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Introduction: A recent study reported that diffuse left ventricular (LV) fibrosis is a predictor of atrial fibrillation (AF) recurrence following catheter ablation, by measuring postcontrast cardiac T1 (an error prone metric as per the 2017 Society for Cardiovascular Magnetic Resonance consensus statement) using an inversion‐recovery pulse sequence (an error prone method in arrhythmia) in AF ablation candidates. The purpose of this study was to verify the prior study, by measuring extracellular volume (ECV) fraction (an accurate metric) using a saturation‐recovery pulse sequence (accurate method in arrhythmia). Methods and Results: This study examined 100 AF patients (mean age = 62 ± 11 years, 69 males and 31 females, 67 paroxysmal [pAF] and 33 persistent [peAF]) who underwent a preablation cardiovascular magnetic resonance (CMR) exam. LV ECV and left atrial (LA) and LV functional parameters were quantified using standard analysis methods. During an average follow‐up period of 457 ± 261 days with 4 ± 3 rhythm checks per patient, 72 patients maintained sinus rhythm. Between those who maintained sinus rhythm (n = 72) and those who reverted to AF (n = 28), the only clinical characteristic that was significantly different was age (60 ± 12 years vs 66 ± 9 years); for CMR metrics, neither mean LV ECV (25.1 ± 3.3% vs 24.7 ± 3.7%), native LV T1 (1093.8 ± 73.5 ms vs 1070.2 ± 115.9 ms), left ventricular ejection fraction (54.1 ± 11.2% vs 55.7 ± 7.1%), nor LA end diastolic volume/body surface area (42.4 ± 14.8 mL/m2 vs 43.4 ± 19.6 mL/m2) were significantly different (P ≥.23). According to Cox regression tests, none of the clinical and imaging variables predict AF recurrence. Conclusion: Neither LV ECV nor other CMR metrics predict recurrence of AF following catheter ablation. [ABSTRACT FROM AUTHOR]

Background: While several studies have evaluated predictors for atrial fibrillation (AF) recurrence following catheter ablation, there are limited data specific to cryoballoon ablation (CBA). Methods: We analyzed a prospective registry of patients at a single institution who underwent CBA. Recurrence of AF (RAF) was defined as recurrence of AF by 12‐month follow‐up, excluding the 3‐month blanking period. Univariate analysis was performed to evaluate predictors of RAF. Receiver operating characteristic analysis was used to compare and evaluate the performance of various risk scores for discriminating risk of RAF. Results: There were 542 patients included in the analysis with mean age 61.3 ± 10.6 years, 67.9% male, and 51.6% paroxysmal AF (PAF). Overall, only left atrial diameter (LAD) > 40 mm and ERAF (early recurrence of AF within 0‐3 month blanking period) were significant predictors of RAF. In the PAF specific subgroup, LAD > 40 mm, AF duration > 12 months, prior stroke or transient ischemic attack, ERAF, and having previously failed an antiarrhythmic drug were significant predictors of RAF. In persistent AF (PeAF) subgroup, obstructive sleep apnea (OSA) and ERAF were significant predictors of RAF. Out of clinical risk scores tested, BASEAF2 had the highest performance with area under the curve of 0.646 (95% confidence interval [0.548, 0.708]; P < .01). Conclusions: In this single‐center retrospective study of CBA, we found only LAD > 40 mm and ERAF to be predictors of RAF. We identified OSA as a potential targetable risk factor in PeAF patients undergoing CBA. Out of risk scores tested for discriminating risk of RAF, BASEAF2 had the best performance. [ABSTRACT FROM AUTHOR]

Background: Transcatheter aortic valve replacement (TAVR) is increasingly used to treat severe aortic stenosis. A frequent complication of TAVR is high‐grade or complete atrioventricular (AV) block requiring a permanent pacemaker (PPM). There are little data on the long‐term dependency on pacing after TAVR. The objective of this study was to determine the proportion of patients receiving a PPM for high‐grade or complete AV block after TAVR who remain dependent on the PPM in follow‐up and to determine any risk factors for, particularly the effect of postballoon dilation (PBD) on, pacemaker dependency. Methods: Of 594 consecutive patients without prior PPM undergoing TAVR (81.9% balloon‐expandable, 18.1% self‐expandable valve), 67 (13.1%) received a PPM after TAVR. PPM dependency was defined as AV block with a ventricular escape rate of ≤ 40 beats/min. Patient and procedural characteristics were examined according to PPM dependency status. Results: Of the 67 patients who received a PPM within 10 days after TAVR, 27/67 (40.3%) were dependent at first follow‐up and only 9/41 (21.9%) at 1 year. PPM dependency was more common after a self‐expanding valve (76.9% vs 31.5%, P < 0.01), in those who underwent PBD (66.7% vs 24.4%, P < 0.01), and in patients in persistent complete AV block at PPM implantation (62.5% vs 7.4%, P < 0.01). Conclusions: Fewer than half of patients who receive a new PPM following TAVR are pacemaker dependent at early follow‐up (< 30 days). The use of self‐expanding valves and PBD are associated with a markedly increased risk of PPM dependency. [ABSTRACT FROM AUTHOR]

Background Cryoballoon ablation (CBA) for paroxysmal atrial fibrillation (pAF) can be performed under general anesthesia (GA) or moderate sedation (MS). Our objective was to compare the effectiveness, safety, procedure duration, and time spent in the electrophysiology (EP) laboratory for CBA performed under GA and MS. Methods Patients undergoing a first CBA for pAF were identified. Patients received either GA administered by an anesthesiologist or MS with midazolam and fentanyl administered by EP laboratory staff. Total time in laboratory (sum of procedure and nonprocedure time); fluoroscopy time; freedom from documented AF, atrial flutter, and atrial tachycardia (FFAF); acute pulmonary vein isolation (PVI) rate; and 30-day complication rate were assessed. Results A total of 55 patients received GA and 119 patients received MS. PVI success rate was 100% in GA and 98.1% in MS (P = 0.04). Total laboratory time was longer for GA (280.4 ± 54.1 minutes vs 245.5 ± 54.7 minutes; P < 0.001), related to longer nonprocedure time (92.2 ± 28.8 minutes GA vs 71.0 ± 30.0 minutes MS; P < 0.001), but not procedure time (188.3 ± 49.3 minutes GA vs 174.5 ± 50.2 minutes MS; P = 0.09). FFAF was not significantly different over a median follow-up duration of 0.9 (interquartile range 0.4-1.9) years (61.8% GA vs 63.0% MS; log-rank P = 0.90). There was no significant difference in complication rate. Conclusion Compared to GA, MS during CBA for pAF was independently associated with shorter total EP laboratory time without compromising FFAF or complication rates. [ABSTRACT FROM AUTHOR]

Background Catheter ablation is an established treatment for atrial fibrillation (AF). Cryoballoon ablation (CBA) has emerged as an alternative to radiofrequency ablation (RFA). However, there are few data comparing these modalities for treatment of paroxysmal AF (pAF) in the U.S. population. The purpose of this study was to compare procedural times, safety, and efficacy of CBA against RFA. Methods A single-center prospective cohort study evaluated patients who underwent catheter ablation for pAF using CBA or RFA between January 1, 2010 and October 31, 2013. Patients with prior ablation and those without rhythm follow-up for at least 3 months were excluded. The primary end point was freedom from AF, atrial flutter, and atrial tachycardia (FFAF) >30 seconds after a 3-month blanking period without requirement for antiarrhythmic drugs. We also compared rates of successful pulmonary vein isolation (PVI), fluoroscopy and procedure times, and major complication rates. Results A total of 201 patients were included (CBA = 101, RFA = 100). The rate of successful PVI was 99.3% in CBA versus 97.4% in RFA (P = 0.08). Procedure times were shorter with CBA (192.9 ± 44.0 minutes vs 283.7 ± 78.0 minutes, P < 0.001) as well as total fluoroscopy times (46.0 ± 22.4 minutes vs 73.0 ± 30.1 minutes, P < 0.001). Overall complication rates were equivalent; however, fewer cardiac perforations occurred with CBA (0% vs 4%, P = 0.042). The 1-year FFAF rates were 60.3% for CBA and 61.1% for RFA (log rank P = 0.93). Conclusion CBA was associated with equivalent 1-year FFAF rate as RFA for pAF. Procedure and fluoroscopy times were shorter for CBA and fewer cardiac perforations occurred. [ABSTRACT FROM AUTHOR]

The current paradigm for anticoagulation in patients with atrial fibrillation is based upon clinical risk factors for stroke without reference to the frequency or duration (i.e., burden) of atrial fibrillation episodes. In the last decade, increasing evidence derived from device-based surveillance of atrial fibrillation has suggested that in some patients the burden of atrial fibrillation may be associated with thromboembolic risk. The development of rapidly acting oral anticoagulants and devices with remote monitoring capability has allowed the testing of a strategy of tailored or 'pill-in-the-pocket' anticoagulation based upon atrial fibrillation burden. [ABSTRACT FROM AUTHOR]

PASSMAN, R.S., et al.: Radiofrequency Ablation of Atrial Flutter: A Randomized Controlled Trial of Two Anatomic Approaches. Atrial flutter often results from a macroreentrant circuit that uses anatomic structures within the right atrium as its borders. RF ablation at the site of an obligatory isthmus can eliminate the atrial flutter circuit. The aim of this study was to compare two approaches to atrial flutter ablation: the septal (septal aspect of the tricuspid valve annulus to coronary sinus ostium and Eustachian ridge) approach versus the posterior (inferior vena cava to tricuspid valve annulus) approach. Twenty patients were randomized to either the “septal” or “posterior” approach. Entrainment mapping and/or confirmation of bidirectional isthmus conduction at baseline were performed in those patients in atrial flutter and normal sinus rhythm, respectively. RF ablation was performed with standard catheters and techniques. Crossover was permitted after two lines of RF lesions. Endpoints included acute success rates and fluoroscopy times. There was no statistically significant difference in the success rate between the two approaches using intention-to-treat analysis. Fluoroscopy times in the septal versus posterior approaches were 58.4 ± 30.3 versus 70.8 ± 31.1 minutes, respectively (P = 0.7). There was more frequent crossover in patients assigned to the septal approach and the one major complication, atrioventricular block, also occurred using this approach. There was no statistically significant difference in the success rate or fluoroscopy times between the septal and posterior approaches to atrial flutter ablation. However, given the risk of atrioventricular block with the septal approach, the posterior approach should be the preferred initial choice. (PACE 2004; 27:83–88) [ABSTRACT FROM AUTHOR]