Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta-analysis

2024 HRS expert consensus statement on arrhythmias in the athlete: Evaluation, treatment, and return to play

Youth and adult participation in sports continues to increase, and athletes may be diagnosed with potentially arrhythmogenic cardiac conditions. This international multidisciplinary document is intended to guide electrophysiologists, sports cardiologists, and associated health care team members in the diagnosis, treatment, and management of arrhythmic conditions in the athlete with the goal of facilitating return to sport and avoiding the harm caused by restriction. Expert, disease-specific risk assessment in the context of athlete symptoms and diagnoses is emphasized throughout the document. After appropriate risk assessment, management of arrhythmias geared toward return to play when possible is addressed. Other topics include shared decision-making and emergency action planning. The goal of this document is to provide evidence-based recommendations impacting all areas in the care of athletes with arrhythmic conditions. Areas in need of further study are also discussed.

Atrial fibrillation catheter ablation in endurance athletes: systematic review and meta-analysis

BACKGROUND

Atrial fibrillation (AF) management in endurance athletes (EA) is challenging due to the paucity of data, especially on the efficacy and safety of catheter ablation (CA). The hypothesis is that the efficacy and safety of AF CA in EA are comparable to the non-EA.

METHODS

Databases from EMBASE, Medline, PubMed, and Cochrane were searched from inception through February 2023. Studies with available information on efficacy and safety profiles were included. Effect estimates from the individual studies were extracted and combined using random effect and generic inverse variance method of DerSimonian and Laird.

RESULTS

Nine observational studies with a total of 1129 participants were identified, of whom 51% were EA. Our analysis found that rate of atrial arrhythmia (AA) recurrences following AF CA was not statistically different between EA and non-EA (RR 1.04, I2 = 57.6%, p = 0.54). The AA survival rates after a single ablation in EA was 60.2%, which improved up to 77% after multiple ablations during the follow-up period. Infrequent complication rates ranging from 0 to 7.6% were observed, with no mortality.

CONCLUSIONS

Our meta-analysis suggests that AF CA is as effective and safe in EA as in non-EA. In the future, AF CA should be considered as a first-line therapeutic choice in this patient group.

A Simple Score to Predict New-Onset Atrial Fibrillation After Ablation of Typical Atrial Flutter

BACKGROUND

New-onset atrial fibrillation (NeAF) is common after cavotricuspid isthmus-dependent counterclockwise atrial flutter (CCW-AFL) ablation. This study aimed to investigate a simple predictive model of NeAF after CCW-AFL ablation.

METHODS

From January 2013, to December 2017, consecutive patients receiving CCW-AFL ablation were enrolled from 3 centres. Clinical, echocardiographic, and electrocardiographic data were collected and followed. Patients from 2 centres and another centre were assigned into the derivation and validation cohorts, respectively. In the derivation cohort, logistic regression was performed to evaluate the ability of parameters to discriminate those with and without NeAF. A score system was developed and then validated.

RESULTS

Two hundred seventy-one patients (mean 59.7 ± 13.6 age; 205 male) were analyzed. During follow-up (73.0 ± 6.5 months), 107 patients (39.5%) had NeAF; 190 and 81 patients were detected in the derivation and validation cohorts, respectively. Hypertension, age ≥ 70 years, left atrial diameter ≥ 42 mm, P-wave duration ≥ 120 ms and the negative component of flutter wave in lead II ≥ 120 ms were selected as the final parameters. A weighted score was used to develop the HAD-AF score ranging from 0 to 9. In the derivation cohort, area under the receiver operating characteristic curve (AUC) was 0.938 (95% confidence interval [CI], 0.902-0.974), superior to those of currently used CHA2DS2-VASC (0.679, 95% CI, 0.600-0.757) and HATCH scores (0.651, 95% CI, 0.571-0.730) (P < 0.001). Performance maintained in the validation cohort.

CONCLUSIONS

Six years after CCW-AFL ablation, 39.5% of patients developed NeAF. HAD-AF score can reliably identify patients likely to develop NeAF after CCW-AFL ablation.

Catheter ablation approach and outcome in HIV+ patients with recurrent atrial fibrillation

INTRODUCTION

Earlier studies have shown a clear association between severity of human immunodeficiency virus (HIV) infection and incident atrial fibrillation (AF). We present the long-term outcome of catheter ablation (CA) and electrophysiological characteristics in HIV+ AF patients.

METHODS

This study evaluated 1438 consecutive AF patients [31 (2.15%) with HIV and 1407 (97.8%) without HIV diagnosis] undergoing their first CA at our center. A total of 31 HIV patients and 31 controls were generated by propensity matching, based on calculated risk factor scores, using a logistic model. During first procedure, all received isolation of pulmonary vein (PV) + posterior wall and superior vena cava. Non-PV triggers, defined as ectopic triggers originating from sites other than PVs, were identified at the redo ablation with high-dose isoproterenol challenge.

RESULTS

Clinical characteristics were not different between the groups. When compared to the control, by the end of 5 years after the first procedure, recurrence was significantly greater in HIV group [100% vs. 54%, p < .001]. Among patients that underwent redo ablation non-PV triggers were higher in HIV group [93.5% vs. 54%, p < .001], and most frequently originated from the coronary sinus [67.7% vs. 45.2%, p < .001] and left atrial appendage [41.9% vs. 25.8%, p < .001]. After focal ablation of non-PV trigger, no difference in arrhythmia recurrence between two groups [80.6% vs. 87.1%, p = .753] at 1-year follow up was found.

CONCLUSION

Our findings suggest that non-PV triggers are highly prevalent in HIV+ AF patients resulting in higher rate of the mid- and long-term arrhythmia recurrence.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter

OBJECTIVE

We aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL).

METHODS

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter was an international, multicentre, open with blinded assessment trial. Patients with CTI-dependent AFL and no documented atrial fibrillation (AF) were randomised to either cryoballoon PVI alone or radiofrequency CTI ablation. Primary efficacy outcome was time to first recurrence of sustained (>30 s) symptomatic atrial arrhythmia (AF/AFL/atrial tachycardia) at 12 months as assessed by continuous monitoring with an implantable loop recorder. Primary safety outcome was a composite of death, stroke, tamponade requiring drainage, atrio-oesophageal fistula, pacemaker implantation, serious vascular complications or persistent phrenic nerve palsy.

RESULTS

Trial recruitment was halted at 113 of the target 130 patients because of the SARS-CoV-2 pandemic (PVI, n=59; CTI ablation, n=54). Median age was 66 (IQR 61-71) years, with 98 (86.7%) men. At 12 months, the primary outcome occurred in 11 (18.6%) patients in the PVI group and 9 (16.7%) patients in the CTI group. There was no significant difference in the primary efficacy outcome between the groups (HR 1.11, 95% CI 0.46 to 2.67). AFL recurred in six (10.2%) patients in the PVI arm and one (1.9%) patient in the CTI arm (p=0.116). Time to occurrence of AF of ≥2 min was significantly reduced with cryoballoon PVI (HR 0.46, 95% CI 0.25 to 0.85). The composite safety outcome occurred in four patients in the PVI arm and three patients in the CTI arm (p=1.000).

CONCLUSION

Cryoballoon PVI as first-line treatment for AFL is equally effective compared with standard CTI ablation for preventing recurrence of atrial arrhythmia and better at preventing new-onset AF.

TRIAL REGISTRATION NUMBER

NCT03401099.

Prophylactic Cavotricuspid Isthmus Ablation in Atrial Fibrillation without Documented Typical Atrial Flutter: A Systematic Review and Meta-analysis

Background: The advantage of prophylactic cavotricuspid isthmus (CTI) ablation for AF patients without documented atrial flutter is still unclear. The present study aimed to evaluate the role of prophylactic CTI ablation in this population. Methods: A systematic review and meta-analysis study was conducted. The overall effects estimation was conducted using random effects models. The pooled effects were presented as the risk difference and standardised mean difference for dichotomous and continuous outcomes, respectively. Results: A total of 1,476 patients from four studies were included. The risk of atrial tachyarrhythmias following a successful catheter ablation procedure was greater in the pulmonary vein isolation + CTI ablation group than pulmonary vein isolation alone group (34.8% versus 28.2%; risk difference 0.08; 95% CI [0.00–0.17]; p=0.04). Prophylactic CTI ablation was associated with a higher recurrent AF rate (33.8% versus 27.1%; risk difference 0.07; 95% CI [0.01–0.13]; p=0.02). Additional prophylactic CTI ablation to pulmonary vein isolation significantly increased the radio frequency application time (standardised mean difference 0.52; 95% CI [0.04–1.01]; p=0.03). Conclusion: This study suggested that prophylactic CTI ablation was an ineffective and inefficient approach in AF without documented typical atrial flutter patients.

Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry

BACKGROUND

The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.

METHODS

REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.

RESULTS

Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.

CONCLUSIONS

REAL-AF operators were high volume low fluoroscopy "real world" operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

Rates of atrial flutter occurrence and cavotricuspid isthmus reconduction after prophylactic isthmus ablation performed during atrial fibrillation ablation: a clinical study, review, and comparison with previous findings

PURPOSE

Based on the high rate of coexisting atrial fibrillation (AF) and atrial flutter (AFL), prophylactic cavotricuspid isthmus ablation (CTIA) adjunctive to AF ablation has recently been attempted in patients with AF and without AFL. The present study aimed to determine the rates of AFL occurrence and CTI reconduction after performing CTI ablation adjunctive to AF ablation.

METHODS

We analyzed the data of 3833 consecutive patients with AF, who underwent prophylactic CTIA with AF ablation between 2009 and 2020.

RESULTS

In all patients, CTIA and AF ablations were successful. Clinical AFL occurred in seven patients (0.18%, 7/3,833), and the observed rate was lower than those reported for cases of AF ablation without CTIA and for those of CTIA for pure AFL. A second ablation was needed in 745 patients at a median of 253 days (25 and 75 percentiles, 116 and 775 days) after the first ablation. In 12.1% (90/745) of the patients, CTI reconduction was observed. The reconduction rate was lower than that previously reported for CTIA for pure AFL.

CONCLUSIONS

The present retrospective study found acceptably low rates of clinical AFL occurrence and CTI reconduction following prophylactic CTIA performed with AF ablation, which was supported by the findings obtained after performing a comparison of the rates with those of other ablations (AF ablation only and CTIA for pure AFL). Considering the high correlation between AF and AFL, the present study provided information regarding the efficacy of adjunctive CTIA.

Safety of cryoballoon ablation for the treatment of atrial fibrillation: First European results from the cryo AF Global Registry

BACKGROUND

Cryoballoon ablation for the treatment of patients with atrial fibrillation (AF) has been utilized in Europe for >15 years.

OBJECTIVES

Report patient and procedural characteristics that influence the safety of cryoablation for the treatment of AF.

METHODS

Patients enrolled in the prospective, multicenter Cryo AF Global Registry were treated at 38 European centers. Freedom from a ≥30s episode of AF/atrial flutter (AFL)/atrial tachycardia (AT) at 12-months and serious complications were analyzed. Univariate and multivariable models identified baseline patient and procedural characteristics that predicted a procedure-related complication.

RESULTS

Of the 1418 subjects who completed an index procedure, the cohort was 62 ± 11 years of age, 37.7% female, and 72.2% paroxysmal AF (PAF). The mean procedure, left atrial dwell, and fluoroscopy times were 81 ± 34, 54 ± 25, and 14 ± 13 min, respectively. Among the 766 patients with 12-month follow-up, freedom from a ≥30 s AF/AFL/AT recurrence was 83.3% (95% CI: 79.8%-86.3%) and 71.6% (95% CI: 64.6%-77.4%) in patients with PAF and persistent AF. The serious procedure- and device-related adverse event rates were 4.7% and 2.0%. No baseline patient characteristic independently predicted a procedure-related adverse event; however, prolonged procedure duration (OR = 1.01 [95% CI: 1.00-1.01]), use of general anesthesia (OR = 1.71 [95% CI: 1.01-2.92]), and delivery of a cavotricuspid isthmus line (OR = 3.04 [95% CI: 1.01-9.20]) were each independently associated with the occurrence of a serious procedural safety event (all p < .05).

CONCLUSIONS

Cryoballoon ablation is safe and effective in real-world use across a broad cohort of patients with AF.