Arrhythmia Recurrence In Patients Research Articles

Durability of pulmonary vein isolation with pulsed field ablation compared to radiofrequency ablation in patients with persistent atrial fibrillation: results from a prospective remapping study

Abstract Background Pulsed field ablation (PFA) is a novel technology used for pulmonary vein isolation (PVI). Durability of PVI is critical to avoid atrial fibrillation (AF) recurrence. There is little data available on durability of PVI with PFA as compared to radiofrequency ablation (RFA), and on the mechanisms of arrhythmia recurrence in patients with persistent AF. Objective To invasively assess the durability of PVI with PFA compared to RFA using mandatory remapping studies after 6 months. Methods In a prospective study we included patients with symptomatic persistent AF to undergo a first PVI by either CLOSE protocol-guided RFA or PFA. Irrespective of AF recurrence, a remapping procedure was mandated 6-8 months following the index procedure to invasively evaluate PVI durability. The outcome of AF ablation was based on clinical recurrence and 7-day Holter-ECGs 3 and 6 months after the index procedure. Arrhythmia recurrence was defined as any atrial arrhythmia episode longer than 30 seconds beyond the 3-month blanking period. Results 60 patients (82% male; median age 68 years [60 – 74], median LAVI 47 ml/m2 [38 – 51]) undergoing PVI for persistent AF (median duration: 5 months [IQR: 3 – 9.5]) were included (30 in RFA group vs. 30 in PFA group). Procedure time was longer in the RFA group (169±39 min vs. 114±33 min, p<0.001), with longer fluoroscopy time in the PFA group (7.7±6.0 min vs. 19.7±7.5 min, p<0.001). Acute PVI was achieved in all 241 veins (100%) and no procedural complications were observed in either group. A median of 7.2 months after the index procedure 49 out of 60 patients underwent the remapping study (26 in RFA and 23 in PFA group; with some remapping procedures pending at the time of abstract submission). In the RFA group 78 out of 102 (76%) pulmonary veins (PVs) showed persistent isolation, compared to 74 out of 95 (78%) PVs in the PFA group (p=0.726). 15/26 (58%) RFA and 11/23 (48%) PFA group patients presented complete isolation of all PVs (p=0.594). Recurrence of arrhythmia was observed in 6/26 (23%) RFA and in 7/23 (30%) PFA group patients (p=0.542). Recurrence of persistent AF, paroxysmal AF, and atrial tachycardia was similar in both groups (RFA: 6 / 0 / 0; PFA: 5 / 1 / 1; p=0.612). In the pooled cohort, arrhythmias recurred irrespective of PV isolation status, in 7/26 (27%) patients with complete PVI vs. 6/23 (26%) patients with reconnected PVs (p=0.947). Similarly, the proportion of durably isolated PVs was not different in patients with (7/13; 54%) and without arrhythmia recurrence (19/36; 53%; p=0.947). Conclusions In patients with persistent AF undergoing mandated remapping procedure, we found comparable rates of durable PVI with RFA and PFA, both on a per-patient and a per-vein level. PVI with PFA was faster than RFA but required longer fluoroscopy time. Recurrence of AF was independent of durable PV isolation, underlining the need for additional ablation targets in a subset of patients with persistent AF.

Scar tissue characterization to predict arrhythmia recurrence in patients undergoing ventricular tachycardia ablation: cardiac computed tomography compared with cardiac magnetic resonance

Abstract Background The role of imaging in evaluating patients undergoing ventricular tachycardia (VT) ablation is crucial for planning, procedural success, and clinical outcomes. In daily practice, cardiac computed tomography (CCT) assessing wall thinning and late iodine uptake (LI) and cardiac magnetic resonance (CMR) assessing late-gadolinium enhancement (LGE) are most commonly implemented. However, data comparing the two imaging modalities for scar tissue characterization is scarce. Aims To compare the performance of both imaging modalities for scar tissue characterization in ischemic (ICM) and non-ischemic (NICM) patients undergoing VT ablation and predict procedural outcomes. Methods In a retrospective analysis, consecutive patients undergoing both CCT and LGE-CMR before scheduled VT ablation were included. The presence and extent of scar was assessed by means of each imaging modality using dedicated softwares (MUSIC and ADAS). To compare scar distribution and agreement between the two modalities, a scar classification scheme was used for all 17 AHA segments: 0 points (no scar present), 1 point (scar <50% of total segment area), 2 points (scar representing 50-99% of total segment area) or 3 points (scar present in 100% of the segment area).<scar<100%)><scar<100%> Results 36 patients (67±10 years; 97% male; LVEF 39±10%; 72% ischemic) undergoing CCT and LGE-CMR before scheduled VT ablation were included. In the ICM group, mean detected scar burden was higher than in the NICM group on LGE-CMR (total volume: 62.3±32.9g vs. 32.8±9.5g, p<0.001), using wall thinning model (WT)(mean scar area 69.0±45.6 cm2 vs. 23.4±23.6cm2, p=0.005) as well as LI (dense scar area: 39.2±28.1 cm2 vs. 11.0±6.3 cm2 , p=0.005). The absolute score difference per segment and patient between CCT and LGE-CMR was calculated and summed for all patients divided by the number of patients. Differences were more pronounced for NICM compared to ICM and LGE-CMR showed better concordance to LI than WT in both NICMP and ICM (Figure). Total procedure time was 205±68 min (ablation time 28±16 min; fluoroscopy time 15 ± 12 min). During a follow-up period of 19±7 months, 87 sustained VT episodes in 12 patients (33%) were documented. Three patients (8%) underwent a second VT ablation and one patient (3%) died during follow-up. In ICM, total scar volume on LGE-CMR and scar area on LI showed numerically higher predictive value for VT recurrence than total scar area by means of WT (AUC: LGE 0.76, LI 0.78 and WT 0.65 respectively), while in NICM scar characterization by means of WT yielded higher performance to predict VT recurrence than LI or LGE-CMR (AUC: LGE 0.67, LI 0.58, WT 0.83 respectively). Conclusions In patients undergoing VT ablation, both LGE-CMR and CCT are valuable for scar tissue characterization. Late iodine uptake on CCT showed a high concordance with LGE-CMR in both NICM and ICM.</scar<100%></scar<100%)>

Durability of CLOSE-Guided Pulmonary Vein Isolation in Persistent Atrial Fibrillation: A Prospective Remapping Study

BackgroundRecurrence of paroxysmal atrial fibrillation (AF) following pulmonary vein isolation (PVI) is presumably caused by pulmonary vein (PV) reconnections. However, there is little data available on the durability of PVI and incidence of arrhythmia recurrence in patients with persistent AF. ObjectivesThe purpose of this study was to evaluate the lesion durability by means of an a priori planned remapping procedure in patients with persistent AF undergoing CLOSE-guided PVI. MethodsIn a prospective study, we included patients with symptomatic, persistent AF undergoing CLOSE-guided radiofrequency ablation. Irrespective of AF recurrence, a redo procedure was mandated 6 months following the index procedure to evaluate PV reconnections. The outcome of AF ablation was based on clinical recurrence and 7-day Holter electrocardiogram 3 and 6 months after the index procedure and 3, 6, and 12 months after the redo procedure. ResultsOf 30 patients included, 26 (81% men; median age 68 years) underwent the planned remapping study a median of 6 months after the index procedure, whereas 4 patients without recurrence refused a repeat procedure. In total, 78 of 102 (76%) PVs showed durable isolation and 15 patients (58%) presented complete isolation of all PVs. Beyond the blanking period, 6 of 26 patients (23%) had arrhythmia recurrence before the redo procedure. Recurrence had occurred in 33% of patients with complete isolation of all veins and in 9% of patients with PV reconnections (P = 0.197). After re-PVI in patients with PV reconnections and additional ablation in patients with recurrence but durable PVI, 17 of 26 patients (65%) were free of arrhythmia after 12 months. ConclusionsIn patients with persistent AF, CLOSE-guided PVI resulted in durable rate of PVI on a per-vein and per-patient level of 76% and 58%, respectively. Arrhythmia recurrence was numerically higher in patients with durable PVI compared with patients without.

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.

Economic evaluation of first-line cryoballoon ablation versus antiarrhythmic drug therapy for the treatment of paroxysmal atrial fibrillation from an English National Health Service perspective

IntroductionThree recent randomised controlled trials have demonstrated that pulmonary vein isolation as an initial rhythm control strategy with cryoablation reduces atrial arrhythmia recurrence in patients with symptomatic paroxysmal atrial fibrillation...

Early pulmonary vein isolation in patients with heart failure

Abstract Background Atrial fibrillation (AF) and heart failure (HF) are often present simultaneously, leading to worse outcomes compared to the respective morbidity alone. Pulmonary vein isolation (PVI) is the most effective treatment modality and should be considered as first-line therapy, however, the optimal timing of the procedure is still unknown. Purpose We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HF. Methods The data of 334 patients with symptomatic paroxysmal (n=118, 35.5%) or persistent (n=212, 63.5%) AF and HF with LVEF < 50% were analyzed, who underwent PVI using radiofrequency energy between 2010 and 2022. All available medical data of the patients were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 1524.5 [365.0-3939.0] days with a minimum of 365 days. Our primary endpoints were all-cause mortality and AF recurrence following 3-months blanking period. Results During the follow-up of the 334 patients, 164 (49.1%) experienced AF recurrence and 86 (25.8%) patients died. The median age was 64 [56.1-69.9] years. The median LVEF was 40% for early PVI and 38% for deferred PVI (p=0.057). Out of the 139 (41.6%) patients who underwent early PVI, 36 (25.9%) had AF recurrence and 83 (59.7%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence (median 1042.5 [474.8-1921.0] days for early PVI, median 424 [134.5-1153.0] days for deferred PVI). Early PVI predicted lower rate of AF recurrence (HR: 0.29, p<0.0001). Early ablation was not associated with mortality benefit. Among those who experienced AF recurrence, a repeat ablation was associated with better survival (HR: 0.29, p<0.0001). Conclusions Our study shows that early rhythm control therapy with catheter ablation may be more beneficial compared to deferred PVI in patients with AF and HF. A repeat ablation may be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.

Catheter Ablation Approaches for the Treatment of Arrhythmia Recurrence in Patients with a Durable Pulmonary Vein Isolation

Catheter ablation has emerged as an effective treatment for atrial arrhythmias, and pulmonary vein isolation (PVI) is the cornerstone of ablation strategies. Significant technological evolution and widespread increase in operator experience have facilitated the effectiveness of catheter ablation to achieve durable PVIs in single or multiple ablation procedures. Nevertheless, arrhythmia recurrence is a common problem even after establishing PVI. Data on catheter ablation in these patients are sparse and repeat ablation in this population is highly challenging. In this review we have summarized the available data as well as potential strategies of catheter ablation following the initial PVI.

Smartphone AF Burden During the Blanking Period Predicts Catheter Ablation Outcomes: Insights From DECAAF II

BackgroundAtrial fibrillation (AF) recurrence during the blanking period is under investigated. With the rise of smartphone-based electrocardiogram (ECG) monitoring, there's potential for better prediction and understanding of AF recurrence trends. ObjectivesIn this study the authors hypothesize that AF burden derived from a single-lead Smartphone ECG during the blanking period predicts recurrence of atrial arrhythmias after ablation. Methods630 patients with persistent AF undergoing ablation were included from the DECAAF II (Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation) trial. Patients recorded daily ECG strips using a smartphone device. AF burden was defined as the ratio of ECG strips with AF to the total number of strips submitted. The primary outcome was the recurrence of atrial arrhythmia. ResultsRecurrence occurred in 301 patients during the 18-month follow-up period. In patients who developed recurrent arrhythmia after 90 days of follow-up, AF burden during the blanking period was significantly higher when compared with patients who remained in sinus rhythm (31.3% vs 7.5%; P < 0.001). AF burden during the blanking period was an independent predictor of arrhythmia recurrence (HR: 1.41; 95% CI: 1.36-1.47; P < 0.001). Through grid searching, an AF burden of 18% best discriminates between recurrence and no-recurrence groups, yielding a C-index of 0.748. After a follow-up period of 18 months, recurrence occurred in 33.7% of patients (147 of 436) with an AF burden <18% and in 79.4% of patients (154 of 194) with an AF burden >18% (HR: 4.57; 95% CI: 3.63-5.75; P < 0.001). ConclusionsA high AF burden derived from a smartphone ECG during the blanking period is a strong predictor of atrial arrhythmia recurrences after ablation.

Recurrence of Arrhythmias after Thoracoscopic MAZE procedure

BACKGROUND: Thoracoscopic version of the MAZE operation alone or in combination with catheter ablation (hybrid approach) has become widespread in the treatment of atrial fibrillation (AFib). However, recurrences of arrhythmias after such operations, in particular recurrence of AFib, remain unresolved problem.&#x0D; AIM: The aim of this study was to establish the structure of arrhythmia recurrence in patients with long-standing persistent AFib after primary epicardial ablation using the Dallas lesion set technique, as well as determining the optimal RFA strategy for recurrence.&#x0D; METHODS: 138 catheter ablation procedures for 100 patients, who applied with recurrence of various atrial arrhythmias after thoracoscopic MAZE. 34 patients had 2 or more RFA (31 pts 2, 2 pts 3, 1 pts 4).&#x0D; RESULTS: After Dallas lesion set thoracoscopic ablation in the structure of recurrences dominated: 1 AFib recurence; 2 incisional left atrial flutter. After the operation, a potential arrhythmogenic substrate remains, which must be fully eliminated by RFA (in addition to ablation the main cause of recurrence). This minimally necessary intervention implies: control and reisolation of the pulmonary veins; control and reisolation of the posterior wall; septal line from the mitral valve to the right superior pulmonary vein with Y-shaped branch to the left superior pulmonary vein; cava-tricuspid isthmus-blockade. This will eliminate and prevent in the future potentially possible incisional arrhythmias in fragmentary scars after thoracoscopic MAZE procedure. The return of AFib represents the most difficult group of patients. Restoration of sinus rhythm in recurrent AFib after epicardial ablation is possible, but may require extensive ablations in both atriums, as a result of repeated procedures, until all potential arrhythmia mechanisms, present in a particular patient, are eliminated.&#x0D; CONCLUSIONS: Catheter ablation remains the only method of effective treatment of recurrences after thoracoscopic MAZE procedure. The complexity and multicomponent nature of long-standing AFib causes the frequent need for repeated procedures, especially in cases of recurrence of atrial fibrillation.

Posterior Wall Isolation Improves Outcomes for Persistent AF With Rapid Posterior Wall Activity: CAPLA Substudy

BackgroundPulmonary vein isolation (PVI) is less effective in persistent atrial fibrillation (PerAF) than in paroxysmal atrial fibrillation (AF). However, the CAPLA (Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation: The CAPLA randomized clinical trial) of PVI vs posterior wall isolation (PWI) did not support empiric PWI in PerAF. We examined pulmonary vein (PV) and posterior wall (PW) electrical characteristics to determine if select patients may benefit from additional PWI. ObjectivesThis study sought to determine the impact of PV and PW electrical characteristics on AF ablation outcomes in the CAPLA randomized study. MethodsParticipants in spontaneous AF at the time of ablation were included from the CAPLA study. The mean, shortest, and longest PV, PW, and left atrial (LA) appendage cycle length measurements were annotated preablation using a multipolar catheter for 100 consecutive cycles. Next, cardioversion was performed with a high-density LA voltage map completed. Cox proportional hazards regression was utilized to determine clinical and electroanatomic predictors of AF recurrence overall and according to ablation strategy. Follow-up included twice daily single-lead electrocardiograms or continuous monitoring for 12 months. ResultsA total of 151 patients (27% female, age 65 ± 9 years, 18% long-standing PerAF, LA volume index 52 ± 16 mL/m2, median AF duration 5 months [IQR: 2-10 months]) were in AF on the day of procedure and were randomized to PVI alone (50%) or PVI+PWI (50%) according to the CAPLA randomized clinical trial protocol. Baseline clinical, echocardiographic, and electroanatomic parameters were comparable between groups (all P > 0.05) including PV and PW characteristics. After 12 months, freedom from AF off antiarrhythmic drug therapy was 51.7% in PVI and 49.7% in PVI+PWI (log-rank P = 0.564). Rapid PW activity was defined as less than the median of the shortest PW cycle length (140 ms) and rapid PV activity was defined as less than the median of the shortest PV cycle length (126 ms). In those with rapid PW activity, the addition of PWI was associated with greater arrhythmia-free survival (56.4%) vs PVI alone (38.6%) (HR: 0.78; 95% CI: 0.67-0.94; log-rank P = 0.030). Moreover, in those undergoing PVI only, the risk of AF recurrence was higher in those with rapid PW activity (55.3% vs 46.5% in slower PW activity; HR: 1.50, 95%CI 1.11-2.26; log-rank P = 0.036). Rapid PV activity and PV cycle length (individual PVs or average of all 4 PVs) were not associated with outcome (all P > 0.05) regardless of ablation strategy. There was no correlation between PW cycle length and posterior low voltage (r = −0.06, P = 0.496). The addition of PWI did not improve arrhythmia-free survival in subgroups with LA enlargement (LA volume index >34 mL/m2) (HR: 0.69; 95% CI: 0.39-1.25; P = 0.301), posterior low-voltage zone (HR: 1.06; 95% CI: 0.68-1.66; P = 0.807), or long-standing PerAF (HR: 1.10; 95% CI: 0.71-1.72; P = 0.669). ConclusionsRapid PW activity is associated with an increased risk of AF recurrence post–catheter ablation. The addition of PWI in this subgroup was associated with a significant improvement in freedom from AF compared with PVI alone. The presence of rapid PW activity may identify patients with PerAF likely to benefit from PWI.

Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomised study

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The study was supported by the Ministry of Health of the Czech Republic. Background Atrial fibrillation (AF) and other atrial tachycardias (ATs), including typical atrial flutter (AFL), are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. Purpose We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with PH and AF / AT. Methods Patients with combined post- and pre-capillary or isolated pre-capillary PH and AF / AT indicated to catheter ablation were enrolled in 3 centers and randomized 1:1 into two parallel treatments arms: (A) Clinical arrhythmia ablation and (B) Clinical arrhythmia plus substrate-based ablation. The primary endpoint was arrhythmia recurrence &amp;gt;30 s without antiarrhythmic drugs after the 3-month blanking period. Results A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (IQR: 12; 19) months, the primary endpoint occurred in 15 patients (42 %) vs. 17 patients (45 %) in the group B vs. A (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in group B. Conclusion Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF / AT and pulmonary hypertension.

Predictive value of clinical risk scores for determination of left atrial low voltage area and arrhythmia recurrences in patients undergoing atrial fibrillation ablation

Abstract Funding Acknowledgements Type of funding sources: None. Background Presence of left atrial low voltage area (LVA) is an independent predictor of atrial tachyarhythmia (ATa) recurrences after atrial fibrillation (AF) ablation. Thus identifying patients with LVA by using non-invasive methods is an important endeavour. Purpose In this study; we investigated the predictors of LVA and postablation recurrences especially focusing on clinical risk scores. Methods We enrolled 328 consecutive patients who underwent initial AF ablation procedure using high density mapping. LVAs were assessed and segmental distribution was noted in each patient. CHA2DS2-VASc, HATCH, APPLE and SPEED scores were calculated. Predictive value and arrhythmia recurrences were evaluated. Results Two hundred and twenty one patients (67.37%) were paroxysmal AF and 107 (32.62%) patients were non-paroxysmal AF at the time of ablation. Mean CHA2DS2-VASc score was 1.88±1.66, mean APPLE score was 1.20±1.20, HATCH score was 0.93±1.00 and SPEED score was 1.54±1.27 in the whole study group. LVA was detected in 131 patients (39.93%). Female gender [OR:2.94, CI: 1.34-6.43, p=0.007), non-paroxsymal AF (OR: 2.49 CI:1.13-5.46, p=0.023), APPLE score ≥1 (OR:1.69 CI:1.12-2.55, p=0.012) and SPEED score ≥ 1 (OR: 1.47 CI:1.00-2.14, p=0.045] were independent predictors for the presence of LVA in multivariate analysis. Presence of LVA (OR:1.98; CI:1.13-4.15; p=0.017) and HT (OR:2.00; CI:1.19-3.38; p=0.009) were the independent predictors of recurrences. Conclusion Higher clinical scores are associated with more LVA which is associated with ATa recurrence. However the predictive value of these risk scores is limited. Better risk scoring systems are needed to precisely identify the underlying atrial substrate in this patient group.

Local impedance drop guided versus lesion size index guided pulmonary vein isolation: long-term outcomes and chronic reconnections

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Insufficient lesion depth and discontinuity of lesion lines are reasons for reconnections after point-by-point radiofrequent pulmonary vein isolation (PVI). Different technologies have shown to be useful for prediction of effective lesions. Measurement of the magnitude of local tissue impedance drop (LID) and calculation of lesion size index (LSI) based on monitoring of contact force are examples for corresponding technologies. Purpose To compare the long-term outcomes of LID guided with LSI guided PVI. Methods In this retrospective study we compared two groups of patients who underwent point-by-point radiofrequency PVI for treatment of atrial fibrillation. In the LID-guided group (n=35) energy was delivered using an ablation catheter with local impedance monitoring. Ablation was terminated when LID reached a plateau (Fig. A). In the LSI-guided group (n=31) lesions were created using an ablation catheter with contact force monitoring until the target LSI was reached in each point (LSI=5 for anterior and LSI=4 for posterior segments, respectively, Fig B). The inter-lesion distance of &amp;lt;6 mm with power of 40 W for anterior and 30W for posterior segments was used in both groups. A gap-map and touch-up ablation was performed along the index ablation line if the first pass PVI did not occur, or in the case of an acute reconnection after 20 min of waiting time. In the long-term follow-up, a holter ECG was scheduled 3, 6 and 12 months after the initial ablation as well as symptom-driven visits with ECG registration. In case of symptomatic arrhythmia recurrence, a second procedure was performed including validation of PVI, mapping of reconnection site and RePVI, if necessary. Results All pulmonary veins were successfully isolated by encirclement of ipsilateral veins during initial procedure. During the 11.5±2.9 months follow-up, 12 out of 35 (34.3%) patients from LID-guided group and 5 out of 31 (16.1%) patients from LSI-guided group experienced arrhythmia recurrence. Kaplan-Meier survival analysis showed statistically significant higher probability of the arrhythmia recurrence in patients treated with LID-guided approach (log-rank=4.37, p=0.037, Fig C). Redo procedure was performed for 10 (28.6%) patients in LID-guided group and 3 (9.7%) patients in LSI-guided group and chronic pulmonary vein reconnections were detected in 7 out of 10 (70%) and 2 out of 3 (67%) patients, respectively (Fig D). Conclusions Despite initial successful isolation of all pulmonary veins, LID-guided ablation resulted in significantly higher probability of arrhythmia recurrence during the long-term follow-up as well as higher rate of chronic PV reconnections (although not statistically significant) as compared to LSI-guided ablation. This reflects the nature of contact force guided ablation anticipating the quality of catheter-tissue interface before each application, which is not possible with an impedance only guided approach.

Effect of early pulmonary vein isolation in patients with heart failure and reduced ejection fraction

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial fibrillation (AF) and heart failure (HF) often coexist leading to worse outcomes compared to AF or HF alone. According to the current guidelines, PVI as first-line therapy should be considered, however, the optimal timing of the procedure is still unknown. Purpose We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HFrEF. Methods We analyzed the data of 162 patients with symptomatic paroxysmal or persistent AF and heart failure with LVEF &amp;lt; 50% who underwent pulmonary vein isolation between 2010 and 2022. The patients’ medical history, laboratory results, echocardiographic and periprocedural parameters were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 59.7 months, the minimum follow-up was 12 months. Our primary endpoints were AF recurrence after a 3 months blanking period and all-cause mortality at any time during follow-up. Results Among the 162 patients, 77 experienced AF recurrence and 39 patients died during the follow-up period. The median age was 63.2 years. The median LVEF was 40% for early PVI and 37% for deferred PVI. Out of the 63 patients who underwent early PVI, 33 (52%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence (median 833 days until recurrence for early PVI, median 696 days for deferred PVI). Early PVI was a predictor of AF recurrence (HR: 0.58 [0.32-0.94], p=0.029).Early ablation was not associated with mortality benefit. However, among those who experienced AF recurrence, repeated ablation was associated with better survival during univariate Cox regression (p=0.01). Furthermore, in multivariate model, reablation was shown to be protective of mortality (HR: 0.312 [0.113-0.865], p=0.025) in the whole cohort. Conclusions Our study shows that early rhythm control therapy with catheter ablation is more successful compared to deferred PVI in patients with AF and HFrEF. A redo-PVI was associated with better survival, thus a repeat ablation should be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.

Catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension: a randomized study

Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with pulmonary arterial hypertension (PH) and supraventricular arrhythmias. Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in three centres and randomized 1:1 into two parallel treatment arms. Patients underwent either clinical arrhythmia ablation only (Limited ablation group) or clinical arrhythmia plus substrate-based ablation (Extended ablation group). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (interquartile range: 12; 19) months, the primary endpoint occurred in 15 patients (42%) vs. 17 patients (45%) in the Extended vs. Limited ablation group (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in the Extended ablation group. Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF/AT and PH. ClinicalTrials.gov; NCT04053361.

PO-02-099 RADIOFREQUENCY CATHETER ABLATION OF ATRIAL TACHYCARDIA AND ATRIAL FIBRILLATION IN PATIENTS WITH PULMONARY HYPERTENSION. A SUBANALYSIS OF A PROSPECTIVE RANDOMIZED TRIAL

Atrial fibrillation (AF) and related atrial tachycardias (AT), including typical atrial flutter (AFL), are common arrhythmias in patients with pulmonary hypertension (PH). We have shown, in the multicenter randomized trial, that extensive radiofrequency catheter ablation of the arrhythmogenic substrate on top of selective ablation of clinical arrhythmia alone was not beneficial in terms of arrhythmia recurrence in patients with AF / AT and PH. Irrespective of the randomization scheme, we compared clinical outcomes in patients with AF versus those with organized ATs. Out of 74 patients (42 males; the median age of 70 [IQR 61; 75] years) with combined post- and pre-capillary or isolated pre-capillary PH enrolled at 3 national sites, two study subgroups were composed: the AF group and the AT group (including AFL). The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. Idiopathic pulmonary arterial hypertension was found in 41 (55%) patients, chronic thromboembolic PH in 22 (30%), and PH associated with lung disease or hypoxia in 11 (15%). The AF group included 38 patients, and AT group included 36 patients (23 with AFL). The median duration of the follow-up period was 13 (IQR: 12; 21) months. The primary endpoint occurred in 23 patients (61 %) with AF vs. 9 patients (25 %) with AT (hazard ratio: 0.3, 95% confidence interval: 0.14-0.66; p = 0.003), Figure. In contrast to AF and other organized ATs, typical AFL did not reoccur during the follow-up. Out of 4 patients with documented arrhythmia after cavotricuspid isthmus ablation, 2 had AF and 2 patients manifested atypical AFL. More details are in the Table. Patients with PH and organized ATs manifested less frequent reoccurrence of arrhythmia after catheter ablation than patients with AF. Despite new arrhythmia could manifest, catheter ablation seems to be the most effective in PH patients with typical AFL. ClinicalTrials.gov Identifier: NCT04053361. Funding: The study was supported by the Ministry of Health of the Czech Republic, Grant Nr. NV18-02-00027.

AB-452666-2 CATHETER ABLATION OF ATRIAL FIBRILLATION AND ATRIAL TACHYCARDIA IN PATIENTS WITH PULMONARY HYPERTENSION: A RANDOMISED STUDY

Atrial fibrillation (AF), typical atrial flutter (AFL), and other atrial tachycardias (ATs) are common in patients with pulmonary hypertension. Frequently, several supraventricular arrhythmias are successively observed in individual patients. We investigated the hypothesis of whether more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone results in superior clinical outcomes in patients with PH and supraventricular arrhythmias. Patients with combined post- and pre-capillary or isolated pre-capillary PH and supraventricular arrhythmia indicated to catheter ablation were enrolled in 3 centres and randomised 1:1 into two parallel treatments arms: (A) Clinical arrhythmia ablation and (B) Clinical arrhythmia plus substrate-based ablation. The primary endpoint was arrhythmia recurrence >30 s without antiarrhythmic drugs after the 3-month blanking period. A total of 77 patients (mean age 67 ± 10 years; 41 males) were enrolled. The presumable clinical arrhythmia was AF in 38 and AT in 36 patients, including typical AFL in 23 patients. During the median follow-up period of 13 (IQR: 12; 19) months, the primary endpoint occurred in 15 patients (42 %) vs. 17 patients (45 %) in the group B vs. A (hazard ratio: 0.97, 95% confidence interval: 0.49-2.0). There was no excess of procedural complications and clinical follow-up events including an all-cause death in group B. Extensive ablation, compared with a limited approach, was not beneficial in terms of arrhythmia recurrence in patients with AF / AT and pulmonary hypertension. ClinicalTrials.gov Identifier: NCT04053361. Funding: The study was supported by the Ministry of Health of the Czech Republic, Grant Nr. NV18-02-00027.

AB-452643-2 EARLY PULMONARY VEIN ISOLATION IN PATIENTS WITH HEART FAILURE AND REDUCED EJECTION FRACTION

Atrial fibrillation (AF) and heart failure (HF) often coexist leading to worse outcomes compared to AF or HF alone. According to the current guidelines, pulmonary vein isolation (PVI) as first-line therapy should be considered, however, the optimal timing of the procedure is still unknown. We aimed to investigate the effect of early PVI on all-cause mortality and AF recurrence in patients with HF. We analyzed the data of 162 patients with symptomatic paroxysmal or persistent AF and HF with LVEF < 50% who underwent PVI between 2010 and 2022. The patients’ medical history, laboratory results, echocardiographic and periprocedural parameters were collected in a structured registry. Early PVI was defined as catheter ablation performed within 12 months of AF diagnosis. The median follow-up was 59.7 months, the minimum follow-up was 12 months. Our primary endpoints were AF recurrence after a 3-months blanking period and all-cause mortality at any time during follow-up. Among the 162 patients, 77 (47.5%) experienced AF recurrence and 39 (24.1%) died during follow-up. The median age was 63.2 years. The median LVEF was 40% for early PVI and 37% for deferred PVI. Out of the 63 patients who underwent early PVI, 33 (52%) were taking amiodarone. Patients who underwent early PVI had longer freedom from recurrence compared to late PVI (median 833 days vs. median 696 days, respectively, p=0.02). Early PVI was a negative predictor of AF recurrence (HR: 0.58 [0.32-0.94], p=0.03). Early ablation had no beneficial impact on mortality (p=0.68). However, among those who experienced AF recurrence, repeat ablation was associated with better survival with univariate Cox regression (p=0.01). Furthermore, in multivariate model, repeat ablation was shown to be protective of mortality (HR: 0.312 [0.113-0.865], p=0.03) in the whole cohort. Our study shows that early rhythm control therapy with catheter ablation is more successful compared to deferred PVI in patients with AF and HF. A redo-PVI was associated with better survival, thus a repeat ablation should be considered in case of arrhythmia recurrence in patients with AF and HF to reduce mortality.

Mechanisms of late arrhythmia recurrence after initially successful pulmonary vein isolation in patients with atrial fibrillation.

Catheter ablation is an effective treatment for atrial fibrillation (AF,) but arrhythmia recurrence occurs in a relevant number of patients. Mechanisms of late occurring arrhythmias after ablation procedures are not fully understood. We analyzed electrophysiological mechanisms of early and late arrhythmia recurrences in patients who underwent radiofrequency-based catheter ablation of AF. Consecutive patients who underwent repeat ablation procedures after initial pulmonary vein isolation (PVI) for symptomatic arrhythmia recurrence were analyzed. A total of 110 consecutive patients who underwent catheter ablation for paroxysmal (79%) or persistent AF (21%) were included. Forty-seven patients suffered from early arrhythmia recurrence (group #1: 3-24 months), 29 patients from mid-term arrhythmia recurrences (group #2: 2-5 years), and 34 patients from late arrhythmia recurrences (group #3:>5 years). Electrical PV reconnection was found in 98% in group #1, 72% in group #2 and 56% in group #3 (p<.001). Mode of arrhythmia recurrence was organized tachycardia in 25%, 28%, and 65% of patients in groups #1, #2, and #3 (p=.001), respectively. Patients with late arrhythmia recurrence had more pronounced left atrial low voltage as compared to patients with early arrhythmia recurrence based on two published scoring system. Electrical PV reconnection was found in the majority of patients with early AF recurrence after PVI. In patients with late arrhythmia recurrences this mechanism may play an inferior role, with many patients presenting without PV reconnection, but with LA structural alterations. Thus, early and late occurring arrhythmia recurrence after catheter ablation may be the same symptom of different diseases.

Effect of Catheter Ablation Using Pulmonary Vein Isolation With vs Without Posterior Left Atrial Wall Isolation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation

Pulmonary vein isolation (PVI) alone is less effective in patients with persistent atrial fibrillation (AF) compared with paroxysmal AF. The left atrial posterior wall may contribute to maintenance of persistent AF, and posterior wall isolation (PWI) is a common PVI adjunct. However, PWI has not been subjected to randomized comparison. To compare PVI with PWI vs PVI alone in patients with persistent AF undergoing first-time catheter ablation. Investigator initiated, multicenter, randomized clinical trial involving 11 centers in 3 countries (Australia, Canada, UK). Symptomatic patients with persistent AF were randomized 1:1 to either PVI with PWI or PVI alone. Patients were enrolled July 2018-March 2021, with 1-year follow-up completed March 2022. The PVI with PWI group (n = 170) underwent wide antral pulmonary vein isolation followed by posterior wall isolation involving linear ablation at the roof and floor to achieve electrical isolation. The PVI-alone group (n = 168) underwent wide antral pulmonary vein isolation alone. Primary end point was freedom from any documented atrial arrhythmia of more than 30 seconds without antiarrhythmic medication at 12 months, after a single ablation procedure. The 23 secondary outcomes included freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures, freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures, AF burden between study groups at 12 months, procedural outcomes, and complications. Among 338 patients randomized (median age, 65.6 [IQR, 13.1] years; 76.9% men), 330 (97.6%) completed the study. After 12 months, 89 patients (52.4%) assigned to PVI with PWI were free from recurrent atrial arrhythmia without antiarrhythmic medication after a single procedure, compared with 90 (53.6%) assigned to PVI alone (between-group difference, -1.2%; hazard ratio [HR], 0.99 [95% CI, 0.73-1.36]; P = .98). Of the secondary end points, 9 showed no significant difference, including freedom from atrial arrhythmia with/without antiarrhythmic medication after multiple procedures (58.2% for PVI with PWI vs 60.1% for PVI alone; HR, 1.10 [95% CI, 0.79-1.55]; P = .57), freedom from symptomatic AF with/without antiarrhythmic medication after multiple procedures (68.2% vs 72%; HR, 1.20 [95% CI, 0.80-1.78]; P = .36) or AF burden (0% [IQR, 0%-2.3%] vs 0% [IQR, 0%-2.8%], P = .47). Mean procedural times (142 [SD, 69] vs 121 [SD, 57] minutes, P < .001) and ablation times (34 [SD, 21] vs 28 [SD, 12] minutes, P < .001) were significantly shorter for PVI alone. There were 6 complications for PVI with PWI and 4 for PVI alone. In patients undergoing first-time catheter ablation for persistent AF, the addition of PWI to PVI alone did not significantly improve freedom from atrial arrhythmia at 12 months compared with PVI alone. These findings do not support the empirical inclusion of PWI for ablation of persistent AF. anzctr.org.au Identifier: ACTRN12616001436460.