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Aims A novel three-dimensional mapping platform combined with a lattice-tip catheter that can toggle between monopolar pulsed field ablation (PFA) and radiofrequency energy delivery was recently launched. So far, the system was predominantly applied in general anaesthesia (GA), not in deep sedation. Methods and results Patients with symptomatic paroxysmal or persistent atrial fibrillation (AF) were enrolled, and pulmonary vein isolation (PVI) and ablation of additional linear lesion sets were performed either in GA or in deep sedation. Pulsed field ablation was applied exclusively to perform ipsilateral PVI. A total of 63 patients (35% female, 75% persistent AF, mean age 64 ± 9 years) were included in the analysis with 23 patients treated in GA and 40 patients in deep sedation. Acute efficacy was comparable in both groups with a PVI rate of 100%. Additional 74 lesion sets were performed in the total cohort. Mean procedure and lab occupancy time in the GA and deep sedation group was 96 ± 24 min vs. 100 ± 23 min (P = 0.52) and 165 ± 40 min vs. 131 ± 35 min (P = 0.0008). Mean dose area product was 489 (216;1093) vs. 452 (272;882) cGycm2 in the GA and the deep sedation group (P = 0.82). There was one conversion from deep sedation to GA. There were no map shifts observed in any group. Pericardial tamponade occurred in one patient of the deep sedation group. Conclusion The use of a novel ablation platform in conjunction with a lattice-tip catheter in deep sedation is feasible, effective, and associated with significantly shorter lab occupancy time when compared with GA. [ABSTRACT FROM AUTHOR]

Backgroundwide antral pulmonary vein isolation (PVI) is effective for treating paroxysmal atrial fibrillation (PAF), although time-demanding. We investigated the impact of a standardized ablation protocol by using a bidirectional transeptal steerable sheath, high-density mapping and very high-power-short-duration (vHPSD) catheters on procedure timing, efficacy, and safety.Methodsconsecutive PAF patients free from previous ablations undergoing PVI alone between January 2022 and March 2023 were prospectively enrolled. The standardized workflow included general anesthesia, a single transeptal puncture trough with a bidirectional, steerable visualizable sheath introduced into the left atrium accommodated a high density, penta-spline mapping catheter and a contact force sensor ablation catheter enabled to deliver vHPSD. Procedural data and electrophysiology (EP) laboratory times were systematically collected and analyzed. The primary endpoint was any AF or atrial tachycardia recurrence at 12 and 24 month follow up.Resultsthe study cohort was composed by 138 patients (mean age was 59 ± 11 years, 38% female) and successful PVI was achieved in 100% of cases. Overall, first pass isolation (PFI) was 93%, with a LA dwell time of 32 ± 4 min. Significant complications were reported in 3% of patients. Skin-to-skin time and total EP laboratory time were 58 ± 5 min and 85 ± 7 min, respectively. The primary endpoint was achieved by 9% and 12% of cases at 12 and 24 month follow up, respectively. Upper limit skin-to-skin time and missed FPI resulted predictors of the primary endpoint.ConclusionThis standardized workflow resulted in low procedural times and arrhythmias recurrence without compromising the safety.

BackgroundEpicardial adipose tissue (EAT) remodeling is associated with atrial fibrillation (AF). However, there is limited research on the contribution of EAT to the risk of AF recurrence (AFR). The purpose of this research was to assess the relationship between the risk of AFR after radiofrequency catheter ablation and the volume and attenuation of the EAT.MethodsWe included a total of 123 consecutive individuals who received AF ablation, 31 of whom suffered AFR. The volume and mean density of the whole-heart and periatrial EAT were measured on computed tomography images using four attenuation ranges. The clinical, atrial, and EAT characteristics of patients with and without AFR were compared. Logistic regression was used to identify independent risk factors and to build a model to predict recurrence. The relationship between EAT characteristics and recurrence was analyzed for the subtypes of AF.ResultsThe AFR group had a larger left atrial anteroposterior diameter (47.4 ± 7.4 vs. 43.7 ± 8.0 mm), left–right diameter (78.6 ± 7.9 vs. 74.7 ± 9.1 mm), and volume (145.9 vs. 127.0 mL) than the non-recurrence group (P = 0.021, 0.037, 0.015, respectively). The total EAT volume in the AFR group was significantly larger than that in the non-recurrence group, for both the overall and persistent AF groups (all P

Background Use of pulmonary vein isolation (PVI) to treat atrial fibrillation continues to increase. Despite great interest in leveraging administrative data for real‐world analyses, contemporary procedural codes for identifying PVI have not been evaluated. Methods and Results In this observational retrospective cohort study, inpatient PVIs were identified among US Medicare fee‐for‐service beneficiaries using Current Procedural Terminology (CPT) code 93656 in Carrier Line Files. Each patient was matched with their claims from Medicare Provider Analysis and Review to compare CPT with International Classification of Diseases, Tenth Revision, Procedure Coding System (ICD‐10‐PCS) claims submitted by health care facilities to bill for PVIs. We performed the reverse for commonly matched ICD‐10‐PCS codes, to identify corresponding CPT‐billed procedures. Finally, we reviewed institutional cases for additional comparison of CPT and ICD‐10‐PCS assignation for PVI. We identified 25 617 inpatient PVIs from January 2017 to December 2021, of which 18 165 (71%) were linked to Medicare Provider Analysis and Review. Of these, 16 672 (92%) were billed as ICD‐10‐PCS 02583ZZ: “Destruction of Conduction Mechanism, Percutaneous Approach.” The reverse process yielded heterogeneous results: among 75 003 procedures billed as ICD‐10‐PCS 02583ZZ, only 15 691 (21%) matched with CPT 93656 (PVI), as several other unrelated procedures were billed under this ICD‐10‐PCS code. Institutional case review confirmed the greater specificity of CPT codes. Conclusions The ICD‐10‐PCS code associated with CPT‐billed PVI procedures actually referred to ablation of the atrioventricular junction. Yet this ICD‐10‐PCS code also matched with a wide range of other procedures distinct from PVI. We conclude that ICD‐10‐PCS codes alone are not sensitive nor specific for identifying PVI in claims and cannot be reliably used in isolation for health services research on this important procedure.

Key Clinical Message: Radiofrequency ablation for atrial fibrillation or atrial flutter is feasible in patients with deep brain stimulation but with extreme caution given the possibility of life‐threatening complications. [ABSTRACT FROM AUTHOR]

Pulmonary vein isolation (PVI), as the cornerstone of atrial fibrillation (AF) ablation, has emerged a widely used therapy for patients suffering from AF. To improve PVI efficiency, single-shot catheters (SSCs) have been developed. Regrettably, SSCs are not integrated into 3D-mapping technology. In that regard, a novel radiofrequency balloon catheter (RFBC, Heliostar, Biosense Webster) with full integration into 3D-mapping technology has been developed. The aim of this study was to assess operative and follow-up outcomes of the RFBC in AF patients. In this monocentric prospective registry, patients with a first-time PVI using the RFBC were included. Follow-up visits were scheduled 3, 6, 12 and 24 months after ablation and in case of symptoms. A total of 171 patients (36.8% female) were included, with a mean age of 68.5 ± 10.2 years. Among them, 63 patients (36.8%) presented with persistent AF. Notably, no major periprocedural complications were observed. The mean follow-up period was 287 ± 157 days. In the Kaplan–Meier analysis, the estimated recurrence-free survival after 12 months was 81.8%. Based on our data, PVI with the fully 3D-mapping-integrated RFBC seems to be safe and effective and to have a favorable 12-month outcome in patients with paroxysmal and persistent AF. [ABSTRACT FROM AUTHOR]

Background: The TactiFlex™ ablation catheter, Sensor Enabled™ (Abbott, Minneapolis, MN, USA), is an open-irrigation radiofrequency (RF) ablation catheter with flexible tip technology. This catheter delivers high-power short-duration (HPSD) RF ablations and has been adopted for atrial fibrillation (AF) ablation. HPSD is well-established not only in pulmonary vein isolation (PVI) but also when targeting extra-pulmonary vein (PV) targets. This study aims to determine the safety, effectiveness, and acute outcomes of PVI plus posterior wall isolation (PWI) in patients with persistent atrial fibrillation (Pe-AF) using HPSD and the TactiFlex™ ablation catheter. Methods: Consecutive patients who underwent the ablation of Pe-AF in our centre between February 2023 and February 2024 were prospectively enrolled in the study. All patients underwent PVI plus PWI using TactiFlex™ and the HPSD strategy. The RF parameters were 50 W on all the PV segments and the roof, and within the posterior wall (PW). Left atrial mapping was performed with the EnSite X mapping system and the high-density multipolar Advisor HD Grid, Sensor Enabled™ mapping catheter. We compared the procedural data using HPSD with TactiFlex™ (n = 52) vs. a historical cohort of patients who underwent PVI plus PWI using HPSD settings and the TactiCath ablation catheter (n = 84). Results: Fifty-two consecutive patients were included in the study. PVI and PWI were achieved in all patients in the TactiFlex™ group. First-pass PVI was achieved in 97.9% of PVs (n = 195/199). PWI was obtained in all cases by delivering extensive RF lesions within the PW. There were no significant differences compared to the TactiCath group: first-pass PVI was achieved in 96.3% of PVs (n = 319/331). Adenosine administration revealed PV reconnection in 5.7% of patients, and two reconnections of the PW were documented. Procedure and RF time were significantly shorter in the TactiFlex™ group compared to the TactiCath group, 73.1 ± 12.6 vs. 98.5 ± 16.3 min, and 11.3 ± 1.5 vs. 23.5 ± 3.6 min, respectively, p < 0.001. The fluoroscopy time was comparable between both groups. No intraprocedural and periprocedural complications related to the ablation catheter were observed. Patients had an implantable loop recorder before discharge. At the 6-month follow-up, 76.8% of patients remained free from atrial arrhythmia, with no significant differences between groups. Conclusions: HPSD PVI plus PWI using the TactiFlex™ ablation catheter is effective and safe. Compared to a control group, the use of TactiFlex™ to perform HPSD PVI plus PWI is associated with a similar effectiveness but with a significantly shorter procedural and RF time.

Background: General anaesthesia (GA) for atrial fibrillation (AF) ablation is often preferred over conscious sedation (CS) to minimize patient discomfort and reduce the risk of map disruption from patient movement but may pose an additional risk to some patients with significant comorbidity or poor cardiac function. Methods: We extracted data for 300 patients who underwent AF ablation between the years 2017 and 2019 and compared the outcomes of AF ablation with CS and GA. Results: Compared to the GA group, patients were younger in the CS group (63 versus 66 years, p = 0.02), had less persistent AF (34% versus 46%, p = 0.048) and the left atrial dimension was smaller (41 versus 45 mm, p = 0.01). More patients had cryoballoon ablation (CBA) than radiofrequency (RFA) ablation in the CS than the GA group (88% CB with CS and 56% RF with GA, p

Background: High-power short-duration (HPSD) radiofrequency (RF) ablation has been adopted to improve atrial fibrillation (AF) ablation. Although the role of HPSD is well-established in pulmonary vein isolation (PVI), fewer data have assessed the impact of HPSD when addressing extra-pulmonary veins (PVs) targets. Therefore, this study aims to determine the safety, effectiveness, and acute outcomes of HPSD lesion index (LSI)-guided posterior wall isolation (PWI) in addition to PVI as an initial strategy in persistent atrial fibrillation (Pe-AF). Methods: Consecutive patients who underwent ablation of Pe-AF in our center between August 2021 and January 2022 were retrospectively enrolled. All patients' ablation strategy was PVI plus PWI using HPSD LSI-guided isolation. RF parameters included 50 W targeting LSI values of ≥5 on the anterior part of the PVs and anterior roofline and ≥4 for the posterior PVs aspect, bottom line, and within the posterior wall (PW). We compared the LSI values with and without acute conduction gaps after the initial first-pass PWI. Left atrial mapping was performed with the EnSite X mapping system and a high-density multipolar Grid-shaped mapping catheter. We compared the procedural characteristics using HPSD (n = 35) vs. a control group (n = 46). Results: Thirty-five consecutive patients were included in the study. PWI on top of PVI was achieved in all cases in the HPSD group. First-pass PVI was achieved in 93.3% of PVs (n = 126/135). First-pass roofline block was obtained in most patients (n = 31, 88.5%), while first-pass block of the bottom line was only achieved in 51.4% (n = 18). There were no significant differences compared to the control group; first-pass PVI was achieved in 94.9% of PVs (n = 169/178), first-pass roofline block in 89.1%, and bottom-line in 45.6% of patients. To achieve complete PWI with HPSD, scattered RF applications within the PW were necessary. No electrical reconnection of the PW was found after adenosine administration and the waiting period. The procedure and RF times were significantly shorter in the HPSD group compared to the control group, with values of 116.2 ± 10.9 vs. 144.5 ± 11.3 min, and 19.8 ± 3.6 vs. 26.3 ± 6.4 min, respectively, p < 0.001. Fluoroscopy time was comparable between both groups. No procedural complications were observed. At the 12-month follow-up, 71.4% of patients remained free from AF, with no differences between the groups. Conclusions: HPSD LSI-guided PWI on top of PVI seems effective and safe. Compared to a control group, HPSD is associated with similar rates of first-pass PWI and PVI but with a shorter procedural and RF time. [ABSTRACT FROM AUTHOR]

High-power short-duration (HPSD) ablation is an increasingly used ablation strategy for pulmonary vein isolation (PVI) procedures, but Lesion Index (LSI)-guided HPSD radiofrequency (RF) applications have not been described in this clinical setting. We evaluated the procedural efficiency and safety of an LSI-guided HPSD strategy for atrial fibrillation (AF) ablation. Paroxysmal and persistent AF patients scheduled for AF ablation were prospectively enrolled and divided into two groups, according to the ablation power used (≥45 W for the LSI-HP Group and ≤40 W for the LSI-LP group). All patients underwent only PVI LSI-guided ablation (5.5 to 6 anteriorly; 5 to 5.5 superiorly, 4.5 to 5 posteriorly) with a point-by-point strategy and an inter-lesion distance <6 mm. Forty-six patients with AF (25 in the LSI-HP Group vs 21 in the LSI-LP Group)—59% paroxysmal, 78% male, with low-intermediate CHA2DS2-Vasc scores (2 [1–3]), a preserved ejection fraction (65 ± 6%) and a mean left atrial index volume of 39 ± 13 mL/m2 were prospectively enrolled. Baseline clinical characteristics were comparable between groups. PVI was successful in all patients. The RF time (29 (23–37) vs. 49 (41–53) min, p < 0.001), total procedure time (131 (126–145) vs. 155 (139–203) min, p = 0.007) and fluoroscopy time (12 (10–18) vs. 21 (16–26) min, p = 0.001) were significantly lower in the LSI-HP Group. No complications or steam pops were seen in either group. LSI-HP AF ablation significantly improved procedural efficiency—reducing ablation time, total procedural duration, and fluoroscopy use, while maintaining a comparable safety profile to lower-power procedures. [ABSTRACT FROM AUTHOR]

IntroductionAtrial fibrillation (AF) is the main cause of cardioembolic stroke. In high-bleeding-risk patients, long-life anticoagulation therapy is not permitted, and left atrial appendage (LAA) closure may be considered. LAA is also a critical substrate for AF. Epicardial LAA occlusion has several advantages: LAA ligation results in a favorable electrical and structural atrial remodeling, which decreases AF recurrence. Endocardial ablation alone is not efficient for all patients, and new evidence shows better outcomes in patients affected by persistent AF after a combined hybrid endo-epicardial ablation. Considering the synergic potential of these techniques, in this case series, they were both combined in a single procedure.Methods and resultsWe describe the treatment of 5 patients referred for refractory AF ablation and LAA closure. All patients had high thrombotic and previous major hemorrhage, with relative contraindication to life-long therapy with anticoagulation. A combined procedure of LAA ligation and endo-epicardial ablation was scheduled with short-term anticoagulation. LAA closure was performed with an epicardial approach using the LARIAT system. Then, LA mapping and ablation were performed, endocardially and then epicardially.All procedures were concluded without complications.At follow-up, in all patients, transesophageal echocardiography showed the complete occlusion of the LAA; therefore, anticoagulation therapy was interrupted. All patients were asymptomatic, and in the sinus rhythm, no hemorrhage or ischemic events occurred.ConclusionThe combination of percutaneous LAA ligation and endo-epicardial ablation was revealed to be feasible and safe and might represent a new approach for the treatment of refractory AF in patients with indication of LAA occlusion.

Common atrium (CA), also called three‐chambered heart, is one of the rare congenital anomalies, defined by a complete absence of the atrial septum, eventually associated with malformation of the atrioventricular (AV) valves. We report the case of a 57‐year‐old woman with CA complicated with Eisenmenger syndrome and inferior vena cava interruption, who suffered from symptomatic persistent atrial fibrillation (AF). She underwent an initial successful pulmonary vein isolation procedure. A repeat procedure for perivalvular atrial flutter was complicated with inadvertent complete AV block, due to unusual AV node location in this challenging anatomy. [ABSTRACT FROM AUTHOR]

Abstract Background The hybrid approach has become the most effective treatment option for restoring sinus rhythm and reducing the risk of atrial fibrillation (AF) recurrence. However, several issues remain to be clearly defined, including the appropriate timing of the staged procedure and the most effective strategy. Methods Over a 12-year period of activity, we performed 609 AF ablation procedures via a right mini-thoracotomy. From this general population, 60 patients underwent a hybrid procedure with catheter ablation performed at least 4 weeks after the surgical procedure to confirm if effective complete electrical isolation of pulmonary veins was achieved. In 20 patients, the second stage procedure was performed during the same hospitalization due to patient’s electrical instability. The results obtained in immediate versus staged patients were compared. Results All patients were discharged after the first stage procedure in sinus rhythm. The 20 immediate patients had a shorter hospital stay compared with the staged patients, in whom the two hospitalizations resulted in a longer hospital stay (immediate 5.5 ± 1.6 days versus staged 8.7 ± 1.4, P

Abstract Common atrium (CA), also called three‐chambered heart, is one of the rare congenital anomalies, defined by a complete absence of the atrial septum, eventually associated with malformation of the atrioventricular (AV) valves. We report the case of a 57‐year‐old woman with CA complicated with Eisenmenger syndrome and inferior vena cava interruption, who suffered from symptomatic persistent atrial fibrillation (AF). She underwent an initial successful pulmonary vein isolation procedure. A repeat procedure for perivalvular atrial flutter was complicated with inadvertent complete AV block, due to unusual AV node location in this challenging anatomy.

AimsSupraventricular tachycardias may trigger atrial fibrillation (AF). The aim of the study was to evaluate the prevalence of supraventricular tachycardia (SVT) inducibility in patients referred for AF ablation and to evaluate the effects of SVT ablation on AF recurrences.Methods and results249 patients (mean age: 54 ± 14 years) referred for paroxysmal AF ablation were studied. In all patients, only AF relapses had been documented in the clinical history. 47 patients (19%; mean age: 42 ± 11 years) had inducible SVT during the electrophysiological study and underwent an ablation targeted only at SVT suppression. Ablation was successful in all 47 patients. The ablative procedures were: 11 slow-pathway ablations for atrioventricular nodal re-entrant tachycardia; 6 concealed accessory pathway ablations for atrioventricular re-entrant tachycardia; 17 focal ectopic atrial tachycardia ablations; 13 with only one arrhythmogenic pulmonary vein. No recurrences of SVT were observed during the follow-up (32 ± 18 months). 4 patients (8.5%) showed recurrence of at least one episode of AF. Patients with inducible SVT had less structural heart disease and were younger than those without inducible SVT.ConclusionA significant proportion of candidates for AF ablation are inducible for an SVT. SVT ablation showed a preventive effect on AF recurrences. Those patients should be selected for simpler ablation procedures tailored only to the triggering arrhythmia suppression.

Pulmonary vein stenosis (PVS) can arise from several etiologies, including congenital, acquired, and iatrogenic sources. PVS presents insidiously, leading to significant delays in diagnosis. A high index of suspicion and dedicated noninvasive evaluation are key to diagnosis. Once diagnosed, both noninvasive and invasive evaluation may afford further insights into the relative contribution of PVS to symptoms. Treatment of underlying reversible pathologies coupled with transcatheter balloon angioplasty and stenting for persistent severe stenoses are established approaches. Ongoing refinements in diagnostic modalities, interventional approaches, postintervention monitoring, and medical therapies hold promise to further improve patient outcomes. [Display omitted] • PVS has various etiologies, and symptoms may overlap those of other conditions. • It is important to manage reversible underlying etiologies of PVS. • Transcatheter interventions may improve symptoms and clinical outcomes in patients with PVS. [ABSTRACT FROM AUTHOR]

Background Although the rate of vascular complications following catheter ablation has been decreasing in the past 10 years, it remains a common and thorny problem in clinical settings. For the majority of iatrogenic pseudoaneurysms (PSAs), non-surgical therapeutic approaches such as ultrasound-guided compression repair (UGCR) and ultrasound-guided thrombin injection (UGTI) have been used as first-line regimens. However, suitable treatment for PSA mainly depends on the characteristics of the PSA. Case summary This report presented the case of a 75-year-old woman who suffered from a beaded multi-chamber femoral PSA combined with arteriovenous fistula between the superficial femoral artery and the common femoral vein following radiofrequency ablation of atrial fibrillation. The treatment process of the PSA was tortuous. After a UGCR attempt, the PSA was not occluded. The UGTI successfully clotted the superficial and middle chambers of the PSA. After repeat UGCR, the residual deep chamber of the PSA was expanded, and the skin deteriorated. The complicated PSA was finally treated with surgical repair. Discussion Appropriate treatment for PSA depends on the anatomical characteristics of the PSA and indications of various treatment measures. [ABSTRACT FROM AUTHOR]

Background Atrial septal defect (ASD) is associated with a risk of developing atrial fibrillation (AF) higher than in the general population, even after percutaneous or surgical septal closure. Catheter ablation is an effective treatment strategy for preventing recurrences and reducing the AF burden. However, electrophysiologists are faced with technical difficulties and the risk of complications with the left atrium access in patients with prior ASD percutaneous closure. Case summary We report a case of a patient with highly symptomatic paroxysmal AF, with an ASD, closed percutaneously many years before, who underwent a successful catheter AF ablation, using a single transeptal (TSP) approach guided by transesophageal echocardiography (TEE). Discussion In patients with ASD and an occluder device implanted, there is a potential risk for septal tear during the TSP passage, device dislodgement, or thrombus formation on the device. Atrial fibrillation ablation in this subset of patients has often been protracted and scarcely reported. TEE and intra-cardiac echocardiography have been increasingly used for interventional procedure guidance during AF ablation. As described here, AF ablation using a simplified single TSP guided by TEE is feasible, safe, and effective after device ASD closure. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) is the most common supraventricular arrhythmia. Despite significant advances in its treatment, it still remains one of the leading causes of cardiovascular morbidity and mortality. In the last two decades, pulmonary vein isolation (PVI) was developed as the most effective treatment option. The reported effectiveness of a single ablation procedure ranges from 40% to 69% with single, and up to 88% with repeated procedures, with acceptable safety profile. The PubMed database was searched, using terms including ‘atrial fibrillation ablation’, ‘pulmonary vein isolation’, ‘computed tomography’, ‘pulmonary vein anatomy’ and ‘ovality index’. Papers were reviewed for relevance and scientific merit. Different imaging techniques are used for pre-procedural assessment of left atrial (LA) anatomy, of which computed tomography (CT) is the most common. It allows assessing pulmonary vein (PV) anatomy, the LA wall thickness in different regions and the left atrial appendage (LAA) anatomy, together with excluding the presence of intracardiac thrombi. Pre-procedural PVs imaging is important regardless of the selected ablation technique, however, cryoballoon (CB) ablation seems to be particularly anatomy-dependent. Additionally, CT also permits assessment of several PVs characteristics (geometry, dimensions, angulations, the ostium area, orientation and ovality index (OI), which are essential for the patients’ qualification and designing the strategy of AF ablation. In this paper, we have reviewed the role of CT imaging in patients undergoing ablation procedure due to recurrent/symptomatic atrial fibrillation. Moreover, we discussed the relevant literature.

AimsTo test the feasibility of postprocedural photoplethysmography (PPG) rhythm telemonitoring during the first week after atrial fibrillation (AF) ablation and its predictive value for later AF recurrence.MethodsPPG rhythm telemonitoring during the first week after the ablation procedure was offered to a total of 382 consecutive patients undergoing AF ablation. Patients were instructed to perform 1 min PPG recordings by a mobile health application 3 times per day and in case of symptoms. Clinicians assessed the PPG tracings via a secured cloud and the information was remotely integrated into the therapeutic pathway via teleconsultation (TeleCheck-AF approach).Results119 patients (31%) agreed to perform PPG rhythm telemonitoring after ablation. Patients included in the TeleCheck-AF approach were younger compared to those who declined participation (58 ± 10 vs. 62 ± 10 years, p

BackgroundCatheter ablation (ABL) for non-valvular (NV) atrial fibrillation (AF) improves rhythm control. Our aim was to compare re-hospitalization for heart failure (HF), acute coronary syndrome (ACS), or recurrent AF among patients with NVAF who underwent ABL versus controls.MethodsFrom the Office of Statewide Planning and Development (OSHPD) database, we identified all patients who had at least one hospitalization for AF between 2005-2013. Patients who subsequently underwent ABL were compared to controls (up to fivematched controls by age, sex and duration of AF between diagnosis and time of ABL). Cases with valve disease, open maze, other arrhythmias, or implanted cardiac devices were excluded. Pre-specified clinical outcomes including readmission for HF, ACS, severe or simple AF (severe = with HF or ACS; simple= without HF or ACS)were assessed using a weighted proportional hazard model adjusting for number of hospital admissions with AF before the ABL, calendar year of ABL, and presence of chronic comorbidities.ResultsThe study population constituted 8338 cases and controls, with mean 3.5+ 1 patient-year follow up. In the ABL cohort, there was lower risk of re-hospitalizations for HF, HR=0.55(95%CI: 0.43-0.69,); ACS,HR=0.5(95%CI: 0.35-0.72,); severe AF [HR=0.86 (CI:0.74-0.99), and higher for simple AF, HR=1.25 (CI:1.18-1.33).ConclusionsIn patients with NVAF,although ABL is associated with increased risk of re-hospitalization for simple AF, ABL was associated with a significant reduction in the risk of re-hospitalization for HF, ACS and severe AF. These findingsrequireconfirmation in a prospective clinical trial.

Introduction: Transcatheter atrial fibrillation (AF) ablation is still carried out with continuous invasive radial arterial blood pressure (IBP) monitoring in many centers. Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a noninvasive alternative method used in ICU. No data on CNBP reliability are available in the electrophysiology lab during AF ablation, where rhythm variations are common. Background: The objective of the present study was to compare continuous noninvasive arterial pressure measured with the ClearSight device (Edwards Lifesciences, Irvine, CA, USA) with invasive radial artery pressure used as the reference method during AF ablation. Methods: We prospectively enrolled 55 consecutive patients (age 62 ± 11 years, 80% male) undergoing transcatheter AF ablation (62% paroxysmal, 38% persistent) at our center. Standard of care IBP monitoring via a radial cannula and a contralateral noninvasive finger volume-clamp CNBP measurement device were positioned simultaneously in all patients for the entire procedure. Bland-Altman analysis was used to analyze the agreement between the two techniques. Results: A total of 1219 paired measurements for systolic, diastolic, and mean arterial pressure were obtained in 55 subjects, with a mean (SD) of 22 (9) measurements per patient. The mean bias (SD) was −12.97 (13.89) mmHg for systolic pressure (level of agreement −14.24–40.20; correlation coefficient 0.84), −1.85 (8.52) mmHg for diastolic pressure (level of agreement −18.54–14.84; correlation coefficient 0.77) and 2.31 (8.75) mmHg for mean pressure (level of agreement −14.84–19.46; correlation coefficient 0.85). Conclusion: In patients undergoing AF ablation, CNBP monitoring with the ClearSight device showed acceptable agreement with IBP monitoring. Larger studies are needed to confirm the potential clinical implications of continuous noninvasive BP monitoring during AF ablation. [ABSTRACT FROM AUTHOR]

Background: Unfractionated heparin (UFH) is used as an anticoagulant during the atrial fibrillation (AF) ablation procedure to prevent the occurrence of thromboembolic events. Guidelines recommend an activated clotting time (ACT) greater than 300 s (s) based on studies of patients treated with vitamin K antagonist (VKA) for their AF. However, direct oral anticoagulants (DOACs) have supplanted VKAs in AF and are now used as first-line therapy. It is recommended not to interrupt them during the procedure, which could interfere with the ACT measures. Objective: To assess the real-life relationship between ACT, DOAC concentrations, and UFH anti-Xa activity in patients treated by uninterrupted DOAC therapy. Methods: We conducted a single-center retrospective study. We analyzed consecutive patients with AF who underwent catheter ablation under DOAC therapy. Results: In total, 40 patients were included, including 15 (37.5%), 20 (50.0%), and 5 (12.5%) on rivaroxaban, apixaban, and dabigatran, respectively. Baseline ACT was significantly lower in the apixaban group. ACT was linearly correlated with the residual concentration of apixaban and dabigatran but not with rivaroxaban. After UFH injection, ACT was linearly correlated with the anti-Xa activity, regardless of DOAC. Patients in the apixaban group received a higher total dose of UFH during the procedure to achieve a target ACT > 300 s, which resulted in significantly higher anti-Xa activity during the procedure. Conclusion: Our results raise the question of optimal management of intra-procedural heparin therapy and highlight the limitations of the ACT test, particularly in patients on apixaban. [ABSTRACT FROM AUTHOR]

Background: Durable pulmonary vein isolation (PVI) is recommended for symptomatic paroxysmal atrial fibrillation (AF) treatment, but it has been demonstrated that it may not be enough to treat persistent AF (Pe-AF). Therefore, posterior wall isolation (PWI) is among the strategies adopted on top of PVI to treat Pe-AF patients. However, PWI using contiguous and optimized radiofrequency lesions remains challenging, and few studies have evaluated the impact of the Ablation Index (AI) on the efficacy of PWI. Moreover, previous papers did not evaluate arrhythmia recurrences using continuous monitoring. Methods: This is a prospective, observational, single-center study on patients affected by Pe-AF undergoing treated PVI plus AI-guided PWI. Procedures were performed using the CARTO mapping system, SmartTouch SF ablation catheter, and PentaRay multipolar mapping catheter. The AI settings were 500–550 for the anterior PV aspect and roofline, while the settings were 450–500 for the posterior PV aspect, bottom line, and/or PW lesions. All patients received an implantable loop recorder (ILR). All patients underwent clinical evaluation in the outpatient clinic at 1, 3, 6, 12, 18, and 24 months. A standard 12-lead ECG was performed at each visit, and device data from the ILR were reviewed to assess for arrhythmia recurrence. Results: Between January 2021 and December 2021, forty-one consecutive patients underwent PVI plus PWI guided by AI at our center and were prospectively enrolled in the study. PVI was achieved in all patients, first-pass roofline block was obtained in 82.9% of the patients, and first-pass block of the bottom line was achieved in 36.5% of the patients. In 39% of the patients, PWI was not performed with a "box-only" lesion set, but with scattered lesions across the PW to achieve PWI. AI on the anterior aspect of the left PVs was 528 ± 22, while on the posterior aspect of the left PVs, it was 474 ± 18; on the anterior aspect of the right PVs, it was 532 ± 27, while on the posterior aspect of the right PVs, it was 477 ± 16; on the PW, AI was 468 ± 19. No acute complications occurred at the end of the procedure. After the blanking period, 70.7% of the patients reported no arrhythmia recurrence during the 12-month follow-up period. Conclusions: In patients with Pe-AF undergoing catheter ablation, PWI guided by AI seems to be an effective and feasible strategy in addition to standard PVI. [ABSTRACT FROM AUTHOR]

Aims The aim of this study was to compare procedural efficacy and safety, including 1-year freedom from AF recurrence, between the novel cryoballoon system PolarX (Boston Scientific) and the Arctic Front Advance Pro (AFA-Pro) (Medtronic), in patients with paroxysmal AF undergoing PVI. Methods and results This multicentre prospective observational study included 267 consecutive patients undergoing a first cryoablation procedure for paroxysmal AF (137 PolarX, 130 AFA-Pro). Kaplan-Meier curves with the log-rank test was used to compare the 1-year freedom from AF recurrence between both groups. Multivariate Cox model was performed to evaluate whether the type of procedure (PolarX vs. AFA-Pro) had an impact on the occurrence of AF recurrences after adjustment on potentially confounding factors. The PolarX reaches lower temperatures than the AFA-Pro (LSPV 52 ± 5, vs. 59 ± 6; LIPV 49 ± 6 vs. 56 ± 6; right superior pulmonary vein: 49 ± 6 vs. 57 ± 7; right inferior pulmonary vein: 52 ± 6 vs. 59 ± 6; P < 0.0001). A higher rate of transient phrenic nerve palsy was found in patients treated with the PolarX system (15% vs. 7%, P = 0.05). After a mean follow-up of 15 ± 5 months, 20 patients (15%) had recurrences in AFA-Pro group and 27 patients (19%) in PolarX group (P = 0.35). Based on survival analysis, no significant difference was observed between both groups with a 12-month free of recurrence survival of 91.2% (85.1–95.4%) vs. 83.7% (76.0%–89.1%) (log-rank test P = 0.11). In multivariate Cox model hazard ratio of recurrence for PolarX vs. AFA-Pro was not significant [HR = 1.6 (0.9–2.8), P = 0.12]. Conclusion PolarX and AFA-Pro have comparable efficacy and safety profiles for pulmonary veins isolation in paroxysmal atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background: One of the reasons that high-frequency jet ventilation (HFJV) is used is due to the near immobility of thoracic structures. However, no study has quantified the movements of cardiac structures during HFJV compared with normal mechanical ventilation. Methods: After ethical approval and written informed consent, we included 21 patients scheduled for atrial fibrillation ablation in this prospective crossover study. Each patient was ventilated with both normal mechanical ventilation and HFJV. During each ventilation mode, displacements of the cardiac structure were measured by the EnSite Precision mapping system using a catheter placed in the coronary sinus. Results: The median [Q1–Q4] displacement was 2.0 [0.6–2.8] mm during HFJV and 10.5 [9.3–13.0] mm during conventional ventilation (p < 0.000001). Conclusion: This study quantifies the minimal movement of cardiac structures during HFJV compared to standard mechanical ventilation. [ABSTRACT FROM AUTHOR]

Atrial fibrillation is one of the most common supraventricular arrhythmias. It has multiple etiologies, some of which include advanced age, hypertension, valvular heart disease, hyperthyroidism, sleep apnea, ischemic heart disease, cardiomyopathy, and certain medications. Herein, we will discuss a case of extensive atrial fibrosis in a 57-year-old male with recalcitrant atrial fibrillation, the significant role extensive atrial fibrosis plays in the recurrence of atrial fibrillation, a brief pathophysiologic interplay between both pathologies based on current literature and research, and various imaging modalities and treatment options utilized in these cases. Likewise, we will also outline some challenges faced or worth keeping in mind when using the various imaging modalities pertaining to the above subject matter., Competing Interests: Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2025, Asuka et al.)

Aims Left atrial ablation using radiofrequency (RF) is associated with endoscopically detected thermal oesophageal lesions (EDELs). The aim of this study was to compare EDEL occurrence after conventional contact force-guided (CFG) RF ablation vs. an ablation index-guided (AIG) approach in clinical routine of voltage-guided ablation (VGA). Predictors of EDEL were also assessed. Methods and results This study compared CFG (n = 100) with AIG (n = 100) in consecutive atrial fibrillation ablation procedures, in which both pulmonary vein isolation and VGA were performed. In the AIG group, AI targets were ≥500 anteriorly and ≥350–400 posteriorly. Upper endoscopy was performed after ablation.The CFG and AIG groups had comparable baseline characteristics. The EDEL occurred in 6 and 5% (P = 0.86) in the CFG and AIG groups, respectively. Category 2 lesions occurred in 4 and 2% (P = 0.68), respectively. All EDEL healed under proton pump inhibitor therapy. The AI > 520 was the only predictor of EDEL [odds ratio (OR) 3.84; P = 0.039]. The more extensive Category 2 lesions were predicted by: AI max > 520 during posterior ablation (OR 7.05; P = 0.042), application of posterior or roof lines (OR 5.19; P = 0.039), existence of cardiomyopathy (OR 4.93; P = 0.047), and CHA2DS2-VASc score (OR 1.71; P = 0.044). The only Category 2 lesion with AI max < 520 (467) occurred in a patient with low body mass index. Conclusions Both methods were comparable with respect to clinical complications and EDEL. In consideration of previous reconnection data and our study results regarding oesophageal safety, optimal AI target range might be between 400 and 450. [ABSTRACT FROM AUTHOR]

Background: The hybrid approach has become the most effective treatment option for restoring sinus rhythm and reducing the risk of atrial fibrillation (AF) recurrence. However, several issues remain to be clearly defined, including the appropriate timing of the staged procedure and the most effective strategy.Methods: Over a 12-year period of activity, we performed 609 AF ablation procedures via a right mini-thoracotomy. From this general population, 60 patients underwent a hybrid procedure with catheter ablation performed at least 4 weeks after the surgical procedure to confirm if effective complete electrical isolation of pulmonary veins was achieved. In 20 patients, the second stage procedure was performed during the same hospitalization due to patient's electrical instability. The results obtained in immediate versus staged patients were compared.Results: All patients were discharged after the first stage procedure in sinus rhythm. The 20 immediate patients had a shorter hospital stay compared with the staged patients, in whom the two hospitalizations resulted in a longer hospital stay (immediate 5.5 ± 1.6 days versus staged 8.7 ± 1.4, P < 0.001). A significantly higher number of immediate patients had an associated ablation of the Bachmann's bundle (n = 16 in the immediate group [80%] versus n = 14 in the staged group [45%]; P = 0.001). After a mean follow-up of 74 months, there was no significant difference in the risk of AF relapse between groups (immediate 1/20 [5%] versus staged 7/40 [17.5%]; P = 0.18).Conclusion: The hybrid approach for the treatment of AF was safe and effective in immediate restoring sinus rhythm and in its maintenance at follow-up. Our preliminary results show that both immediate and staged procedures show similar efficacy but this result is strongly influenced by the concomitant ablation of the Bachmann's bundle, which appears to be the most important component of the treatment strategy in order to reduce the risk of recurrent AF. [ABSTRACT FROM AUTHOR]

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Abstract Background Recent randomized controlled trials (RCTs) suggest that ablation is superior to antiarrhythmic drugs (AADs) as an initial therapy for paroxysmal atrial fibrillation (pAF) to prevent arrhythmia recurrences. We performed an updated meta‐analysis of RCTs, to include recent data from cryoballoon‐based ablation and to compare arrhythmia‐free survival and adverse events between ablation and AADs. Methods We searched MEDLINE and EMBASE from inception to December 2020. We included RCT comparing patients with pAF undergoing ablation or receiving AADs as an initial therapy. We combined data using the random‐effects model to calculate hazards ratio (HR) for arrhythmia‐free survival and odds ratio (OR) for adverse events. Results Five studies from 2005 to 2020 involving 985 patients were included (495 patients and 490 patients underwent ablation and medication as initial therapy, respectively). Patients who underwent ablation had higher freedom from atrial tachyarrhythmias (ATs) during the 12‐24 months follow‐up period (pooled HR = 0.48, 95% CI: 0.40‐0.59, P

BackgroundThe novel DiamondTemp™ (DT)-catheter (Medtronic®) was designed for high-power, short-duration ablation in a temperature-controlled mode.AimTo evaluate the performance of the DT-catheter for ablation of the mitral isthmus line (MIL) using two different energy dosing strategies.Materials and methodsTwenty patients with recurrence of atrial fibrillation (AF) and/or atrial tachycardia (AT) following pulmonary vein (PV) isolation were included. All patients underwent reisolation of PVs in case of electrical reconnection and ablation of a MIL using the DT-catheter. Application durations of 10 (group A, n = 10) or 20 s (group B, n = 10) were applied. If bidirectional block was not reached with endocardial ablation, additional ablation from within the coronary sinus (CS) was conducted.ResultsIn 19/20 (95%) patients, DT ablation of the MIL resulted in bidirectional block. Mean procedure and fluoroscopy time, and dose area product did not differ significantly between the two groups. In group B, fewer radiofrequency applications were needed to achieve bidirectional block of the MIL when compared to group A (26 ± 12 vs. 42 ± 17, p = 0.04). Ablation from within the CS was performed in 8/10 patients (80%) of group A and in 5/10 (50%) patients of group B (p = 0.34). No major complication occurred.ConclusionMitral isthmus line ablation with use of the DT-catheter is highly effective and safe. Longer radiofrequency-applications appear to be favorable without compromising safety.

Abstract Introduction There are several prognostic scores for the assessment of risk of atrial fibrillation (AF) recurrence post ablation procedure. However, the use of these complex scores is difficult and the validation on different populations brought divergent results. Our goal was to compare the performance of these risk scores as the basis for the development of a new, simplified score based only on few universally predictive variables. Methods All cryoballoon‐based AF ablations performed in a single‐center over a 10‐year period were prospectively analyzed with regard to AF recurrence. This served to analyze the performance of APPLE, CAAP‐AF, SCALE‐CryoAF, MB‐LATER, CHADS2, and CHA2DS2‐VASc risk scores. Results A total of 597 patients, mostly (78.1%) with paroxysmal AF were studied. Analyzed risk scores performed poorer than in the original publications because some risk factors were not predictive of AF recurrence. A simplified score named 0‐1‐2 PL, composed of just two universally predictive variables, AF type (1 point for Persistent AF) and LA dimension (1 point for LA size >45 mm) was developed. The 0‐1‐2 PL score stratified patients into low risk (0 points), intermediate risk (1 point), and high risk categories (2 points) which were related to a 2‐year risk of AF recurrence of 21%, 37%, and 55%, respectively. This score had C‐statistics (0.620) higher/comparable to other investigated much more complex scores. Conclusion The assessment of risk of AF recurrence at the pre‐ablation stage can be simplified without compromising accuracy. This could help to popularize risk assessment and standardization of AF management.

Background: The randomized EAST-AFNET4 (Early Treatment of Atrial Fibrillation for Stroke Prevention Trial-Atrial Fibrillation Network) demonstrated that early rhythm control (ERC) reduces adverse cardiovascular outcomes in patients with recently diagnosed atrial fibrillation and stroke risk factors. The effectiveness and safety of ERC in patients with multiple cardiovascular comorbidities is not known.Methods: These prespecified subanalyses of EAST-AFNET4 compared the effectiveness and safety of ERC with usual care (UC) stratified into patients with higher (CHA2DS2-VASc score ≥4) and lower comorbidity burden. Sensitivity analyses ignored sex (CHA2DS2-VA score).Results: EAST-AFNET4 randomized 1093 patients with CHA2DS2-VASc score ≥4 (74.8±6.8 years, 61% female) and 1696 with CHA2DS2-VASc score <4 (67.4±8.0 years, 37% female). ERC reduced the composite primary efficacy outcome of cardiovascular death, stroke, or hospitalization for worsening of heart failure or for acute coronary syndrome in patients with CHA2DS2-VASc score ≥4 (ERC, 127/549 patients with events; UC, 183/544 patients with events; hazard ratio [HR], 0.64 [0.51-0.81]; P < 0.001) but not in patients with CHA2DS2-VASc score <4 (ERC, 122/846 patients with events; UC, 133/850 patients with events; HR, 0.93 [0.73-1.19]; P=0.56, Pinteraction=0.037). The primary safety outcome (death, stroke, or serious adverse events of rhythm control therapy) was not different between study groups in patients with CHA2DS2-VASc score ≥4 (ERC, 112/549 patients with events; UC, 132/544 patients with events; HR, 0.84 [0.65, 1.08]; P=0.175), but occurred more often in patients with CHA2DS2-VASc scores <4 randomized to ERC (ERC, 119/846 patients with events; UC, 91/850 patients with events; HR, 1.39 [1.05-1.82]; P=0.019, Pinteraction=0.008). Life-threatening events or death were not different between groups (CHA2DS2-VASc score ≥4, ERC, 84/549 patients with event, UC, 96/544 patients with event; CHA2DS2-VASc scores <4, ERC, 75/846 patients with event, UC, 73/850 patients with event). When female sex was ignored for the creation of higher and lower risk groups (CHA2DS2-VA score), the Pinteraction was not significant for the primary efficacy outcome (P=0.25), but remained significant (P=0.044) for the primary safety outcome.Conclusions: Patients with recently diagnosed atrial fibrillation and CHA2DS2-VASc score ≥4 should be considered for ERC to reduce cardiovascular outcomes, whereas those with fewer comorbidities may have less favorable outcomes with ERC.Registration: URL: https://www.Clinicaltrials: gov; Unique identifier: NCT01288352. URL: https://www.clinicaltrialsregister.eu; Unique identifier: 2010-021258-20. URL: https://www.isrctn.com/; Unique identifier: ISRCTN04708680. [ABSTRACT FROM AUTHOR]

Minimally invasive mitral valve repair and ablation of atrial fibrillation, combined with FVIII level‐controlled replacement therapy, can be safely performed in patients with severe hemophilia. [ABSTRACT FROM AUTHOR]

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation ablation. Radiofrequency ablation has been the most common source of energy used to achieve PVI until now. In recent years, cryoballoon ablation has gained popularity due to its ability to perform PVI in a 'single-shot' fashion. In both cases (radiofrequency and cryoablation), the main limitation is their inability to achieve durable lesions without causing collateral damage to adjacent structures. In contrast, pulsed electric field (PEF) ablation is a non-thermal energy source that causes cell apoptosis by applying an electric current to the tissue. Lesions created by a field of energy seem to be more contiguous than traditional ablation, and the risk of damage to adjacent tissues is largely avoided due to the properties of the tissues and electrical fields. In recent years, new catheters capable of delivering PEF have been developed and are now undergoing clinical testing. In this article, we describe a complete solution for PVI: a single multielectrode catheter with 3D mapping capabilities that can deliver PEF in a single-shot PVI fashion with targeting beyond the pulmonary veins. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is associated with anatomical and electrical remodeling. Some patients with AF have concomitant sick sinus syndrome and may need permanent pacemaker (PPM) implantation. Association between catheter ablation of AF timing and need for PPM in sick sinus syndrome has not been assessed. Methods and Results We used pooled electronic health data to perform retrospective cross‐sectional analysis of 66, 595 patients with AF and sick sinus syndrome to assess the need of PPM implantation temporally, with AF performed divided into earlier within 5 years (group 1), 5 to 10 years (group 2), or beyond 10 years (group 3) of diagnosis. PPM implantation was lowest among those who had catheter ablation within 5 years of sick sinus syndrome diagnosis: group 1 versus group 2 (18.15% versus 27.21%) and group 1 versus group 3 (18.15% versus 27.22%). Interestingly, there was no difference in risk of PPM between group 2 and group 3 (27.21% versus 27.22%; odds ratio [OR], 1.00 [95% CI, 0.85–1.20]). Conclusions Even after controlling known risk factors that increase the need for pacemaker implantation, timing of AF ablation was the strongest predictor for need for PPM. Patients adjusted OR of PPM was lower if patients had catheter ablation within 5 years of diagnosis compared with later than 5 years (adjusted OR, 0.64 [95% CI, 0.59–0.70]).

Background: Pulmonary veins isolation (PVI) is a standard treatment for recurrent atrial fibrillation (AF). Uninterrupted anticoagulation for a minimum of 3 weeks before ablation and exclusion of left atrial (LA) thrombus with transesophageal echography (TEE) immediately before or during the procedure minimize peri-procedural risk. We aimed to demonstrate the utility of cardiac tomography (CT) and cardiac magnetic resonance (CMR) to rule out LA thrombus prior to PVI. Methods: Patients undergoing PVI for recurrent AF were retrospectively evaluated. Only patients that started anticoagulation at least 3 weeks prior to the CT/CMR and subsequently uninterrupted until the ablation procedure were selected. An intracardiac echo (ICE) catheter was used in all patients to evaluate LA thrombus. The results of CT/CMR were compared to ICE imaging. Results: We included 272 consecutive patients averaging 54.5 years (71% male; 30% persistent AF). Average CHA2DS2VASC score was 0.9 ± 0.83 and mean LA diameter was 42 ± 5.7 mm, 111 (41%) patients were on Acenocumarol and 161 (59%) were on direct oral anticoagulants. Anticoagulation was started 227 ± 392 days before the CT/CMR, and 291 ± 416 days before the ablation procedure. CT/CMR diagnosed intracardiac thrombus in two cases, both in the LA appendage. A new CT/CMR revealed resolution of thrombus after six additional months of uninterrupted anticoagulation. No macroscopic thrombus was observed in any patients with ICE (negative predictive value of 100%; p < 0.01). Conclusions: CT and MRI are excellent surrogates to TEE and ICE to rule out intracardiac thrombus in patients adequately anticoagulated prior AF ablation. This is true even for delayed procedures as long as anticoagulation is uninterrupted. [ABSTRACT FROM AUTHOR]

The identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification. The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF as a predictor of AF recurrence within a year after successful catheter ablation. From a total of 138 consecutive patients scheduled for AF ablation, 12-lead ECG and 10 min vectorcardiogram (VCG) recordings were obtained. Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24–4.44, p: 0.010), along with prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score. Multivariate analysis of assessable predictors before ablation revealed that B2B P-wave index, along with heart failure history and a history of previous stroke or transient ischemic attack, are independent predicting factors of atrial fibrillation recurrence. Further studies are needed to assess the predictive value of the B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis. [ABSTRACT FROM AUTHOR]

This network meta-analysis was performed to rank the safety and efficacy of periprocedural anticoagulant strategies in patients undergoing atrial fibrillation ablation. MEDLINE, EMBASE, CENTRAL, and Web of Science were searched to identify randomized controlled trials comparing anticoagulant regimens in patients undergoing atrial fibrillation ablation up to July 1, 2021. The primary efficacy and safety outcomes were thromboembolic and major bleeding events, respectively, and the net clinical benefit was investigated as the primary-outcome composite. Seventeen studies were included (n = 6950). The mean age ranged from 59 to 70 years; 74% of patients were men and 55% had paroxysmal atrial fibrillation. Compared with the uninterrupted vitamin-K antagonist strategy, the odds ratios for the composite of primary safety and efficacy outcomes were 0.61 (95%CI: 0.31–1.17) with uninterrupted direct oral anticoagulants, 0.63 (95%CI: 0.26–1.54) with interrupted direct oral anticoagulants, and 8.02 (95%CI: 2.35–27.45) with interrupted vitamin-K antagonists. Uninterrupted dabigatran significantly reduced the risk of the composite of primary safety and efficacy outcomes (odds ratio, 0.21; 95%CI, 0.08–0.55). Uninterrupted direct oral anticoagulants are preferred alternatives to uninterrupted vitamin-K antagonists. Interrupted direct oral anticoagulants may be feasible as alternatives. Our results support the use of uninterrupted direct oral anticoagulants as the optimal periprocedural anticoagulant strategy for patients undergoing atrial fibrillation ablation. [ABSTRACT FROM AUTHOR]

Introduction: Prospective studies on rivaroxaban and apixaban have shown the safety and efficacy of direct anticoagulation agents (DOAC)s used peri-procedurally during radiofrequency ablation (RFA) of atrial fibrillation (AF). Studies comparing the two agents have not been performed. Methods: Consecutive patients from a prospective registry who underwent RFA of AF between April 2012 and March 2015 and were on apixaban or rivaroxaban were studied. Clinical variables and outcomes were noted. Results: There were a total of 358 patients (n = 56 on apixaban and n = 302 on rivaroxaban). There were no differences in baseline characteristics between both groups. The last dose of rivaroxaban was administered the night before the procedure in 96% of patients. In patients on apixaban, 48% of patients whose procedure was in the afternoon took the medication on the morning of the procedure. TIA/CVA occurred in 2 patients (0.6%) in rivaroxaban group with none in apixaban group (p = 0.4). There was no difference in the rate of pericardial effusion between apixaban and rivaroxaban groups [1.7% vs 0.6% (p = 0.4)]. Five percent of patients in both groups had groin complications (p = 0.9). In apixaban group, all groin complications were small hematomas except one patient who had a pseudoaneurysm (1.6%). One pseudo-aneurysm, 1 fistula and 3 large hematomas were noted in patients on rivaroxaban (1.7%) with the rest being small hematomas. DOACs were restarted post procedure typically 4 h post hemostasis. Conclusions: Peri-procedural uninterrupted use of apixaban and rivaroxaban during AF RFA is safe and there are no major differences between both groups.

A 58-year-old woman with drug-refractory symptoms of paroxysmal atrial fibrillation (AF) was referred for AF ablation. A single site of ganglionated plexus triggering pulmonary vein ectopy and AF was ablated, without pulmonary vein isolation. This procedure led to long-term freedom from AF. (Level of Difficulty: Advanced.)

Introduction: Conflicting results regarding the impact of left common pulmonary vein (LCPV) on clinical outcome of atrial fibrillation (AF) ablation with cryoballoon technology have been reported. Methods: We systematically searched PubMed and Cochrane library for articles that compared the arrhythmia recurrence rate after cryoballoon ablation between patients with normal pattern PVs and patients with LCPV. Studies of first ablation for persistent and paroxysmal AF using the 28 mm Arctic Front Advance, Medtronic cryoballoon (CB-A) reporting clinical success rates at a mean follow-up of ≥12 months were included. Data were analyzed by applying a random effects model. Results: A total of 5 studies with a total of 1178 patients met our predefined inclusion criteria. After a mean follow-up of 18.4 months, the overall success rate of CB-A ablation among patients with persistent and paroxysmal AF was 57%; in the LCPV group the success rate was 46% and in the normal anatomical pattern group it was 61%. No significant heterogeneity was noted among the studies (I2 = 35.8%; Q (df = 3) = 6.23 p-value = 0.18). Arrhythmia recurrence after CB-A ablation was not statistically significant between the two groups (LogOR 0.24; 95% CI [-0.16-0.63]; p-value = 0.23). No significant difference in PNI was observed between the two groups (p-value = 0.693). Conclusion: The presence of LCPV does not affect the long-term outcome of paroxysmal and persistent atrial fibrillation ablation with 28 mm CB-A compared to normal left PVs pattern.