Search

Background Fragmented QRS (fQRS) on 12-lead electrocardiography is a noninvasive marker of intramyocardial conduction delay due to ventricular scarring that has not previously been studied in atrial fibrillation. Objective The purpose of this study was to assess the association of fQRS with left atrial (LA) scarring in patients with persistent atrial fibrillation (PsAF) undergoing first catheter ablation. Methods A total of 376 patients with PsAF were enrolled. Severity of LA scarring was assessed using electroanatomic mapping. Narrow fQRS was defined by the presence of an additional R wave (R′) or notching in the nadir of the S wave, or the presence of >1 R′ in 2 contiguous leads corresponding to inferior, lateral, or anterior myocardial regions. Results Both any degree (97.3% vs 63.3%) and severe (42.2% vs 6.3%) LA scarring were higher in patients with fQRS. Age and fQRS were found to be independent predictors of severe LA scarring. At multiple ventricular regions, fQRS had diagnostic accuracy of 79.8% for prediction of severe LA scarring. Nonpulmonary vein triggers were more often detected and ablated in patients with fQRS and severe LA scarring (84.4% vs 70%; P = .001). Atrial tachyarrhythmia recurrence was observed in 131 patients (34.8%) during 18.9 ± 7.7 months of follow-up, which was significantly higher in patients with fQRS (53.2% vs 16.8%). In multivariate analysis, fQRS was found to be a significant predictor of recurrence (hazard ratio 4.65; 95% interval confidence 2.91–7.42; P Conclusion The study results showed that fQRS is a simple, available, and noninvasive marker, and that fQRS at multiple ventricular regions is significantly associated with the severity of LA scarring in PsAF patients.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

Background Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. Objective The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). Methods A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. Results In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. Conclusion These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

Background An increasing number of adults with congenital heart disease (CHD) are undergoing catheter ablation for atrial fibrillation (AF). Data on ablation strategy and outcomes in CHD are limited. Rhythm control is often believed to be of greater importance among patients with complex CHD. Objective The purpose of this study was to examine the safety and efficacy of AF ablation in adult patients with CHD. Methods A multicenter retrospective analysis was performed of CHD patients undergoing AF ablation. Clinical data were collected, including AF and CHD type, procedural data, and outcomes. Patients were divided into 3 groups (simple, moderate, and severe) based on CHD complexity, as defined by the 2014 PACES/HRS (Pediatric and Congenital Electrophysiology Society/Heart Rhythm Society) consensus statement. One-year procedural success was defined as freedom from recurrent AF, off antiarrhythmic drugs (complete) or off/on previously failed antiarrhythmic drugs (partial). Results Overall, 84 CHD patients (mean age 51.5 ± 12.1 years; 65.5% male; 45.2% with paroxysmal AF) undergoing AF ablation (51 simple, 22 moderate, 11 severe complexity) were included. Pulmonary vein isolation was performed in 80 (95.2%), of whom 30 (35.7%) underwent pulmonary vein isolation alone. Overall, complete and complete/partial freedom was achieved at 1 year in 53.1% and 71.6%, respectively, with no significant differences between those with simple, moderate, or severe complexity. There were no major complications and 7 minor complications, and 2 patients died during follow-up. Conclusion There are dramatic differences in the degree of CHD complexity among patients referred for AF ablation. When performed at experienced centers, AF ablation is safe and effective even among patients with the most complex forms of CHD.

The optimal site of ablation of idiopathic left ventricular outflow tract (LVOT) ventricular arrhythmias (VAs) is challenging as activation mapping can reveal similar activation times in different anatomical sites, suggesting an intramural origin.We sought to assess whether in patients with intramural VAs and with multiple early activation sites (EASs), sequential ablation of all the early EASs could improve acute and long-term clinical outcomes.A total of 116 patients undergoing catheter ablation for symptomatic LVOT VAs were enrolled in this study. Thirty-nine patients (34%) were referred for a redo procedure, whereas the remaining presented for a first procedure. Mapping was performed manually in 86 cases (74%) and with a magnetic robotic system (Niobe, Stereotaxis, St. Louis, MO) in the remainder of the cases.Of the 116 patients, 15 (13%) were found to have multiple sites of equally early activation. In patients with multiple EASs, the mean pre-QRS activation time was significantly less than in patients with a single EASs (-26 ± 3 ms vs -38 ± 6 ms; P .005). Sequential ablation of all the EASs was possible in 14 patients (93%), resulting in complete arrhythmia suppression. After a mean follow-up of 21 ± 5 months, all patients with successful ablation of all multiple early EASs remained free from clinical VAs.Intramural LVOT VAs manifesting with multiple EASs require ablation at all sites to achieve acute and long-term success, particularly if none of the EASs is-30ms pre-QRS activation time.

The purpose of this study was to evaluate the characteristics and outcome of patients undergoing ablation after electrical storm (ES).Clinical and procedural characteristics, ventricular tachycardia (VT) recurrence, and mortality rates from 1940 patients undergoing VT ablation were compared between patients with and without ES.The group of 677 patients with ES (34.9%) were older, were more frequently men, and had a lower ejection fraction, more advanced heart failure, and a higher prevalence of cardiovascular comorbidities as compared with those without ES (86.1% patients with ES had ≥2 comorbidities vs 71.4%; P.001). Patients with ES had more inducible VTs (2.5 ± 1.8 vs 1.9 ± 1.9; P.001), required longer procedures (296.1 ± 119.1 minutes vs 265.7 ± 110.3 minutes; P.001), and had a higher in-hospital mortality (42 deaths [6.2%] vs 18 deaths [1.4%]; P.001). At 1-year follow-up, patients with ES experienced a higher risk of VT recurrence and mortality (32.1% vs 22.6% and 20.1% vs 8.5%; long-rank, P.001 for both). Among patients with ES, those without any inducible VT after ablation had a higher survival rate (86.3%) than did those with nonclinical VTs only (72.9%), those with clinical VTs inducible at programmed electrical stimulation (51.2%), and not-tested patients (65.0%) (long-rank, P.001 for all). In multivariate analysis, ES remained an independent predictor of in-hospital mortality, VT recurrence, and 1-year mortality (P.001).Patients with ES have a high risk of VT recurrence and mortality. Patient and procedure characteristics are consistent with advanced cardiac disease and longer and more complex procedures. In patients with ES, acute procedural success is associated with a significant reduction in VT recurrence and improved 1-year survival.

Background Focal impulse and rotor modulation (FIRM)-guided ablation targets sites that are thought to sustain atrial fibrillation (AF). Objective The purpose of this study was to evaluate the acute and mid-term outcomes of FIRM-guided only ablation in patients with nonparoxysmal AF. Methods We prospectively enrolled patients with persistent and long-standing persistent (LSP) AF at three centers to undergo FIRM-guided only ablation. We evaluated acute procedural success (defined as AF termination, organization, or ≥10% slowing), safety (incidence of periprocedural complications), and long-term success (single-procedure freedom from atrial tachycardia [AT]/AF off antiarrhythmic drugs [AAD] after a 2-month blanking period). Results Twenty-nine patients with persistent (N = 20) and LSP (N = 9) AF underwent FIRM mapping. Rotors were presents in all patients, with a mean of 4 ± 1.2 per patient (62% were left atrial); 1 focal impulse was identified. All sources were successfully ablated, and overall acute success rate was 41% (0 AF termination, 2 AF slowing, 10 AF organization). There were no major procedure-related adverse events. After a mean 5.7 months of follow-up, single-procedure freedom from AT/AF without AADs was 17%. Conclusion In nonparoxysmal AF patients, targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization, or slowing during the procedure. After mid-term follow-up, the strategy of ablating FIRM-identified rotors alone did not prevent recurrence from AT/AF.

It is unclear whether isolation of the left atrial posterior wall (LAPW) offers additional benefits over pulmonary vein antrum isolation (PVAI) alone in patients with persistent atrial fibrillation (AF).We sought to determine the impact of PVAI and LAPW isolation (PVAI+LAPW) versus PVAI alone on the outcome of ablation of persistent AF.During the first procedure, PVAI was performed in 20 patients (group 1), whereas in 32 patients (group 2), PVAI was extended to the left atrial (LA) septum and coronary sinus (CS), and isolation of the LAPW was targeted (ePVAI+LAPW). Isolation of the superior vena cava was achieved in both groups. All patients, regardless of arrhythmia recurrence, underwent a second procedure 3 months after the first procedure. In patients with reconnection of pulmonary veins or LAPW, reisolation was performed, and a third procedure was performed 3 months later to verify isolation. Patients entered follow-up only after PVAI (group 1) or PVAI+LAPW (group 2) isolation was proven.At the 1-, 2-, and 3-year follow-up examinations, the rates of freedom from atrial tachyarrhythmia without use of an antiarrhythmic drug were 20%, 15%, and 10% in group 1 and 65%, 50%, and 40% in group 2, respectively (log-rank P.001). The median recurrence-free survival time was 8.5 months (interquartile range 6.5-11.0) in group 1 and 28.0 months (interquartile range 8.5-32.0) in group 2.Proven isolation of the LAPW provides additional benefits over PVAI alone in the treatment of persistent AF and improves procedural outcome at follow-up. However, the ablation strategy of ePVAI+LAPW is still associated with a significant high incidence of very late recurrence of atrial tachyarrhythmia."Outcome of Atrial Fibrillation Ablation After Permanent Pulmonary Vein Antrum Isolation With or Without Proven Left Atrial Posterior Wall Isolation" (LIBERATION). ClinicalTrials.gov Identifier: NCT01660100.

The effectiveness of radiofrequency catheter ablation (RFCA) in atrial tachyarrhythmias correlates with lesion transmurality. Ablation Index (AI) is an index that incorporates contact force, time, and radiofrequency power simultaneously and is able to predict lesion size and outcomes in RFCA of atrial fibrillation.The purpose of this study was to assess whether AI could be an acute and long-term success predictor in RFCA of premature ventricular complexes (PVCs).One hundred forty-five patients with idiopathic outflow tract PVCs undergoing RFCA were retrospectively enrolled. The maximum and maximum AI values were calculated for each ablation site. Acute and 6-month outcomes were analyzed. Patients were divided into 3 outcome subgroups-success, acute failure, and 6-month failure-and the maximum and mean AI values were compared.Acute and 6-month success rates were 95% and 77%, respectively. The maximum and mean AI values were statistically higher in the success group (median of the maximum AI 630 [IQR 561-742]; median of the mean AI 489 [IQR 411-560]) than in the acute failure group (median of the maximum AI 487 [IQR 445-583]; median of the mean AI 372 [IQR 332-434]; P .0001 for both) and the 6-month failure group (median of the maximum AI 519 [IQR 476-568]; median of the mean AI 410 [IQR 368-472]; P .0001 for both). Both maximum and mean AI values were confirmed to be statistically higher in the success group than in the failure/6-month failure group (P = .001 and P = .04, respectively) and right ventricular free wall (P = .007 and P = .01, respectively) PVC origin subgroups.Our data support the concept that AI could be a long-term success predictor in RFCA of PVCs. However, further prospective studies are required to assess the feasibility of the AI-guided PVC ablation approach.

Data evaluating repeat radiofrequency ablation (1RFA) of ventricular tachycardia (VT) are limited.The purpose of this study was to determine the safety and outcomes of VT1RFA in patients with structural heart disease.Patients with structural heart disease undergoing VT RFA at 12 centers with data on prior RFA history were included. Characteristics and outcomes were compared between first-time (1RFA) and1RFA patients.Of 1990 patients, 740 had1RFA (mean 1.4 ± 0.9, range 1-10).1RFA vs 1RFA patients did not differ with regard to age (62 ± 13 years vs 62 ± 13 years), left ventricular ejection fraction (33% ± 13% vs 34% ± 13%), or sex (88% vs 87% men), but they more often were nonischemic (53% vs 41%), had implantable cardioverter-defibrillator shocks (70% vs 63%) or VT storm (38% vs 33%), and had been treated with amiodarone (55% vs 48%) or ≥2 antiarrhythmic drugs (22% vs 14%).1RFA procedures were longer (300 ± 122 minutes vs 266 ± 110 minutes), involved more epicardial access (41% vs 21%), induced VTs (2.4 ± 2.2 vs 1.9 ± 1.6) and only unmappable VTs (15% vs 9%), and VT was more often inducible after RFA (42% vs 33%, all P.03). Total complications were higher for1RFA vs 1RFA (8% vs 5%, P.01), mostly related to pericardial effusion (2.4% vs 1.3%, P = .07) and venous thrombosis (0.8% vs 0.2%, P = .06). VT recurrence was higher for1RFA vs 1RFA (29% vs 24%, P.001). Survival was worse for1RFA vs 1RFA if VT recurred (67% vs 78%, P = .003) but was equivalent if successful (93% vs 92%, P = .96).Patients requiring repeat VT ablation differ significantly from those undergoing first-time ablation. Despite more challenging ablation characteristics, VT-free survival after repeat ablations is encouraging. Mortality is comparable if VT does not recur after RFA at specialized centers.

Background In the stroke prevention trials of left atrial appendage closure with the Watchman device (Boston Scientific), a postimplantation antithrombotic regimen of 6 weeks of warfarin was used. Objective Given the clinical complexity of warfarin use, the purpose of this study was to study the relative feasibility and safety of using non-warfarin oral anticoagulants (NOACs) instead of warfarin during the peri- and initial postimplantation periods after Watchman implantation. Methods This was a retrospective multicenter study of consecutive patients undergoing Watchman implantation and receiving peri- and postprocedural NOACs or warfarin. Transesophageal echocardiography or chest computed tomography was performed between 6 weeks and 4 months postimplant to assess for device-related thrombosis. Bleeding and thromboembolic events also were evaluated at the time of follow-up. Results In 5 centers, 214 patients received NOACs (46% apixaban, 46% rivaroxaban, 7% dabigatran, and 1% edoxaban) in either an uninterrupted (82%) or a single-held-dose (16%) fashion. Compared to a control group receiving uninterrupted warfarin (n = 212), the rates of periprocedural complications, including bleeding events, were similar (2.8% vs 2.4%, P = 1). At follow-up, the rates of device-related thrombosis (0.9% vs 0.5%, P = 1), composite of thromboembolism or device-related thrombosis (1.4% vs 0.9%, P = 1), and postprocedure bleeding events (0.5% vs 0.9%, P = .6) also were comparable between the NOAC and warfarin groups. Conclusion NOACs proved to be a feasible peri- and postprocedural alternative regimen to warfarin for preventing device-related thrombosis and thromboembolic complications expected early after appendage closure with the Watchman device, without increasing the risk of bleeding.

Background Islets of myocytes within fibrofatty scars represent the substrate for reentrant ventricular arrhythmias in arrhythmogenic right ventricular cardiomyopathy (ARVC). Electroanatomic mapping can reliably identify such areas. Objective To prospectively test the association between late and fragmented electrograms within scar and arrhythmic events in patients with ARVC. Methods High-density right ventricle electroanatomic mapping was performed in 32 patients with ARVC without history of cardiac arrest or sustained ventricular arrhythmias. Standard definitions of electroanatomic scars and fragmented, isolated, and very late potentials were used. All patients received an implantable cardioverter-defibrillator for the primary prevention of sudden death. Results After a mean follow-up of 25 ± 7 months, 12 (38%) patients received appropriate implantable cardioverter-defibrillator shock for sustained ventricular arrhythmias. With the exception of a higher rate of previous syncope ( P = .053), patients with arrhythmic events at follow-up did not differ from those who remained free from arrhythmic events in terms of other clinical variables, including cardiac magnetic resonance findings. Electroanatomic scars were present in all patients. The distribution and extent of electroanatomic scars were similar in the 2 groups (38 ± 25 cm 2 vs 33 ± 20 cm 2 ; P = .51). However, patients with implantable cardioverter-defibrillator shock had a higher prevalence of fragmented electrograms (92% vs 20%; P P = .004), and of very late potentials (67% vs 25%; P = .030). Fragmented electrograms were the only variable independently associated with arrhythmic events at follow-up (hazard ratio 21; P = .015). Conclusion The presence of fragmented and delayed electrograms within the scar predicts arrhythmic events in ARVC.

Background Management of ventricular tachycardia (VT) in patients with hypertrophic cardiomyopathy (HCM) is challenging. Objective The purpose of this study is to assess the value of radiofrequency catheter ablation (RFCA) for the treatment of the VTs in the setting of HCM. Methods Twenty-two patients (18 with ICD) with HCM and multiple episodes of VTs resistant to medical therapy underwent RFCA with an open irrigation catheter. Epicardial access was obtained if required. All patients were followed for at least 1 year after RFCA. Results Mean age was 50.4 ± 15.3, and mean ejection fraction was 34.3% ± 9.8%. RFCA was performed endocardially in all patients, while epicardial radiofrequency applications were needed in 13 patients. A previous endocardial ablation was unsuccessful in six patients. At 20 ± 9 months of follow-up, elimination of VTs reached 73%. No major complication was observed during and after the procedures in all patients. Conclusion Catheter ablation of VTs in patients with hypertrophic cardiomyopathy refractory to medical therapy is safe, feasible, and successful in eliminating VT. Epicardial VT mapping and ablation should be considered as an important access option for the treatment of these patients to increase the success rate.

Phrenic nerve (PN) injury, a known complication of radiofrequency (RF) catheter ablation of atrial fibrillation (AF), has been more commonly reported with balloon-based pulmonary vein isolation.We present a novel approach to locating the PN and predicting patients at higher risk of this complication.The study included 2 groups of patients. In the first group of 71 patients, computerized tomographic angiography (CTA) with 3-dimensional reconstruction of the left atrium (LA) was obtained prior to an RF ablation procedure. The location of the right pericardiophrenic artery (RPA) was identified on the axial CTA images, and the artery distance to the right superior pulmonary vein (RSPV) ostium was measured in the 3-dimensional image. During ablation, the location of the right PN was identified by pacing maneuvers. The distance to the ostium of the RSPV was measured by venography and compared with the CTA artery measurement. In the second group, CTA imaging from 37 subjects who were enrolled in 3 investigational balloon ablation trials were analyzed using the same PN location technique and compared against the clinical outcomes. In this analysis, the CTA segmentation and PN location was performed in a blinded fashion as to any clinical evidence of PN injury.The mean measurement difference between PN capture and imaged RPA was 0.8 mm (P = .539). In all cases, the imaged RPA could reliably identify the approximate location of the right PN (R-square 0.984, P.001). Moreover, this analysis suggests that a PN location within 10 mm of the RSPV poses a higher risk of PN injury using these balloon ablation devices.Imaging the right pericardiophrenic artery can reliably locate the right phrenic nerve. This technique might identify anatomy more vulnerable to phrenic nerve injury using balloon-based ablation systems.

Most atrial fibrillation (AF) ablation studies have consisted predominantly of males; accordingly, there is a paucity of information on the safety and efficacy of catheter ablation in a large cohort of female AF patients.The purpose of this study was to evaluate catheter ablation for AF in female patients.From January 2005 to May 2008, 3265 females underwent pulmonary vein antrum isolation. Success rates, patient profiles, and complications were collected.Approximately 16% of our population was female (P.001). Females were older (59 +/- 13 vs. 56 +/- 19 years; P.01) and had a lower prevalence of paroxysmal atrial fibrillation (PAF; 46% vs. 55%; P.001). Females failed more antiarrhythmics (4 +/- 1 vs. 2 +/- 3; P = .04) and were referred later for catheter ablation (6.51 +/- 7 vs. 4.85 +/- 6.5 years; P = .02) than males. More females failed ablation (31.5% vs. 22.5%; P = .001) and had nonantral sites of firing than males (P.001). Female patients had 11 (2.1%) hematomas versus 27 (0.9%) in males.Five times as many males underwent catheter ablation than females. Females failed more ablations possibly because of a higher prevalence of nonantral firing, non-PAF, and longer history of AF. Females had more bleeding complications than males.

Background Despite the recent advances in cardiac mapping, ablation of scar-related ventricular tachycardia (VT) still remains a clinical challenge. A detailed electroanatomical map is a prerequisite for accurate localization and ablation of the VT substrate. Objective The purpose of this study was to evaluate the feasibility and accuracy of integrating the positron emission tomography (PET)/computed tomography (CT) with the electroanatomical map and compare the accuracy of the voltage-based scar with the biological scar. Methods Patients undergoing radiofrequency ablation (n = 19) for scar-related VT were enrolled. CT angiography and PET scans were performed for all patients. Tomographic and volumetric data from both images were processed and coregistered using internally designed software. That image was segmented in an electrophysiology mapping system and registered to the electroanatomical map. Eight different thresholds were applied on the voltage map to define the scar. The surface areas of the biological and electrical dense scars at different thresholds were measured and compared. Results The PET/CT image was well integrated with the electroanatomical map with a mean surface registration error of 5.1 ± 2.1 mm. Of the eight different thresholds defining the scar, the surface area of the scar at a threshold of 0.9 mV (68.6 ± 49.2 cm 2 ) correlated best with the surface area of the PET-based scar (70.4 ± 49.3 cm 2 ) and had the least total area error (4.8 ± 1.8 cm 2 ) compared with the 0.5 threshold (29.7 ± 23.9 cm 2 ). Conclusion Integrating PET/CT with the electroanatomical map is feasible and accurate. Based on the biological scar, readjustment of the voltage scar threshold to 0.9 mV is suggested. In view of the better accuracy of PET/CT in defining scar, the need for acquiring detailed voltage maps may be obviated.

BackgroundThe impact of catheter ablation of ventricular tachycardia (VT) on all-cause mortality remains unknown.ObjectiveThe purpose of this study was to examine the association between VT recurrence after ablation and survival in patients with scar-related VT.MethodsAnalysis of 2061 patients with structural heart disease referred for catheter ablation of scar-related VT from 12 international centers was performed. Data on clinical and procedural variables, VT recurrence, and mortality were analyzed. Kaplan-Meier analysis was used to estimate freedom from recurrent VT, transplant, and death. Cox proportional hazards frailty models were used to analyze the effect of risk factors on VT recurrence and mortality.ResultsOne-year freedom from VT recurrence was 70% (72% in ischemic and 68% in nonischemic cardiomyopathy). Fifty-seven patients (3%) underwent cardiac transplantation, and 216 (10%) died during follow-up. At 1 year, the estimated rate of transplant and/or mortality was 15% (same for ischemic and nonischemic cardiomyopathy). Transplant-free survival was significantly higher in patients without VT recurrence than in those with recurrence (90% vs 71%, P

Summary Currently, warfarin is the standard for stroke reduction inatrial fibrillation. Warfarin reduces the risk of systemicembolism and stroke in atrial fibrillation and is indicated aslong-term treatment for patients with atrial fibrillation andrisk factors for stroke, even when a rhythm control strategyis being used. Unless contraindications to anticoagulationdevelop, warfarin should not be stopped in these patients,even if atrial fibrillation is paroxysmal or if sinus rhythmappears to be maintained. Warfarin should be maintained attherapeutic levels (PT/INR 2.0–3.0) for best efficacy andsafety. Therapeutic PT/INRs 2.0 are particularly impor-tant at and prior to cardioversion attempts. Aspirin may beused in some low-risk patients with lone atrial fibrillation,no additional risk factors, and age 65 years.New therapies may revolutionize the approach to strokereduction in atrial fibrillation and include thrombin inhibi-tors and, in selected patients, left atrial occlusion tech-niques. However, safety and efficacy, particularly comparedto warfarin, need to be established prior to routine use ofthese treatments.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Percutaneous positioning of closure devices is a well-established treatment of atrial septal defects (ASDs). However, patients who have undergone the procedure are at increased risk for developing atrial fibrillation (AF), and treatment by catheter ablation is underutilized due to the perceived difficulty of obtaining transseptal access in the presence of the closure device.The purpose of this study was to report the acute and long-term results of radiofrequency catheter ablation of AF in patients with ASD closure devices.Thirty-nine patients (age 54 ± 6 years, 72% males) with drug-refractory AF (33% paroxysmal, 51% persistent, 16% long-standing persistent) and ASD closure devices (82% Amplatzer, 18% CardioSEAL) underwent radiofrequency catheter ablation. A double transseptal access guided by intracardiac echocardiography was obtained in all patients.In 35 of 39 patients (90%), the transseptal access was obtained in a portion of the native septum, whereas in 4 of 39 patients (10%), a direct access through the device was required. The latter group had a significantly longer time for achieving the double transseptal access (73.6 ± 1.1 minutes vs. 4.3 ± 0.4 minutes, P.001), longer fluoroscopy time (122 ± 5 minutes vs. 80 ± 8 minutes, P.001), and total procedural time (4.1 ± 0.2 hours vs. 3.1 ± 0.3 hours, P.001). At follow-up of 14 ± 4, months the overall success rate was 77% (85% in paroxysmal AF, 73% in nonparoxysmal AF). Transthoracic contrast-enhanced echocardiography with the Valsalva maneuver, performed between 3 and 6 months after the procedure, failed to detect shunt in all patients.Radiofrequency catheter ablation of AF is feasible, safe, and effective in patients with ASD closure devices. Transseptal access can be obtained in portions of the native septum in the majority of cases. Direct transseptal puncture of the device is feasible and safe but requires longer time for each transseptal access.

2D and 3D TEE evaluation of an early reopening of the LARIAT epicardial left atrial appendage closure device Luigi Di Biase, MD, PhD, FHRS, J. David Burkhardt, MD, FHRS, Douglas N. Gibson, MD, FHRS, Andrea Natale, MD, FHRS From the Texas Cardiac Arrhythmia Institute, St. David’s Medical Center, Austin, Texas, Albert Einstein College of Medicine at Montefiore Hospital, New York, New York, Department of Biomedical Engineering, University of Texas, Austin, Texas, Department of Cardiology, University of Foggia, Foggia, Italy, and Interventional Electrophysiology, Scripps Clinic, San Diego, California.

There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the "stiff left atrial syndrome."The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors.Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified.The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation.After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.

Radiofrequency catheter ablation of atrial fibrillation can be performed under general anesthesia or conscious sedation at the physician's preference.We randomized a series of consecutive patients with paroxysmal atrial fibrillation (AF) undergoing radiofrequency catheter ablation to either general anesthesia or conscious sedation to assess differences in pulmonary vein (PV) reconnection during redo procedures and impact on success rate.A total of 257 consecutive patients with paroxysmal AF undergoing AF ablation were enrolled and randomized to either conscious sedation with fentanyl or midazolam (128 patients, group 1) and general anesthesia (129 patients, group 2). In all patients, a high dosage of isoproterenol up to 30 μg/min was used to disclose PV reconnection or extra PV firings.Baseline clinical characteristics were not significantly different between the 2 groups. At 17 ± 8 month follow-up after the first ablation, 88 (69%) patients in group 1 were free of atrial arrhythmias off all antiarrhythmic drugs (AAD), as compared with 114 (88%) in group 2 (log-rank P.001). All patients with recurrence had a second procedure. At the repeat procedure, 42% (66 of 158) of PVs in group 1 had recovered PV conduction, compared with 19% (11 of 57) in group 2 (P = .003). Compared with group 1, group 2 had a significantly shorter fluoroscopy time (53 ± 9 min vs. 84 ± 21 min, P.001) and procedure time (2.4 ± 1.4 h vs. 3.6 ± 1.1 h, P.001).The use of general anesthesia is associated with higher cure rate with a single procedure, and it seems to reduce the prevalence of PV reconnection observed at the time of repeat ablation.