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Introduction: The optimized ablation index (AI) value for catheter ablation of atrial fibrillation (AF) remains to be defined. We aimed to compare the efficacy and safety of CLOSE protocol and lower AI protocol in paroxysmal AF. Methods and Results: Patients with symptomatic, drug‐resistant paroxysmal AF for first ablation were prospectively enrolled from September 2020 to January 2022. The patients were randomly divided into CLOSE group (AI ≥ 550 for anterior/roof segments and ≥400 for posterior/inferior segments) and lower AI group (AI ≥ 450 for anterior/roof segments and ≥350 for posterior/inferior segments). First‐pass isolation, acute pulmonary vein (PV) reconnections, 1‐year arrhythmia recurrence, and major complications were assessed. Of the 270 enrolled patients, 238 completed 1‐year follow‐up (118 in CLOSE group and 120 in lower AI group). First‐pass isolation in left PVs was higher in CLOSE group (71.2% vs. 53.3%, p =.005). Acute PV reconnections were comparable between groups (9.3% vs. 14.2%, p =.246). At 1 year, 86.4% in CLOSE group versus 81.7% in lower AI group were free from atrial arrhythmia (log rank p =.334). The proportion difference was −4.8% (95% CI: −14.1% to 4.6%), and p =.475 for noninferiority. Stroke occurred in four patients of lower AI group, and no cardiac tamponade, atrioesophageal fistula, major bleeding or death occurred post procedure. Conclusion: For patients with paroxysmal AF and treated by AI‐guided PV ablation, lower AI is not noninferior to CLOSE protocol. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) is well established as a primary treatment for atrial fibrillation (AF). The POLAR ICE study was designed to collect prospective real world data on the safety and effectiveness of the POLARxTM cryoballoon for PVI to treat paroxysmal AF. Methods: POLAR ICE, a prospective, non‐randomized, multicenter (international) registry (NCT04250714), enrolled 399 patients across 19 European centers. Procedural characteristics, such as time to isolation, cryoablations per pulmonary vein (PV), balloon nadir temperature, and occlusion grade were recorded. PVI was confirmed with entrance block testing. Results: Data on 372 de novo PVI procedures (n = 2190 ablations) were collected. Complete PVI was achieved in 96.8% of PVs. Procedure and fluoroscopy times were 68.2 ± 24.6 and 15.6 ± 9.6 min, respectively. Left atrial dwell time was 46.6 ± 18.3 min. Grade 3 or 4 occlusion was achieved in 98.2% of PVs reported and 71.2% of PVs isolation required only a single cryoablation. Of 2190 cryoapplications, 83% had a duration of at least 120 s; nadir temperature of these ablations averaged −56.3 ± 6.5°C. There were 6 phrenic nerve palsy events, 2 of which resolved within 3 months of the procedure. Conclusion: This real‐world usage data on a novel cryoballoon suggests this device is effective, safe, and relatively fast in centers with cryoballoon experience. These data are comparable to prior POLARx reports and in keeping with reported data on other cryoballoons. Future studies should examine the long‐term outcomes and the relationship between biophysical parameters and outcomes for this novel cryoballoon. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for atrial fibrillation (AF) is a common therapeutic strategy for patients with either paroxysmal AF (PAF) or persistent AF (persAF), but long‐term ablation success rates are imperfect. Maintenance of sinus rhythm immediately before ablation with antiarrhythmic drug (AAD) therapy has been associated with improved outcomes in patients undergoing ablation. Amiodarone has superior efficacy relative to other AADs. Whether failure of amiodarone to maintain sinus rhythm before ablation for either PAF or persAF is associated with poor outcomes is unknown. Methods: A total of 307 patients who received amiodarone in a 1‐year window before undergoing catheter ablation for AF were included. Patients were divided into amiodarone success (n = 183) and amiodarone failure (n = 124) groups based on the response to pre‐ablation amiodarone treatment. Analysis of procedural outcomes as a function of response to amiodarone therapy was performed. Patients were followed for at least 12 months postablation, to assess outcomes (adverse events and arrhythmia recurrence). Procedural success was defined by the absence of documented arrhythmia (>30 s) without any antiarrhythmic agents beyond a 90‐day blanking period. Results: Following ablation for either PAF or persAF, freedom from any recurrent atrial arrhythmia at 1 year was 57.7% for the entire cohort. One‐year freedom from recurrent arrhythmia in the amiodarone success group was comparable to that in the amiodarone failure group (55.7% vs. 60.5%; p =.54). Success rates following ablation did not vary by the response to amiodarone when analyzed for PAF or persAF subgroups. Conclusion: Failure to restore and maintain sinus rhythm with amiodarone before ablation for either PAF or persAF is not a predictor of ablation procedural failure. Amiodarone failure alone should not deter practitioners from considering ablation therapy for patients with AF. [ABSTRACT FROM AUTHOR]

Introduction: High-frequency low-tidal-volume (HFLTV) ventilation during radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) has been shown to be superior to standard ventilation (SV) in terms of procedural efficiency, acute and long-term clinical outcomes. Our study aimed to compare ablation lesions characteristics utilizing HFLTV ventilation versus SV during RFCA of PAF., Methods: A retrospective analysis was conducted on patients who underwent pulmonary vein isolation (PVI) for PAF between August 2022 and March 2023, using high-power short-duration ablation. Thirty-five patients underwent RFCA with HFLTV ventilation and were matched with another cohort of 35 patients who underwent RFCA with SV. Parameters including ablation duration, contact force (CF), impedance drop, and ablation index were extracted from the CARTONET database for each ablation lesion., Results: A total of 70 patients were included (HFLTV = 35/2484 lesions, SV = 35/2830 lesions) in the analysis. There were no differences in baseline characteristics between the groups. While targeting the same ablation index, the HFLTV ventilation group demonstrated shorter average ablation duration per lesion (12.3 ± 5.0 vs. 15.4 ± 8.4 s, p < .001), higher average CF (17.0 ± 8.5 vs. 10.5 ± 4.6 g, p < .001), and greater impedance reduction (9.5 ± 4.6 vs. 7.7 ± 4.1 ohms, p < .001). HFLTV ventilation group also demonstrated shorter total procedural time (61.3 ± 25.5 vs. 90.8 ± 22.8 min, p < .001), ablation time (40.5 ± 18.6 vs. 65.8 ± 22.5 min, p < .001), and RF time (15.3 ± 4.8 vs. 22.9 ± 9.7 min, p < .001)., Conclusion: HFLTV ventilation during PVI for PAF was associated with improved ablation lesion parameters and procedural efficiency compared to SV., (© 2024 Wiley Periodicals LLC.)

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., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: Antiarrhythmic drugs (AADs) and catheter ablation are first line treatments of paroxysmal atrial fibrillation (PAF), however, there exists a paucity of data regarding the potential benefit of different catheter ablation technologies versus AADs as an early rhythm strategy. Objective: To assess the safety and efficacy of cryoablation versus radiofrequency ablation (RFA) versus AADs as a first line therapy of PAF. Methods: MEDLINE, Embase, Scopus and CENTRAL were searched to retrieve randomized clinical trials (RCTs) comparing cryoablation, RFA or AADs to one another as first line therapies for atrial fibrillation (AF). The primary outcome was overall freedom from arrhythmia recurrence (AF, atrial flutter [AFL], atrial tachycardia). Secondary outcomes included freedom from symptomatic arrhythmia recurrence, hospitalization, and serious adverse events. A random‐effects Bayesian network meta‐analysis was used to calculate odds ratios (OR) and 95% credible intervals (CrI). Results: Six RCTs (N = 1212) met the inclusion criteria (605 AADs, 365 Cryoablation, and 245 RFA). Compared with AADs, overall recurrence was reduced with RFA (OR: 0.31; 95% CrI: 0.10–0.71) and cryoablation (OR: 0.39; 95% CrI: 0.16–1.00). Comparing ablation (cryoablation and RFA) with AADs in respect to freedom from symptomatic AF recurrence, neither cryoablation (OR: 0.35; 95% CrI: 0.06–1.96) nor RFA (OR: 0.34; 95% CrI: 0.07–1.27) resulted in statistically significant reductions individually compared to AADs, though pooled ablation with both technologies showed lower odds of arrhythmia recurrence (OR: 0.35; 95% CrI: 0.13–0.79). In terms of serious adverse events rates, neither cryoablation (OR: 0.77; 95% CrI: 0.44–1.39) nor RFA (OR: 1.45; 95% CrI: 0.67–3.23) were significantly different to AADs. RFA resulted in a statistically significant reduction in hospitalizations compared to AAD (OR: 0.08; 95% CrI: 0.01–0.99), whereas cryoablation did not (OR: 0.77; 95% CrI: 0.44–1.39). The surface under the cumulative ranking curve showed RFA to be the most effective treatment at reducing overall rates of recurrence, symptomatic recurrence and hospitalizations; whereas cryoablation was most likely to reduce serious adverse events. Conclusion: Cryoablation and RFA are both effective and safe first line therapies for AF compared to AADs, with RFA being the most effective at reducing recurrences. Atrial fibrillation (AF) has been associated with significant morbidity and mortality. Early treatment of AF can decrease recurrences or arrhythmia burden; avoiding, as such, functional and economically debilitating consequences. In this network meta‐analysis, the safety and efficacy of cryoablation, radiofrequency ablation (RFA), and antiarrhythmic drugs (AAD) as initial treatments of paroxysmal AF were compared. The study shows that cryoablation and RFA, employed as the first‐line strategy for the treatment of AF, significantly reduce atrial tachyarrhythmia recurrences compared to AAD without increasing the risk of serious adverse events. [ABSTRACT FROM AUTHOR]

Introduction: Ablation index (AI)‐guided radiofrequency ablation has been increasingly used for the treatment of drug‐resistant paroxysmal atrial fibrillation (AF)，but the optimal AI targets remain to be determined. We aimed to examine the efficacy and safety of catheter ablation guided by moderate AI values but more strict procedural endpoints in patients with paroxysmal AF. Methods: We conducted a retrospective review of a consecutive series of patients who received their first AI‐guided ablation for paroxysmal AF from 2017 to 2018. The standard procedural protocol recommends AI targets as follows: anterior: 400–450; posterior: 280–330; and roof/inferior wall: 380–430. After circumferential pulmonary vein isolation (PVI), we performed bipolar pacing along the ablation line, adenosine triphosphate (ATP)‐provocation, and waited for 30 min to verify PVI. The primary clinical outcome was the rate of freedom from AF recurrence at 12 months. Results: A total of 140 consecutive patients were included. The mean procedure and ablation times were 132.2 ± 30.2 min and 24.2 ± 7.9 min, respectively. The first‐pass isolation and final isolation rates were documented in 49.3% and in 100% of the patients, respectively. At 12 months, single‐procedure freedom from atrial tachyarrhythmias was observed in 92.1% of patients. No major procedure‐related complications were encountered. Conclusions: Moderate AI‐guided catheter ablation is highly effective for the treatment of drug‐refractory paroxysmal AF in real‐world settings. Over 90% of patients achieved single‐procedure arrhythmia‐free survival at 1 year. The outcome was obtained without major complications and the procedure involved relatively short procedure and ablation times. [ABSTRACT FROM AUTHOR]

Introduction: Contact force (CF) guided ablation of paroxysmal atrial fibrillation (PAF) with stable catheter‐tissue contact optimizes clinical success and may increase an operator's ability to achieve pulmonary vein isolation (PVI) in a single encirclement. First pass PVI reduces procedure time but the relationship with long term clinical success is not well understood. This study evaluated patient characteristics and procedural details as predictors of 1‐year clinical success after PAF ablation, including first pass isolation. Methods: Consecutive de novo PAF ablations were performed with a porous tip CF catheter in 2017 and 2018. All ablations used wide‐area circumferential ablation, with first pass isolation captured separately for the left and right pulmonary veins (PVs). CF was held between 10 and 20 g and the catheter was moved every 10–20 s. Radiofrequency energy was set at 40–45 W throughout the atrium. Patient characteristics and procedural details were tested for association with clinical success, defined as freedom from recurrent atrial tachyarrhythmia through 1 year. Results: A total of 404 patients were included in the study. Clinical success at 1 year was 86.6%. Achieving first pass isolation on at least one ipsilateral PV pair was the most significant predictor of clinical success (p =.0126). After controlling for first pass isolation, only recurrence within the 90‐day blanking period was independently predictive (p =.0015). First pass isolation was not associated with early recurrence (p =.2454). Conclusion: In a real‐world setting, first pass isolation was highly predictive of 12‐month clinical success after CF‐guided ablation in a PAF population. [ABSTRACT FROM AUTHOR]

Background: The success rate after cryoballoon ablation (CB‐A) performed for paroxysmal atrial fibrillation (PAF) might be overestimated by traditional noninvasive monitoring techniques. The purpose of this study was to evaluate the mid‐term outcome of CB‐A in patients with PAF implanted with an implantable loop recorder (ILR) after the procedure. Methods: Between January 2017 and March 2019, all patients who underwent CB‐A for PAF and who were subsequently implanted with an ILR were retrospectively included. All devices were equipped with remote monitoring. All ILR‐documented atrial tachycardia (AT) or AF episodes ≥ 6 min were considered as recurrence; both true and false episodes were collected. A 3‐month post‐procedural blanking period (BP) was applied. Results: A total of 102 patients (77 men, mean age 60.6 ± 9.6 years) who underwent pulmonary vein isolation (PVI) by CB‐A were included; mean time from first diagnosis of AF to PVI was 51.5 ± 46.9 months. Mean follow‐up was 29.3 ± 8.1 months; at 12‐month follow‐up, the success rate was 65.7%, while at 2‐year follow‐up, freedom from AT/AF recurrences was achieved in 59.3% of the patients. In the follow‐up, a total of 4987 ECG strips were analyzed; true‐positive episodes were confirmed in 2026 cases (40.6%), whereas 2961 episodes (59.4%) were considered false‐positive. Conclusion: In patients with PAF implanted with an ILR, CB‐A results in freedom from any AT/AF recurrence in 65.7% of patients at 12‐month follow‐up and in 59.3% of patients when evaluated at 2‐year. Careful adjudication of all ILR‐documented AF episodes is required to avoid misdiagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Given that few studies investigated the efficacy of catheter ablation (CA) in patients with paroxysmal atrial fibrillation (AF) and atrial septal defect (ASD), this study evaluated its effectiveness in patients with paroxysmal AF and ASD. Methods and Results: Of the 216 patients who underwent ASD device closure at two hospitals, 36 patients had paroxysmal AF. After April 2012, CA for AF was performed before ASD device closure (ASD‐CA group; n = 20). The ASD‐CA group had a significantly higher AF‐free survival rate after ASD device closure compared to patients without CA for AF before ASD device closure (ASD‐non‐CA group; n = 16) (ASD‐CA group: 2 patients vs. ASD‐non‐CA group: 9 patients; follow‐up period: 4.2 ± 2.5 years; log‐rank p =.01). In addition, the AF‐free survival rates were similar between the ASD‐CA group and 80 paroxysmal AF patients who underwent CA without any detectable structural heart disease (non‐SHD‐CA group). The two groups were matched by propensity scores for age, sex, and left atrium dimension (ASD‐CA group: 2 patients vs. non‐SHD‐CA group: 5 patients; follow‐up period: 3.3 ± 1.8 years; log‐rank p =.28). Conclusion: CA for AF before ASD device closure might be an effective treatment option for patients with paroxysmal AF and ASD. [ABSTRACT FROM AUTHOR]

Introduction: Screening of coexistent typical atrial flutter (AFL) in patients with atrial fibrillation (AF) is sometimes challenging. This study investigated whether a prolonged right atrial conduction time (RACT) estimated by tissue Doppler imaging (TDI) predicts patients with concomitant AFL and AF. Methods and Results: We retrospectively analyzed 398 patients (mean age: 61.6 years, 73.4% men) undergoing catheter ablation of paroxysmal AF. The patients were classified into two groups according to whether they had evidence of AFL (N = 122, 30.7%) determined by a clinical observation (N = 68), induction during procedures (N = 33), or AFL recurrence after procedures (N = 21) or not (N = 276, 69.3%). The preoperative RACT, defined as a longer duration between the onset of the P‐wave and peak A′‐wave on the right atrial lateral wall or septal wall, and total atrial conduction time (TACT), defined as the same time duration on the left atrial lateral wall, were evaluated in all patients. Patients with evidence of AFL had a significantly longer RACT than those without AFL (p <.001). A multiple logistic regression and receiver operator characteristics curve analysis revealed the ratio of the RACT and TACT (RACT/TACT) was the independent and most superior accurate cofounder for predicting evidence of AFL (area under the curve: 0.867). When adding a discriminator of an RACT/TACT ≧ 93% into the conventional screening, 98.4% of the patients with evidence of AFL were estimated to be treated during the initial procedures. Conclusion: The estimated RACT/TACT using the TDI may be useful for predicting patients with concomitant AFL in patients with AF. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to compare touch‐up ablation (TUA) rates and pulmonary vein isolation (PVI) durability of hot balloon ablation (HBA) and cryoballoon ablation (CBA) in paroxysmal atrial fibrillation (PAF) patients. Methods: In total, 137 PAF patients were enrolled in the study. Among them, 59 underwent two HBA procedures at 6‐month intervals and 78 patients underwent two CBA sessions, both regardless of atrial fibrillation recurrence. Propensity score matching was performed to estimate similar patient characteristics between the HBA and CBA groups. Results: Each group comprised of 46 matched patients for comparison. The TUA rate at the first session was higher for HBA (49 of 184 PVs) than for CBA (20 PVs) (P =.01), with the highest incidence at the left superior pulmonary vein (LSPV). The rates of PVI durability at the second session performed 7 months later were similar between HBA (168 of 184 PVs) and CBA (162 PVs) groups. The PVI durability rate at the TUA sites of the first session was higher for HBA than for CBA (41 of 49 PVs vs 10 PVs, respectively; P =.01). Fifty percent of the patients underwent HBA at 73°C for the LSPV. HBA performed at 73°C yielded a lower TUA rate than that at 70°C (16 of 23 PVs vs 7 of 23 PVs; P =.008). Conclusions: While PVI durability was similar between HBA and CBA, the TUA rate was higher for HBA than for CBA, especially on the LSPV. For LSPV, HBA at a balloon temperature of 73°C may reduce the TUA rate. [ABSTRACT FROM AUTHOR]

Backgrounds: Several studies have shown the serum high sensitive cardiac troponin I (hs‐TnI) a biomarker of myocardium injury, and C‐reactive protein (CRP), a biomarker of inflammation, are associated with worse cardiovascular outcomes. We evaluated the relationship between the hs‐TnI level in patients with paroxysmal atrial fibrillation (PAF) after pulmonary vein isolation (PVI) and atrial fibrillation (AF) recurrence. Methods and Results: We enrolled 263 consecutive PAF patients who underwent PVI from May 2017 to April 2018. We investigated the difference in the relationship between the myocardial injury marker (serum hs‐TnI), inflammatory marker (CRP, white blood cell) at 36 to 48 hours after the PVI, and early or late recurrence of AF (ERAF; <3 months and LRAF; from 3 months to 1 year) between the radiofrequency ablation group (R group) and cryoballoon ablation group (C group). The R group consisted of 147 patients and the C groups consisted of 116 patients. The serum hs‐TnI level in R group was significantly lower than in the C group (2.33 vs 5.08 ng/mL; P <.001), while the CRP was significantly higher in the R group than C group (2.02 vs 1.10 mg/dL; P <.001). The incidences of an ERAF/LRAF were similar between the two groups. Conclusion: Cryoballoon ablation may cause more myocardial injury than radiofrequency catheter ablation, on the contrary, radiofrequency catheter ablation, may cause more inflammation than cryoballoon ablation. However, these phenomena may not affect the recurrence of AF after the PVI in patient with PAF. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) using cryoballoon is effective for patients with paroxysmal atrial fibrillation (PAF); however, few reports have evaluated the non‐pulmonary vein (PV) foci after cryoballoon ablation. We aimed to evaluate the characteristics of non‐PV foci and predictors of atrial fibrillation (AF) recurrence after cryoballoon ablation. Methods and Results: This was a single‐center retrospective study of 647 patients with PAF who underwent initial PVI using a second‐generation cryoballoon. After PVI, all patients underwent high‐dose isoproterenol infusion to assess the existence of non‐PV foci. Non‐PV foci were observed in 211 patients (32.6%), which were most frequently observed in the superior vena cava. Higher age (odds ratio [OR] = 1.02; 95% confidence interval [CI] = 1.00‐1.04; P =.025), female sex (OR = 1.65; 95% CI = 1.13‐2.41; P =.009), and lower body mass index (OR = 0.95; 95% CI = 0.89‐1.00; P =.049) were significantly associated with non‐PV foci. The existence of non‐PV foci was an independent predictor of AF recurrence (Hazard's ratio = 1.70; 95% CI = 1.12‐2.60; P =.014). When non‐PV foci were mappable and successfully ablated, patients with non‐PV foci showed similar outcomes with those without non‐PV foci (1‐year AF‐free survival rates of 88.5% vs 91.5%; P =.338). Conversely, when we failed to detect and eliminate non‐PV foci because they had multiple origins and were not consistently inducible (multichanging non‐PV foci), the 1‐year AF‐free survival rate was 56.4% even after substrate modification. Conclusion: Non‐PV foci were observed in one‐third of patients with PAF after cryoballoon ablation and were associated with AF recurrence. Catheter ablation for non‐PV foci was effective when they were mappable; however, multichanging non‐PV foci were associated with worse prognosis. [ABSTRACT FROM AUTHOR]

Background: We present a new, easily applicable approach for the guidance of cryoballoon (CB) pulmonary vein isolation (PVI) procedures that use the combination of a 3D‐mapping system image integration module and computed tomographic (CT)–derived anatomy. The aim of this retrospective, nonrandomized study was to investigate: (a) an alternative use for an established radiofrequency image integration module for cryo procedures; (b) a guidance technology for cryo PVI based on integrated CT anatomy; and (c) its clinical impact. Methods and results: CT left atrium–angiography was performed in 50 consecutive patients before a CB PVI procedure, and a 3D reconstruction of the cardiac anatomy was segmented. A total of 25 patients were treated using conventional fluoroscopy; 25 patients were treated using the 3D image integration technique. In the image integration group, the CARTO3 UNIVU (Biosense Webster) module was used for image integration of 3D anatomy and fluoroscopic imaging. Transseptal puncture and cryo PVI were guided by 3D‐overlay imaging. Procedures were feasible without complications in all patients and cryo PVI procedures were successfully guided using the image integration technique. The intraprocedural time needed to perform image integration was 37 ± 10 seconds. Fluoroscopy time was 31.7 ± 11.7 minutes in the conventional group and 20.1 ± 7.9 minutes in the image integration group (P < .001), procedure time was 116.3 ± 29.0 minutes in the conventional group vs 101.2 ± 20.9 minutes in the 3D group (P = .04). Conclusion: 3D‐overlay guidance of CB PVI is feasible, safe, and applicable in real time with minimal effort. It may significantly reduce radiation exposure by introducing 3D information, known from electroanatomic mapping systems, into cryo PVI procedures. [ABSTRACT FROM AUTHOR]

Objective: We tested whether ablation methodology and study design can explain the varying outcomes in terms of atrial fibrillation (AF)‐free survival at 1 year. Background: There have been numerous paroxysmal AF ablation trials, which are heterogeneous in their use of different ablation techniques and study design. A useful approach to understanding how these factors influence outcome is to dismantle the trials into individual arms and reconstitute them as a large meta‐regression. Methods: Data were collected from 66 studies (6941 patients). With freedom from AF as the dependent variable, we performed meta‐regression using the individual study arm as the unit. Results: Success rates did not change regardless of the technique used to produce pulmonary vein isolation (PVI). Neither was adjunctive lesion sets associated with any improvement in outcome. Studies that included more males and fewer hypertensive patients were found more likely to report better outcomes. The electrocardiography method selected to assess outcome also plays an important role. Outcomes were worse in studies that used regular telemonitoring (by 23%; P < 0.001) or in patients who had implantable loop recorders (by 21%; P = 0.006), rather than those with the less thorough periodic Holter monitoring. Conclusions: Outcomes of AF ablation studies involving PVI are not affected by the technologies used to produce PVI. Neither do adjunctive lesion sets change the outcome. Achieving high success rates in these studies appears to be dependent more on patient mix and on the thoroughness of AF detection protocols. These should be carefully considered when quoting the success rates of AF ablation procedures that are derived from such studies. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: Left atrium (LA) systolic dysfunction is observed in the early stages of atrial fibrillation (AF) prior to LA anatomical change. We investigated whether LA systolic dysfunction predicts recurrent AF after catheter ablation (CA) in patients with paroxysmal AF. Methods and results: We studied 106 patients who underwent CA for paroxysmal AF. LA systolic function was assessed with the LA emptying volume = Maximum LA volume (LAVmax) – Minimum LA volume (LAVmin), LA emptying fraction = [(LAVmax – LAVmin)/LAVmax] × 100, and LA ejection force calculated with Manning's method [LA ejection force = (0.5 × ρ × mitral valve area × A2)], where ρ is the blood density and A is the late‐diastolic mitral inflow velocity. Recurrent AF was detected in 35/106 (33%) during 14.6 ± 9.1 months. Univariate analysis revealed reduced LA ejection force, decreased LA emptying fraction, larger LA diameter, and elevated brain natriuretic peptide as significant variables. On multivariate analysis, reduced LA ejection force and larger LA diameter were independently associated with recurrent AF. Moreover, patients with reduced LA ejection force and larger LA diameter had a higher risk of recurrent AF than preserved LA ejection force (log‐rank P = 0.0004). Conclusions: Reduced LA ejection force and larger LA diameter were associated with poor outcome after CA for paroxysmal AF, and could be a new index to predict recurrent AF. [ABSTRACT FROM AUTHOR]

Background and objective Contact force (CF) sensing is a novel technology used for catheter ablation of atrial fibrillation (AF). We compared the single procedure success of CF-guided pulmonary vein isolation (PVI) with that of non-CF guided PVI during a 3-year (1,095 days) follow up period and analyzed the pattern of pulmonary vein (PV) reconnection. Methods A cohort of 167 subjects (68 CF vs. 99 non-CF) with paroxysmal AF were included in the study. Atrial arrhythmia (AA) recurrence was defined as documented AF, atrial flutter, or atrial tachycardia lasting >30 seconds and occurring after 90 days. Results Subjects in the CF group showed a statistically nonsignificant improvement in AA free survival compared to those in the non-CF group (66.2% vs. 51.5%; P value: 0.06). A greater propensity for reconnection was noted around the right-sided PVs compared to left-sided PVs related in both catheter ablation groups. For example, in the CF group 36% of right-sided segments reconnected compared to 16% of left-sided segments (P value <0.01). Conclusions A greater propensity for reconnection was noted around the right sided PV segments in both the CF and non-CF groups. The explanation for this finding was related to greater catheter instability around the right sided veins. Further research is needed to explore the utility of a 'real-time' composite indicator that includes RF energy, CF and catheter stability in predicting transmural lesion formation during catheter ablation. [ABSTRACT FROM AUTHOR]

Introduction Pulmonary vein isolation (PVI) using a cryoballoon (CB) is a useful tool for treating atrial fibrillation (AF); however, the clinical efficacy of the CB has never been fully investigated in patients with a left common pulmonary vein (LCPV). Methods and results Three hundred twenty-four consecutive paroxysmal AF patients underwent PVI with a CB. Three-dimensional computed tomography was performed in all patients before the ablation. The clinical outcomes of the AF ablation between patients with (Group A) and without an LCPV (Group B) were compared. An LCPV was observed in 27 (8%) patients. There were no significant differences in the procedure time (149 ± 45 min vs. 143 ± 40 min, respectively; P = 0.42) and percentage needing touch up ablation between the 2 groups (26% vs. 20%, respectively; P = 0.45). At a mean follow-up of 454 ± 195 days, 282 of 324 (87%) patients were free from any atrial tachyarrhythmias (ATs) after a single procedure. Twenty out of 27 (74%) Group A patients and 262 of 297 (88%) Group B patients were free from ATs (15-month Kaplan-Meier event free rate estimates, 77% and 89%, respectively; P = 0.02). A multivariate analysis identified the presence of an LCPV and the left atrial diameter as reliable predictors of recurrent ATs. Conclusions The long-term clinical outcomes of ablation of AF with the CB was worse in patients with an LCPV than in those without. The presence of an LCPV and the LA size seemed to be reliable predictors of a worse outcome. [ABSTRACT FROM AUTHOR]

Early and Late Recurrences in AF Cryoablation Introduction Recurrences within the blanking period (early recurrences) are common after atrial fibrillation (AF) ablation by pulmonary vein isolation (PVI), but their clinical significance is still controversial. We aimed at evaluating the significance of within-blanking recurrences at 12-month follow-up after cryoballoon (CB) PVI, and to assess the real procedural success rate by continuous monitoring of cardiac rhythm. Methods and Results Sixty consecutive AF patients (34 paroxysmal, 56.7%) underwent their first CB-PVI at one Italian center (May 2013 to April 2015), and subsequent implantation of an implantable loop recorder (ILR). Overall, 12-month success rate after the blanking period was 55%. The shortest detected event was 7 minutes long. Late recurrences were more frequent in non-paroxysmal (19/26, 73.1%) than in paroxysmal AF (8/34, 23.5%; P <0.001). Early recurrences occurred in 17 (28.3%) patients, with 14 also having late recurrences (82.3%), while only 13 out of 43 (30.2%) without within-blanking recurrences experienced post-blanking events (P <0.001). Overall, early recurrences showed 51.8% sensitivity (95% CI 31.9-71.3%) and 90.9% specificity (95% CI 75.7-98.1%) for later recurrences, with 82.3% (95% CI 56.6-96.2%) positive and 69.8% (95% CI 53.9-82.8%) negative predictive value. The positive likelihood ratio was 5.7 (95% CI 1.8-17.8). At multivariable analysis, non-paroxysmal AF (HR: 3.113; 95% CI 1.309-7.403; P = 0.010) and within-blanking recurrences (HR: 3.453; 95% CI 1.544-7.722; P = 0.003) were independent predictors of post-blanking AT/AF. Conclusion CB-PVI for paroxysmal AF shows a 12-month success rate of 76.5% after one single procedure, as assessed by continuous cardiac rhythm monitoring. Within-blanking recurrences predict the ablation failure in more than 80% of patients. [ABSTRACT FROM AUTHOR]

Surface ECG f Wave Analysis X Introduction Dominant frequency (DF) analysis of electrocardiograms (ECGs) from patients with paroxysmal (PAF) and persistent (PeAF) atrial fibrillation has identified higher DFs in PeAF. We therefore hypothesized that among patients initially presenting to the emergency department (ED) with new onset AF, surface ECG features could differentiate PeAF from PAF. Methods and Results Initial 12-lead ECGs from patients presenting to the ED with a first episode of symptomatic AF were analyzed. Following QRS-T subtraction, fast Fourier transform (FFT) analysis of the AF fibrillatory waves was performed to measure DF and organization index (OI). Median DF of all leads and the DF in the lead with maximum OI were determined. Maximum f wave amplitude and vector magnitudes were measured. One hundred sixty-one patients (age 59 ± 16 years, 68% men) were included in this analysis, of whom 96 (58%) spontaneously converted to sinus rhythm within 7 days (PAF group). The remaining 65 patients underwent cardioversion or remained in AF (PeAF group). ECG features (DF, OI, f wave amplitude, and vector magnitude) did not differ among PAF and PeAF patients. Conclusions ECG features (DF, OI, amplitude, vector magnitude) do not differ among patients with PAF versus PeAF when the ECGs are obtained at the initial onset of symptoms. Thus, prior data showing higher DF in PeAF likely reflect electrophysiologic remodeling rather than a marker for any specific type of AF or extent of underlying substrate. [ABSTRACT FROM AUTHOR]

Empiric Thoracic Vein Isolation Introduction The guidelines suggest that an adjuvant substrate modification in addition to pulmonary vein isolation (PVI) may be needed for persistent atrial fibrillation (PerAF) assuming that catheter ablation is less successful for PerAF than paroxysmal AF (PAF). To revisit the above assumption, we compared the outcome of the same catheter ablation strategy between PAF and PerAF. Methods and Results Two hundred and thirty-three consecutive patients (mean age 60 ± 10 years, 53 PerAF and 8 long-lasting PerAF) without structural heart disease underwent catheter ablation of AF by the same strategy using an empiric thoracic vein isolation (a wide circumferential PVI plus empiric superior vena cava isolation) as a major part of the strategy without any adjuvant substrate modification. The duration of AF in the patients with PerAF was 6 ± 4 months. During 25 ± 10 months of follow-up after single procedures, 71 (30%) patients had atrial tachyarrhythmia recurrences without antiarrhythmic drugs. A Kaplan-Meier analysis of the recurrence-free survival rate after a single procedure and after repeat procedures revealed no significant difference between the patients with PAF and those with PerAF (log-rank, P = 0.38 and P = 0.27, respectively). A Cox regression multivariate analysis of the variables including the age, gender, PerAF, body mass index, left ventricular ejection fraction, and left atrial volume index demonstrated that none of the variables were an independent predictor of an atrial tachyarrhythmia recurrence after a single ablation procedure. Conclusion In patients without underlying heart disease, the procedural outcome of an empiric thoracic vein isolation is comparable for PAF and PerAF. [ABSTRACT FROM AUTHOR]

Single 3 vs. Double 4 Strategy in CB ablation Introduction Second-generation cryoballoon (CB-Adv) ablation is highly effective in achieving pulmonary vein isolation (PVI) with promising mid-term clinical outcome. However, the ideal freezing strategy is still under debate. The aim of this study was to assess the efficacy of a single 3-minute approach compared to the conventional 4-minute plus bonus application using CB-Adv. Methods and Results One hundred and sixty patients (67% male; mean age 58.0 ± 13.3 years) underwent PVI using CB-Adv for paroxysmal atrial fibrillation (PAF). Among 160 patients, 80 received a single 3-minute approach (3-mns group), while the remaining 80 conventional 4-minute plus bonus-freeze (4-mns group). Mean procedure and fluoroscopy times were 90.6 ± 15.8 and 18.3 ± 6.9 in the 4-mns group, 75.2 ± 17.1 and 13.5 ± 8.7 in the 3-mns group (P < 0.001, respectively). First-freeze isolation rate was 91.6% in the 4- versus 90.6% in the 3-mns group (P = 0.78). Persistent phrenic nerve palsy (PNP) occurred in 6/80 (3.5%) in the 4-mns group and 4/80 in the 3-mns group (P = 0.75). The overall freedom from ATas 2 years after the procedure was 78.1% (125/160): 77.5% (62/80 patients) in the 3-mns and 78.8% (63/80 patients) in the 4-mns group (P = 0.82). In multivariate analysis, time to PVI and nadir temperature independently predicted ATa recurrences (P < 0.001). Conclusions CB-Adv ablation for PAF is highly effective, resulting in 78% 2-year freedom from arrhythmic recurrences. A 'single 3-minute strategy' showed equal efficacy as compared to the conventional 4-minute plus bonus freeze approach at 2-year follow-up, providing shorter procedure and fluoroscopy time. Nadir temperature and time to PVI were predictors of arrhythmic recurrences. 'Bonus-freeze' strategy might be unnecessary. [ABSTRACT FROM AUTHOR]

Low-Power Ablation of AF Using the nMARQ Catheter Introduction The circular irrigated decapolar nMARQ ablation catheter designed for treating atrial fibrillation (AF) has recently been recalled following two deaths due to esoatrial fistula. Injury to the esophagus has been previously reported in up to 50% of patients using 20-25 W unipolar radiofrequency (RF) energy. Low power of 15 W has been proposed to prevent this complication, but the efficacy of this strategy to avoid AF recurrence is unknown. Methods and Results Consecutive patients with drug-refractory, symptomatic AF were included. Under electroanatomical navigation, the nMARQ catheter was used to isolate all PVs by applying 15 W of unipolar RF simultaneously from up to 10 poles during 40 seconds. Multiple applications were used for each vein, until isolation was achieved. Follow-up was performed after a 2-month blanking period. A total of 50 patients (37 males, age 58 ± 10 years) were included. All PVs were acutely isolated without requiring touch-up by conventional ablation catheters. Pericardial effusion occurred in two patients, of whom one required periocardiocentesis. Right phrenic nerve palsy occurred in another patient, which partially resolved. There were no cases of esophageal fistula or stroke. After a follow-up of 15±4 months, AF recurred in 27/50 (54%) patients. Conclusion The recurrence rate of AF with 15 W unipolar applications is high. Despite use of low power, complications such as pericardial effusion and phrenic nerve palsy may occur. [ABSTRACT FROM AUTHOR]

Primary Persistent AF. Introduction: Persistent atrial fibrillation (persAF) can occur either as a sustained arrhythmia that has progressed from initially paroxysmal AF or as primary persAF without a history of any spontaneously terminated episode. There is a paucity of data differentiating between the 2 different persAF entities. Thus, we prospectively evaluated baseline characteristics, electrophysiological features, and ablation outcome in these 2 patient cohorts. Methods and results: A total number of 154 consecutive persAF patients (63 ± 10 years, f = 42, longstanding persAF = 60) were characterized in terms of having primary persAF (P-persAF group) or persAF that secondarily progressed from paroxysmal AF (S-persAF group). All patients underwent de novo catheter ablation using the stepwise approach. PersAF entities were characterized by detailed patient history, sequential Holter monitoring, and reports of documented modes of AF conversion, respectively. The P-persAF group had a higher number of young patients (<50 years), a shorter AF history, and a higher number of congestive heart failure. The HATCH score did not differ between the groups. Procedural AF termination rate was significantly higher in S-persAF than in P-persAF patients (n = 55 [81%] vs. n = 58 [68%], P = 0.043). At 1-year follow-up, the arrhythmia-free survival after a single procedure was significantly lower in patients with P-persAF (26% vs. 43%, P = 0.016). Categorization to P-persAF was the strongest independent predictor of arrhythmia recurrence. Conclusions: P-persAF seems to be a specific arrhythmia entity that is associated with a lower AFtermination rate and a worse outcome after catheter ablation as compared to S-persAF. [ABSTRACT FROM AUTHOR]

Loss of Pace Capture and Dormant Conduction in PVI Introduction Permanent pulmonary vein isolation (PVI) remains an essential goal of ablation therapy in patients with atrial fibrillation. Aim of this study was the intraindividual comparison of unexcitability to pacing along the ablation line versus dormant conduction (DC) as additional procedural endpoints. Methods A total of 58 patients with paroxysmal atrial fibrillation (PAF) underwent PVI by circumferential ablation of ipsilateral pulmonary veins (PVs), followed by testing for DC by adenosine administration. Irrespective of the presence of DC, pacing along the ablation line for left atrium capture was performed and additional radio frequency energy applied if necessary. PVs with initial DC were retested after achieving unexcitability. Results PVI was achieved in 224 of 224 PVs. In 33 of 224 PVs (15%) DC was revealed. At 92 of 112 ablation lines (82%) sites of excitability were found. Three (9%) of the initial 33 PVs with DC showed further DC after achieving unexcitability at repeated testing. Thirty-two of 33 assumed areas of unmasked PV-LA reconduction as revealed by DC-testing showed a corresponding site of excitability on the ablation line. After a follow-up of 11.6 ± 3.4 months 79% of patients were free of arrhythmia. Conclusions Pacing for unexcitability can safely identify potential sites of DC and even sites that would have not been detected by testing for DC. Unexcitability, therefore, serves as a suitable and safe procedural endpoint not only for patients with contraindications to adenosine administration. Our data suggest that adenosine may be expendable when achieving unexcitability along the ablation line. [ABSTRACT FROM AUTHOR]

Atrioesophageal Fistula Complicating Cryoballoon Pulmonary Although atrioesophageal fistula (AEF) formation is a well known, albeit rare, catastrophic complication of atrial fibrillation radiofrequency ablation procedures, there are less data regarding this complication using the cryoballoon technique. We report on 3 cases of AEF as a complication of cryoballoon pulmonary vein isolation at 3 different institutions with 2 different generations of cryoballoons. [ABSTRACT FROM AUTHOR]

Electromechanical Interval and Paroxysmal Atrial Fibrillation. Introduction: It is difficult to discriminate patients with and without paroxysmal atrial fibrillation (PAF). The atrial electromechanical interval determined by the transthoracic echocardiogram is demonstrated to be a predictor of new onset AF. The aim of our study was to investigate whether the electromechanical interval is a useful parameter to identify patients with PAF. Methods and Results: A total of 297 patients (PAF group = 103; control group = 194) with mean age of 59.4 ± 12.4 years were enrolled. The electromechanical interval (PA-PDI) defined as the time interval from the initiation of the P-wave deflection to the peak of the mitral inflow A wave on the pulse-wave Doppler imaging was measured for every patient. Patients with PAF had significantly longer PA-PDI intervals compared with that of patients without it (152.7 ± 13.8 ms vs 133.4 ± 16.8 ms). The area under ROC curve based on the PA-PDI interval to diagnose PAF was 0.803 (95% confidence interval = 0.755-0.851, P < 0.001). At the cut-off value of 142 ms, the sensitivity and specificity in identifying PAF were 77.7% and 80.1%, respectively. In the PAF group, the PA-PDI interval was closely associated with the CHADS2 score and inversely related with the peak velocity of left atrial appendage. Conclusions: The PA-PDI interval may be a useful parameter to identify patients with PAF. Further studies are necessary to evaluate the usefulness of PA-PDI intervals in diagnosing PAF in addition to the current methods and tools. (J Cardiovasc Electrophysiol, Vol. 22, pp. 1325-1330, December 2011) [ABSTRACT FROM AUTHOR]

Introduction: Ablation of pulmonary veins (PV) is an established therapeutic option for patients with symptomatic drug-refractory paroxysmal atrial fibrillation (AF). Radiofrequency (RF) is currently the most widespread energy source for PV ablation. Cryothermal energy applied with a cryoballoon technique as an alternative has recently evolved. Methods and Results: In a case-control setting, we compared 20 patients with paroxysmal AF who underwent their first PV ablation with the cryoballoon technique to 20 matched patients with conventional RF ablation. In the case of persistent electrical potentials after cryoballoon ablation, it was combined with ablation with a conventional cryocatheter. All patients performed daily event recording for 3 months after ablation procedure. Ablation parameters and success rate after 3 and 6 months were compared. In the cryoballoon group, the overall success rate was 55% (50% in the cryoballoon only group [14 patients] and 66% in the combination group [6 patients]), as opposed to the RF group with 45%. AF episode burden was lower after cryoballoon ablation. There was no significant difference between cryoballoon and RF ablation regarding procedure parameters. In the cryoballoon group, 3 phrenic nerve palsies occurred using the 23 mm balloon that resolved spontaneously. Conclusion: PV ablation with the cryoballoon technique is feasible and seems to have a similar success rate in comparison to RF ablation. Procedure- and fluoroscopy duration are not longer than in conventional RF ablation. [ABSTRACT FROM AUTHOR]

Introduction: Atrial electromechanical dysfunction might contribute to the development of atrial fibrillation (AF) in patients with sinus node disease (SND). The aim of this study was to investigate the prevalence and impact of atrial mechanical dyssynchrony on atrial function in SND patients with or without paroxysmal AF. Methods: We performed echocardiographic examination with tissue Doppler imaging in 30 SND patients with (n = 11) or without (n = 19) paroxysmal AF who received dual-chamber pacemakers. Tissue Doppler indexes included atrial contraction velocities (Va) and timing events (Ta) were measured at midleft atrial (LA) and right atrial (RA) wall. Intraatrial synchronicity was defined by the standard deviation and maximum time delay of Ta among 6 segments of LA (septal/lateral/inferior/anterior/posterior/anterospetal). Interatrial synchronicity was defined by time delay between Ta from RA and LA free wall. Results: There were no differences in age, P-wave duration, left ventricular ejection fraction, LA volume, and ejection fraction between with or without AF. Patients with paroxysmal AF had lower mitral inflow A velocity (70 ± 19 vs 91 ± 17 cm/s, P = 0.005), LA active empting fraction (24 ± 14 vs 36 ± 13%, P = 0.027), mean Va of LA (2.6 ± 0.9 vs 3.4 ± 0.9 cm/s, P = 0.028), and greater interatrial synchronicity (33 ± 25 vs 12 ± 19 ms, P = 0.022) than those without AF. Furthermore, a lower mitral inflow A velocity (Odd ratio [OR]= 1.12, 95% Confidence interval [CI] 1.01–1.24, P = 0.025) and prolonged interatrial dyssynchrony (OR = 1.08, 95% CI 1.01–1.16, P = 0.020 ) were independent predictors for the presence of AF in SND patients. Conclusion: SND patients with paroxysmal AF had reduced regional and global active LA mechanical contraction and increased interatrial dyssychrony as compared with those without AF. These findings suggest that abnormal atrial electromechanical properties are associated with AF in SND patients. [ABSTRACT FROM AUTHOR]

Introduction: Increasing evidence suggests that high-frequency excitation in the pulmonary vein (PV) plays a dominant role in the maintenance of paroxysmal atrial fibrillation (AF). However, in a certain population of patients, AF remains inducible after PV isolation (PVI). We sought to clarify whether dominant frequency (DF) analysis of atriopulmonary electrograms can predict paroxysmal AF maintained by non-PV sources. Methods and Results: Sixty-one patients with paroxysmal AF (aged 59 ± 12 years) were studied. Before PVI, bipolar electrograms during AF were recorded simultaneously from three PV ostia, the coronary sinus (CS), and the septum and free wall of the right atrium (RA). DF was obtained by fast Fourier transform (FFT) analysis. AF was rendered noninducible after PVI in 39 of the 61 patients (noninducible group), but was still inducible in the remaining 22 (inducible group). Among the six recording sites, the highest DF was documented in the PV in all of the patients in the noninducible group; the maximum DF among the three PVs (PV-DFmax) was higher than that among the CS and two RA sites (atrial DFmax; 7.2 ± 1.0 Hz vs 5.8 ± 0.7 Hz, P < 0.0001). In contrast, the highest DF was documented in the CS or RA in 45.5% of the patients in the inducible group; PV-DFmax was comparable with atrial DFmax (6.6 ± 0.8 Hz vs 6.6 ± 0.6 Hz). AF inducibility after PVI was predicted by a PV-to-atrial DFmax gradient of <0.5 Hz, with a sensitivity of 90.9% and a specificity of 89.7%. Conclusion: Paroxysmal AF maintained by non-PV sources can be predicted by the PV-to-atrial DF gradient. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) is an established treatment for paroxysmal atrial fibrillation (AF). The ablation of complex fractionated atrial electrograms (CFAE) has emerged as a novel treatment approach. We sought to evaluate the additional effect of CFAE ablation to PVI in paroxysmal AF. Methods and Results: Ninety-eight patients with paroxysmal AF (57 ± 10 years, 74 male) were randomized to the PVI (n = 48) or PVI + CFAE group (n = 50). After PVI, CFAE ablation was performed in patients with inducible AF in the PVI + CFAE group. The primary endpoint was combined objective (7-day Holter ECG) and subjective (symptoms) freedom of atrial tachyarrhythmia 3 months after ablation. Long-term follow-up (19 ± 8 months) was available in 94 of 98 patients. CFAE ablation was performed in 30 of 50 patients of the PVI + CFAE group. After 3 months, 36 of 48 patients (75%) in the PVI group and 38 of 50 patients (76%) in the PVI + CFAE group were in stable sinus rhythm (P = NS). During long-term follow-up (19 ± 8 months), 34 of 46 patients (74%) in the PVI group and 40 of 48 patients (83%) in the PVI + CFAE group were in sinus rhythm (P = 0.08). In a subgroup analysis, a significantly better long-term outcome was achieved if inducible AF after PVI had been treated by additional CFAE ablation as compared with PVI only (sinus rhythm in 25/28 patients; 89% vs 22/30 patients 73%; P = 0.003). Conclusion: In the intention-to-treat analysis, additional CFAE ablation did not improve the success rate of PVI in patients with paroxysmal AF. However, during long-term follow-up, patients with still inducible AF after PVI seemed to profit from additional CFAE ablation. [ABSTRACT FROM AUTHOR]

Introduction: A patent foramen ovale (PFO) is located at the anterior and superior part of the anatomical interatrial septum, the area that is targeted during transseptal puncture. This study sought to investigate the impact of accessing the left atrium via a PFO on paroxysmal AF ablation. Methods: From March 2004, 203 patients (55 ± 11 years) underwent catheter ablation for paroxysmal AF (80 ± 71 months), with the endpoint being electrical isolation of all pulmonary veins (PV) and AF noninducibility. The presence of a PFO was determined by both transesophageal echocardiography and catheter probing. Procedural difficulty was evaluated by radiofrequency (RF), procedural, and fluoroscopic durations. Clinical follow-up was also investigated. Results: A PFO was detected in 27 patients (13%) by transesophageal echocardiography and in 22 additional patients (total 49 patients, 24%), by catheter probing (P < 0.001). A PFO was associated with longer total RF applications (57 ± 19 vs 51 ± 18 min, P = 0.04) and RF applications to isolate the PVs (42 ± 16 vs 35 ± 12 min, P = 0.001). Procedural and fluoroscopic times were unaffected. Seventy-three patients (36%) required a second procedure; there was no difference in the number of PV reconnections (1.3 vs 1.8 veins, P = NS). After a mean follow-up of 19 ± 9 months, 194/203 patients (96%) were free of AF, with no difference in patients in whom a PFO had been used. Conclusion: Although isolation of PVs is longer, overall procedural duration and success is not affected when using a PFO compared with a transseptal puncture. The presence of a PFO is underestimated by transesophageal echocardiography with brachial injection when compared with catheter probing. [ABSTRACT FROM AUTHOR]

Background: We questioned whether the empirical four pulmonary vein (PV) isolation (EmPVI) was necessary in patients with paroxysmal atrial fibrillation (PAF) triggered from clearly and reproducibly defined arrhythmogenic PVs. Methods: We compared the selective or ipsilateral isolation of the PVs triggering AF (SePVI: n = 42) and EmPVI (n = 35) in 77 patients (males 80.5%, mean age 53.0 ± 13.4 years) with PAF who underwent radiofrequency catheter ablation (RFCA). Arrhythmogenic PVs were identified by the immediate recurrence of AF three consecutive times after cardioverting AF. Results: (1) The duration of the RF energy deliveries (P < 0.01) and total procedure time (P < 0.01) were shorter for the SePVI than the EmPVI. (2) During a mean follow-up of 38.6 ± 23.1 months, the AF recurrence rate was 38.1% in the SePVI group and 25.7% in the EmPVI group (P = NS). (3) A redo-ablation was performed in 25 patients, and 81.0% of the recurrent arrhythmogenic foci were found at a previously ablated PV or ipsilateral PV. (4) In 15.4% of the SePVI and 20.0% of the EmPVI procedures, AF recurred after 32.5 ± 15.2 months of the redo-ablation. Subsequently, the AF-free rate for each group was 88.1% (37/42) in the SePVI group and 91.4% (32/35) in the EmPVI group (P = NS). Conclusions: In patients with clearly documented arrhythmogenic PVs, the SePVI of the PV triggering the AF or an ipsilateral PV had a comparable long-term success rate and shorter RF energy delivery and procedure times than the EmPVI. [ABSTRACT FROM AUTHOR]