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Aims: Pulmonary vein isolation (PVI) is an effective treatment option for paroxysmal atrial fibrillation (PAF). Reconnection of pulmonary veins (PVs) is the predominant cause for recurrence of PAF. However, treatment of patients with recurrence of PAF despite isolated PV in the absence of extra-PV foci remains challenging.Methods and Results: Of 265 patients undergoing repeat catheter ablation (CA) for recurrence of PAF 21 (8%) patients (14 men, age 58 ± 14 years) showed no reconnection of PV. Therefore, inducibility of sustained atrial arrhythmias was tested. If sustained atrial fibrillation (AF) or sustained atrial tachycardia (AT) was induced, patients underwent CA. During follow-up (FU), Holter- and Tele-electrocardiogram were performed. In 19 (91%) of 21 patients, sustained atrial arrhythmias [16 (84%) AF; 3 (15%) patients AT] were induced. One patient showed PAF. Eighteen patients underwent CA aiming for termination of induced arrhythmia. In 14 (77%) patients, termination into sinus rhythm was achieved. Despite extensive CA, three (16%) patients were externally cardioverted. No periprocedural complications occurred. During 21.2 ± 6.8-month FU, 10 (53%) patients were free of any arrhythmia. Paroxysmal atrial fibrillation recurred in 4 (21%) and AT in 5 (26%) patients. One patient showed persistent AF. Repeat CA was scheduled and successfully performed for these patients.Conclusion: In patients with recurrence of PAF despite isolated PV, termination of induced atrial arrhythmias can be achieved in most patients by defragmentation and AT ablation. Moreover, this ablation strategy results in favourable mid-term outcome results. [ABSTRACT FROM AUTHOR]

Background: Marfan syndrome is associated with ventricular arrhythmia but risk factors including FBN1 mutation characteristics require elucidation. Methods and Results: We performed an observational cohort study of 80 consecutive adults (30 men, 50 women aged 42±15 years) with Marfan syndrome caused by FBN1 mutations. We assessed ventricular arrhythmia on baseline ambulatory electrocardiography as >10 premature ventricular complexes per hour (>10 PVC/h), as ventricular couplets (Couplet), or as non-sustained ventricular tachycardia (nsVT), and during 31±18 months of follow-up as ventricular tachycardia (VT) events (VTE) such as sudden cardiac death (SCD), and sustained ventricular tachycardia (sVT). We identified >10 PVC/h in 28 (35%), Couplet/nsVT in 32 (40%), and VTE in 6 patients (8%), including 3 with SCD (4%). PVC>10/h, Couplet/nsVT, and VTE exhibited increased N-terminal pro–brain natriuretic peptide serum levels(P<.001). All arrhythmias related to increased NT-proBNP (P<.001), where PVC>10/h and Couplet/nsVT also related to increased indexed end-systolic LV diameters (P = .024 and P = .020), to moderate mitral valve regurgitation (P = .018 and P = .003), and to prolonged QTc intervals (P = .001 and P = .006), respectively. Moreover, VTE related to mutations in exons 24–32 (P = .021). Kaplan–Meier analysis corroborated an association of VTE with increased NT-proBNP (P<.001) and with mutations in exons 24–32 (P<.001). Conclusions: Marfan syndrome with causative FBN1 mutations is associated with an increased risk for arrhythmia, and affected persons may require life-long monitoring. Ventricular arrhythmia on electrocardiography, signs of myocardial dysfunction and mutations in exons 24–32 may be risk factors of VTE. [ABSTRACT FROM AUTHOR]

Objectives: There is currently no agreement on the best method of assessing active left atrial (LA) emptying. This study evaluated the relative merits of cine- and velocity encoded (VENC) magnetic resonance imaging (MRI) for the assessment of active LA emptying. Methods: Total LA emptying volume (TLAEV) and active LA stroke volume (ALASV) were assessed in 107 consecutive patients using cine-MRI and transmitral flow measurements by VENC-MRI. The fraction of active LA emptying (ALAEF) was calculated as the ratio of ALASV to TLAEV. LA and left ventricular (LV) output were calculated by multiplying TLAEV and LV stroke volume by heart rate, respectively. Results: Intra- and inter-observer variances were significantly larger for cine-MRI than for VENC-MRI measurements of ALASV (24.7 mL vs. 3.7 mL and 57.7 mL vs. 4.2 mL; P < 0.0001). Biplane cine-MRI underestimated TLAEV (mean difference −57 ± 32 %; P < 0.0001) and ALASV (mean difference −24 ± 51 %; P < 0.0001) but overestimated ALAEF (mean difference 31 ± 54 %, P < 0.0001) compared with VENC-MRI. There was significantly better agreement between LV output and LA output measured by VENC-MRI compared with LA output measured by cine-MRI (mean difference 0.30 ± 1.12 L/min vs. −2.05 ± 1.44 L/min; P < 0.0001). Conclusion: VENC-MRI is the more appropriate method of assessing active LA emptying and its use should be favoured. Key Points: • Cardiac magnetic resonance imaging (MRI) offers new possibilities in assessing atrial emptying. • Cine-MRI measurements of active LA emptying have lower reproducibility than velocity encoded MRI. • Cine-MRI overestimates the fraction of active LA emptying compared with VENC-MRI. • VENC-MRI is the more appropriate method of assessing active LA emptying. [ABSTRACT FROM AUTHOR]

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Background: Conventional catheter ablation for common-type atrial flutter (AFL) is a widely established therapy but has not been compared with the use of a robotic navigation system (RNS) thus far. Objectives: The purpose of this study was to investigate the feasibility of a new, nonmagnetic RNS with regard to safety, efficacy, and X-ray exposure to investigator and patient compared with the conventional ablation approach in patients with AFL. Methods: Fifty patients (65.7 ± 9.3 years, 40 male) undergoing de novo catheter ablation for AFL were randomly assigned to conventional or RNS-guided cavotricuspid isthmus (CTI) ablation. Results: Complete bidirectional isthmus block was achieved for all patients without occurrence of procedure-related complications. The fluoroscopy time and the investigator X-ray exposure (8.2 ± 4.6 vs. 5.8 ± 3.6, P = .038; and 8.2 ± 4.6 vs. 1.9 ± 1.1 minutes, P<.001) as well as the mean radiofrequency (RF) duration and the energy delivered were significantly higher in the conventional than in the RNS group (321.7 ± 214.6 vs. 496.4 ± 213.9 seconds, P = .006; 8279 ± 5767 vs. 16,308 ± 6870 J, P<.001, respectively). The overall procedure time in the RNS group was significantly longer than in the conventional group (79.2 ± 30.6 vs. 58.4 ± 17.7 minutes; P = .04) but significantly decreased comparing the first 10 with the last 10 patients in the RNS group (105.3 ± 34.8 vs. 60.6 ± 6.3 minutes; P = .003). Starting ablation during AFL, bidirectional block instantly after termination was observed in 90% of the RNS and 50% of the conventionally treated patients (P = .03). Conclusion: The present study demonstrates the safety and feasibility of RNS for performing CTI ablation in patients with common-type AFL for use in the clinical routine. As a result of the remote navigation, X-ray exposure and RF duration to achieve bidirectional block were significantly decreased and occurred more often immediately after AFL termination. These findings are consistent with increased catheter stability and RF application efficacy using RNS compared with conventional catheter manipulation. [Copyright &y& Elsevier]

Background Catheter ablation (CA) of ventricular tachycardia (VT) is an important treatment option in patients with structural heart disease (SHD) and implantable cardioverter defibrillator (ICD). A subset of patients requires epicardial CA for VT. Objective The purpose of the study was to assess the significance of epicardial CA in these patients after a systematic sequential endocardial approach. Methods Between January 2009 and October 2012 CA for VT was analyzed. A sequential CA approach guided by earliest ventricular activation, pacemap, entrainment and stimulus to QRS-interval analysis was used. Acute CA success was assessed by programmed ventricular stimulation. ICD interrogation and 24 h-Holter ECG were used to evaluate long-term success. Results One hundred sixty VT ablation procedures in 126 consecutive patients (114 men; age 65 ± 12 years) were performed. Endocardial CA succeeded in 250 (94%) out of 265 treated VT. For 15 (6%) VT an additional epicardial CA was performed and succeeded in 9 of these 15 VT. Long-term FU (25 ± 18.2 month) showed freedom of VT in 104 pts (82%) after 1.2 ± 0.5 procedures, 11 (9%) suffered from repeated ICD shocks and 11 (9%) died due to worsening of heart failure. Conclusions Despite a heterogenic substrate for VT in SHD, endocardial CA alone results in high acute success rates. In this study additional epicardial CA following a sequential endocardial mapping and CA approach was performed in 6% of VT. Thus, due to possible complications epicardial CA should only be considered if endocardial CA fails. [ABSTRACT FROM AUTHOR]

Catheter ablation is a well established and widely used therapy option of atrial fibrillation. The use of 3D mapping systems to aid the ablation process has become standard in most centers. Whether preprocedural imaging is an asset to catheter ablation procedures is of debate. Available methods and the existing evidence are outlined in this article. [ABSTRACT FROM AUTHOR]

Introduction The need for transesophageal echocardiography (TEE) before catheter ablation of atrial fibrillation (CA-AF) is still being questioned. The aim of this study is to analyze patients' (patients) risk factors of left atrial appendage thrombus (LAAT) prior to CA-AF in daily clinical practice, according to oral anticoagulation (OAC) strategies recommended by current guidelines. Methods and results All patients scheduled for CA-AF from 01/2015 to 12/2016 in our center were included and either treated with NOACs (novel-OAC; paused 24-hours preablation) or continuous vitamin K antagonists (INR 2.0-3.0). All patients received a preprocedural TEE at the day of ablation. Two groups were defined: (1) patients without LAAT, (2) patients with LAAT. The incidence of LAAT was 0.78% (13 of 1,658 patients). No LAAT was detected in patients with a CHA2DS2-VASc score of ≤1 (n = 640 patients) irrespective of the underlying AF type. Independent predictors for LAAT are: higher CHA2DS2-VASc scores (odds ratio [OR] 1.54, 95%-confidence interval [CI]: 1.07-2.23, P = 0.0019), a history of nonparoxysmal AF (OR 7.96, 95%-CI: 1.52-146.64, P = 0.049), hypertrophic cardiomyopathy (HCM; OR 9.63, 95% CI: 1.36-43.05, P = 0.007), and a left ventricular ejection fraction (LVEF) < 30% (OR 8.32, 95% CI: 1.18-36.29, P = 0.011). The type of OAC was not predictive (P = 0.70). Conclusions The incidence of LAAT in patients scheduled for CA-AF is low. Therefore, periprocedural OAC strategies recommended by current guidelines seem feasible. Preprocedural TEE may be dispensed in patients with a CHA2DS2-VASc score ≤1. However, a CHA2DS2-VASc score ≥2, reduced LVEF, HCM, or history of nonparoxysmal AF are independently associated with an increased risk for LAAT. [ABSTRACT FROM AUTHOR]

The ADVICE trial substudies show that the rate of pulmonary vein stenosis is low after pulmonary vein isolation with radiofrequency ablation and that the recommendations regarding the duration of the standard blanking period should be revised. The FreezeAF study demonstrates noninferiority of cryoballoon ablation to radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Age-Related Complication Rates in AF Ablation Introduction Despite a rising demand for catheter ablation (CA) of atrial fibrillation (AF) in an elderly population, complication and success rates are not fully elucidated. We sought to compare complication rates of CA of AF in patients ≥75 versus <75 years of age. Methods and Results Patients with symptomatic, drug-refractory AF were prospectively enrolled from January 2007 to 2010 in this multicenter study. A total of 4,449 patients, group 1 ≥75 years and group 2 <75 years (n = 227, age 77.3 ± 2.2 vs. 59.7 ± 9.8 years, 52.0% vs. n = 4,222, 68.9% male, CHA2DS2-VASc-Score 3.7 ± 1.0 vs. 1.7 ± 1.2; P < 0.001, respectively), with paroxysmal AF (59.9% in group 1 vs. 63.3% in group 2, P = 0.30), and persistent AF (34.8% in group 1 vs. 29.4% in group 2, P = 0.082) underwent CA of AF. A centralized follow-up was obtained in 4,347 patients by the Institute for Myocardial Infarction Research (IHF, Ludwigshafen). There was a significant difference between periprocedural stroke rates in the elderly versus the younger cohort (1.3% vs. 0.1%, P < 0.01). In-hospital severe nonfatal complications did not differ significantly between the groups (4.4% vs. 2.7%, P = 0.14). Other procedure-related, in-hospital complications were not significantly different. After a mean follow-up of 472 ± 99 days (group 1) and 477 ± 94 days (group 2), no differences were found in complication rates. Conclusion CA of AF in patients ≥75 years is associated with higher in-hospital stroke rates. In a 1-year follow-up, complication rates do not differ between the groups. [ABSTRACT FROM AUTHOR]

Background Extensive and repeated substrate modification (SM) is frequently performed as an ablation strategy in persistent atrial fibrillation (persAF). The effect of these extended ablation strategies on atrial function has not been investigated sufficiently so far. The purpose was to assess atrial function by cardiac magnetic resonance (CMR) and its association with left atrial (LA) scar burden by electroanatomical voltage-mapping after multiple persAF ablation procedures. Methods We included 16 persAF patients who had ≥2 SM procedures and a control group (CG) of 21 persAF patients without prior ablation. CMR was performed in sinus rhythm at least 4 weeks after the last cardioversion. Active left and right (RA) atrial emptying fractions (AEF) as well as peak active left atrial appendage (LAA) emptying velocities were obtained by CMR flow measurements. Furthermore, LA scar burden was quantified on electroanatomical voltage maps by the portion of points with local voltage amplitude <0.2 mV. Results We found median LA-AEF to be lower (13 [9-22] vs 32 [26-36] %, P < 0.001) and median LA scar burden to be higher (40 [20-68] vs nine [3-18] %, P < 0.05) in the SM group compared with the CG. Furthermore, a significant correlation was found between mean LA voltage and LA-AEF (r2 = 0.62, P < 0.001). No significant differences were detected with respect to median RA-AEF (41 [28-48] vs 47 [35-50] %, P = 0.43) and median peak LAA emptying velocities (30 [16-40] vs 17 [13-28] cm/s, P = 0.07). Conclusions Active LA function is preserved but significantly impaired and associated with ablation-related LA scar burden after multiple extensive persAF ablations. [ABSTRACT FROM AUTHOR]

Catheter ablation of complex fractionated atrial electrograms (CFAE), also known as defragmentation ablation, may be considered for the treatment of persistent atrial fibrillation (AF) beyond pulmonary vein isolation (PVI). Concomitant antiarrhythmic drug (AAD) therapy is common, but the relevance of AAD administration and its optimal timing during ablation remain unclear. Therefore, we investigated the use and timing of AADs during defragmentation ablation and their possible implications for AF termination and ablation success in a large cohort of patients. Retrospectively, we included 200 consecutive patients (age: 61 ± 12 years, LA diameter: 47 ± 8 mm) with persistent AF (episode duration 47 ± 72 weeks) who underwent de novo ablation including CFAE ablation. In all patients, PVI was performed prior to CFAE ablation. The use and timing of AADs were registered. The follow-ups consisted of Holter ECGs and clinical visits. Termination of AF was achieved in 132 patients (66 %). Intraprocedural AADs were administered in 168/200 patients (84 %) 45 ± 27 min after completion of PVI. Amiodarone was used in the majority of the patients (160/168). The timing of AAD administration was predicted by the atrial fibrillation cycle length (AFCL). At follow-up, 88 patients (46 %) were free from atrial arrhythmia. Multivariate logistic regression analysis revealed that administration of AAD early after PVI, LA size, duration of AF history, sex and AFCL were predictors of AF termination. The administration of AAD and its timing were not predictive of outcome, and age was the sole independent predictor of AF recurrence. The administration of AAD during ablation was common in this large cohort of persistent AF patients. The choice to administer AAD therapy and the timing of the administration during ablation were influenced by AFCL, and these factors did not significantly influence the moderate single procedure success rate in this retrospective analysis. [ABSTRACT FROM AUTHOR]