other arrhythmias and integration into 3D mapping systems is discussed. This work is part of a series of articles on further training in special rhythmology.

Case Report: Fatal atrioesophageal fistula following atrial fibrillation ablation-critical reflections on prevention

Radiofrequency ablation (RFA) is an important therapeutic modality for atrial fibrillation (AF), widely utilized in clinical practice due to its safety and significant efficacy. However, post-procedural complications may arise, influenced by anatomical positioning and the intensity of ablation energy, with atrioesophageal fistula (AEF) being particularly rare yet severe. This case report describes a unique instance of a patient developing AEF following AF ablation, accompanied by ischemic stroke and myocardial infarction. A 71-year-old male admitted to the emergency department on July 19, 2024, with acute loss of consciousness and convulsions. Upon admission, physical examination and laboratory tests revealed vital signs within abnormal ranges and indicators suggesting inflammation and potential myocardial injury. Head CT scans showed hypoattenuating areas indicative of cerebral infarction, chest CT suggested possible air accumulation in the left atrial region. ECG findings were consistent with atrial flutter, myocardial infarction, and incomplete right bundle branch block. Given his history of atrial fibrillation and RFA, alongside clinical manifestations, the patient was diagnosed with cardio-cerebral syndrome, suspected to be complicated by an AEF due to the presence of air in the left atrium. AEF diagnosis was confirmed via cardiac CTA, leading to conservative management decisions. Despite initiating thrombolysis for cerebral infarction and supportive treatments for heart failure, including VA-ECMO, the patient's condition continued to decline, evidenced by cardiogenic shock, heart failure, and progressive neurological deficits including coma and dilated non-reactive pupils. Ultimately resulting in family-elected discharge against medical advice on the fourth day of hospitalization.

In-hospital safety of cryoballoon and radiofrequency ablation in patients with atrial fibrillation-German nationwide analysis of more than 300,000 procedures

BACKGROUND

Pulmonary vein isolation can be performed by radiofrequency (RF) or cryoballoon (CB) ablation. Guidelines do not favor one technique, and knowledge about complication rates is limited.

OBJECTIVE

We aimed to report the procedural safety of RF and CB ablation using data from a German nationwide real-world registry.

METHODS

By use of health records, all left atrial catheter ablation procedures with RF or CB ablation in Germany from 2013 to 2021 were analyzed. After adjustment for confounders, safety performance end points were compared.

RESULTS

From 2013 to 2021, RF ablation was performed in 184,616 patients and CB ablation in 118,984 patients with increasing trends in patient numbers and performing centers for both procedures. Patients with RF ablation had slightly more comorbidities. In-hospital mortality (RF, 0.08%; CB, 0.06%) and other investigated complications were rare. After adjustment for patient baseline characteristics, the risk of in-hospital mortality, serious bleeding, stroke, intracerebral bleeding, and acute kidney injury did not differ. The risk of pericardiocentesis (relative risk, 0.50; 95% confidence interval, 0.46-0.55; P < .001), vascular complication (0.36; 0.33-0.39; P < .001), and ventilation >48 hours (0.81; 0.66-0.99; P = .042) was significantly lower for CB ablation. Pericardiocentesis risk negatively correlated with annual procedure numbers per center with a faster learning curve for CB ablation (both P < .01).

CONCLUSION

RF and CB ablation had low overall procedural complication rates, with CB ablation showing a 50% reduced risk of pericardiocentesis. Centers with higher volume provided a better in-hospital safety with a faster learning curve for CB ablation.

Near-zero fluoroscopy workflow for pulmonary vein isolation in atrial fibrillation using a variable loop, 3D-integrated circular PFA catheter (Varipulse™): initial single-center experience with the first 35 patients

BACKGROUND

Catheter ablation is a standard atrial fibrillation (AF) treatment, traditionally using radiofrequency (RF) or cryoablation, which carries the risk of damaging nearby structures. Pulsed field ablation (PFA) offers partly tissue-selective energy application with minimal collateral damage. This study evaluated a near-zero fluoroscopy workflow with the novel VARIPULSE™ catheter, combining advanced mapping for optimized PFA delivery and reduced radiation. Here, we investigate the safety, efficiency, and effectiveness of this approach in the first 35 patients treated.

OBJECTIVE

This study aimed to assess the procedural characteristics, safety, and acute efficacy of pulmonary vein isolation (PVI) using the VARIPULSE™ PFA catheter in patients with AF, while specifically evaluating a near-zero fluoroscopy workflow to minimize radiation exposure during the procedure.

METHODS

Thirty-five consecutive patients with paroxysmal or persistent AF underwent pulmonary vein isolation (PVI) using the VARIPULSE™ PFA catheter. Procedures were conducted under general anesthesia or deep sedation. Key procedural endpoints included acute pulmonary vein isolation, total procedure time, left atrial (LA) dwell time, fluoroscopy time and dose, and safety outcomes, with a focus on assessing the feasibility of a near-zero fluoroscopy workflow.

RESULTS

Thirty patients underwent near-zero fluoroscopy atrial fibrillation ablation using the novel VARIPULSE™ Pulsed Field Ablation catheter. Patients had a median age of 70 years and typical cardiovascular comorbidities, with 54% presenting with paroxysmal AF. Thirty-three of 35 patients (94%) had a normal left ventricular systolic function (> 60%). The median CHA2DS2-VA score was 2 (IQR 1-3.75). Sinus rhythm was observed in 66% of cases at procedure start. Median fluoroscopy time was 0.8 min, total median procedure time 53 min, median LA dwell time 38 min, and median fluoroscopy dose 20.4 µGym2. Pulmonary vein isolation was achieved in 100% of cases without radiofrequency touch-up. No major complications occurred.

CONCLUSION

The VARIPULSE™ Pulsed Field Ablation system enables an efficient, nearly fluoroscopy-free atrial fibrillation ablation with a simple, easily integrable workflow in the electrophysiology lab. Complete pulmonary vein isolation was achieved in all cases without radiofrequency touch-ups, and the procedure was safe with no major complications. This demonstrates the potential for widespread adoption of this technology and workflow.

Pus in the Pericardium: A Pericardial-Oesophageal Fistula with Cardiac Tamponade after Ablation for Atrial Fibrillation

Background

Pericardial/atrial oesophageal fistula (PEF/AEF) is the most feared complication of cardiac atrial fibrillation (AF) ablation. Without urgent surgical treatment, most cases of this infrequent complication rapidly prove fatal.

Case report

We present an uncommon case of a 60-year-old male who had undergone an AF ablation 2 weeks prior and presented with chest pain. Following diagnosis and treatment of ST-elevation myocardial infarction (STEMI), a small pericardial effusion was noticed on computed tomography (CT) scan. Despite an initially reassuring hospital course, rapid decompensation and expansion of his purulent pericardial effusion led to his death within 24 hours of presentation. A post-mortem review of his CT imaging revealed an inconspicuous PEF.

Conclusions

It is essential to maintain a high suspicion of PEF/AEF in patients presenting after AF ablation with suggestive symptoms, such as fever, chest pain/odynophagia, and neurological deficits. CT chest is the most common diagnostic modality and surgical correction is the treatment of choice.

LEARNING POINTS

Pericardial/atrial oesophageal fistula is a devastating complication of atrial fibrillation ablation and early detection is the keystone of effective management.Urgent surgical repair is the most effective treatment to prevent mortality.Preventative measures include power titration, limiting energy delivery times, and avoiding overlapping ablation lines during the ablation procedure.

A Simple Way to Exclude a Lethal Complication Following Atrial Fibrillation Radiofrequency Ablation: A Case Report

Esophageal injury is a serious complication following atrial fibrillation catheter ablation procedures. It may manifest as atrio-esophageal fistula, pericardio-esophageal fistula (PEF), or restricted perforation, with high mortality rate if left unoperated. Chest computed tomography with intravenous contrast is the mainstay of diagnosis; however, a definite imaging diagnosis is often delayed and may worsen patient outcomes. This case demonstrates that pericardial fluid amylase detection may contribute to early differential diagnosis of PEF versus restricted esophageal perforation combined with inflammatory pericarditis, in patients with relevant symptoms who present with pericardial effusion and may guide either conservative-as our case-or surgical approach.

Incidence, Mechanism, and Management of Atrial Ablation Procedure Complications: A Literature Review

The number of atrial catheter ablation procedures has significantly increased in recent years, becoming a first-line treatment modality for various supraventricular tachycardias due to their safety and efficacy. Complications, ranging from mild to life-threatening, can arise during different stages of the procedure, including vascular access complications (eg, hematoma or vascular fistula formation, retroperitoneal bleeding, etc.), thromboembolic complications (eg, stroke, transient ischemic attack, air embolism, etc.), mechanical complications (eg, cardiac perforation and tamponade), as well as pulmonary vein stenosis, atrio-esophageal fistulas, phrenic nerve injury, and gastroparesis. Atrial fibrillation ablation procedures, in particular, carry a higher complication rate due to their complexity. This review discusses the incidence, mechanisms, diagnosis, management, and prevention of these complications. Key strategies to reduce risks include optimized anticoagulation protocols, the use of intracardiac echocardiography, reduced energy delivery, and esophageal temperature monitoring, among others. Timely detection and intervention, especially in the case of life-threatening complications, is crucial. Pulsed-field ablation, a novel technique using nonthermal electrical energy, offers a promising and precise alternative to conventional thermal ablation with a favorable safety profile. However, further research is needed to fully understand its complications and refine management strategies.

Pentaspline catheter or cryoballoon for pulmonary vein plus posterior wall isolation in persistent atrial fibrillation: 1-Year outcomes

BACKGROUND

Left atrial posterior wall isolation (LAPWI) plus pulmonary vein isolation (PVI) can be performed with radiofrequency ablation, cryoballoon ablation (CB-A), or, recently, pulsed field ablation (PFA).

OBJECTIVE

The aims of this study were to evaluate efficacy and safety of the pentaspline PFA catheter for PVI + LAPWI in patients with persistent AF undergoing an index ablation procedure and to compare 1-year outcomes of PVI + LAPWI with PFA vs CB-A.

METHODS

All consecutive patients undergoing an index ablation for persistent atrial fibrillation (AF) at Universitair Ziekenhuis Brussel, Belgium, between 2021 and 2023 were retrospectively screened. Inclusion criteria were persistent AF diagnosis following current guidelines, first AF ablation procedure with PVI + LAPWI using the CB-A or the pentaspline PFA catheter, and 1-year follow-up completed.

RESULTS

A total of 160 patients were included (80 with CB-A and 80 with the pentaspline PFA catheter). PVI + LAPWI was performed with success in 160 (100%) patients, and isolation was confirmed at postprocedure high-density mapping in all. Compared with CB-A, PFA was associated with shorter skin-to-skin procedure time, shorter left atrium dwell time, and shorter fluoroscopy time. At survival analysis, freedom from recurrent atrial tachyarrhythmias at 1-year follow-up was similar between the CB-A and PFA groups (76.2% vs 78.8%; log-rank P = .63).

CONCLUSION

In patients with persistent AF undergoing an index catheter ablation, the pentaspline PFA catheter is safe and effective for PVI + LAPWI. Outcomes after pentaspline PFA catheter ablation at 1 year are favorable and similar to those with the CB-A catheter.

[Update atrial fibrillation in older adults]

Atrial fibrillation is the most frequent cardiac arrhythmia in old age. As a result of the positive data on ablation, the focus has shifted to rhythm control. Older adults can also benefit from catheter ablation. Oral anticoagulation remains an essential part of the pharmacological treatment of atrial fibrillation. Recent study results show that geriatric patients require an individual treatment approach, which should be based on the recommendations of the current guidelines and the use of supplementary aids. The assessment of functionality should be taken into account in the treatment and the treatment goal planning as well as symptoms associated with atrial fibrillation. In acute situations cardioversion and long-term drug or interventional (catheter ablation) rhythm-stabilizing treatment are available for rhythm control.

[Pulsed-field ablation-is it the only energy source for ablation in the future? : Pro/Contra]

Pulsed field ablation (PFA) is a nonthermal energy source used for cardiac ablation procedures. Cell death during PFA occurs via electroporation: ultrarapid (micro- to nanosecond) electrical pulses are applied to destabilize cell membranes causing irreversible pores. PFA leads to preferential ablation of myocardiocytes, sparing adjacent tissue like the esophagus or phrenic nerve. Preliminary clinical studies show high efficacy and a good safety profile in atrial fibrillation patients undergoing pulmonary vein isolation. The question remains, however, whether this new technology will replace well-known and established thermal energy sources like radiofrequency current or cryoablation within the next 5 years.

Surgical management of atrioesophageal fistula after catheter ablation of atrial fibrillation: A French nationwide study

Objective

The study objective was to assess the efficacity of different surgical strategies for atrioesophageal fistula after catheter ablation of atrial fibrillation.

Methods

Between January 2010 and April 2023, all patients with a diagnosis of atrioesophageal fistula or pericardo-esophageal fistula after catheter ablation of atrial fibrillation were analyzed retrospectively from the French database EPITHOR. Patients without surgical management were excluded.

Results

Eighteen patients were included, 15 with atrioesophageal fistula and 3 with pericardo-esophageal fistula. Median follow-up was 89.5 days with an overall survival of 50%. Five patients underwent esophageal stenting, 2 as a bridge-to-esophagectomy with 50% of survival and 3 in association with esophagus and left atrial direct repair with 66% survival. Primary esophageal repair with flap coverage was performed in 8 patients with 25% survival, most of them with sepsis and neurological failure. Seven patients had an esophagectomy with 71% survival, only 2 of them having a neurological failure. Among them, 5 patients underwent a restorative surgery and are still alive. Four patients had a retrosternal colon interposition, and 1 patient had an esogastric anastomosis. Risk factors for death were neurological failure (hazard ratio [HR], 4.91, 95% CI, 0.95-25.22; P = .0057) in univariate analysis and sepsis (HR, 6.25, 95% CI, 1.17-33.3; P = .032) in multivariate analysis. Esophagectomy tended to offer a survival benefit (HR, 0.163, 95% CI, 0.019-1.340; P = .092). The use of cardiopulmonary bypass did not significantly impact survival (HR, 1.953, 95% CI, 0.392-9.719; P = .413).

Conclusions

Aggressive surgical strategies for managing atrioesophageal fistula are mandatory to offer the best chance of survival.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

National workflow experience with pulsed field ablation for atrial fibrillation: learning curve, efficiency, and safety

BACKGROUND

Recent data on pulsed field ablation (PFA) for atrial fibrillation (AF) ablation suggest a progressive reduction in procedural times. Real-world data regarding the relationship between the learning curve of PFA and clinical outcomes are scarce. The objective was to evaluate the PFA learning curve and its impact on acute outcomes.

METHODS

Consecutive patients undergoing AF ablation with the FARAPULSE™ PFA system were included in a prospective, non-randomized multicenter study. Procedural times were stratified on the operators' learning curve. Comparative analysis of skin-to-skin time was conducted with radiofrequency (RF) and cryoablation (CB) pulmonary vein isolation (PVI) procedures performed by the same operators in the previous year.

RESULTS

Among 752 patients, 35.1% were females, and 66.9% had paroxysmal AF; mean age was 62.2 ± 10 years. A total of 62.5% of procedures were performed by operators with > 20 PFA procedures. Both time to PVI (25.6 ± 10 min vs 16.5 ± 8, p < 0.0001) and fluoroscopy time (19.8 ± 8 min vs 15.9 ± 8 min, p = 0.0045) significantly improved after 10 associated with consistent linear trend towards procedural time reduction (R2 0.92-0.68 across various procedural metrics). Current PFA skin-to-skin time was lower than the historical skin-to-skin one in 217 (62.4%) procedures; it was similar in 112 (32.2%) cases and higher than the historical skin-to-skin one in 19 (5.5%). No major complications were reported.

CONCLUSIONS

In this nationwide multicentric experience, the novel PFA system proved to be fast, safe, and acutely effective in both paroxysmal and persistent AF patients. The learning curve appears to be rapid, as improvements in procedural parameters were observed after only a few procedures.

CLINICAL TRIAL REGISTRATION

Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA). URL: http://clinicaltrials.gov/ Identifier: NCT05617456.

Next-generation atrial fibrillation ablation: clinical performance of pulsed-field ablation and very high-power short-duration radiofrequency

INTRODUCTION

Pulsed-field energy (PFA) and very high-power short-duration radiofrequency (vHPSD-RF) are two novel ablation methods for pulmonary vein isolation (PVI). Both PFA and vHPSD-RF show promise for improving efficacy, safety, and reducing procedure durations. However, direct comparisons between these two techniques are scarce.

METHODS AND RESULTS

Retrospective analysis of 82 patients with symptomatic AF. Of these, 52 patients received PFA and 30 received vHPSD-RF (90 W, 4 s) as index procedure. At the 6-month follow-up, AF recurrence occurred in 4 patients following PFA and 5 patients following vHPSD-RF (p-value = 0.138). Significant improvements in the EHRA and NYHA stages were evident in both PFA (p < 0.001 and p = 0.047, respectively) and vHPSD-RF groups (p = 0.007 and p = 0.012, respectively). The total procedure duration and the left atrial dwell time were significantly shorter in the PFA group (64 ± 19 min vs. 99 ± 32 min, p < 0.001 and 41 ± 12 min vs. 62 ± 29 min, p < 0.001, respectively). The fluoroscopy time and dose area product were significantly higher in PFA (14 ± 6 vs. 9 ± 5 min, p < 0.001 and 14 ± 9 vs. 11 ± 9 Gy cm2, p = 0.046, respectively). One patient in the vHPSD-RF group suffered a stroke, not directly linked to the procedure (0 vs. 1 major complication, p = 0.366).

CONCLUSION

Based on this retrospective single-center study, PFA and vHPSD-RF were associated with similar effectiveness and safety profiles. PFA was linked to shorter procedure times and higher radiation exposure compared to vHPSD-RF.

Pericardial-Esophageal Fistula After Combined Ablation and Left Atrial Appendage Occlusion Procedure for Atrial Fibrillation

Pericardial-esophageal fistula is a rare complication after radiofrequency ablation for atrial fibrillation. A 52-year-old man developed pneumopericardium, which was revealed by echocardiogram and computed tomography, after a combined ablation and left atrial appendage occlusion procedure for atrial fibrillation. He was diagnosed with a pericardial-esophageal fistula and underwent surgical pericardial and mediastinal drainage tube placement. However, the patient developed constrictive pericarditis 2 months after the first surgery and subsequently underwent pericardiolysis. A month after the second surgery, the patient's condition was significantly improved and he was allowed home.

Comparison of Therapeutic Effects Between Pulsed Field Ablation and Cryoballoon Ablation in the Treatment of Atrial Fibrillation: A Systematic Review and Meta-analysis

Pulsed field ablation (PFA) is a novel nonthermal ablation technique for the treatment of atrial fibrillation (AF) patients, with safety comparable to traditional catheter ablation surgery. The present study aims to evaluate and compare the procedural efficiency and safety profiles of PFA and cryoballoon ablation (CBA) in the management of AF. We performed a systematic search across PubMed, the Cochrane Library, and Embase databases, encompassing the literature up to February 2024, to inform our systematic review and meta-analysis. When assessing outcome indicators, the risk ratio and its corresponding 95% confidence interval (CI) were calculated for dichotomous variables. For continuous variables, the mean difference (MD) and the associated 95% CI were determined. In this scenario, a relative risk (RR) value of less than 1 and an MD value of less than 0 are deemed favorable for the PFA group. This could translate to a reduced likelihood of procedural complications or enhanced procedural performance within the PFA group. In this analysis, 9 observational studies encompassing 2875 patients with AF were included. Among these, 38% (n = 1105) were treated with PFA, while 62% (n = 1770) received CBA. The results indicated that PFA was associated with a significantly shorter procedural duration compared with CBA, with an MD of -10.49 minutes (95% CI, -15.50 to -5.49; P < 0.0001). Nevertheless, no statistically significant differences were observed when comparing the 2 treatment cohorts concerning fluoroscopy time (MD, 0.71; 95% CI, -0.45 to 1.86; P = 0.23) and the recurrence of atrial arrhythmias during follow-up (RR, 0.95; 95% CI, 0.78-1.14; P = 0.57). In terms of perioperative complications, the PFA group showed a significantly decreased risk of phrenic nerve palsy (RR, 0.15; 95% CI, 0.06-0.39; P < 0.0001) and an increased risk of cardiac tamponade (RR, 3.48; 95% CI, 1.26-9.66; P = 0.02) compared with the CBA group. No significant differences were noted between the PFA and CBA groups regarding the incidence of stroke/transient ischemic attack (RR, 0.99; 95% CI, 0.30-3.22; P = 0.99), vascular access complication (RR, 0.87; 95% CI, 0.36-2.10; P = 0.76), atrial esophageal fistula (RR, 0.33; 95% CI, 0.01-8.13; P = 0.50), and major or minor bleeding events (RR, 0.39; 95% CI, 0.09-1.74; P = 0.22). Our research results indicate that compared with CBA, PFA not only shortens the procedure time but also demonstrates noninferiority in terms of fluoroscopy duration and the recurrence rate of atrial arrhythmias. PFA and CBA have both demonstrated their respective advantages in perioperative complications.

Catheter ablation for atrial fibrillation: indications and future perspective

Recent advances in techniques, technologies and proven superiority over anti-arrhythmic drugs have made catheter ablation the cornerstone of management for atrial fibrillation (AF), which has shown a steady increase in prevalence in the ageing population worldwide. The aim of therapeutic interventions is to achieve stable sinus rhythm that would improve the quality of life and reduce the risk of AF-associated complications. Pulmonary veins (PVs) were first described as the source of initiation of ectopic triggers driving AF, which led to the establishment of PV isolation (PVI) as the most widely practiced procedure to treat AF. Antral PVI is still recognized as the stand-alone ablation strategy for newly diagnosed paroxysmal AF (PAF). However, in non-PAF patients, PVI seems to be inadequate and several adjunctive strategies, including ablation of left atrial posterior wall and non-PV triggers, AF mapping and ablation of rotors and drivers, ethanol infusion of vein of Marshall and renal denervation, etc. have been reported with mixed results. Recent trials have also documented the benefits of early rhythm control in preventing cardiovascular events in addition to slowing the progression of PAF to more persistent forms. Similarly, very late relapse of the arrhythmia after successful PVI has drawn attention to the critical role of non-PV triggers and highlighted their relevance as potential ablation targets during repeat procedures. Ablation technology is also under constant evolution with the introduction of non-thermal energy sources and new tools to create durable lesions. This review summarizes the indications, advancements, and future perspective of AF ablation.

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p < 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p > 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3-97.3] and 82.8% [95% CI, 68.1-97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Esophageal-Pericardial and Esophageal-Atrial Fistulae

Fistulae between the esophagus and the pericardium or the left atrium are rare but feared complications of transcatheter ablations and esophageal procedures and pathologies. Patients may present variably with cardiopulmonary, gastrointestinal, infectious, and/or neurologic symptoms; a high index of suspicion is paramount. The presence of atrial involvement will dictate the approach and extent of the necessary intervention. While mortality is high overall, surgical repair confers the highest likelihood of survival.

Surveillance of esophageal injury after atrial fibrillation catheter ablation

AIMS

Atrial-esophageal fistula following ablation procedures for atrial fibrillation (AF) remains a major concern. There is no standardized approach to minimize the risk and morbidity of this serious complication. The objective of this study was to present the 7-year experience of systematic endoscopic surveillance of esophageal injury after AF catheter ablation.

METHODS

This was a retrospective single-center registry of systematic endoscopic evaluations after consecutive AF ablation procedures performed from 2016 to 2022.

RESULTS

A total of 677 AF ablation procedures with controlled esophagogastroduodenoscopy (EGD) were analyzed during that period. Most patients were male (71%) with paroxysmal AF (71%). Radiofrequency with electroanatomical mapping was the main ablation approach for 633 patients (93.5%). Esophageal temperature monitoring was performed using a single sensor in 220 patients (34.3%) and a multisensor probe in 296 patients (46%). Most of the patients presented no esophageal lesions (75,7%). Severe lesions (Kansas-city-classification KCC 2B) were found in 46 (6.8%) of them, requiring a new EGD in 7 days. KCC2B lesions were persistent in 3 patients, 2 of whom had ulcers during healing and 1 patient with a deep ulcer of 10 mm who was admitted to the hospital and underwent fasting and parenteral nutrition. The ulcer healed in the second week after the procedure. Both esophageal temperature monitoring strategies were equivalent at preventing thermal lesions. Additionally, a greater left atrium (LA) was associated with a lower incidence of esophageal ulcer (P = 0.028). Most of the lesions spontaneously healed.

CONCLUSION

The incidence of esophageal injury after ablation was 24.3%. Most (72%) were mild lesions that required no therapeutic intervention. A larger left atrium (LA) was correlated with a lower incidence of thermal lesions. Early endoscopy can help diagnose severe esophageal lesions and may provide additional information for the surveillance of esophageal injury after AF ablation.

Treatment of oesophageal perforation with through-the-scope clips post-high-power short-duration atrial fibrillation ablation: case report

Background

Atrio-oesophageal fistula following percutaneous catheter ablation is a rare but potentially life-threatening complication. This case report highlights the advantages of a less invasive treatment for covered oesophageal perforation.

Case summary

A 66-year-old male patient underwent catheter ablation with high-power short-duration radiofrequency for symptomatic (EHRA III, tachy-cardiomyopathy) persistent atrial fibrillation (AF). Post-procedural routine endoscopic examination revealed a thermal oesophageal lesion. Progression of the lesions in early follow-up examinations led to a CT scan that showed a covered perforation. Antibiotic coverage and parenteral nutrition were initiated. The patient was transferred to a multidisciplinary centre for evaluation of invasive treatments. Endoscopically, the lesions were slowly progressing, while retaining their endoluminal borders. Application of five through-the-scope clips resulted in temporary shielding that was replaced with two further clips 3 days later. This allowed for internal oesophageal healing and prevention of mediastinal infections. Due to recurrence of the AF, a repeat ablation with pulsed field was performed. Follow-up endoscopic examination after one year revealed no relevant lesions. Sinus rhythm and slight odynophagia persisted.

Discussion

This case underlines the importance of less invasive treatments for oesophageal lesions after catheter ablation, where endoluminal borders are preserved and approximation of the wound-margins allows for tissue repair. Although, this kind of treatment requires timely and thorough investigations as endoscopy and CT scan to exclude (peri-)cardiac involvement.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society, the Asia Pacific Heart Rhythm Society, and the Latin American Heart Rhythm Society.

VARIPULSE: A step-by-step guide to pulmonary vein isolation

INTRODUCTION

The VARIPULSE™ variable-loop circular catheter (VLCC) is a bidirectional, multielectrode catheter that can perform electrophysiological mapping and deliver pulsed field energy through the TRUPULSE™ Generator for the treatment of atrial fibrillation. This ablation system, including the CARTO 3™ three-dimensional electroanatomical mapping system, represents a fully integrated system.

METHODS

Pulsed field ablation (PFA) is a novel, primarily cardiac tissue-selective ablation technology with a minimal thermal effect, potentially eliminating the collateral tissue damage associated with radiofrequency ablation or cryoablation. Integration of a mapping system may lead to shorter fluoroscopy times and improve the usability of the system, allowing tracking of energy density and placement to confirm no areas around the vein are left untreated.

RESULTS

This step-by-step review covers patient selection, mapping, the step-by-step ablation workflow, details on catheter repositioning and ensuring contact, considerations for ablation of specific anatomical variations, and discussion of ablation without fluoroscopy based on our initial clinical experience.

CONCLUSIONS

The VLCC is part of the fully integrated PFA system designed for pulmonary vein isolation, using mapping to guide catheter placement and lesion set creation. The current workflow, which is based on our initial clinical experience, may be further refined as the PFA system is used in real-world settings.

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.

Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation

INTRODUCTION

Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C.

METHODS AND RESULTS

Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-three out of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patients Kansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula.

CONCLUSION

Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.

Pulsed-field vs cryoballoon vs radiofrequency ablation: Outcomes after pulmonary vein isolation in patients with persistent atrial fibrillation

BACKGROUND

Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patients with paroxysmal atrial fibrillation (AF).

OBJECTIVE

The purpose of this study was to compare the procedural and long-term outcomes in patients with persistent AF undergoing PVI using PFA, CBA, or RFA.

METHODS

Consecutive patients with persistent AF undergoing first PVI with PFA, CBA, or RFA were included. Patients underwent 7-day Holter electrocardiography at 3, 6, and 12 months postablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events.

RESULTS

A total of 533 patients with persistent AF underwent PVI using PFA (n = 214, 39%), CBA (n = 190, 36%), or RFA (n = 129, 24%). Procedures with PFA guided by fluoroscopy were shorter than those with CBA (median 60 minutes; interquartile range [IQR] 53-80 minutes vs 84 minutes; IQR 68-101 minutes; P ≤ .001), and procedures with PFA in combination with 3-dimensional electroanatomic mapping were shorter than those with RFA (median 101 minutes; IQR 85-126 minutes vs 171 minutes; IQR 141-204 minutes; P < .001). Acute safety events occurred in 2.3%, 2.6%, and 0.8% in the PFA, CBA, and RFA groups, respectively (P = .545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA, and 48.3% for RFA (CBA vs PFA: P = .79; CBA vs RFA: P = .009; PFA vs RFA: P = .010).

CONCLUSION

In patients with persistent AF undergoing first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA than with RFA.

2024 European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation

In the last three decades, ablation of atrial fibrillation (AF) has become an evidence-based safe and efficacious treatment for managing the most common cardiac arrhythmia. In 2007, the first joint expert consensus document was issued, guiding healthcare professionals involved in catheter or surgical AF ablation. Mounting research evidence and technological advances have resulted in a rapidly changing landscape in the field of catheter and surgical AF ablation, thus stressing the need for regularly updated versions of this partnership which were issued in 2012 and 2017. Seven years after the last consensus, an updated document was considered necessary to define a contemporary framework for selection and management of patients considered for or undergoing catheter or surgical AF ablation. This consensus is a joint effort from collaborating cardiac electrophysiology societies, namely the European Heart Rhythm Association, the Heart Rhythm Society (HRS), the Asia Pacific HRS, and the Latin American HRS.

Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study)

AIMS

Pulsed field ablation (PFA) is a novel, non-thermal, cardiac tissue-selective ablation modality. To date, radiofrequency (RF)-guided high-power short-duration (HPSD) ablation represents the gold standard besides cryo-ablation for pulmonary vein isolation (PVI). This single-centre, retrospective study investigated the efficacy of PFA-PVI vs. HPSD-RF PVI in terms of single-procedure arrhythmia-free outcome and safety in a real-world setting.

METHODS AND RESULTS

Consecutive, paroxysmal atrial fibrillation (AF) patients who underwent PVI using PFA or HPSD-RF were enrolled. In group PFA, PVI was performed using a pentaspline PFA catheter. The ablation procedure in group HPSD-RF was performed with RF energy (45 W, ablation index). A total of 410 patients (group PFA, 201; group HPSD-RF, 209) were included. There was no difference between both groups regarding age, gender, and CHA2DS2-VASc score. The procedure time was significantly shorter in group PFA [61 (44-103) vs. 125 (105-143) min; P < 0.001]; fluoroscopy time and dose area product were significantly higher in group PFA [16 (13-20) vs. 4 (2-5) min; P < 0.01 and 412 (270-739) vs. 129 (58-265) μGym2; P < 0.01]. The overall complication rates were 2.9% in group PFA and 6.2% in group HPSD (P = 0.158). There was one fatal stroke in the PFA group. The 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia was 85% with PFA and 79% with HPSD-RF (log-rank P = 0.160). In 56 repeat ablation procedures, the PV reconnection rate was 30% after PFA and 38% after HPSD-RF (P = 0.372).

CONCLUSION

Both PFA and HPSD-RF were highly efficient and effective in achieving PVI in paroxysmal AF patients. The arrhythmia-free survival is comparable. The PV reconnection rate was not different.

Safety of pulsed field ablation in more than 17,000 patients with atrial fibrillation in the MANIFEST-17K study

Pulsed field ablation (PFA) is an emerging technology for the treatment of atrial fibrillation (AF), for which pre-clinical and early-stage clinical data are suggestive of some degree of preferentiality to myocardial tissue ablation without damage to adjacent structures. Here in the MANIFEST-17K study we assessed the safety of PFA by studying the post-approval use of this treatment modality. Of the 116 centers performing post-approval PFA with a pentaspline catheter, data were received from 106 centers (91.4% participation) regarding 17,642 patients undergoing PFA (mean age 64, 34.7% female, 57.8% paroxysmal AF and 35.2% persistent AF). No esophageal complications, pulmonary vein stenosis or persistent phrenic palsy was reported (transient palsy was reported in 0.06% of patients; 11 of 17,642). Major complications, reported for ~1% of patients (173 of 17,642), were pericardial tamponade (0.36%; 63 of 17,642) and vascular events (0.30%; 53 of 17,642). Stroke was rare (0.12%; 22 of 17,642) and death was even rarer (0.03%; 5 of 17,642). Unexpected complications of PFA were coronary arterial spasm in 0.14% of patients (25 of 17,642) and hemolysis-related acute renal failure necessitating hemodialysis in 0.03% of patients (5 of 17,642). Taken together, these data indicate that PFA demonstrates a favorable safety profile by avoiding much of the collateral damage seen with conventional thermal ablation. PFA has the potential to be transformative for the management of patients with AF.

Advances in Clinical Cardiology 2023: A Summary of Key Clinical Trials

INTRODUCTION

Over the course of 2023, numerous key clinical trials with valuable contributions to clinical cardiology were published or presented at major international conferences. This review seeks to summarise these trials and reflect on their clinical context.

METHODS

The authors collated and reviewed clinical trials presented at major cardiology conferences during 2023 including the American College of Cardiology (ACC), European Association for Percutaneous Cardiovascular Interventions (EuroPCR), European Society of Cardiology (ESC), Transcatheter Cardiovascular Therapeutics (TCT), American Heart Association (AHA), European Heart Rhythm Association (EHRA), Society for Cardiovascular Angiography and Interventions (SCAI), TVT-The Heart Summit (TVT) and Cardiovascular Research Technologies (CRT). Trials with a broad relevance to the cardiology community and those with potential to change current practice were included.

RESULTS

A total of 80 key cardiology clinical trials were identified for inclusion. Key trials in acute coronary syndrome (ACS) and antiplatelet management such as HOST-IDEA, T-PASS and STOP-DAPT3 were included in addition to several pivotal interventional trials such as ORBITA 2, MULTISTARS-AMI, ILUMIEN-IV, OCTIVUS and OCTOBER. Additionally, several trials evaluated new stent design and technology such as BIOSTEMI, PARTHENOPE and TRANSFORM. Structural intervention trials included long-term data from PARTNER 3, new data on the durability of transcatheter aortic valve intervention (TAVI), in addition to major new trials regarding transcatheter tricuspid valve intervention from TRISCEND II. Heart failure (HF) and prevention covered several key studies including DAPA-MI, STEP-HF, ADVOR, DICTATE HF and CAMEO-DAPA. In cardiac devices and electrophysiology, several trial exploring novel ablation strategies in atrial fibrillation (AF) such as PULSED AF and ADVENT were presented with further data evaluating the efficacy of anticoagulation in subclinical AF in NOAH-AFNET 6, FRAIL AF and AZALEA-TIMI 71.

CONCLUSION

This article presents a summary of key clinical cardiology trials published and presented during the past year and should be of interest to both practising clinicians and researchers.

Severe Periprocedural Complications After Ablation for Atrial Fibrillation: An International Collaborative Individual Patient Data Registry

BACKGROUND

Catheter ablation for atrial fibrillation (AF) including pulmonary vein isolation and possibly further substrate ablation is the most common electrophysiological procedure. Severe complications are uncommon, but their detailed assessment in a large worldwide cohort is lacking.

OBJECTIVES

The aim of this study was to determine the incidence of periprocedural severe complications and to provide a detailed characterization of the diagnostic evaluation and management of these complications in patients undergoing AF ablation.

METHODS

Individual patient data were collected from 23 centers worldwide. Limited data were collected for all patients who underwent catheter ablation, and an expanded series of data points were collected for patients who experienced severe complications during periprocedural follow-up. Incidence, predictors, patient characteristics, management details, and overall outcomes of patients who experienced ablation-related complications were investigated.

RESULTS

Data were collected from 23 participating centers at which 33,879 procedures were performed (median age 63 years, 30% women, 71% radiofrequency ablations). The incidence of severe complications (n = 271) was low (tamponade 6.8‰, stroke 0.97‰, cardiac arrest 0.41‰, esophageal fistula 0.21‰, and death 0.21‰). Age, female sex, a dilated left atrium, procedure duration, and the use of radiofrequency energy were independently associated with the composite endpoint of all severe complications. Among patients experiencing tamponade, 13% required cardiac surgery. Ninety-three percent of patients with complications were discharged directly home after a median length of stay of 5 days (Q1-Q3: 3-7 days).

CONCLUSIONS

This large worldwide collaborative study highlighted that tamponade, stroke, cardiac arrest, esophageal fistula, and death are rare after AF ablation. Older age, female sex, procedure duration, a dilated left atrium, and the use of radiofrequency energy were associated with severe complications in this multinational cohort. One in 8 patients with tamponade required cardiac surgery.

DNA Framework-Enabled 3D Organization of Antiarrhythmic Drugs for Radiofrequency Catheter Ablation

Preorganizing molecular drugs within a microenvironment is crucial for the development of efficient and controllable therapeutic systems. Here, the use of tetrahedral DNA framework (TDF) is reported to preorganize antiarrhythmic drugs (herein doxorubicin, Dox) in 3D for catheter ablation, a minimally invasive treatment for fast heartbeats, aiming to address potential complications linked to collateral tissue damage and the post-ablation atrial fibrillation (AF) recurrence resulting from incomplete ablation. Dox preorganization within TDF transforms its random distribution into a confined, regular spatial arrangement governed by DNA. This, combined with the high affinity between Dox and DNA, significantly increases local Dox concentration. The exceptional capacity of TDF for cellular internalization leads to a 5.5-fold increase in intracellular Dox amount within cardiomyocytes, effectively promoting cellular apoptosis. In vivo investigations demonstrate that administering TDF-Dox reduces the recurrence rate of electrical conduction after radiofrequency catheter ablation (RFCA) to 37.5%, compared with the 77.8% recurrence rate in the free Dox-treated group. Notably, the employed Dox dosage exhibits negligible adverse effects in vivo. This study presents a promising treatment paradigm that strengthens the efficacy of catheter ablation and opens a new avenue for reconciling the paradox of ablation efficacy and collateral damage.

Cryoballoon-Assisted Pulmonary Vein Isolation and Left Atrial Roof Ablation Using a Simplified Sedation Strategy without Esophageal Temperature Monitoring: No Notable Thermal Esophageal Lesions and Low Arrhythmia Recurrence Rates after 2 Years

BACKGROUND

Atrial fibrillation (AF) ablation is increasingly effective for managing heart rhythm but poses risks like esophageal fistulas. Minimizing esophageal thermal lesions while simplifying procedures is crucial.

METHODS

This prospective study involved 100 consecutive AF patients undergoing cryoballoon ablation with simplified sedation, without esophageal temperature monitoring. Patients with paroxysmal AF (Group A) received pulmonary vein isolation only, while those with persistent AF (Group B) also had left atrial roof ablation. Gastroesophageal endoscopy was performed post-procedure to detect lesions, and cardiological follow-ups were conducted at 3, 12, and 24 months.

RESULTS

The cohort included 69% men, with a median age of 65.5 years. Post-ablation endoscopy was performed in 92 patients; esophageal lesions were found in 1.1% of Group A and none of Group B. GERD was diagnosed in 14% of patients, evenly distributed between groups and not linked to lesion occurrence. Gastric hypomotility was observed in 16% of patients, with no significant difference between groups. At 24 months, arrhythmia-free survival was 88% in Group A and 74% in Group B.

CONCLUSION

Cryoballoon-assisted pulmonary vein isolation, with or without additional left atrial roof ablation and without esophageal temperature monitoring during a simplified sedation strategy, shows low risk of esophageal thermal injury and effective ablation outcomes.

Hydropneumopericardium Due to a Traumatic Esophageal-Pericardial Fistula

Esophago-pericardial fistula is a rare, life-threatening condition, usually arising as a complication of benign esophageal disorders or iatrogenic causes. Prompt diagnosis via multimodality imaging is crucial, with computed tomography being the most sensitive. Management varies based on severity, with a growing trend toward early endoscopic interventions, which result in improved outcomes.

Oesophago-pericardial fistula after catheter ablation of atrial fibrillation: a case report

Background

Oesophageal fistula is a rare complication of catheter ablation of atrial fibrillation with most fistulas being atrio-oesophageal fistulas, but oesophageal-pericardial fistula can also happen in the absence of atrial perforation.

Case summary

A 68-year-old male patient presented with chest pain 10 days after catheter ablation of paroxysmal atrial fibrillation. He was discharged after an initial negative workup that included a CT chest without contrast. He later presented again with severe chest pain and fever and was found to have an oesophageal-pericardial fistula. He underwent surgical and endoscopic treatment with good recovery.

Discussion

Patients with oesophago-pericardial fistulas often have delayed presentation 1-4 weeks after the ablation procedure. Early diagnosis can be challenging. CT with oral and intravenous contrast is often used for diagnosis. Treatment often includes antibiotics, surgical or interventional drainage of infected spaces with oesophageal repair, clipping or stenting. In contrast to atrio-oesophageal fistulas that carry a high mortality rate, mortality for oesophago-pericardial fistulas appears to be much lower.

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.

Self-sealing atrio-oesophageal fistula as a complication of pulmonary vein isolation: a case report

Background

Atrio-oesophageal fistulas (AEFs) are an uncommon complication of pulmonary vein ablation, and its diagnosis is challenging. Multidisciplinary interventions and diagnostic imaging are usually required and may play a role in the initial assessment.

Case summary

A 69-year-old female with atrial fibrillation who had undergone recent pulmonary vein ablation consulted with unspecific symptoms and sudden hemiparesis. Brain imaging showed pneumocephalus and acute infarcts. Chest computed tomography (CT) was highly suspicious for AEF. Surgical exploration revealed a swollen mediastinum attached to the right inferior pulmonary vein.

Discussion

Non-specific symptoms after pulmonary vein ablation should prompt the suspicion of complications. In the presence of fever or neurological deficit, AEF must be suspected and assessed with a contrast-enhanced chest CT, which has become the gold standard. In brain imaging, pneumocephalus and multiple punctate acute infarcts might also indicate the presence of this complication.

2023 Cardiac Society of Australia and New Zealand Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation

Catheter ablation for atrial fibrillation (AF) has increased exponentially in many developed countries, including Australia and New Zealand. This Expert Position Statement on Catheter and Surgical Ablation for Atrial Fibrillation from the Cardiac Society of Australia and New Zealand (CSANZ) recognises healthcare factors, expertise and expenditure relevant to the Australian and New Zealand healthcare environments including considerations of potential implications for First Nations Peoples. The statement is cognisant of international advice but tailored to local conditions and populations, and is intended to be used by electrophysiologists, cardiologists and general physicians across all disciplines caring for patients with AF. They are also intended to provide guidance to healthcare facilities seeking to establish or maintain catheter ablation for AF.

Pulsed field ablation technology for pulmonary vein and left atrial posterior wall isolation in patients with persistent atrial fibrillation

INTRODUCTION

Limited data exist on pulsed-field ablation (PFA) in patients with persistent atrial fibrillation (PeAF) undergoing left atrial posterior wall isolation (LAPWI).

METHODS

The Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA) prospective registry included consecutive patients referred for PeAF catheter ablation at 9 Italian centers, treated with the FARAPULSETM-PFA system. The primary efficacy and safety study endpoints were the acute LAPWI rate, freedom from arrhythmic recurrences and the incidence of major periprocedural complications. Patients undergoing pulmonary vein isolation (PVI) alone, PWI + LAPWI and redo procedures were compared.

RESULTS

Among 249 patients, 21.7% had long-standing PeAF, 79.5% were male; mean age was 63 ± 9 years. LAPWI was performed in 57.6% of cases, with 15.3% being redo procedures. Median skin-to-skin times (PVI-only 68 [60-90] vs. PVI + LAPWI 70 [59-88] mins) did not differ between groups. 45.8% LAPWI cases were approached with a 3D-mapping system, and 37.3% with intracardiac echocardiography. LAPWI was achieved in all patients by means of PFA alone, in 88.8% cases at first pass. LAPWI was validated either by an Ultrahigh-density mapping system or by recording electrical activity + pacing maneuvers. No major complications occurred, while 2.4% minor complications were detected. During a median follow-up of 273 [191-379] days, 41 patients (16.5%) experienced an arrhythmic recurrence after the 90-day blanking period, with a mean time to recurrence of 223 ± 100 days and no differences among ablation strategies.

CONCLUSION

LAPWI with PFA demonstrates feasibility, rapidity, and safety in real-world practice, offering a viable alternative for PeAF patients. LAPWI is achievable even with a fluoroscopy-only method and does not significantly extend overall procedural times.

Pulsed field ablation with the pentaspline catheter compared with cryoablation for the treatment of paroxysmal atrial fibrillation in the UK NHS: a cost-comparison analysis

OBJECTIVES

Pulsed field ablation (PFA) is a promising new ablation modality for the treatment of atrial fibrillation (AF) that has recently become available in the UK National Health Service (NHS). We provide the first known economic evaluation of the technology.

METHODS

A cost-comparison model was developed to compare the expected 12-month costs of treating AF using the pentaspline PFA catheter compared with cryoablation for a single hypothetical patient. Model parameters were based on a recent cost-effectiveness analysis by the National Institute for Health and Care Excellence where possible or published literature otherwise. Deterministic sensitivity, scenario and threshold analyses were conducted.

RESULTS

Costs for a single patient treated with PFA were -3% (-£343) less over 12 months than those who received treatment with cryoablation. PFA was associated with 16% higher catheter costs but repeat ablation costs were over 50% less, driven by a reduction in repeat ablations required. Costs of managing complications were -£211 less in total for PFA compared with cryoablation.

CONCLUSIONS

Routine adoption of PFA with the pentaspline PFA catheter looks to be as affordable for the NHS as current treatment alternative cryoablation.