Pulmonary Vein Isolation Ablation Research Articles

Radiofrequency catheter ablation for re-do procedure after single-shot pulmonary vein isolation with pulsed field ablation for paroxysmal atrial fibrillation: case report

BackgroundCatheter ablation is frequently used to manage recurrent atrial fibrillation (AF) resistant to drug therapy, with pulmonary vein isolation (PVI) as a key tactic. Pulsed field ablation (PFA) has emerged as an innovative technology for PVI but poses challenges for redo procedures.Case presentationWe report on a 73-year-old female patient who experienced recurrent AF after initial successful PVI using a novel PFA technology and subsequently underwent radiofrequency catheter ablation during a repeat intervention. The reconnection of pulmonary veins was discovered primarily in the anterior region of the right superior PV and the superior portion of the left superior PV. An anatomically-based segmental approach and larger circumferential PVI, followed by additional linear ablations at non-PV trigger sites, proved decisive in preventing further recurrence of atrial tachycardia.ConclusionWhile PFA exhibits promise as a secure and efficient modality for PVI, it necessitates excellent contact quality to ensure lasting results. For patients experiencing AF recurrences post-PFI, expanded strategies incorporating both comprehensive PVI and linear ablations at targeted non-PV sites might enhance treatment outcomes.

Association between proactive esophageal cooling and increased lab throughput.

Proactive esophageal cooling has been FDA cleared to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation procedures. Data suggest that procedure times for RF pulmonary vein isolation (PVI) also decrease when proactive esophageal cooling is employed instead of luminal esophageal temperature (LET) monitoring. Reduced procedure times may allow increased electrophysiology (EP) lab throughput. We aimed to quantify the change in EP lab throughput of PVI cases after the introduction of proactive esophageal cooling. EP lab throughput data were obtained from threeEPgroups. We then compared EP lab throughput over equal time frames at each site before (pre-adoption) and after (post-adoption) the adoption of proactive esophageal cooling. Over the time frame of the study, a total of 2498 PVIs were performed over a combined 74 months, with cooling adopted in September 2021, November 2021, and March 2022 at each respective site. In the pre-adoption time frame, 1026 PVIs were performed using a combination of LET monitoring with the addition of esophageal deviation when deemed necessary by the operator. In the post-adoption time frame, 1472 PVIs were performed using exclusively proactive esophageal cooling, representing a mean 43% increase in throughput (p < .0001), despite the loss of two operators during the post-adoption time frame. Adoption of proactive esophageal cooling during PVI ablation procedures is associated with a significant increase in EP lab throughput, even after a reduction in total number of operating physicians in the post-adoption group.

The association between hyperuricemia and atrial fibrillation recurrence after catheter ablation

AbstractBackgroundHyperuricemia (HU) has been reported to be associated with a high incidence of atrial fibrillation (AF). However, the relationship between HUA and recurrent AF after catheter ablation (CA) is unclear.MethodsFour hundred consecutive AF patients (paroxysmal/persistent AF [PAF/PsAF]: 200/200) who underwent the initial CA were retrospectively enrolled. HU was defined as serum uric acid (SUA) level &gt;7.0 mg/dL. We measured SUA levels 1 day before (pre‐CA) and 1 month after CA (post‐CA). A second‐generation 28 mm cryoballoon was used for pulmonary vein isolation (PVI) for PAF, while PVI plus linear ablation (roof and mitral isthmus lines) by radiofrequency catheter was conducted for PsAF.ResultsDuring 57 ± 24 months of follow‐up, AF recurred in 16% and 42% in PAF and PsAF patients (p &lt; .0001). Pre‐CA SUA level in PsAF was significantly higher than that in PAF (6.5 ± 1.3 vs. 5.8 ± 1.3 mg/dL, p &lt; .001). SUA level was significantly decreased after CA in both PAF and PsAF (5.8 ± 1.3 vs. 5.6 ± 1.3 mg/dL; p &lt; .01 and 6.5 ± 1.3 vs. 6.1 ± 1.2 mg/dL; p &lt; .0001, respectively). The association between pre−/post‐CA HU and recurrent AF was not identified in PAF, while the incidence of post‐CA HU was significantly higher in patients with recurrent AF than those without in PsAF (36% vs. 15%, p &lt; .001). In multivariable analysis, longer AF duration and the presence of post‐CA HU were identified as independent predictors of AF recurrence in PsAF (OR:1.01, 95%CI:1.003–1.011, p = .0001 and OR:2.77, 95%CI:1.333–5.755, p = .007, respectively).ConclusionsSUA level was significantly higher in PsAF than PAF patients. The presence of post‐CA HU was strongly related to AF recurrence in PsAF patients.

Cryoballoon pulmonary vein isolation as first-line treatment of typical atrial flutter: long-term outcomes of the CRAFT trial.

CRAFT was an international, multicentre, randomised controlled trial across 11 sites in the United UK and Switzerland. Given the evidence that pulmonary vein triggers may be responsible for atrial flutter (AFL) as well as atrial fibrillation (AF), we hypothesised that cryoballoon pulmonary vein isolation (PVI) would provide greater symptomatic arrhythmia reduction than cavotricuspid isthmus (CTI) ablation, whilst also reducing the subsequent burden of AF. Twelve-month outcomes were previously reported. In this study, we report the extended outcomes of the CRAFT study to 36months. Patients with typical AFL and no evidence of AF were randomised 1:1 to cryoballoon PVI or radiofrequency CTI. All patients received an implantable loop recorder (ILR) for continuous cardiac rhythm monitoring. The primary outcome was time-to-symptomatic arrhythmia recurrence > 30s. Secondary outcomes included time-to-first-AF episode ≥ 2min. The composite safety outcome included death, stroke and procedural complications. A total of 113 patients were randomised to cryoballoon PVI (n = 54) or radiofrequency CTI ablation (n = 59). Ninety-one patients reconsented for extended follow-up beyond 12months. There was no difference in the primary outcome between arms, with the primary outcome occurring in 12 PVI vs 11 CTI patients (HR 0.97; 95% CI 0.43-2.20; p = 0.994). AF ≥ 2min was significantly less frequent in the PVI arm, affecting 26 PVI vs 36 CTI patients (HR 0.48; 95% CI 0.29-0.79; p = 0.004). The composite safety outcome occurred in 5 PVI and 6 CTI patients (p = 0.755). Cryoballoon PVI shows similar efficacy to radiofrequency CTI ablation in reducing symptomatic arrhythmia recurrence in patients presenting with isolated typical AFL but significantly reduces the occurrence of subsequent AF.

Procedural performance and outcome after pulsed field ablation for pulmonary vein isolation: comparison with a reference radiofrequency database.

Pulsed field ablation (PFA) is a promising ablation technique for pulmonary vein isolation (PVI) with appealing advantages over radiofrequency (RF) including speed, tissue selectivity, and the promise of enhanced durability. In this study, we determine the procedural performance, efficacy, safety, and durability of PFA and compare its performance with a dataset of optimized RF ablation. After propensity score matching, we compared 161 patients who received optimized RF-guided PVI in the PowerPlus study (CLOSE protocol) with 161 patients undergoing PFA-guided PVI for paroxysmal or persistent atrial fibrillation (AF; pentaspline basket catheter). The median age was 65 years with 78% paroxysmal AF in the PFA group (comparable characteristics in the RF group). Pulsed field ablation-guided PVI was obtained in all patients with a procedure time of 47 min (vs. 71 min in RF, P < 0.0001) and a fluoroscopy time of 15 min (vs. 11 min in RF, P < 0.0001). One serious adverse event [transient ischaemic attack] occurred in a patient with thrombocytosis (0.6 vs. 0% in RF). During the 6-month follow-up, 24 and 27 patients experienced a recurrence with 20 and 11 repeat procedures in the PFA and the RF groups, respectively (P = 0.6 and 0.09). High-density mapping revealed a status of 4 isolated veins in 7/20 patients in the PFA group and in 2/11 patients in the RF group (35 vs. 18%, P = 0.3). Pulsed field ablation fulfils the promise of offering a short and safe PVI procedure, even when compared with optimized RF in experienced hands. Pulmonary vein reconnection is the dominant cause of recurrence and tempers the expectation of a high durability rate with PFA.

Case report: Cardiac arrest after radiofrequency ablation in a 76-year-old male.

Previous studies have found that the main treatment of sinus arrest is pacemaker treatment. It is rare to have 12 s of sinus arrest after radiofrequency ablation, and whether a permanent pacemaker is implanted immediately in this case is not described in the guidelines. A 76-year-old male patient with persistent atrial fibrillation (AF) developed sinus arrest lasting 12 s in the early morning of the fourth day after using radiofrequency ablation for pulmonary vein isolation. The patient was diagnosed with AF and sinus arrest. The patient received cardiopulmonary resuscitation, intravenous injection of atropine 1 mg, and intravenous infusion of isoproterenol 1mg and immediately recovered consciousness thereafter. Approximately, 1.5 h later, the patient underwent surgery to install a temporary pacemaker in the right femoral vein. The patient had repeated episodes of sinus arrest after the implantation of a temporary pacemaker. After 3 weeks, the patient stabilized and was discharged. The patient was followed up for 1 year and did not experience any recurrence of sinus arrest or AF. We consider the potential for postoperative myocardial edema, injury to the sinoatrial node during the procedure, propafenone poisoning, and autonomic dysfunction as contributors to the occurrence of sinus arrest after radiofrequency ablation. When sinus arrest occurs after radiofrequency ablation, we can choose the appropriate treatment according to the patient's condition.

Pulsed field versus cryoballoon ablation for atrial fibrillation: areal-world observational study on procedural outcomes and efficacy.

Atrial fibrillation often necessitates catheter ablation when antiarrhythmic drug therapy fails. Single-shot technologies using thermal energy, such as cryoballoon ablation, are commonly used, but pulsed field ablation (PFA), an innovative non-thermal ablation technique, is apotential alternative. This retrospective observational study aimed to compare the safety and efficacy of cryoballoon ablation and PFA in patients undergoing their first pulmonary vein isolation (PVI) procedure for atrial fibrillation treatment. We utilised real-world data from patients who underwent PVI using cryoballoon ablation or PFA. The primary outcome encompassed procedural complications, including phrenic nerve palsy, cardiac tamponade, thromboembolic complications, bleeding complications and mortality. Secondary outcomes were procedural characteristics including procedure duration, length of hospital admission, and re-do ablation rates within 6months. Atotal of 1714 procedures were analysed: 1241 in the cryoballoon group and 473 in the PFA group. Gender distribution (p = 0.03) and estimated glomerular filtration rate (p = 0.01) differed significantly. With regard to the primary outcome, the cryoballoon group demonstrated ahigher incidence of phrenic nerve palsy compared with the PFA group (15 vs0; p = 0.02). The procedure duration was shorter in the PFA group, even after adjusting for baseline characteristics (95.0 vs 74.0 min; p < 0.001). After adjustment for baseline characteristics, admission duration differed between the groups as well (p = 0.04). The study results supported the safety and efficacy of PFA over cryoballoon ablation for PVI, highlighting advantages such as shorter procedure duration and absence of phrenic nerve palsy.

Pulsed field ablation and cryoballoon ablation for pulmonary vein isolation: insights on efficacy, safety and cardiac function.

Pulmonary vein isolation (PVI) has become the cornerstone treatment of atrial fibrillation (AF). While in cryoablation cell damage is caused by thermal effects, lately, pulsed field ablation (PFA) has been established as a novel non-thermal tissue-specific ablation modality for PVI. However, data comparing outcomes of patients undergoing either PFA or cryoballoon ablation (CBA) for primary PVI are sparse. Consecutive patients with AF undergoing PVI by either CBA or PFA were included in the analysis. The primary outcome was the time to AF/AT recurrence. For secondary outcomes, clinical and periprocedural parameters were compared. In total, outcomes of 141 AF patients treated by PFA (94 patients) or CBA (47 patients) were compared. After 365 days, 70% of patients in the PFA group and 61% of patients in the CBA group were free from AF/AT (HR 1.35, 95% CI 0.60-3.00; p = 0.470). No deaths occurred. While symptoms alleviated in both groups, only after PFA, we observed significant improvement of left atrial volume index (PFA group baseline: 40 [31;62] ml/m2, PFA group follow-up: 35 [29;49] ml/m2; p = 0.015), NT-pro BNP levels (PFA group baseline: 1106 ± 2479 pg/ml, PFA group follow-up: 1033 ± 1742 pg/ml; p = 0.048), and left ventricular ejection fraction (LVEF) (PFA group baseline: 55 [48;60] %, PFA group follow-up: 58 [54;63] %; p = 0.006). PVI by PFA was the only independent predictor of LVEF improvement. In our study, we show that CBA and PFA for PVI are of similar efficacy when it comes to AF recurrence. However, our findings suggest that PFA rather than CBA might induce left atrial reverse remodeling thereby contributing to left ventricular systolic function.

Cryoballoon ablation for pulmonary vein isolation in the treatment of chronic heart failure with reduced left ventricular ejection fraction following tachycardia-induced cardiomyopathy

Cryoballoon ablation for pulmonary vein isolation in the treatment of chronic heart failure with reduced left ventricular ejection fraction following tachycardia-induced cardiomyopathy

Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis.

The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of -14.4 minutes (p=0.017) and -14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3-9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60-1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.

Repeat pulmonary vein isolation and anterior line ablation using a novel point-by-point pulsed-field ablation system

BackgroundPulsed-field ablation (PFA) is a nonthermal energy source for ablation of cardiac arrhythmias. This study investigated the prospective outcomes of a novel PFA generator in conjunction with a commercially available, contact force-sensing, focal ablation catheter. ObjectiveThe purpose of this study was to assess the feasibility, safety, and lesion characteristics of point-by-point PFA in consecutive patients undergoing repeat ablation of atrial fibrillation (AF). MethodsThe study involved reisolation of pulmonary veins (PVs) with electrical reconnection and the creation of an anterior line (AL) in patients with anterior substrate or durable pulmonary vein isolation (PVI). ResultsIn 24 patients (46% female; mean age 67 ± 10 years; 67% persistent AF), successful reisolation of 27 of 27 reconnected PVs (100%) was performed. In 19 patients, AL ablation was performed, with bidirectional block in 16 (84%), median ablation time 26 [21, 33] minutes, and first-pass bidirectional block in 13 patients (68%). Acute AL reconduction occurred in 8 of 19 patients (42%). Among these 8 patients, a subsequent sustained block of the AL was achieved in 5 (63%). Ultra-high-density electroanatomic mapping revealed homogeneous but relatively large low-voltage areas in the ablated regions. Median procedural, left atrial dwell, and fluoroscopy times were 100 [90, 109] minutes, 83 [75, 98] minutes, and 10 [8, 13] minutes, respectively. No major or minor complications occurred. ConclusionThis study demonstrated feasibility, acute efficacy, and safety of point-by-point PFA for repeat PVI and AL ablation. Further studies are warranted to assess the long-term durability and comparison with established ablation methods.

The omnipolar voltages as an ablation indicator for pulmonary vein isolation in patients with atrial fibrillation

Abstract Background Lesion Index (LSI) without considering myocardial voltage is well-known to guide pulmonary vein isolation (PVI) ablation using the TactiCath™ Ablation Catheter in paroxysmal atrial fibrillation (PAF) patients. However, some patients show gaps after LSI-guided PVI ablation. Meanwhile, the omnipolar voltages detected using EnSite™ Omnipolar Technology (OT) have been reported to improve the underestimation of voltage. Purpose We aimed to clarify their differences by comparing the omnipolar voltages with conventional bipolar voltages and to verify whether it could be an additional indicator of LSI. Methods [Study1] We retrospectively studied 48 PAF patients (32 male, 69±8yrs) who received catheter ablation (CA). The left atrial voltage mapping was performed with Advisor™ HD Grid Mapping Catheter under right atrial pacing. The voltages within a 1cm diameter circle were measured at each site (Roof, Anterior, Posterior, Septal, Lateral; 238 sites) and evaluated the omnipolar and conventional bipolar voltages. [Study2] Twelve patients (8 males, 71±9yrs) with PAF who underwent CA were prospectively studied. The left atrial voltage mapping was performed before PVI ablation. The pre-ablation omnipolar voltages / bipolar voltages and LSI on each ablation site (558 points) of the PVI line were measured and compared in gapped and non-gapped regions. The gapped areas were defined as sites that required additional ablation after the first-round ablation of PVI. Results [Study1] The omnipolar voltages were higher than the bipolar voltages (total 238 sites, 2.84±2.05 vs. 2.67±1.81 mV, P&amp;lt;0.0001) in the entire left atrium. There was no feature in the difference between the omnipolar voltage and the bipolar voltage, according to the site and the voltage height (Figure). [Study2] Five gaps (14 ablation points) were confirmed after the first round of LSI-guided PVI (LSI 4.5±0.4, minimum 3.8 - maximum 5.8) in 4 of 12 patients. The omnipolar voltage in the gapped areas was higher than the non-gapped areas (544 ablation points) (5.64±1.93 vs. 3.73±2.82mV, P=0.0118, cut-off value 3.56mV, the area under the curve 0.74678). Meanwhile, there was no difference between the gapped and non-gapped areas in LSI and the conventional bipolar voltage. Conclusion Although the omnipolar voltage obtained by OT is detected only slightly higher than the bipolar potential, the higher omnipolar voltage could be an indicator of additional ablation to the LSI.

The efficacy of ultra-high-density mapping guided partial antral ablation for pulmonary vein isolation in atrial fibrillation patients

BackgroundThe muscular discontinuities or lack of myocardial extensions around the pulmonary veins (PVs) antrum were previously reported. The objective of our study was to compare the efficacy of a partial antral ablation for PV isolation (PVI) using ultra-high density (UHD) mapping with a conventional wide antral circumferential ablation (WACA) in atrial fibrillation (AF) patients.MethodsA total of 119 patients medical records who received catheter ablation for AF in our hospital were analyzed. In one group of patients, detailed activation mapping of each PV was performed using a UHD mapping system. Each PV antral segment’s activation pattern was classified into “directly-activated from the LA” or “passively-activated from an adjacent PV segment” patterns. The ablation applications were performed at the directly-activated PV antral segment only for the PVI when the PV had “passively-activated segments” (partial antral ablation; PA-UHD group). Another patient group received a conventional WACA for the PVI (WACA group).ResultsSixty patients received partial antral ablation (PA-UHD), and age/sex-matched 59 patients received WACA. In the PA-UHD group, passively-activated segments were observed in 58.3% of all PV segments. The success rate of a partial antral ablation for the PVI in PVs with passively-activated segments was 85%. The 1-year atrial tachyarrhythmia recurrence did not differ between the PA-UHD and WACA groups.ConclusionsOur study revealed the presence of passively-activated PV segments, which could potentially indicate muscular discontinuity at the PV-LA junction. In most PVs with passively-activated segments, PVI was successfully achieved by ablation with only directly-activated segments. The 1-year recurrence rate of atrial tachyarrhythmia in PA-UHD group was comparable to that observed in the WACA group.

Comparison of ultralow temperature cryoablation and classical cryoballoon ablation for pulmonary vein isolation in patients with atrial fibrillation

Abstract Introduction Pulmonary vein isolation (PVI) has become the standard-of-care in the treatment of atrial fibrillation (AF). In cryoablation cell damage is caused by freezing using predominantly nitrous oxide gas allowing temperature drops down to -60°C usually using a cryoballoon-based catheter (CB). Ultralow temperature cryoablation (ULTC) represents a novel ablation technique promising higher efficacy rates by achieving better transmurality of generated lesions. By using Nitrogen near it’s liquid vapor critical point (Near-critical nitrogen) in a linear catheter, ULTC achieves cooling temperatures as low as -196 °C. First studies using ULTC for PVI reported promising success rates. However, to date there is only limited data on outcomes of patients undergoing cryoablation with ULTC compared to CB. Material and Methods Our study aimed to compare the efficacy and safety of CB and ULTC ablation for PVI in AF patients. 90 consecutive patients with AF undergoing PVI by cryoablation at our university hospital between July 2020 and November 2022 were included in the analysis. The primary outcome was freedom from atrial arrythmia after 12 months. Furthermore, procedural parameters and periprocedural complications were compared. Results In total 90 patients, n=72 treated by CB ablation and n=18 by ULTC, were included in our study. Median age was 64yrs in CB and 70yrs in ULTC patients. Majority of patients of the CB (64%) and of the ULTC group (72%) were male. Paroxysmal AF was present in 57% of CB and 55% in the ULTC group. Median follow up was 365d for the CB and 232d for the ULTC group, respectively. The primary endpoint (Atrial arrythmia recurrence) occurred in 24/72 patients in the CB and in 10/18 patients in the ULCT group (HR: 0.47; 95% CI: 0.19-1.16; p=0.037). There were no differences in periprocedural complications (CB: 12,5% vs. ULCA: 17%). Analysis of procedural parameters showed that the total procedure time was longer in the ULTC group (CB: 135 [124, 167] min, ULTC: 198 [168, 242] min; p=&amp;lt;0.0001). Fluoroscopy time was increased (CB: 23 min [16, 28] min, ULTC: 44 [38, 48] min; p=&amp;lt;0.0001) as was the median number of required freezes per vein in the ULTC group (ULTC: 4 [3, 6] vs CB: 1 [1, 2], p=&amp;lt; 0.0001). Conclusion The findings of this retrospective analysis comparing cryoablation by ULTC vs. CB for PVI in AF patients suggests that ULTC is not yet equivalent to CB ablation with respect to procedural parameters and freedom from AF. Nevertheless, learning curve and limited device handling experience has to be taken into account. Future controlled studies and randomized trials are required to further elucidate the value of ULTC in AF ablation procedures, especially in the context of the novel Pulsed field ablation technology.

Pulmonary vein isolation versus PVI + adjunctive strategy (substrate modification and renal denervation therapy) for the reduction of 12-month AF recurrence

Abstract Background of the Study This meta-analysis assessed the latest evidence on the use of adjunct ablation strategies to standard pulmonary vein isolation (PVI) for treating atrial fibrillation (AF). Adjunct treatments were further classified as substrate modification (posterior wall isolation, linear ablation and ablation of complex fractionated atrial electrograms) or renal denervation (RDN). Purpose While ablation maintains sinus rhythm more effectively than antiarrhythmic drug therapy, recurrent AF remains common after 12 months, occurring in up to 40-60% of patients undergoing standard PVI ablation. Treatment strategies have diversified in a response to these challenges. These include reduction of the arrhythmogenic substrate, modulation of autonomic inputs and improvement of risk factors, such as hypertension. Methods A systematic literature search from MEDLINE and PubMed electronic databases was performed until November 2022. The primary outcome was 12-month AF recurrence defined as AF lasting ≥30 seconds on follow-up. The secondary outcome was incidence of procedure-related major adverse events (MAEs), defined as death, clinical strokes, acute heart failure decompensation, pericardial effusion causing tamponade, arteriovenous fistulas, and atrioesophageal fistulas. Results Nine studies comprising 1686 patients were included in the final analysis. AF recurrence was 487/1082 (45%) in the PVI + Adjunct group and 204/604 (33.8%) in PVI Alone. Pooled analysis showed that PVI + adjunct was inconclusively associated with less incidence of 12-month AF recurrence (RR 0.79, 95% CI 0.60–1.04, I2 = 70%, p-value 0.09). Subgroup analyses of six RCTs under the PVI with substrate modification arm showed non-significant increase in 12-month AF recurrence in PVI + substrate modification (RR 0.85, 95% CI 0.6-1.21, p-value 0.38). Subgroup analyses of the 3 RCTs on hypertensive AF patients showed strong evidence of decreased 12-month AF recurrence in PVI + RDN compared to PVI alone (RR 0.65, 95% CI 0.48-0.89, p-value 0.007). Secondary outcome of major adverse procedure-related events in overall pooled analysis showed 8 events in 604 patients undergoing PVI alone, and 23 events in 1082 patients undergoing PVI + adjunct ablation. There is no significant difference in the number of reported MAE in PVI alone over PVI + adjunct (RR 1.16 [0.49-2.75], p = 0.73). Conclusion Overall, PVI with adjunctive strategies did not significantly reduce 12-month AF recurrence after ablation. Among these strategies, RDN demonstrated a significant reduction in the primary endpoint, whereas substrate modification did not. There was no significant difference in MAEs reported between standard therapy versus those with adjunctive treatment. We conclude that PVI ablation strategies should be individualized, and modification of both triggers and risk factors for AF show better rhythm control on follow-up.

Revisiting pulmonary vein stenosis after high-power short-duration radiofrequency ablation in patients with atrial fibrillation

Abstract Background High-power short-duration atrial fibrillation catheter ablation (HPSD-AFCA) of pulmonary vein (PV) isolation reduces the procedure time without a difference in the efficacy as compared to conventional power AFCA (ConvP-AFCA). PV stenosis (PVS) after AFCA is a rare complication. Purpose We compared the frequency of symptomatic PVS as a long-term complication between the ConvP-AFCA and HPSD-AFCA groups. Methods We included 3,851 patients undergoing AFCA between 2009 and 2022 prospectively. We evaluated the characteristics of patients diagnosed with clinically symptomatic PVS, ascertained using computed tomography during the follow-up period. The risk of PVS was compared between the ConvP-AFCA and HPSD-AFCA groups using propensity overlap weighting. Results Symptomatic PVS was diagnosed in 14 (0.4%) patients at a mean of 342.9 days after the procedure. After overlap weighting, PVS was significantly more frequent in the HPSD-AFCA group (incidence: HPSD-AFCA, 0.8% vs. ConvP-AFCA, 0.2%; weighted hazard ratio [HR] 6.27, 95% confidence interval [CI] 2.15-18.28; P&amp;lt;0.001). In the multivariable Cox regression analyses, repeat AFCA procedures (HR 3.52, 95% CI 1.18-10.55; P=0.024) and paroxysmal AF (HR 8.29, 95% CI 1.08-63.82; P=0.042) were also independently associated with PVS after AFCA. Among the PVs of patients with PVS, stenotic PVs had shorter antral diameters and a smaller cross-sectional area than non-stenotic PVs on preprocedural computed tomographic evaluations. Conclusion HPSD-AFCA, compared to ConvP-AFCA, was associated with a 6-fold increased risk of symptomatic PVS. Caution is required, especially in patients with plans for a repeated AFCA, paroxysmal AF, or small PV antrum.

Abstract 15698: Association of Social Factors on Sex-Specific Management of Atrial Fibrillation

Introduction: Prior studies have reported disparities by sex in managing atrial fibrillation (AF), with many studies having limited analysis of the effects of social risk factors. We examined the effect of social risk factors on sex differences in the management of AF in a large, socially diverse cohort of insured patients. Hypothesis: We hypothesized that women with AF would receive less AF care, including the receipt of AF-related medications, pulmonary vein isolation ablation, and cardiology follow-up, compared to men. Methods: We identified individuals with AF from 2013-2019 captured by Optum’s de-identified Clinformatics® Data Mart Database. Sex was categorized as men and women. Covariates included demographics (age, sex, race, and ethnicity), Elixhauser variables, and social factors such as estimated annual household income and race or ethnicity. We used stepwise multivariable-adjusted Cox proportional hazards models to assess the effect of race, ethnicity, and household annual income on sex-specific differences in the receipt of AF-related medications, pulmonary vein isolation ablation, and cardiology follow-up. Results: We identified 190,760 individuals (age 74.0±11.4 years; 49.9% women) with incident AF. Women with AF were less likely to receive pulmonary vein isolation ablation and cardiology follow-up over a six-year follow-up than men. Prescriptions of antiarrhythmic were identical among both sexes. When stratified by race and ethnicity, women of Black (HR 0.75, 95% CI 0.61,0.92) and White race (HR 0.83, 95% CI 0.78, 0.88) were less likely to receive pulmonary vein isolation ablation than men. Women of Asian (HR 0.90, 95% CI 0.83,0.97) and White race (HR 0.93, 95% CI 0.92,0.94) were less likely to have cardiology follow-up after initial diagnosis of AF than men. Higher household income did not attenuate sex-specific differences in AF care. Across all income categories, women were less likely to have pulmonary vein isolation and cardiology follow-up. Conclusions: We identified sex differences in AF management that were not attenuated when considering race, ethnicity, and annual household income. Our findings suggest continued evidence of sex, racial, ethnic, and socioeconomic inequities in contemporary AF management.

Abstract 15716: Meta-Analysis of Randomized Controlled Trials Comparing Ablation Targets Beyond Pulmonary Vein Isolation versus Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation

Introduction: Catheter ablation for persistent atrial fibrillation (PeAF) is challenging and pulmonary vein isolation(PVI) alone has limited success. Adjunctive ablation strategies like posterior wall isolation (PWI), linear ablation, substrate modification utilizing complex fractionated atrial electrograms (CFAE) or MRI guided fibrosis ablations have demonstrated variable results beyond PVI alone. We performed a meta analysis of randomized controlled trials (RCTs) comparing efficacy, safety and procedural outcomes of PVI plus adjunctive ablation strategies versus PVI alone. Methods: We performed a comprehensive search of electronic databases from inception to April 2023 searching RCTs comparing PVI alone versus PVI+adjunctive strategies(linear ablations, CFAE, PWI, low voltage area ablation and MRI-guided atrial fibrosis ablation). Primary efficacy outcome was recurrence of atrial arrhythmias &gt; 30s after a single ablation procedure, with or without antiarrhythmics. Secondary safety outcome was composite of access site complications, tamponade, hemopericardium, pericardial effusion, pericarditis, stroke/TIA, pulmonary vein stenosis, atrioesophageal fistula or phrenic nerve palsy. Procedural characteristics included mean procedural time and mean ablation time. Pooled risk ratio (RR), mean difference (MD) and 95% confidence interval (CI) were calculated. Statistical analysis was performed using RevMan5.4.1 Results: 10 RCTs with a total of 3042 patients (PVI plus adjunctive n= 1717; PVI alone n= 1325) were included. The mean age was 61.6 ± 0.14 years. The mean follow-up was 16.5 months. There was no significant difference in primary efficacy outcome (RR: 0.99; CI: 0.88-1.12; p&gt; 0.05; I2 = 28%) or secondary safety outcome (RR: 1.46; CI: 0.97-2.18; p&gt; 0.05; I2 = 16%), between two groups. Procedural characteristics including mean procedural time in minutes (MD: 31.84; CI: 4.92-58.75; p&lt; 0.05; I2 = 95%) and mean ablation time in minutes (MD: 20.30; CI: 8.16-32.43; p&lt; 0.05; I2 = 95%) were significantly shorter for PVI alone group. Conclusions: Adjunctive ablation strategies provide no additional benefit over PVI alone in PeAF, but are associated with significantly longer procedural and ablation time.

Abstract 18656: Characterization of Pulmonary Vein Reconnection in Repeat Procedures After After Initial Cryoballoon Ablation Identified With High Density Mapping

Introduction: Catheter ablation of atrial fibrillation using the cryoballoon has become an alternate strategy to radiofrequency for pulmonary vein isolation (PVI). Both techniques, however, can result in pulmonary vein reconnection and the need for recurrent ablations. Objective: To study the incidence and specific location of pulmonary vein reconnection in patients with prior cryoballoon ablation for atrial fibrillation Methods: Retrospective analysis of patients that underwent radiofrequency ablation following a single initial cryoballoon PVI ablation was performed. Twenty patients were studied, all of whom underwent repeat ablation using radiofrequency with a mapping system (Rhythmia, Boston Scientific). A gap was defined as entrance conduction from the LA into the PV as suggested by the activation map. Results: Patients had an average of a 20 month period of normal sinus rhythm after initial ablation. A total of 48 gaps were identified in 18/20 patients (2.4 gaps per patient). The most common site of PV-LA conduction reconnection was at the superior pulmonary veins, specifically on the anterior portions. 60% (12/20) of patients had noted reconnection sites at the left superior pulmonary vein. All but one of these patients had gaps on the anterior surface of the vein. 75% (15/20) of patients were identified as having reconnection sites at the right superior pulmonary vein. All of these patients had gaps on the anterior surface of the vein. Less commonly, the left and right inferior veins each had 40% (8/20) patients with reconnection at these areas, with no consistent surface as the main site of reconnection. Further, 85% (17/20) patients had procedural ablation beyond only pulmonary vein re-isolation, owing primarily to the occurrence of atypical atrial flutters or atrial tachycardias that were seen during the repeat procedure itself Conclusion: Cryoballoon ablation is a successful technique for PVI in AF patients. However, reconnection of these sites is possible. Our analysis shows that the most common sites are at the anterior surface of the superior pulmonary veins. This could portend a potential drawback to be cognizant of during these initial procedures. Further analysis with a larger patient population will be necessary

Box Lesion Isolation of the Left Atrial Posterior Wall with Radiofrequency Ablation Restricted in Predetermined Lines for the Treatment of Persistent Atrial Fibrillation: The Prognostic Role of Acute Interventional Outcome and Trigger Identification.

The left atrial posterior wall (PW) is known to be a critical substrate for the initiation and perpetuation of atrial fibrillation (AF) and has been explored as a target for catheter ablation, particularly in persistent AF (PerAF). In this retrospective study, we investigate the clinical outcome of patients with PerAF who underwent PW isolation (PWI) restricted in predetermined lines in addition to pulmonary vein isolation (PVI). One hundred consecutive patients (64 ± 9.1 years, 66% male, 20% with previous PVI ablation) underwent PWI in a box lesion setting for PerAF lasting >3 months (34% long-standing PerAF). PW triggers were defined as either foci from the PW that repeatedly induced AF or as isolated AF or atrial tachycardia (AT) within the PW. After a mean follow-up period of 25.6 ± 6.7 months, 61% of the patients remained in sinus rhythm after the last procedure. In 79 patients, the PW was successfully isolated, while, in 21 patients, complete isolation was not possible due to failure in completion of the roof line (n = 16), the floor line (n = 7), or both (n = 2). Patients with incomplete isolation had similar AF/AT recurrence rates compared to those with complete PWI. In 12 patients, PW triggers were identified, and PWI in these patients was shown to have a significantly better prognosis in terms of sinus rhythm maintenance (P = .031). Failure of complete PWI does not predispose a patient to an inferior outcome nor is it responsible for iatrogenic ATs. The presence of AF triggers within the PW leads to a particularly favorable result after box lesion isolation.