Arrhythmia Recurrence Research Articles

Pulsed Field Ablation in Atrial Fibrillation: Initial Experience of the Efficacy and Safety in Pulmonary Vein Isolation and Beyond

Regional differences in pulsed field ablation (PFA) adoption for pulmonary vein isolation (PVI) with additional posterior wall ablation (PWA) in Asia remains unknown. We hereby report our experience on the safety and efficacy of PFA in AF ablation. Consecutive AF patients who underwent PFA from September 2022 to January 2024 were included. The primary efficacy endpoint was freedom from atrial arrhythmia recurrence after a 90-day blanking period at 12 months. Safety endpoints included 30 days of all-cause death, cardiac tamponade, stroke, myocardial infarction, and heart failure hospitalization. One hundred and one (72.3% males, 79.2% pAF) patients underwent PFA for AF. Thirty-one (30.7%) had structural heart disease with mean LVEF of 57.4 ± 8.1% and CHA2DS2-VASc score of 1.4 ± 1.3. Twenty-nine (28.7%) underwent additional PWA (PVI + PWA) using PFA. PWA was acutely successful in all patients. Patients who underwent PWA were more likely to have persistent AF and require general anesthesia and electroanatomic mapping (all p < 0.05). Total PFA applications for PVI, LA dwell time, procedural time, and fluoroscopy time were similar between the PVI-only and PVI + PWA groups (all p > 0.05). The 1-year atrial arrhythmia recurrence rates were 10% for pAF and 21% for the persistent AF group. The primary efficacy endpoint was not significantly different between the PVI-only and PVI+PWA groups (12-month KM estimates 90.3% [95% CI, 83.3–97.3] and 82.8% [95% CI, 68.1–97.4], respectively). There were no complications related to PFA use. PFA can be safely, effectively, and efficiently adopted for AF ablation. Additional PWA, if pursued, had similar procedural metrics to the PVI-only strategy without increased complications.

Anatomical-guided third-generation laser balloon ablation for the treatment of paroxysmal atrial fibrillation assessed by continuous rhythm monitoring: results from a multicentre prospective study

Abstract Aims The third-generation laser balloon (LB3) is an established ablation device for pulmonary vein isolation (PVI) that allows direct visualization of the anatomical target. Equipped with an automatic circumferential laser delivery modality, it aims at continuous circumferential PVI, improving both acute and clinical outcomes. We sought to evaluate the clinical efficacy of LB3 ablation using an anatomical-based approach without verifying electrical isolation. Methods and results Among 257 paroxysmal AF patients undergoing LB3 ablation across four Italian centres, 204 (72% male, mean age 60.4 ± 11.1 years) were included. The primary endpoint was freedom from any atrial tachyarrhythmia (ATa) recurrence after the blanking period (BP), assessed with implantable cardiac monitors (ICMs). All pulmonary veins (PVs) were targeted using the LB3, with the RAPID mode used on an average of 96 ± 8, 86 ± 19, 98 ± 11, and 84 ± 15% for the left superior, left inferior, right superior, right inferior PV, and left common ostium, respectively. Freedom from arrhythmia recurrences was 84.8% at 1, 80.4% at 2, and 76.0% at 3 years. An ATa burden ≥ 5% was documented in 2.5, 4.4, and 5.4% at 1, 2, and 3 years, respectively. Relapses during the BP [hazard ratio (HR) = 2.182, P = 0.032] and left atrial dilation (HR = 1.964, P = 0.048) were independent predictors of recurrences. Conclusion Anatomical-guided LB3 ablation for paroxysmal AF is a safe and effective approach, providing excellent clinical outcomes as assessed by ICM over nearly 3 years of follow-up.

Prevalence and risk factors associated with decompensated heart failure after successful elective cardioversion for atrial fibrillation and atrial flutter

Study objectiveTo determine the incidence of and risk factors for HF after successful electrical and ablative cardioversion (CV) of atrial fibrillation (AF) and atrial flutter (AFL). DesignRetrospective cohort study. SettingSingle center academic institution. ParticipantsSeven hundred fifty-five patients underwent successful elective CV from July 1, 2018 to May 20, 2019. Patients presenting in arrhythmias other than AF or AFL, those who developed HF due to alternative etiologies, and those who developed arrhythmia recurrence within 30 days were excluded. Medical records of the remaining 451 patients were reviewed before and after CV. Main outcomes measuredDevelopment of heart failure despite sinus rhythm following CV and the risk factors associated with this outcome. ResultsThirty-three (7.3 %) of 451 patients who met inclusion criteria for our study developed new or worsening HF symptoms while maintaining sinus rhythm (SR) after successful CV. Symptoms were reported an average of 5.1 days following CV (range 0–17 days, SD 4.71). Following a multivariate stepwise logistic regression model, prior HF hospitalization (OR 3.91, 95 % CI 1.82–8.39), BMI (OR 1.06, 95 % CI 1.02–1.11), and valve disease (OR 2.51, 95 % CI 1.12–5.60) remained significant risk factors, and anti-arrhythmic drug (AAD) use was marginally significant (OR 2.02, 95 % CI 0.95–4.31). ConclusionDespite maintenance of SR, 7.3 % of patients developed decompensated HF in the 30 days following successful CV of AF or AFL, indicating this complication may be more frequent than previously believed. Predictors of HF post-CV included elevated BMI, valve disease, previous HF hospitalization, and prior AAD use.

LA strain analysis in patients undergoing atrial fibrillation ablation using cryoballoon or pulsed-field-ablation

Abstract Background Catheter ablation for atrial fibrillation (AF) is increasing as rhythm control therapy. Besides thermal ablation approaches, such as cryoballoon ablation (CBA), a novel non-thermal and tissue-specific ablation modality – pulsed field ablation (PFA) – has been introduced. Left atrial reservoir strain (LArS) has been suggested to predict arrhythmia recurrences after AF ablation. Up to now, data describing LArS in patients undergoing their first AF ablation using PFA or CBA are sparse. Purpose To compare LArS in patients undergoing first catheter ablation for AF using either PFA or CBA. Methods Patients with transthoracic echocardiography prior to their first catheter ablation for AF were included. Patients in AF during transthoracic echocardiography, with poor 2D image quality and those that did not have a transthoracic echocardiography after AF ablation were excluded. Clinical characteristics and echocardiography parameters were analyzed. LArS was measured before and after AF ablation and was correlated with the recurrence of atrial arrhythmias in the follow-up period. Results Of 267 patients undergoing their first AF ablation, 67 patients (69% male, 65 ± 11 years) fulfilled the inclusion criteria and were further analyzed. AF ablation was performed using PFA in 55% and CBA in 45% of patients. Baseline characteristics were similar in both groups. Before ablation LArS was similar for PFA (17.69 ± 6.92%) and CBA patients (19.38 ± 9.42%, P=0.45). After AF ablation, LArS did not change significantly compared to the values before (before ablation: 20.96 ± 15.9 vs. after ablation: 19.87 ± 9.38, P=0.18), irrespective of the ablation mode (PFA before: 17.69 ± 6.92%vs. PFA after: 18.06 ± 8.9%, P=0.53; CBA before: 19.38 ± 9.42% vs. CBA after: 21.08 ± 9.48%, P=0.36). After a median of 190 days [95% confidence interval: 89 - 454 days], 25 patients (37%) experienced an arrhythmia recurrence (PFA: 38%, CBA: 37%). Comparing patients with and without arrhythmia recurrences, LArS before catheter ablation was lower in those experiencing an arrhythmia recurrence (16.02 ± 6.8%) compared to those without arrhythmia recurrence (25.58 ± 20.32%, P=0.02). However, this was independent from the ablation mode (PFA: AF-recurrence: 16.51 ± 4.27 vs. no recurrence: 21.31 ± 15.9, P=0.19; CBA: AF-recurrence: 15.48 ± 9.03 vs. no recurrence: 27.34 ± 22.14, P=0.07). Univariable regression analysis - including sex, age and comorbidities - revealed a trend for baseline LArS being associated with arrhythmia recurrence (HR 0.92, 95% CI: 0.86 – 1.01; P=0.065). Conclusions This hypothesis generating study indicates that LArS is not affected by AF ablation irrespective of the ablation mode. Patients with lower LArS before ablation had more arrhythmia recurrences independent of the ablation mode. A larger patient population is needed to assess the association of LArS and arrhythmia recurrences after AF ablation using different ablation modalities.

Clonal haematopoiesis of indeterminate potential predicts recurrence of atrial arrhythmias after surgical ablation for atrial fibrillation

Abstract Background Clonal haematopoiesis of indeterminate potential (CHIP), characterized by the presence of somatic blood cell clone expanding without other haematological abnormalities, was recently shown to be significantly associated with the development and progression of atrial fibrillation (AF). However, the clinical relevance of CHIP in patients underwent surgical atrial ablation remained unexplored. Aims This study investigated the potential role of CHIP in the recurrence of atrial arrhythmias after surgical ablation in patients with AF. Methods Deep-target sequencing of 74 CHIP (a mean depth of coverage = 4051x) was performed in 132 patients with AF (mean age, 60 years; 75.8% male; mean left atrial diameter, 47mm) who underwent surgical ablation without previous atrial ablation between December 2014 and September 2021. Variant allele fraction (VAF) ≥ 2.0% of any targeted genes indicated the presence of CHIP mutations. The primary outcome is the recurrence of any atrial arrhythmias for >30s after a blanking period of 3 months within a year. The clinical significance of CHIP was determined by multivariable Cox proportional hazards regression. Results A total of 17.4% (23 of 132) patients with AF carried CHIP mutations (DNMT3A, 8.3% and TET2, 3.8%). CHIP prevalence varied among AF types, with paroxysmal, persistent, and long-lasting AF counting for 12.5%, 16.5%, and 36.4%, respectively. During one-year follow-up after blanking period, recurrent atrial arrhythmia was documented in 15 (65.2%) and 37 (33.4%) patients in the CHIP and non-CHIP groups, respectively (p = 0.005 for log-rank test). The association of CHIP with atrial arrhythmias recurrence remained significant after fully adjustment (hazard ratio, [95% confidence interval], 1.92 [1.02-3.63]). Conclusions CHIP mutations with a VAF ≥ 2.0% were identified in 17.4% AF patients undertaken surgical ablation and was associated with poor prognosis. CHIP assessment may be useful in the personalized management of patients who planned to perform surgical ablation for AF.

Impact of altered pulmonary vein anatomy on long-term outcomes after cryoablation of paroxysmal atrial fibrillation

Abstract Background Cryoballoon catheter treatment for pulmonary vein (PV) isolation is an effective method for treating paroxysmal atrial fibrillation (AF). Purpose Evaluation of the significance of certain anatomical features of pulmonary veins for predicting the development of arrhythmia recurrence after pulmonary vein cryoballoon ablation (PV CBA) in paroxysmal AF. Materials and Methods 465 consecutive patients (61% were male) with paroxysmal AF (57±11 years) were included and analyzed. All underwent CPVA between 2018 and 2022. PV and left atrial (LA) anatomy were evaluated in all patients using multi-slice computed tomography (MSCT) before the CPVA procedure. After the ablation procedure, all patients were followed up for 24-56 months to assess the impact of pathologic abnormalities in PV anatomy on recurrences in the long-term follow-up period. Results Complete PV isolation was achieved in all patients. LA and PV anatomy was normal in 298 patients (64%). Pathologic change of PV anatomy was present in 167 patients. (36%). During 24-56 months of follow-up, AF recurrence was registered in 178 patients (38%). Patients with recurrent AF had mainly enlarged right (RSPV) and left superior PVs (LSPV) (p<0.001). The presence of left common PVs (n=126, Log-rank p<0.001), as well as the presence of additional right pulmonary veins (n=67, Log-rank p<0.001), was associated with early development of sustained arrhythmia recurrences, compared to patients with typical PV characteristics. Conclusion Altered PV anatomy is a risk factor for arrhythmia recurrence after PV CBA. Mandatory visualization of the LA and PV with MSCT improves patient selection for effective catheter-based treatment of atrial fibrillation.

A nurse-led intervention improves quality of life and reduces arrhythmic recurrences in patients undergoing atrial fibrillation ablation. Results of the NURSECAT-AF randomized clinical trial

Abstract Background/Introduction Atrial fibrillation (AF) is a prevalent condition that can lead to a decrease in quality of life and frequent re-hospitalizations. Some data suggest that integrated care nurse-led may blunt these consequences in unselected patients with AF, but not all studies support this. While AF ablation is becoming a cornerstone treatment for symptomatic patients with AF, it is unclear what impact a nurse-led intervention would have on these, quite likely, more receptive patients. Purpose To assess the impact of nurse-led intervention on quality of life among AF patients undergoing ablation. Methods We conducted a single-centre prospective randomised clinical trial to test the effect of an expert nurse-based intervention consisting of an educational programme on AF, support for the patient undergoing cardiac ablation to ensure its success, and management of risk factors associated with this arrhythmia. The control group underwent standard medical follow-up. Patient selection was based on chronological order. Only patients who underwent their first ablation and did not have heart failure were included. The primary endpoint was quality of life at 12 months post-ablation using the Arrhythmia-Specific Scale in Tachycardia and Arrhythmia (ASTA) questionnaire (higher values denote impaired quality of life). Secondary endpoints were AF knowledge and satisfaction at 15 days post-ablation using validated instruments, symptoms using the ASTA questionnaire as well, and readmissions rates, emergency room visits, and AF recurrence rates over a one-year period. Results 116 patients were screened (50 were excluded mostly because were re do). A total of 66 patients were eventually included and randomized (33 per arm; mean age [mean±SD] 63±10 years; 44 men [67%]). At 12 months, quality of life was significantly better in the intervention group than in the control group (4.5 ± 6.1 vs 0.57 ± 2.3, respectively, p=0.001)(Figure). Furthermore, satisfaction levels (17 ± 4.1 vs 12.7 ± 5.4, p>0.001) and disease knowledge (20.5 ± 5.1 vs 15.9 ± 4.5, p<0.001) were higher in the intervention group. Patients in the control group experienced a higher symptom burden during the first year (0.6 ± 1.5 vs 3.8 ± 4.5, p<0.001. Relevant clinical endpoints such as readmissions (3% vs 18.2%, p=0.046), emergency room visits (21.2% vs 57.5%, p=0.021), and arrhythmia recurrences (15.2% vs 45.5%, p=0.02) were all significantly lower in the intervention group. Conclusion(s) Nurse-led integrated care for patients undergoing AF ablation yields substantial improvements in quality of life and symptomatic relief at one year post-procedure. Additionally, it enhances patient knowledge of AF and satisfaction levels, and reduces readmissions, emergency room visits, and arrhythmia recurrences.

Comparative effectiveness of pulsed field ablation and cryoballoon ablation for atrial fibrillation: a systematic review and meta-analysis

Abstract Background Cryoballoon ablation (CBA) is a well-established technique for treating atrial fibrillation (AF), with a low complication rate related to cryoenergy-induced lesions. Pulsed Field Ablation (PFA) has emerged as a non-thermal alternative, with promising potential to further reduce complications. Purpose We aim to conduct a systematic review and meta-analysis comparing the efficacy and safety of PFA versus CBA in patients with AF. Methods We conducted a systematic search across PubMed, Embase, and the Cochrane Central Register of Controlled Trials to identify randomized controlled trials (RCTs) or observational studies published between 2013 and 2024 that compared PFA and CBA ablation techniques in patients with AF. Statistical analysis was carried out utilizing RevMan 5.1.7. Heterogeneity was assessed with I² statistics; p-values inferior to 0.05 and I²>25% were considered as significant heterogeneity. Results A total of 840 studies were screened in the initial search, and 26 studies were selected for full-text review based on inclusion criteria. Out of these, 8 observational studies involving 3,113 patients were included. Among these, 1,088 (34.9%) underwent PFA, while 2,025 (65.0%) underwent CBA. Periprocedural complications were significantly lower in patients who underwent PFA compared with the CBA group (RR 0.46; 95% CI 0.29 to 0.74; p=0.001; I²=1%; Fig. 1A). Furthermore, there was a significant reduction in procedure time in the PFA group (MD -8.21 min; 95% CI -13.74 to -2.69; p=0.004; I²=96%; Fig. 1B). However, no statistically significant difference was observed among groups regarding fluoroscopy time (MD 1.63 min; 95% CI -0.22 to 3.48; p=0.08; I²=92%; Fig. 2A), or recurrence of atrial arrhythmias after the blanking period (RR 0.84; 95% CI 0.68 to 1.04; p=0.12; I²=6%; Fig. 2B). Additionally, a subgroup analysis involving only propensity score-matched cohorts was conducted but didn’t show any statistical difference for any outcomes evaluated. Conclusion In this systematic review and meta-analysis, PFA was associated with a lower risk of periprocedural complications and a shorter procedure duration, compared to CBA in patients with AF. Additionally, it didn’t show a potential for reducing the recurrence of atrial arrhythmias, and the data regarding fluoroscopy time were inconclusive.Primary outcomesSecondary outcomes

Timing of early recurrence of atrial fibrillation during the blanking period after catheter ablation for persistent atrial fibrillation and implications for long-term success: a multicentre study

Abstract Background After catheter ablation (CA) for atrial fibrillation (AF), early recurrences of AF (ERAF) that occur within a 90-day post-ablation "blanking period" are considered to represent transient post-ablation pro-arrhythmia. Purpose To determine if the timing of early recurrence of AF during the traditional 90-day post-CA blanking period is associated with long-term AF recurrence after CA for persistent AF (PsAF). Methods We performed a multicentre retrospective study of patients undergoing first-time CA for PsAF between 2015-2018. All patients had undergone pre-CA DCCV. Incidences of ERAF during the post-CA blanking period were reviewed, and patients were categorised into three groups based on the timing of last episode of ERAF during the blanking period: (1) no ERAF (reference population); (2) last ERAF <30 days post-CA; (3) last ERAF 31-90 days post-CA. The primary outcome was long-term recurrence of atrial arrhythmia, i.e. time to first recurrence of atrial arrhythmia occurring beyond the first 90 days after CA. Patients who had ERAF and exited the blanking period in AF (i.e. those with immediate recurrence at 90 days) were excluded from this analysis. Results 331 patients were identified from five centres. 206 patients had no ERAF during follow-up, 124 patients had ERAF during the blanking period, and in one patient the presence of ERAF was not documented. Of the 124 patients experiencing ERAF during the 90-day post-CA blanking period, the timing of the last episode was known in 122 patients (Table 1). Of these, 58 patients exited the 90-day blanking period in AF and were excluded. Over median post-CA follow-up of 590 days, 147 patients (54%) experienced the primary outcome. Compared with Group 1 (no ERAF), ERAF within each of the time periods was associated with a statistically significant progressively increased risk of long-term recurrence (Group 2, last ERAF <30 days post-CA: hazard ratio [HR] 1.95 [95% CI 1.15-3.31]; Group 3, last ERAF 31-90 days post-CA: HR 4.86 [95% CI 2.13-11.08]; Figure 1). Conclusion ERAF during the traditional 90-day post-CA blanking period is associated with long-term AF recurrence, with later recurrence within the 90-day period conferring greater risk. Patients with ERAF during the blanking period may need to be considered for earlier repeat intervention where clinically appropriate.

Anabolic steroids as the substrate for atrial fibrillation: A case report

Abstract Background Atrial fibrillation (AF) is the most frequently encountered sustained arrhythmia worldwide. This supraventricular rhythm disorder is precipitated by advanced age, valvular heart disease, hypertension, heart failure, congenital heart defects and others. However, the role of anabolic steroids abuse in precipitating AF remains insufficiently researched and largely underreported, despite their known cardiovascular risks. Case summary We present the case of a 40-year-old male bodybuilder who was admitted to the emergency department with symptomatic atrial fibrillation. His medical history revealed the use of anabolic steroids, which was suspected to be the trigger. A thorough biological evaluation and echocardiography were performed, revealing no structural or functional cardiac abnormalities. After electrical cardioversion and discontinuation of anabolic steroid use, the patient's rhythm returned to normal, with no recurrence of arrhythmia during follow-up. Discussion This case highlights the potential but underexplored link between anabolic steroid use and the onset of atrial fibrillation. Although anabolic steroids are known to affect cardiovascular health by promoting hypertension, left ventricular hypertrophy, and endothelial dysfunction, their role in arrhythmogenesis, particularly in AF, remains unclear. In this patient, the absence of other identifiable triggers, combined with the resolution of symptoms upon steroid cessation, strongly suggests a causal relationship. Further research is needed to clarify the mechanisms through which anabolic steroids may contribute to the development of AF, particularly in younger, otherwise healthy individuals such as athletes and bodybuilders. This case underscores the importance of awareness among clinicians regarding the potential cardiac risks associated with anabolic steroid use.

Ppulsed field ablation and ultra-high-density mapping for PVI: use of machine learning and data augmentation to guide procedure and identify recurrent tachycardia mechanisms at one-year follow-up

Abstract Background In managing atrial fibrillation (AF), radiofrequency and cryoablation have been cornerstone techniques for achieving pulmonary vein isolation (PVI). Recently, pulsed-field ablation (PFA) has introduced a novel method for PVI. There remains a gap in knowledge regarding the permanent efficacy of ablation, related explicitly to acute lesion characteristics following PVI. Purpose Our study delves into an in-depth examination of acute lesion characteristics following PFA-PVI through ultra-high-density mapping (UHDM). We aim to identify specific clinical, anatomical, and periprocedural lesion features independently related to 1) intraoperative identification of UHDM non-isolated gaps with electrical conduction after first isolation and 2) three months follow-up recurrency of specific arrhythmias. Methods Results The present study includes 204 patients submitted to PFA-PVI for AF. UHDM guided all procedures to identify non-isolated gaps with electrical conduction. Perioperative and 3-month follow-up data were collected prospectively and analyzed. To build our prediction model, avoiding biases related to the unbalanced nature of the data, data augmentation was performed with SMOTE (Synthetic Minority Over-sampling Technique). Two machine learning (ML) models have been built, using logistic regression as learner, to predict the presence of isolation gaps identified by UHDM and follow-up recurrence of arrhythmias. A 20-fold cross-validation has been performed to train and test the models. The non-isolated gap was detected and immediately corrected in 14 (6.9%) patients and was present more often in patients with larger left atria (LA) (p<0.0001) and those with persistent AF (p=0.02). The ML model achieved an AUC of 0.88 in the prediction of the non-isolated gap after PFA (Precision: 0.65; Sens.: 0.90; F1: 0.76; Spec.: 0.83; NPV: 0.96). At three months follow-up, no patient experienced recurrent AF; recurrent roof-dependent atrial tachycardia was present in 10 (4.9%). Patients with recurrent atrial tachycardia had a significantly narrower remaining atrial-roof conduction bridge (p=0.01) identified intra-procedurally by UHDM, significantly larger LA (p=0.03), and non-significant trend for older age (p=0.07). The ML model achieved an AUC of 0.86, predicting recurrent tachycardia after PFA (Precision: 0.63; Sens.: 0.86; F1: 0.72; Spec.: 0.82; NPV: 0.94). Conclusions Consistent use of UHDM can help identify non-isolated gaps with electrical conduction that may occur even after PVI with updated technologies, such as PFA. Non-isolated gaps should be expected, particularly in patients with larger LA, where UHDM could be of particular use. Moreover, UHDM can help predict the eventual recurrence of arrhythmias. Again, LA size plays an essential role in such recurrencies, together with the size of the remaining conducting tissue "bridges" within the LA roof, measure by UHDM.

Characterization of sedation strategies in real-world use of pulsed field ablation: sub-analysis of the EU-PORIA registry

Abstract Background/Introduction With the introduction of pulsed field ablation (PFA) to treat patients with atrial fibrillation (AF), there has been interest in studying workflow and sedation strategies to better understand how this new technology can be integrated into clinical practice. Purpose Characterize the use of general anesthesia (GA) versus deep sedation during real-world use of the pentaspline PFA catheter to treat AF. Methods EU-PORIA is an all-comer AF registry enrolling consecutive patients treated with the pentaspline PFA catheter at seven high-volume centers in Europe. Patients were treated based on institutional standard of care. During follow-up, any episode of atrial tachycardia (AT) or AF lasting longer than 30 seconds was considered an arrhythmia recurrence. Results EU-PORIA enrolled 1233 patients, of which 250 ablation cases were performed under GA and 983 cases were performed with deep sedation. Six out of the 7 participating centers employed a single sedation strategy (2 GA; 4 deep sedation), with one center doing a mix of both sedation and GA. The patient population treated with GA had fewer female patients (30% vs 40%; p=0.04), a lower prevalence of hypertension (43% vs 57%; p<0.01), and fewer paroxysmal AF patients (54% vs 62%; p<0.01). The ablation strategy was performed based on operator’s discretion. In the GA group, 72% of patients received a pulmonary vein isolation (PVI)-only ablation approach versus 90% of patients in the sedation group (p<0.01). The most common additional lesion set performed was posterior wall isolation which accounted for 23% and 7% of cases in the GA and sedation groups, respectively (p<0.01). Procedure times and fluoroscopy times were significantly shorter in the sedation group versus the GA group (51 [36-84] min vs 75[60-90] min; 13 [8-19] min vs 19 [15-26] min; p<0.01 for both). Mapping was used in 60% of cases in the GA group versus only 26% of cases in the sedation group. Overall, there were no differences in the incidence of serious adverse events, and no difference in chronic treatment success. At 1-year follow-up, 74.8% of patients (187/250) in the GA group and 73.8% of patients (725/983) in the sedation group were free from recurrent AF/AT. Conclusion(s) In this registry, the use of deep sedation for AF ablation with the pentaspline PFA catheter demonstrated a safety and efficacy profile consistent with those procedures performed under GA. The majority of the deep sedation procedures were PVI-only and performed in a less progressed AF disease state. It is worth noting that there may be certain patient populations and center restrictions where GA will remain the necessary approach for AF ablation. This characterization of real-world use warrants further evaluation to understand optimal sedation strategies that can be used with PFA technologies.

Long-term follow-up after catheter ablation of atrial fibrillation and atrial tachycardia in patients with pulmonary hypertension

Abstract Introduction Catheter ablation of atrial fibrillation and atrial tachycardia (AF / AT) is established treatment in selected population. Only limited data, including long-term results, exist in patients with pulmonary hypertension (PH). Recently published prospective multicentric trial showed that more extensive radiofrequency catheter ablation of the bi-atrial arrhythmogenic substrate instead of clinical arrhythmia ablation alone is not beneficial in terms of arrhythmia recurrence in patients with AF / AT and PH. Now, we present the results of an extended, long-term follow-up from one of the study centres. Methods Patients with combined post- and pre-capillary or isolated pre-capillary PH and AF / AT indicated to catheter ablation were enrolled and randomised 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. Results A total of 52 patients (median age 71 years (IQR 62-75); 27 males) were enrolled. The presumable clinical arrhythmia was AF in 20 and AT in 32 patients, including typical AFL in 22 patients. Limited and extended ablation group included 28 and 24 patients, respectively. During the extended follow-up period of median 31 (IQR: 18; 46) months, the primary endpoint occurred in 17 patients (71 %) vs. 13 patients (46 %) in the Extended vs. Limited ablation group (p = 0.096). In parallel, overall mortality was comparable between groups (9 [38 %] vs. 11 [39 %]). Only 2 patients had recurrence of AFL during the extended follow-up. However, new different arrhythmia was documented in another 7 patients after the AFL ablation. Conclusion In PH patients, recurrence of AF / AT after a catheter ablation is frequent and the recurrence rate increases with the duration of follow-up. Ablation strategy seems to have no impact on arrhythmia free survival. Patients with typical atrial flutter have significantly higher chance to maintain sinus rhythm after a catheter ablation compared to AF or other AT.

Clinical characteristic and zero-fluoroscopy ablation outcomes of tachyarrhythmias in pregnant: a single center study

Abstract Background Although recommended avoid any intervention during gestation in cases of drug refractory of arrhythmias catheter ablation may be necessary in pregnant women. Purpose To present clinical characteristics and outcomes of zero-fluoroscopy catheter ablation during gestation. Methods This prospective, single center study included 84 cases of tachyarrhythmias during gestation. In 44 cases of drug refractory was performed catheter ablation without fluoroscopy (main group). We evaluated the further course of gestation and obstetric outcomes after ablation in comparison with pregnant with antiarrhythmic therapy of tachyarrhythmias (n=40, control group). Results Both groups were comparable by mean age of pregnant (28.2±4.2 vs. 27.3±3.9 years, p=0.093) and mean duration of gestation (24 ±3.4 vs. 23.8 ±3.2 weeks, p=0.123). New onset arrhythmia prevailed in both groups (64% vs. 55%, p=0,280). Supraventricular tachycardia was the most common arrhythmia during gestation (81,8% vs. 52,5%, p=0,005), which was followed by premature contraction (13,6% vs. 40%, p=0,007). Cases of ventricular tachycardia were rare (4,6% vs. 7,5%, p=0,665). Ablation was performed under the guidance of CARTO (45%) and Ensite Precision systems (55%) without using fluoroscopy in all cases. Acute procedural success of zero-fluoroscopy ablation was in 100% with mean procedural time 71±17 minutes without any complication. Outcomes: further course of gestation characterized by increased incidence of uterine contractile activity and placental abruption only in main group (4,54%, p=0.464 and 2.3%, p=642 respectively). There were no differences in the rate of other complication: uterine blood flow violation (15.9% vs 12.9%, p=0.234) and preeclampsia (4.55% vs 5%, p=0.237). Vaginal type of delivery was in the majority of cases in both groups (82% vs 83%, p=0.242). Neonatal outcomes characterized with normal range of fetal birth weight (median 3207,39±485,61 vs. 3312,3±234,1 grams, p=0.709) and 5 minute Apgar score (median 8,4±1,6 vs. 8,7±1,2, p=0.921). There was no incidence of maternal and fetal mortality. In 12 month, follow-up all there was no arrhythmia recurrence. Conclusions Zero-fluoroscopy ablation of tachyarrhythmias in pregnant is feasible and can be safety performed during gestation in cases of drug refractory with benign outcomes.

A meta-analysis of the safety and efficacy of pulsed-field versus conventional thermal ablation for atrial fibrillation

Abstract Background Since pulsed-field ablation (PFA) specifically targets myocardial tissue, it has become a cutting-edge substitute for radiofrequency (RF) and cryoablation. Purpose We aim to compare the safety and efficacy of PFA vs thermal ablation for AF ablation. Methods We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs) and observational comparative studies, which were retrieved by systematically searching: PubMed, EMBASE, Web of Science, SCOPUS, and Cochrane through September 2023. RevMan version 5.4 software was used to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD) with a 95% confidence interval (CI). Results Seventeen studies with a total of 2,255 patients were included. PFA was significantly associated with a decreased AF recurrence (RR: 0.65, 95% CI [0.51, 0.84], P= 0.0010) but not any arrhythmia recurrence (RR: 0.87, 95% CI [0.69, 1.09], P= 0.22). Also, PFA was significantly associated with decreased total procedure time (MD: -15.15, 95% CI [-20.23, -10.07], P< 0.00001) and heart rate (MD: -7.56, 95% CI [-12.78, -2.34], P= 0.005); however, there was no significant difference between PFA and thermal ablation in fluoroscopy time (MD: 2.83, 95% CI [-0.38, 6.04], P= 0.08). PFA decreased phrenic nerve palsy (RR: 0.38, 95% CI [0.15, 0.98], P= 0.05) and esophageal lesions (RR: 0.09, 95% CI [0.01, 0.69], P= 0.02); however, PFA was significantly associated with increased pericardial tamponade (RR: 6.14 with 95% CI [1.43, 26.33], P= 0.01). Conclusion PFA was significantly associated with decreased AF recurrence, heart rate, total procedure time, phrenic nerve palsy, esophageal lesion, and increased incidence of pericardial tamponade compared with thermal ablation. However, current evidence is mainly weighted by observational studies, requiring further large-scale randomized trials.Figure

Right ventricular outflow tract arrhythmias in patients with obstructive sleep apnea- electrophysiological insights

Abstract Background Obstructive sleep apnea (OSA) was associated with atrial fibrillation and heart failure. Furthermore, the arrhythmic sudden death during sleep in patients with OSA raises serious concerns. Non-ischemic ventricular arrhythmias arise frequently from the right ventricular outflow tract (RVOT). The involvement of obstructive sleep apnea in the genesis of arrhythmia (premature ventricular contraction or tachycardia) originating specifically in the RVOT is not yet coherently established. Purpose This study aims to demonstrate the possible relationship between untreated obstructive sleep apnea and the occurrence of RVOT arrhythmia and to follow the electrophysiological features and outcomes after radiofrequency catheter ablation (RFA) in patients carrying this double burden. Methods One-hundred-twelve (112) consecutive asymptomatic and symptomatic patients admitted with RVOT arrhythmia ((PVCs and VTs) underwent a sleep study (polysomnography). Apnea was set out as the cessation of breathing and hypopnea was defined as shallow, slow, and restricted breathing occurring in episodes of ten seconds or more. The patients had normal left and right ventricle ejection fractions and no structural cardiovascular disease or other known extracardiac arrhythmia predisposing conditions. No significantly elevated systolic pressure in the pulmonary artery was assessed at echocardiography. Every patient was investigated by electrophysiologic study (EPS) and RFA of the clinical ventricular arrhythmia was immediately performed. Practicing and former professional athletes were excluded. Results Seventy-eight (69 %) of the included patients had an apnea-hypopnea index > 10/h. The included patients had the following characteristics: mean age 52 ± 8 years, 62% males, 81% had a BMI >30kg/m². The cardiac electrophysiologic study did not induce sustained VTs. The distribution of the PVCs and non-sustained VTs evidenced a predilection for the superior, septal and anterior (68%) and also superior and anterolateral aspects of the RVOT (23%). Radiofrequency catheter ablation (RFA) guided by activation mapping, precocity (the site of earliest activation > 30 ms before the setting of the QRS complex) and pace-mapping were performed in all patients. Immediate success was obtained in 98 patients (88%). After a mean follow-up of 24± 6 months, 28 patients (28%) from the success arm had a recurrence of the PVCs or the non-sustained VTs, 22 patients (22%) with and 6 patients (6%) without sleep apnea. Conclusions RVOT arrhythmia genesis and relapse after successful RFA seem highly associated with sleep apnea. Furthermore, patients with sleep apnea are more prone to have recurrent arrhythmias after radiofrequency catheter ablation in the absence of appropriate control of OSA.

Comparison of ventricular tachyarrhythmias in HF patients on dapagliflozin versus empagliflozin

Abstract Background Ventricular tachycardia (VT) and ventricular fibrillation (VF) are devastating tachyarrhythmias that can cause sudden cardiac death in patients with heart failure (HF) if not anticipated or treated promptly. Although post-hoc analysis in DAPA-HF showed promise in their benefit, Sodium-glucose transport protein 2 inhibitors (SGLT2i) have not yet been evaluated for their effect on these tachyarrhythmias. This retrospective analysis aims to compare the 2 most commonly used SGLT2i agents, dapagliflozin and empagliflozin, and the incidence of VT in patients with HF. Methods The TriNetX Research network was used for this study. The two initial patient cohorts were created using ICD-10 codes and medication codes from the TriNetX platform. Both cohorts consisted of patients over age 60 with a history of heart failure and either VF or VT. One cohort was on treatment with dapagliflozin and the other with empagliflozin. The cohorts were balanced by propensity score matching and the greedy nearest neighbor algorithm for age, gender, race, ethnicity, hyperkalemia, and the current use of spironolactone, amiodarone, metoprolol, and carvedilol, resulting in 9,841 patients in each arm. The cohorts were then evaluated for the development of VF or VT over the subsequent five years as well as all-cause mortality. Additional cohorts were created to evaluate dapagliflozin vs empagliflozin in diabetics, nondiabetics, and patients with ejection fractions less than 35% Results Dapagliflozin was associated with an increased risk of ventricular arrhythmia in heart failure patients compared to empagliflozin (46.0% vs. 40.8%, RR 1.13, 95% CI (1.09,1.16), P value < 0.0001). It was also associated with higher mortality at five years (RR 1.10, 95% CI (1.03,1.18), P value 0.0034). Conclusions In comparisons between dapagliflozin and empagliflozin in heart failure patients with previously documented ventricular arrhythmias, empagliflozin had 13% less risk of recurrence of ventricular arrhythmias. Secondarily, the empagliflozin cohort also exhibited lower all-cause mortality (14.8% vs 16.3%) at five years from starting the drug. Our analysis does not disprove findings in DAPA-HF, but rather may support the potential class effect of SGLT2 inhibitors in their ability to suppress VT.(1) Importantly, the overall incidence of ventricular tachyarrhythmias is high in both cohort, given we selected a high-risk population. Notably, our documented recurrence rate is similar to past reports of recurrence after VT ablation, the gold standard for treatment of VT. (2) SGLT2 inhibitors have shown clear benefit in multiple placebo-controlled studies in terms of heart failure outcomes like mortality and readmission, but their effect on arrhythmias is one more additional benefit this class may have. (3) Given these associations, empagliflozin may be a more favorable options for HF patients who have already had VT or VF.

Clinical findings from a large endo-epicardial atrial arrhythmia ablation registry

Abstract Background Despite advances, catheter ablation success rates for persistent AF remain at 50-60%. The approach for recurrent persistent AF, beyond pulmonary vein isolation, remains contentious. Surgical maze procedures have demonstrated superior outcomes compared to catheter ablation. Catheter-based linear lesions sets have failed to demonstrate efficacy, perhaps due to a lack of consistent transmurality with endocardial radiofrequency. Objective We report our safety and clinical data of an endo-epicardial approach using high-power radiofrequency ablation for atrial arrhythmias. Methods 126 patients (80% male; mean age 65 years [43-81]) underwent redo ablation, between August 2020 and February 2024, for recurrent symptomatic atrial arrhythmias using an endo-epicardial approach. We used a standardised linear lesion set (posterior wall isolation and anterior mitral line) for recurrent persistent AF. Results Utilising an intentional coronary sinus exit and C02 insufflation technique, we achieved epicardial access in 121 anti-coagulated patients. 5 patients were found to have pericardial adhesions, prohibiting access. There were 2 LIMA punctures which were coiled, 2 cases of excess pericardial bleeding (not access related), that settled conservatively, and no surgery or death. 92% of patients received epicardial ablation. 86 anterior mitral lines (95% acute block, 79% with epi ablation), 88 roof lines (92% blocked, 50% with epi ablation) and 81 floor lines (98% blocked, 36% with epi ablation) were undertaken. 106 posterior wall isolations were performed (94% isolated, 51% epi ablation). 75 patients had a standardised lesion set and were included for recurrence analysis. 49 had persistent AF (71% male, mean age 65 years, mean LAVI 38 ml/m2, 26 PVI at baseline and 23 PV reconnections) and 26 longstanding persistent AF (92% male, median age 64 years, mean LAVI 37.1 mls/m2, 16 PVI at baseline and 10 PV reconnections). 82% with persistent AF (median follow up time 11 months) and 38% with longstanding persistent AF (median follow up time 10.1 months) maintained sinus rhythm. The submitted image demonstrates the freedom from persistent AF, for the cohort who are beyond the 3-month blanking period, as per classification of atrial arrhythmia. Conclusion In one the largest cohorts to date, we have shown that endo-epicardial atrial ablation is feasible and safe with epicardial ablation allowing improved transmurality and thus acute linear block. Clinical outcomes, using a posterior wall isolation and anterior mitral line, were favourable for persistent but not longstanding persistent AF.

HD grid versus circular mapping catheter for assessment of pulmonary vein (pv) reconnections

Abstract Background Traditionally, circular mapping catheters (CMC) have been considered superior to other designs for mapping pulmonary vein reconnections due to the circular shape of the PV ostium. The grid multipolar catheter produces higher definition maps potentially overcoming the disadvantage of being rectangular. Purpose We assessed the acute procedural results, comparing Grid versus CMC in the setting of PV re-isolation to understand if one was superior to the other. Methods In this multicentre randomised controlled trial, 169 patients (62% male; median age 66 years [22-83) underwent repeat ablation, between July 2021 and March 2023, for recurrent symptomatic atrial arrhythmias. We undertook two LA maps for patients, utilising the Grid and the CMC. Blinded maps were collected with both catheters, followed by randomisation to one map for analysis and ablation. The primary outcome was the radiofrequency time required to isolate the pulmonary veins. Secondary outcomes include LA mapping time and density for both catheters, ability to identify pulmonary vein sleeves and duration of the ablation procedure. Results 126 patients had PV reconnections. 66 patients (64% male; median age 65 years [22-83]) in the Grid arm and 60 patients (68% male; median age 65.5 years [31-83]) in the CMC arm. There was one pericardial effusion and one TIA. There was no significant difference (p=0.202) found in the RF time required to achieve PV isolation in both Grid (mean RF time 200 ± 232 secs) vs CMC (mean RF time 169 ± 298 secs) arms. There was no significant difference (p=0.407) found between LA mapping time for the CMC (mean 1047 ± 454 seconds) and the Grid (Median 1080 ± 440 seconds). There was no significant difference (p=0.411) found in the total procedure time for the CMC (mean 122.7 minutes) and the HD grid (130 minutes). There were significantly more (p<0.001) PV mapping points identified with the grid (mean 354±213 points) than the CMC (mean 234±154 points) arm. There was no significant difference in PV sleeve reconnections found (p=0.106) between the grid (120 PV sleeve reconnections with a mean 1.4±0.71 reconnections) and the CMC (98 PV sleeve reconnections with a mean 1.52±0.72 reconnections). Both maps were analysed to assess reconnections on opposing catheter arms. The grid identified 20 PV sleeve reconnections not visible on the CMC, whilst 9 were visible on the CMC and not the grid. Conclusion There was no significant difference found in RF time, mapping time and overall procedure time. The Grid identified more reconnections not seen with the CMC and had an overall improved mapping density suggesting that this configuration could be superior for LA mapping.

Early repeat catheter ablation in patients with early recurrent arrhythmia

Abstract Background Repeat catheter ablation reduces adverse cardiovascular endpoints in patients with recurrent atrial tachyarrhythmia after index ablation. However, when to proceed with re-ablation in patients with early recurrent arrhythmia is unknow. Objective In this study, we aim to access the effectiveness of early repeat ablation on cardiovascular outcomes in early recurrent atrial tachycardia patients. Methods A total of 502 post-ablation patients, who experienced early atrial tachyarrhythmia recurrence within 6 months outside the blank period post index ablation and had undergone a repeat ablation, were consecutively enrolled from China AF registry from January 2012 to December 2018. Early repeated ablation (ERA) was defined as patients underwent a subsequent catheter ablation procedure within early recurrent period, then late repeated ablation (LRA) referred to a redo procedure that performed after 6 months since the de novel ablation. Cox proportional hazard models were used to estimate the effect of early re-ablation on primary endpoint (a composite of cardiovascular death, stroke and cardiovascular rehospitalization) and secondary endpoint (each component of primary outcome and AF/AT recurrence). Results The median follow-up time was 26 months after the redo-AF/AT ablation. First primary composite outcome occurred in 39 of the patients received early re-ablation (24.38 per 100 person-years) and in 136 of the patients performed with late re-ablation (39.77 per 100 person-years) (HR = 0.55, 95% CI = 0.38-0.79; P0.001). Cardiovascular re-hospitalization (hazard ratio 0.52 95% confidence interval [0.36; 0.73]) and AF recurrence occurred less often (hazard ratio 0.76, 95% confidence interval [0.58; 0.98]) in the ERA group. No significant difference between the two groups was found in terms of cardiovascular death, stroke and major bleeding events. Conclusion Early initiation of redo-ablation conveys better clinical benefit in patients with early arrhythmia recurrence.