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Atrial fibrillation (AF) and heart failure are common overlapping cardiovascular disorders. Despite important therapeutic advances over the past several decades, controversy persists about whether a rate control or rhythm control approach constitutes the best option in this population. There is also considerable debate about whether antiarrhythmic drug therapy or ablation is the best approach when rhythm control is pursued. A brief historical examination of the literature addressing this issue will be performed. An analysis of several important clinical outcomes observed in the prospective, randomized studies, which have compared AF ablation to non‐ablation treatment options, will be discussed. This review will conclude with recommendations to guide clinicians on the status of AF ablation as a treatment option when considering management options in heart failure patients with atrial fibrillation. [ABSTRACT FROM AUTHOR]

New ablation catheters have continuously developed to improve the safety and efficacy of ablation procedures. The TactiFlex Ablation Catheter Sensor Enabled (Abbott, Minneapolis, MN) is a novel open‐irrigation radiofrequency ablation catheter that has contact force‐sensing technology and flexible tip, allowing real‐time contact force assessment with directionality. This case report reported a loss of contact force vector and directionality with the TactiFlex SE ablation catheter during de novo atrial fibrillation (AF) ablation. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency catheter ablation (RFA) for atrial fibrillation (AF) is being increasingly performed without fluoroscopy. This study aims to determine the safety of fluoroless RFA for patients with pre‐existing cardiac implantable electronic devices (CIED). Methods: This is a single‐center, single‐operator, retrospective, observational study of 225 consecutive fluoroless RFA procedures for AF from June 1, 2019 to June 1, 2022. All procedures were performed with intracardiac echocardiography (ICE) support. Patients with pre‐existing CIED were extracted from the database. Each CIED was interrogated at the start and end of each procedure and at 30‐day follow‐up. Pre‐ and post‐procedure CIED interrogations were compared for any change in device or lead parameters. Patients were tracked for any subsequent device malfunction. Results: Out of 225 fluoroless AF ablations, 25 (10.2%) had pre‐existing CIED (14 dual‐chamber pacemakers, three dual‐chamber defibrillators, three single‐chamber defibrillators, one single chamber pacemaker, and four biventricular devices). Mean patient age was 71 ± 6 years. The mean duration of indwelling CIED was 1804 ± 1645 days (range: 78–6267 days). One (4%) patient had lead‐related fibrin on ICE imaging. There was no significant difference in lead(s) threshold, impedance, or sensing post procedure or at 30‐day follow‐up compared to pre procedure. None of the patients required lead revision. There were no intra‐ or post‐op thromboembolic events or subsequent device infection. One patient underwent CIED extraction after 11 months for an unrelated secondary device infection. Conclusions: Radiofrequency catheter ablation for AF can be safely performed without fluoroscopy in patients with pre‐existing CIED. [ABSTRACT FROM AUTHOR]

Background and Objectives: The common practice after atrial fibrillation ablation is to admit patients for an overnight stay. The aim of this study was to compare a strategy of vascular suture mediated closure system utilization and early discharge (strategy A) compared to traditional closure and overnight hospitalization (strategy B) regarding feasibility, safety, quality of life and health care cost effectiveness. Methods and Results: Hundred patients were randomized to compare both strategies. No clinical differences were reported except diabetes mellitus. Six patients (6%) had and emergency visit or were admitted in the first 30 days after procedure. Three occurred in strategy A versus three in strategy B (p = 1) (p <.005 for non‐inferiority). Forty out of 50 patients (80%) were safely discharged in a time frame of 3 h and 42 patients (84%) were discharged in the same day of the procedure in strategy A. Time to discharge was shorter in strategy A compared to strategy B. (5.89 ± 7.47 h vs. 27.09 ± 2.29 p <.005). No differences were obtained in quality‐of‐life outcomes. Mean (95% CI) euros cost saving per patient in strategy A was 379.16 ± 93.55 p <.001. Ten acute complications (10% patients CI 95% 4.02%–15.98%) were reported during the trial. Seven (14% CI 95% 4.04%–23.96%) occurred in strategy A patients versus 3 (6% CI 95% 0.8%–12.8%) in strategy B. (p =.182) Conclusion: A strategy of vascular suture mediated closure system utilization and early discharge was feasible, reduced time to discharge, saved costs and was not associated with more complications or admissions/emergency visits in a 30‐day time frame after procedure compared to a strategy of regular admission and discharge after overnight stay. There were no differences regarding quality‐of‐life parameters between both strategies. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) using radiofrequency catheter ablation is a widely accepted therapy for drug‐refractory atrial fibrillation patients. Elimination of the negative component of the local unipolar electrogram (UEGM) during PVI is a marker of transmural lesion formation. The ablation index (AI) can predict the quality of ablation lesion. Combining these two parameters could make PVI safer and efficient. The purpose of this pilot study was to examine the correlation between UEGM modification characteristics of the different target areas of left atrium and the associated AI values during PVI. Methods: We analyzed 10 patients who underwent PVI using radiofrequency energy. The local electrophysiological properties and ablation parameters of 15 designated areas of interest in the left atria targeted by radiofrequency catheter ablation were collected. Results: Out of the 10 patients, six were men (mean age 66 years) and 80% had paroxysmal AF. The mean time to achieve the UEGM modification in the posterior wall was shorter than that of the anterior wall (8.9 seconds vs. 11.1 s, respectively). The UEGM modification for every lesion was achieved at significantly lower AI values than conventional AIs (p <.001). Conclusion: During PVI, the AIs deduced according to the local UEGM modification are markedly shorter than those generally recommended AIs in contemporary practice. This indicates that conventionally recommended AIs could be safely reduced while ensuring the efficacy and quality of radiofrequency ablation during PVI. This approach would probably reduce to risk of collateral thermal injuries. [ABSTRACT FROM AUTHOR]

Background: In the modern era, atrial fibrillation (AF) ablation trend has been shifted toward same‐day discharge (SDD), from a traditional overnight stay. Yet, recent studies have not well stated the safety profiles which remained poor‐understood and dispersed. We hence performed systematic review and meta‐analysis to assess the adverse outcomes of SDD in comparison with an overnight stay. Methods: Databases were searched through January 2021. Effect estimates from the individual studies were extracted and combined using random‐effects, generic inverse variance method of der Simonian and Laird. The primary outcomes included total cumulative complications and immediate complications following AF ablation. Results: Ten observational studies were met our inclusion criteria, comprising of total population of 11,660 patients, with SDD 51.3%. For total cumulative complications, there were no differences observed between SDD and overnight stay (5.2% vs. 6.2%: pooled OR 0.77: 95% CI 0.55–1.08, p =.13 with I2 = 27.1%). In addition, comparable immediate complications were also demonstrated (5.2 % vs. 4.3: pooled OR 1.08: 95% CI 0.72–1.62, p =.718, with I2 = 37.3 %). Conclusion: Our study suggested that SDD had similar complication rates, both total cumulative and immediate outcomes, compared with overnight stay in selected patients following AF ablation. Nevertheless, randomized control trials are warranted to validate the findings. [ABSTRACT FROM AUTHOR]

Aims: Atrial fibrillation (AF) catheter ablation is a common procedure requiring in most cases the use of fluoroscopy. We aimed to evaluate the factors associated with a lower dose of fluoroscopy used during AF ablation with cryoballoon or radiofrequency. Methods: In this prospective European registry, centers were requested to provide procedural characteristics of consecutive AF ablation cases. Lower doses of fluoroscopy were defined as those with dose‐area‐product (DAP) under the median dose used in the radiofrequency and the cryoballoon ablation groups. Results: A total of 638 AF ablation procedures were collected (n = 492 for radiofrequency and n = 146 for cryoballoon ablation groups) in 25 centers. The median [IQR] DAP were 926 [349;2092] and 1516 [418;3408] cGy*cm2 in the radiofrequency and cryoballoon groups, respectively. Main factors associated with lower DAP in cryoballoon ablation group were electrophysiology dedicated laboratory (OR 6.04, 95%CI 1.16–31.54; P =.03) and frequent dosimetry report (OR 21.39, 95%CI 5.43–98.54; P =.03). Main factors associated with lower DAP in the radiofrequency ablation group were the use of a chest dosimeter (OR 12.57, 95% CI 2.88‐54.90; P =.01), biplane X‐ray equipment (OR 3.12, 95%CI 1.89‐5.16; P <.01), university hospital (OR 2.10, 95%CI 1.35‐3.25; P =.01), electrophysiology dedicated laboratory (OR 2.45, 95%CI 1.48‐4.05; P <.01) and use of contact force enabled catheter (OR 22.60, 95%CI 6.82‐74.88; P <.01). Conclusion: This real‐life study of fluoroscopy use during AF ablation provides new data about current practices across European countries. Technological advances and quality of the fluoroscopic environment were the main factors associated with lower radiation dose during AF ablation. [ABSTRACT FROM AUTHOR]

Background: Advancements in minimally invasive surgical ablation (MISA) have focused on improving pulmonary vein isolation. Additional ablation targets have been developed (such as posterior wall isolation). The mid‐ and long‐term effects of current techniques (including electrophysiologic findings and recurrent arrhythmia mechanisms) have not previously been reported. Methods: Twenty eight patients with recurrent atrial arrhythmias after bipolar clamp ablation of the pulmonary vein antrum, ganglionated plexi, posterior wall isolation (roof and floor lines to create a posterior box), and ligament of Marshall ligation/cauterization and left atrial appendage clipping underwent follow up electrophysiology study including left atrial mapping an average of 2.3 years postoperatively. Results: Atrial fibrillation was the most common recurrent arrhythmia (n = 18) followed by micro‐reentrant atrial tachycardia (n = 5), macro‐reentry left atrial flutter (n = 3), and typical cavo‐tricuspid isthmus atrial flutter (n = 2). Eighty six of 112 (77%) PVs mapped were electrically isolated, 16 (57%) patients had all four pulmonary veins (PVs) isolated. The posterior wall (PW) was completely isolated in only four (14%) patients, seven (25%) patients had normal PW voltage, while 17 (61%) patients had abnormal delayed or fractionated electrograms in the posterior wall (incomplete isolation). Abnormal PW electrograms were more frequently found in patients with complex recurrent left atrial arrhythmia (micro‐reentry or left atrial macro‐reentry flutter). Conclusion: With current surgical techniques PV isolation has improved, but PW isolation remains challenging. Incomplete PW isolation may produce arrhythmogenic substrate. [ABSTRACT FROM AUTHOR]

Background: Same‐day discharge (SDD) after atrial fibrillation (AF) ablation is increasingly being considered. This study examined the barriers and financial impact associated with SDD in a contemporary cohort of patients undergoing elective AF ablation. Methods: A single center retrospective review was conducted of the 249 first case‐of‐the‐day outpatient AF ablations performed in 2019 to evaluate the proportion of patients that could have undergone SDD. Barriers to SDD were defined as any intervention that prevented SDD by 8 p.m. The financial impact of SDD was based on savings from avoidance of the overnight hospital stay and revenue related to management of chest pain facilitated by a vacant hospital bed. Results: SDD could have occurred in 157 patients (63%) without change in management and in up to 200 patients (80%) if avoidable barriers were addressed. Barriers to SDD included non‐clinical logistical issues (43%), prolonged post‐procedure recovery (42%) and minor procedural complications (15%). On multivariate analysis, factors associated with barriers to SDD included increasing age (P =.01), left ventricular ejection fraction ≤ 35% (P =.04), and severely dilated left atrium (P =.04). The financial gain from SDD would have ranged from $1,110,096 (assuming discharge of 63% of eligible patients) to $1,480,128 (assuming 80% discharge) over the course of a year. Conclusions: Up to 80% of patients undergoing outpatient AF ablation were amenable to SDD if avoidable delays in care had been anticipated. Based on reduced hospital operating expenses and increased revenue from management of individuals with chest pain, this would translate to a financial savings of ∼$1.5 million. [ABSTRACT FROM AUTHOR]

Catheter ablation using radiofrequency (RF) energy has been widely used to treat patients with atrial fibrillation (AF). The optimal levels of power and duration to increase the success rate while minimizing complications have not been fully established. Different centers continue to use various power protocols for catheter ablation of AF. Herein, we present a comprehensive review of the impact of power output on efficacy and safety of RF ablation for AF. High‐power short‐duration (HPSD) ablation can be performed safely with similar procedural efficacy as low‐power long‐duration ablation strategy. HPSD ablation has the potential to shorten procedural and RF times and create more durable and localized lesions. [ABSTRACT FROM AUTHOR]

Atrioesophageal fistula (AEF) is a rare but deadly complication of radiofrequency ablation for atrial fibrillation. Given its rarity, the diagnosis of AEF is usually delayed with a wide variation in management strategies, which contribute to the high mortality associated with AEF. As such, the most important step of AEF management is prevention, whereas early diagnosis and treatment are crucial to reduce its associated high mortality. [ABSTRACT FROM AUTHOR]

Aims: Pulmonary vein isolation (PVI) is an effective procedure for atrial fibrillation (AF). The role of additional cavotricuspid isthmus (CTI) block ablation remains controversial in AF patients without atrial flutter (AFL). Therefore, this study aimed to explore the clinical outcome of additional CTI block ablation in patients without AFL. Methods: Between January 2013 and December 2017, a total of 139 patients who did not have documented AFL and who underwent catheter ablation for AF were recruited. Fifty‐seven patients were classified in additional CTI block ablation group and 82 patients were classified in without CTI group. The incidence of early‐onset and late‐onset atrial arrhythmia recurrence was compared between the two groups. Results: The additional CTI group had a higher prevalence of persistent or long‐standing AF and larger left atrial volume. The additional CTI group had a higher incidence of late‐onset atrial arrhythmia recurrence (38.6% vs 12.2%; P < .001). When compared to without CTI group, additional CTI therapy did not have a better outcome in terms of freedom of atrial arrhythmia in subgroup analysis. The incidence of early‐onset and late‐onset atrial arrhythmia recurrence did not differ between additional CTI group and without CTI group in paroxysmal AF patients and nonparoxysmal AF patients after propensity scoring matching. Conclusion: CTI block ablation in addition to PVI for AF patients without a history of AFL or inducible AFL during ablation may not improve the clinical outcome of AF ablation in the patients with larger LA volume, nonparoxysmal AF, or post‐PVI inducible AF. [ABSTRACT FROM AUTHOR]

Background: Immediate hemostasis following removal of sheaths is essential to prevent access site complications after atrial fibrillation (AF) ablation. Despite various precautions to achieve complete hemostasis in a safe and effective manner, no standard approach is present yet. Objective: We aimed to compare the efficacy and safety of standard vs modified figure‐of‐eight (sFoE vs mFoE) suture for immediate venous hemostasis after cryoballoon (CB) AF ablation. Methods: A total of 150 patients who underwent CB catheter ablation were sequentially allocated to either sFoE (n = 75) or mFoE (n = 75) suture to achieve immediate venous hemostasis at right femoral access site after 15 Fr sheath removal. A "three‐way stopcock" was used in the mFoE group rather than tying the knot as in a sFoE group. Demographics, clinical and procedural data, and access site complications were recorded. Results: Immediate haemostasis was achieved in all patients (n = 75) with mFoE suture as compared to 90.7% (n = 68) of sFoE suture group (P <.001). Light manual pressure of ≤1 min was required in five patients (6.7%) due to looseness and conventional manual compression because of the snapped silk suture during knotting was required in two patients (2.6%) in the sFoE group. Time to hemostasis was shorter in the mFoE group (P <.001), but time to ambulation and time to discharge were similar in both groups (P >.05). Although no minor or major access site complication has occurred in the mFoE group, in‐hospital rebleeding (n = 2, 2.7%) and early local access site infection (n = 2, 2.7%) were observed in the sFoE group. Conclusion: The mFoE suture using three‐way stopcock is an available, effective, maybe safe, and time‐ and cost‐saving alternative technique to achieve immediate hemostasis after removal of 15 Fr right femoral venous sheath in patients undergoing cryoablation. [ABSTRACT FROM AUTHOR]

Background: In the setting of second‐generation cryoballoon (CB2) ablation, left atrial (LA) access is generally achieved using a standard sheath (SS) that is exchanged for the 15Fr cryoballoon delivery sheath (CBS) and dilator over a long wire (CBS over‐the‐wire technique, CBS‐W). Our objective was to evaluate the direct use of the CBS to gain LA access, by advancing the latter over the trans‐septal needle (CBS over‐the‐needle technique, CBS‐N), under transesophageal echocardiographic (TEE) guidance. Methods: Consecutive patients who underwent CB2 ablation with the CBS‐N technique were evaluated for feasibility of gaining LA access using TEE guidance and fluoroscopy views. Complications related to the LA access were compared with a matched CBS‐W control group. Subanalysis (30 CBS‐W vs 30 CBS‐N patients) evaluated time‐to‐LA of the CBS: time from superior vena cava (with SS vs CBS) to LA insertion of the CBS, after exchange or directly, respectively. Results: LA access could be achieved in all 505 patients of the CBS‐N group, without technique modification or additional equipment. Challenging interatrial septa were noted in 13% of these patients: previous atrial septal defect repair (1%), hypermobile (10%), aneurysmal (1%), and abnormally thickened/fibrotic (1%). Incidence of complications was similar to the CBS‐W group. Subanalysis showed a shorter time‐to‐LA in the CBS‐N versus CBS‐W group, 72 ± 46 seconds versus 293 ± 180 seconds, P < .001. Conclusions: Our study showed that the CBS‐N technique is feasible and safe under echocardiographic guidance. Without sheath exchange, it simplifies the CB2 procedure, is less costly, time sparing, and might reduce the risk of air embolism. [ABSTRACT FROM AUTHOR]

Background: Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA. Methods: PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes. Results: Four randomized control trials were included in the meta‐analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n = 158 CTI, n = 156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P < 0.00001). A total of 550 patients (n = 336 CTI, n = 214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P < 0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P < 0.00001), respectively. Total complications were statistically similar between groups. Conclusion: This meta‐analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications. [ABSTRACT FROM AUTHOR]

Background: Despite improvement in catheter ablation for atrial fibrillation (AF), ability to recognize and prevent esophageal injury remains challenging. We hypothesized that esophageal course may impact esophageal heating, as measured through ablation, and thereby, risk of injury. Methods: We evaluated all patients undergoing first‐time AF ablation with preprocedural computed tomography (CT) imaging from 2014 to 2016 at our institution, focusing on esophageal position at the left atrial (LA)/pulmonary vein junction. Esophageal luminal temperatures (ELTs) were analyzed by esophageal course. In exploratory work by investigation of published reports of atrioesophageal fistula (AEF), we evaluated for a relationship between esophageal course and risk of AEF. Results: Of 68 patients, 48.5% had midline, 36.8% leftward, and 14.7% rightward esophageal positions. Of 20 patients (29% of cohort) with esophageal confinement—defined as a midline or leftward position relative to the LA, vertebrae, and aorta, with luminal distortion—14 had leftward position. No significant differences in patient or procedure characteristics were noted between confinement and nonconfinement cohorts. The average peak ELT was significantly higher in those with confinement (36.9°C vs 36.2°C, P < 0.05) and confinement with a left‐sided esophagus (37.1°C vs 36.2°C, P < 0.05). There was a significant correlation between esophageal confinement and risk of AEF (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.2‐6.2, P < 0.01). Conclusion: Approximately one‐third of patients undergoing AF ablation display leftward esophageal course along the ablation zone on preprocedure CT imaging, with a significant portion exhibiting esophageal confinement. In those with confinement, higher peak ELTs are noted with ablation. Esophageal confinement may be a risk factor for development of AEF. [ABSTRACT FROM AUTHOR]

Abstract: Background: Cryoballoon (CB) applications to pulmonary veins (PVs) can cause stenosis just as radiofrequency (RF) energy deliveries. The goal of the present study was to clarify whether or not there was any difference in the extent of acute or chronic PV narrowing after PV isolation between the two different energy sources. Methods: Consecutive patients with paroxysmal atrial fibrillation who were scheduled to undergo a PV isolation were randomized 1:1 to receive CB or RF ablation. The endpoints were any acute PV narrowing assessed with the use of intracardiac ultrasound during the procedure and PV stenosis measured with cardiac computed tomography at the 3‐month follow‐up. Results: An acute reduction in the luminal area of the left superior PV (mean ± standard deviation, –6.8 ± 8.7 vs –19.9 ± 14.7%; P < 0.001) and left inferior PV (–5.1 ± 20.2 vs –15.3 ± 11.6%; P = 0.03) was significantly smaller in the CB arm (N = 25) than the RF arm (N = 25). There was no difference in the extent of PV stenosis 3 months after the ablation between the arms (0–25% stenosis, 90% vs 88%, 25–50% stenosis, 10% vs 12%, >50% stenosis, both 0%; P = 0.82). A greater acute PV narrowing was likely to lead to chronic stenosis in the RF arm (P = 0.004). Conclusions: CB ablation may reduce the acute narrowing of the left‐sided PVs as compared to RF ablation. [ABSTRACT FROM AUTHOR]

Background Adenosine administration after pulmonary vein (PV) isolation is effective for identifying dormant conduction (DC). We aimed to compare the efficacy and safety of local injection of adenosine into the PV with systemic intravenous injection. Methods After complete PV isolation was performed, adenosine was injected directly into the PV (local method, 6-18 mg) and the femoral vein (systemic method, 12-30 mg) sequentially. We compared the incidence of DC and the hemodynamic effect of adenosine between the methods. Results We analyzed 150 PVs in 40 patients who underwent atrial fibrillation ablation. A total of 16 DCs were seen in 14 patients with either the local or systemic method. Among them, two DCs were detected only by the local method (detection rate: local 10.7% vs systemic 9.3%). The effective doses of adenosine required to induce atrioventricular (AV) block or detect DC were 7.7 ± 3.1 mg (local) and 13.1 ± 3.4 mg (systemic), respectively (P < 0.001). The time interval between adenosine injection and AV block was shorter with the local than systemic method (5.8 seconds vs 11.7 seconds, P < 0.001). Six DCs (four with local and two with systemic method) were detected without manifested AV block. Additionally, there were fewer decrements in blood pressure with the local than systemic method. Conclusion Local adenosine injection via the PV was comparable to systemic administration for detecting DC after PV isolation. Furthermore, the local method required a smaller dose of adenosine, took less time to induce AV block, and resulted in less systemic hemodynamic compromise than did the systemic method. [ABSTRACT FROM AUTHOR]

Background First description of a technique for left atrium transseptal puncture (TSP) with minimal radiation exposure by using the nonfluoroscopic MediGuide™ tracking system (MG; St. Jude Medical, St. Paul, MN, USA) without the assistance of intracardiac echocardiography. Methods This study included 31 consecutive patients with atrial fibrillation undergoing an MG-assisted percutaneous catheter ablation procedure. A Brockenbrough transseptal needle (BRK) is connected to a standard pressure transducer through a two-input valve. Then, an MG-enabled guidewire is inserted so that its tip exactly matches the BRK's distal tip. After the acquisition of two short radioscopic cine-loops we are able to trace the needle tip on the MG screen, performing the usual TSP maneuver but without fluoroscopy. Successful left atrium access is confirmed by noticing the change in the pressure curve and by advancing the guidewire into the left pulmonary veins. As a control group, 31 matched patients who underwent atrial fibrillation ablation with fluoroscopically guided, pressure-monitored TSP were included. Results Sixty-two MG-assisted TSP attempts were performed; all but two were successfully accomplished without changing to the conventional technique (96.7%). The mean total fluoroscopy time, until the double transseptal access was performed, was 26.65 ± 37.97 seconds in the MG group and 129.13 ± 37.77 seconds in the conventional-TSP group (P < 0.001). No major complications occurred during any of the procedures. Conclusion This new technique for TSP using MG is feasible and can be performed with minimal radiation exposure without the need for additional imaging techniques, achieving a significant reduction of fluoroscopy time. [ABSTRACT FROM AUTHOR]

Background We investigated computed tomography (CT) angiography (CTA) in assessment of left atrial appendage (LAA) stasis and thrombus in preprocedural evaluation for atrial fibrillation (AF) ablation in a large community cohort. Methods and Results We reviewed CTA and transesophageal echocardiographic images obtained in 861 consecutive patients with a history of AF undergoing same-day CTA and transesophageal echocardiogram (TEE) before AF ablation at a single hospital (2006-2013). CTA findings of LAA filling defects from acquisitions without electrocardiogram gating were compared to TEE features of LAA stasis (grade 0-4) and thrombus. Stasis grade 0 or 1 by TEE in the absence of thrombus was defined as a negative result. In addition, LAA peak flow velocity was assessed by TEE. Average age was 61 ± 10 years and 75% were male. On CTA, 161 patients (19%) had LAA filling defects on CTA and 21 had ≥grade 2 stasis on TEE, including two with thrombus, resulting in a positive predictive value of only 13%. However, among 670 CTA-negative patients, 669 (99%) were negative for thrombus or stasis by TEE with one false-negative CTA in a patient with grade 2 stasis by TEE but no thrombus, yielding a negative predictive value of 99.9%. Slow LAA Doppler flow velocity was the most important determinant of false-positive CTA results in multivariate analysis (P < 0.0001) Conclusion LAA filling defects on CT are associated with slow LAA flow velocity. AF patients without LAA filing defects on CT are free of significant stasis and thrombus on TEE. It may be possible to eliminate TEE in up to 80% of AF ablation patients based on negative CTA findings. [ABSTRACT FROM AUTHOR]

Background The impact of contact force (CF) monitoring in pulmonary vein (PV) isolation after a circumferential anatomic ablation (CAA) is unknown. We analyze the usefulness of CF monitoring in acute PV isolation and procedure parameters using a CAA. Methods Fifty patients with paroxysmal atrial fibrillation were randomized into CF-on (CF >10 grams; n = 25) or CF-off (CF blinded; n = 25) groups. We performed a first round of CAA with a ThermoCool® SmartTouch® catheter blinded to the LASSO® catheter (Biosense Webster, Diamond Bar, CA, USA), with radiofrequency (RF) lesions tagged with the VisiTag™ Module. After the CAA, each PV was reviewed with the LASSO® catheter recording the segments with gaps. Results All the PVs were isolated with a CAA in 20 patients of the CF-on versus eight of the CF-off (P = 0.001). Of the 45 segments with gaps in the left PVs, 38 were from the CF-off (P = 0.0001). Of the eight segments with gaps in the right PVs, seven were from the CF-off (P = 0.06). The CF in the left PVs was higher in the CF-on (16.3 ± 3.2 grams vs 10.5 ± 4.3 grams; P = 0.0001) and similar in the right PVs (17.6 ± 3.6 grams vs 15.2 ± 5.3 grams; P = 0.08). All of the gaps were closed with additional RF LASSO®-guided touch-up. Procedure and fluoroscopy times were shorter in the CF-on (139 ± 24 minutes vs 157 ± 32 minutes and 20 ± 6 minutes vs 24 ± 7 minutes; both P = 0.039). At 12 months the AF recurrence was 84% CF-on versus 75% CF-off (log-rank P = 0.4). Conclusions In paroxysmal atrial fibrillation, a CAA guided by CF reduces PV gaps and shortens the procedure parameters at the expense of the left PVs. [ABSTRACT FROM AUTHOR]

We report the entrapment of Pulmonary Vein Ablation Catheter (Medtronic, Minneapolis, MN, USA) and its guidewire within the right pulmonary veins in two patients. The catheters could be retrieved without complications but they were disabled in both cases. This nondescribed incident should be recognized by PVAC users since it may be a source of potential severe complications during pulmonary vein isolation procedures. [ABSTRACT FROM AUTHOR]

Background The results of catheter ablation of atrial fibrillation (AF) beyond 6 years remain unknown. The goal of this study is to assess the risk of thromboembolic events (TEs) and outcomes of AF ablation at long-term follow-up (FU). Methods All patients who had AF ablation from 2002 until 2005 in our center were contacted for a FU including a questionnaire, cardiac rhythm monitoring, and transthoracic echocardiography. Results Among the 264 eligible patients, 164 (62%) completed the study. The mean FU was 9.1 years (7.7-10.5). Seven patients had a TE during FU (event ratio 0.41 per 100 patient years [PY]) and their mean CHA2DS2-VASc score was 3.1 ± 1.3. Two patients died from stroke (0.14 per 100 PY) and five of the seven were considered in sinus rhythm (SR) and were off anticoagulation at the time of event. Prior to ablation, 13 patients had history of TE, and only one had a TE during FU. Overall, 14 deaths were documented (0.58 per 100 PY). Stable SR was present in 111 patients (68% of 164 patients) after 1.5 ± 0.6 procedures/patient. Univariate analysis showed that dyslipidemia (odds ratio [OR] = 2.95, P = 0.003), CHA2DS2-VASc ≥2 (OR = 3.22, P = 0.001), and amiodarone (OR = 5.64, P < 0.001) were predictors of long-term recurrence. Multivariate analysis showed that only CHA2DS2-VASc ≥2 (OR = 2.67, P = 0.023) and amiodarone (OR = 4.62, P = 0.001) were predictors. Conclusions Our study shows low TE rates 9 years after ablation of AF that are lower than published data for AF patients with anticoagulation only. AF patients with a CHA2DS2-VASc ≥2 should, however, be maintained on anticoagulation. [ABSTRACT FROM AUTHOR]

Background Accuracy in left atrial (LA) anatomical reconstruction is crucial to the safe and effective performance of catheter ablation of atrial fibrillation (AF). The aim of this study was to evaluate the accuracy of LA reconstruction performed with intracardiac echocardiography (ICE) as compared to fast anatomical mapping (FAM) both integrated in the CARTO mapping system (Biosense Webster, Diamond Bar, CA, USA). Methods A multislice computed tomography (MSCT) was preacquired from 29 patients with AF who underwent catheter ablation and 3D-LA geometry was reconstructed using both ICE and FAM separately. The accuracy of the LA anatomical definition was evaluated by comparing LA volumes, LA and pulmonary vein (PV) diameters obtained using ICE and FAM versus MSCT (gold standard). Results Anterior-posterior and superior-inferior LA diameters were shorter in ICE versus MSCT (32 ± 10 vs 46 ± 9 mm and 48 ± 7 vs 53 ± 7 mm, P < 0.01) but similar in FAM versus MSCT (45 ± 9 vs 46 ± 9 mm and 52 ± 10 vs 53 ± 7 mm). Latero-septal LA diameter was similar in ICE versus MSCT (63 ± 11 vs 63 ± 9 mm) but larger in FAM versus MSCT (69 ± 9 vs 63 ± 9 mm, P < 0.001). LA volume was lower in ICE versus MSCT (73 ± 30 mL vs 116 ± 45 mL, P < 0.0001) and slightly larger in FAM versus MSCT (132 ± 45 vs 116 ± 45 mL, P = 0.06). PV diameters were similar in FAM versus MSCT but significantly underestimated with ICE. Conclusions Overall accuracy in the LA and PV anatomical reconstruction was found to be superior with FAM compared to ICE-guided approach. ICE resulted in a significant underestimate of both LA and PV dimensions, while FAM slightly overestimated LA geometry. [ABSTRACT FROM AUTHOR]

Introduction Electrical reconnection of the pulmonary veins (PVs) plays a key role in the recurrence of atrial fibrillation (AF) after ablative treatment. This randomized controlled study tested the hypothesis that prolonged ablations, on areas that may be critical for left atrial (LA)-PV conduction, can significantly reduce the rate of acute PV reconnection and AF recurrence. Methods Patients with paroxysmal AF were randomly assigned to either a control or an add-on group. Ostial PV isolation (PVI) was performed by point-to-point RF ablation (irrigated tip, 30 Watts, 30 seconds). An ostial segment was assumed to be critical for LA-PV connection if any of the following reactions occurred during RF application: (1) sudden delay of LA-PV conduction, (2) change of activation sequence, and (3) PVI. In this case, RF application was prolonged from 30 seconds to 90 seconds in the add-on group only. Results A total of 131 patients (58 ± 11 years, 47 female) were assigned to a control (n = 64) and an add-on (n = 67) group. Ablation time was longer in the add-on (48 ± 16 minutes vs 37 ± 15 minutes, P = 0.03). Acute PV reconnection was observed in 20 of 64 controls and in eight of 66 add-on patients (31% vs 12%, P < 0.001). During a follow-up of 26 months, AF recurred in 33 of 64 controls and in 16 of 66 add-on patients (52% vs 24%, P = 0.001) after a single ablation procedure. Conclusions Prolonged radiofrequency application on critical segments of LA-PV connection is a safe and effective ablative strategy that significantly reduces acute PV reconnection and AF recurrence rates after a single ablation procedure for paroxysmal AF. [ABSTRACT FROM AUTHOR]

Point-by-point use of open irrigated tip catheters (OITCs) at 50 W increases atrial fibrillation (AF) ablation cure rates but also increases complications. We determined if constantly moving the OITC (perpetual motion) when using 50 W increases ablation cure rates without increasing complications. We evaluated procedural data, complications, and individual procedure cure rates (IPCRs) for AF ablation using closed tip catheters (CTC) versus OITC at 40, 45, and 50 W in 1,122 ablations. We used 'perpetual motion' to move the OITC at 50 W every 3-10 seconds. The OITC showed higher IPCR than CTC at 45 W (P = 0.012) and 50 W (P < 0.0005). For the OITC, IPCR increased from 44.6% to 60.7% as power increased from 40 to 50 W (P = 0.008). The OITC appeared superior to the CTC for all types of AF. For paroxysmal AF, increasing OITC power from 40 to 50 W provided no increase in IPCR (70.6% vs 71.2%, P = 0.827). For persistent AF, increasing power from 40 to 50 W increased IPCR from 34.5% to 59.5% (P = 0.001). Complications were similar for the CTC and the OITC at any power. The OITC at 50 W had shorter procedure, left atrial, and fluoroscopy times (P < 0.0005). Increasing OITC power from 40 to 50 W increases IPCR with no increase in complications as long as the 50 W setting is done using 'perpetual motion.' The OITC 50 W power setting results in shorter procedure and fluoroscopy times and should be considered for AF ablations. (PACE 2011; 34:531-539) [ABSTRACT FROM AUTHOR]

Background: The esophagus is in close proximity to the posterior wall of the left atrium, which renders it susceptible to thermal injury during radiofrequency (RF) ablation procedures for atrial fibrillation (AF). Real-time assessment of esophageal position and temperature (T °) during pulmonary vein (PV) isolation has not been extensively explored. Objective: To develop a protocol that allows estimation of the potential for, and avoidance of, esophageal heating. Methods: In consecutive patients who underwent PV isolation, a thermal probe was used to monitor T ° fluctuations in the esophagus during application of RF energy. The tip of the thermal probe was positioned at the level of the targeted PV and RF was discontinued for T ° rise >0.5°C. The proximity of individual PVs to the esophagus was measured from the temperature probe tip to the closest posterior part of the Lasso catheter from review of biplane projections (left anterior oblique 60° and right anterior oblique 30°). These raw distances were entered into the Pythagorean theorem and the actual distance between the esophageal thermal probe and PV antrum was determined. Results: The study cohort included 44 patients (60 ± 11 years, 61% male, 57% lone AF). The thermal probe in the esophagus was closer to the left-sided PVs (left common pulmonary vein: 20.9 ± 13 mm, left upper pulmonary vein: 20.5 ± 11 mm, left lower pulmonary vein: 23.4 ± 10 mm) than the right-sided ones (right common pulmonary vein: 31.0 ± 11 mm, right upper pulmonary vein: 41.9 ± 18 mm, right lower pulmonary vein: 34.5 ± 16 mm). A T ° increase >0.5°C occurred during 116/1,495 (7.8%) deliveries. A T ° rise was more likely during ablation of left-sided PVs than right-sided PVs (55% vs 10%, P < 0.0001) and when RF was delivered ≤24 mm from the esophagus (sensitivity 91%, specificity 81%, positive predictive value 75%, and negative predictive value 93%). Conclusion: A thermal probe placed in the esophagus provides real-time T ° monitoring and anatomic localization. A T ° rise is more likely during ablation of left PVs and during RF deliveries within 24 mm of the esophageal thermal probe. (PACE 2010; 33:1239-1248) [ABSTRACT FROM AUTHOR]

Background: Differences in atrial fibrillation (AF) cycle length (CL) between the left (LA) and right (RA) atrium and coronary sinus (CS) may help separate paroxysmal from persistent AF and identify patients most likely to respond to pulmonary vein isolation, but has not been measured noninvasively. Methods and Results: We developed methods to estimate regional intraatrial AF CL from the surface electrocardiogram (ECG) in 20 patients with persistent AF and 10 patients with paroxysmal AF prior to ablation. Intraatrial AF CL was measured near the LA appendage, mid-CS, and lateral RA. In simultaneous filtered ECG, AF CL was estimated using autocorrelation. The mean of ECG-derived AF CL in leads V5, I, and aVL was used to estimate LA CL; leads aVF, II, and III for CS CL; and V1, V2, and aVR for RA CL. ECG CL estimates for the LA, CS, and RA had R2 > 0.91 versus measured CL (all P < 0.001). Though magnitudes of left-versus-right AF CL gradients were small in this series, the ECG predicted the direction of gradients in 62% of measurements (P < 0.05). When the gradient was >10 ms, the direction was accurately predicted in eight of 11 patients. The accuracy of AF CL estimates was not adversely affected by AF type or LA dilatation (≤40 or >40 mm). The ECG-estimated AF-CL showed high 5-minute temporal stability (P < 0.001 each chamber). Conclusions: Left and right atrial AF CL, and their gradients, can be accurately determined from the ECG using autocorrelation analysis. This approach may be a helpful guide prior to ablation procedures. [ABSTRACT FROM AUTHOR]

Background: The role of pulmonary veins (PV) isolation in patients with persistent atrial fibrillation (AF) is still debated. The aim of this study was to evaluate the adjunctive role of PV isolation in patients with persistent AF who underwent circumferential PV ablation (anatomical approach). Methods: We treated 97 consecutive patients presenting with drug-refractory persistent AF by an anatomical approach (group A, n = 36, mean age = 60 ± 8 years, 29 males) or an integrated approach (group B, n = 61, mean age 59 ± 10 years, 48 males). In all patients, radiofrequency (RF) ablation was performed by means of a nonfluoroscopic navigation system, in order to anatomically create circumferential lines around the PV. In group B, the persistence of PV potentials was ascertained with a multipolar circular catheter. If PV potentials persisted, RF energy targeting the electrophysiological breakthroughs was delivered to disconnect the PV. Past a 2-month period of observation, success was defined as absence of any atrial tachyarrhythmia recurrence lasting >30 seconds. Results: Total procedure duration (220 ± 62 minutes vs 140 ± 43 minutes, P < 0.001), fluoroscopy time (35 ± 15 minutes vs 17 ± 9 minutes, P < 0.001), and RF delivery time (48 ± 22 minutes vs 27 ± 9 minutes, P < 0.001) were significantly longer in group B than in group A. One cardiac perforation occurred in group A. After 15 ± 9.1 months, 21 patients in group A (58%) and 34 patients in group B (56%) were free of atrial tachyarrhythmia recurrence (P = 0.9). Conclusions: In patients with persistent AF, who underwent an anatomical approach, electrophysiological confirmation of PV disconnection significantly increased the fluoroscopy and procedural times, without effect on the long-term outcomes. [ABSTRACT FROM AUTHOR]

CHEN, J.,et al.: A Clinical Study of Patients with and Without Recurrence of Paroxysmal Atrial Fibrillation After Pulmonary Vein Isolation. Patients with paroxysmal atrial fibrillation (PAF) can be treated by pulmonary vein (PV) isolation. However, the recurrence rate after this procedure is relatively high. We sought to evaluate the quality of life (QOL) of patients with PAF recurrence after PV isolation and to analyze factors related to recurrences. Seventy-two drug-refractory PAF patients (59 men, 13 women, mean age 52± 10) were included. PV isolation was based on the disappearance of PV potentials recorded from a Lasso catheter after segmental ostium ablation. Automatic foci were observed in 47 patients (65.3%) during the procedure. A mean of 3.1± 0.9 PVs was isolated. Patients were followed for a mean of 10.3± 5.1 months, during which 27 experienced>1 episode of PAF. QOL was scored from 0 (situation before ablation) to 10 (no episode after ablation) based on a questionnaire completed by 69 patients (95.8%). QOL was judged very good in 26 patients (none with PAF recurrences), better in 30 (15 with PAF recurrences), unchanged in 11 (10 with recurrences), and worse in 2 patients with PAF recurrences. Longer histories of PAF and a lower percentage of patients with automatic foci identified during the procedure were observed in the group with, than in the group without recurrences (P<0.05). PV isolation improved QOL in patients with PAF, including in patients with recurrences. The length of PAF history and observation of automatic foci may be of importance for recurrences of PAF during long-term follow-up.(PACE 2005; 28:S86–S89) [ABSTRACT FROM AUTHOR]