Atrial Arrhythmia Recurrence Research Articles

Radiofrequency catheter ablation of persistent atrial fibrillation by pulmonary vein isolation with or without left atrial posterior wall isolation: long-term outcomes of the CAPLA trial.

Posterior wall isolation (PWI) is commonly incorporated into catheter ablation (CA) strategies for persistent atrial fibrillation (AF) in an attempt to improve outcomes. In the CAPLA randomized study, adjunctive PWI did not improve freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation (PVI) alone. Whether additional PWI reduces arrhythmia recurrence over the longer term remains unknown. In this multicenter, international, randomized study patients with persistent AF undergoing index CA using radiofrequency (RF) were randomized to PVI+PWI versus PVI alone. Patients underwent regular follow-up including rhythm monitoring for a minimum of 3 years post CA. AF burden at 3 years post-ablation was evaluated with either 28-day continuous ambulatory ECG monitoring, twice daily single-lead ECG or from cardiac implanted device. Evaluated endpoints included freedom from any documented atrial arrhythmia recurrence after a single procedure, AF burden, need for redo catheter ablation, rhythm at last clinical follow-up, healthcare utilisation metrics and AF-related quality of life. 333 of 338 (98.5%) patients (mean age 64.3±9.4 years, 23% female) completed 3-year follow-up, with 169 patients randomized to PVI+PWI and 164 patients to PVI alone. At a median of 3.62 years post-index ablation, freedom from recurrent atrial arrhythmia occurred in 59 patients (35.5%) randomized to PVI+PWI vs 68 patients (42.1%) randomized to PVI alone (HR 1.15, 95% CI 0.88-1.51, p=0.55). Median time to recurrent atrial arrhythmia was 0.53 years (IQR 0.34-1.01 years). Redo ablation was performed in 54 patients (32.0%) in the PVI+PWI group vs 49 patients (29.9%, p=0.68) in the PVI alone group. Pulmonary vein reconnection was present in 54.5% (mean number of reconnected PVs 2.2±0.9) and posterior wall reconnection in 75%. Median AF burden at 3 years was 0% in both groups (IQR 0-0.85% PVI+PWI vs 0-1.43% PVI alone, p=0.49). Sinus rhythm at final clinical follow-up was present in 85.1% with PVI+PWI vs 87.1% with PVI alone (p=0.60). Mean AF Effect On Quality-Of-Life (AFEQT) score at 3 years post-ablation was 88.0±14.8 with PVI+PWI vs 88.9±15.4 with PVI alone (p=0.63). In patients with persistent AF, the addition of PWI to PVI alone at index RF catheter ablation did not significantly improve freedom from atrial arrhythmia recurrence at long-term follow-up. Median AF burden remains low and AF quality of life high at 3 years with either ablation strategy.

Pulsed-field- vs. cryoballoon-based pulmonary vein isolation: lessons from repeat procedures.

Pulsed-field ablation (PFA) is an emerging technology to perform pulmonary vein isolation (PVI). Initial data demonstrated high safety and efficacy. Data on long-term PVI durability and reconduction patterns in comparison to established energy sources for PVI are scarce. We compare findings in repeat ablation procedures after a first PFA to findings in repeat ablation procedures after a first cryoballoon ablation (CBA) based PVI. A total of 550 consecutively enrolled patients underwent PFA or CBA index PVI. Repeat ablations in patients with symptomatic atrial arrhythmia recurrences were analysed. A total of 22/191 (12%) patients after index PFA-PVI and 44/359 (12%) after CBA-PVI underwent repeat ablation. Reconduction of any pulmonary vein (PV) was detected by multipolar spiral mapping catheter at each PV with careful evaluation of PV potentials and by 3D-mapping in 16/22 patients (73%) after PFA-PVI and in 33/44 (75%) after CBA-PVI (P = 1.000). Of 82 initially isolated PVs after PFA-PVI, 31 (38%) were reconducting; of 169 isolated PVs after CBA-PVI, 63 (37%) were reconducting (P = 0.936). Clinical atrial tachycardia occurred similarly in patients after PFA (5/22; 23%) and CBA (7/44; 16%; P = 0.515). Roof lines were set more often after PFA- (8/22; 36%) compared with CBA-PVI (5/44; 11%; P = 0.023). Repeat procedure duration [PFA: 87 (76, 123) min; CBA: 93 (75, 128) min; P = 0.446] was similar and fluoroscopy time [PFA: 11 (9, 14) min; CBA: 11 (8, 14) min; P = 0.739] equal between groups at repeat ablation. During repeat ablation after previous PFA- or CBA-based PVI, electrical PV-reconduction rates and patterns were similar.

Long-term outcomes of catheter ablation for atrial fibrillation in octogenarians.

Catheter ablation is superior to pharmacological therapy in controlling atrial fibrillation (AF). There are few data on the long-term outcome of AF ablation in octogenarian patients. This analysis aims to evaluate the outcome of AF ablation in octogenarians vs. younger patients. In this retrospective study in 13 centres in the UK, France, and Switzerland, the long-term outcomes of 473 consecutive octogenarian patients undergoing ablation for AF were compared to 473 matched younger controls (median age 81.3 [80.0, 83.0] vs. 64.4 [56.5, 70.7] years, 54.3% vs. 35.1% females; p-value for both < 0.001). The primary endpoint was the recurrence of atrial arrhythmia after a blanking period of 90days within 365days of follow-up. Acute ablation success as defined as isolation of all pulmonary veins was achieved in 97% of octogenarians. Octogenarians experienced more procedural complications (11.4% vs 7.0%, p = 0.018). The median follow-up time was 281 [106, 365] days vs. 354 [220, 365] days for octogenarians vs. non-octogenarians (p < 0.001). Among octogenarians, 27.7% (131 patients) experienced a recurrence of atrial arrhythmia, in contrast to 23.5% (111 patients) in the younger group (odds ratio 1.49; 95% confidence interval 1.16-1.92; p = 0.002). In a multivariable regression model including gender, previous AF ablation, vascular disease, chronic kidney disease, CHA2DS2-VASc score, left atrial dilatation, and indwelling cardiac implantable electronic device, age above 80 remained an independent predictor of recurrence of arrhythmia. Ablation for AF is effective in octogenarians, but is associated with slightly higher procedural complication rate and recurrence of atrial arrhythmia than in younger patients.

Early versus Late Radiofrequency Catheter Ablation in Atrial Fibrillation: Timing Matters.

Background: Despite the progressive course of atrial fibrillation (AF), the optimal timing of radiofrequency catheter ablation (RFCA) during disease course is still unknown. We aimed to investigate the impact of early RFCA within a year after AF diagnosis on procedural outcomes. Methods: A single-center retrospective study was conducted on symptomatic AF patients (n = 130) referred for RFCA with a 16-month median follow-up. Patients were stratified based on the diagnosis-to-ablation time (DAT) into early (≤1 year) and late (>1 year) RFCA groups. Atrial arrhythmia recurrence after single RFCA was the primary outcome. Secondary outcomes included cardiovascular hospitalizations, AF progression, and antiarrhythmic drug (AAD) use. Results: Within a year of AF diagnosis, 33 patients (25.4%) underwent RFCA. In the early-RFCA group, 84.4% of patients did not have recurrent atrial arrhythmia, in contrast to 60.8% in the late-RFCA group (p = 0.039). Late RFCA (HR = 2.74, 95% CI = 1.062-7.052, p = 0.037) and AF recurrence during the blanking period (HR = 4.57, 95% CI = 2.38-8.57, p < 0.0001) were independent predictors of atrial arrhythmia recurrence on multivariate analysis. Compared to the late-RFCA group, the early-RFCA group had significantly lower rates of cardiovascular hospitalizations (18% vs. 42%, p = 0.023), AF progression (0.0% vs. 11.3%, p = 0.044), and AAD use (45.4% vs. 81.4%, p < 0.001). Conclusions: Early RFCA within a year of AF diagnosis is associated with less atrial arrhythmia recurrence, fewer cardiovascular hospitalizations, less AF progression, and less AAD use. DAT of more than one year and AF recurrence during the blanking period are independent predictors of atrial arrhythmia recurrence after single RFCA.

Low-Voltage Area Ablation in Addition to Pulmonary Vein Isolation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Background: Low-voltage area (LVA) ablation, in addition to pulmonary vein isolation (PVI), has been proposed as a new strategy in patients with atrial fibrillation (AF), but clinical trials have shown conflicting results. We performed a systematic review and meta-analysis to assess the impact of LVA ablation in patient undergoing AF ablation (PROSPERO-registered CRD42024537696). Methods: Randomized clinical trials investigating the role of LVA ablation in addition to PVI in patients with AF were searched on PubMed, Embase, and the Cochrane Library from inception to 22 April 2024. Primary outcome was atrial arrhythmia recurrence after the first AF ablation procedure. Secondary endpoints included procedure time, fluoroscopy time, and procedure-related complication rate. Sensitivity analysis including only patients with LVA demonstration at mapping and multiple subgroups analyses were also performed. Results: 1547 patients from 7 studies were included. LVA ablation in addition to PVI reduced atrial arrhythmia recurrence (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52-0.81, p < 0.001) with a number needed to treat to prevent recurrence of 10. No difference in procedure time (mean difference [MD] -5.32 min, 95% CI -19.01-8.46 min, p = 0.45), fluoroscopy time (MD -1.10 min, 95% CI -2.48-0.28 min, p = 0.12) and complication rate (OR 0.81, 95% CI 0.40-1.61, p = 0.54) was observed. Consistent results were demonstrated when considering only patients with LVA during mapping and in prespecified subgroups for AF type (paroxysmal vs. persistent), multicentric vs. monocentric trial, and ablation strategy in control group. Conclusions: In patients with AF, ablation of LVAs in addition to PVI reduces atrial arrhythmia recurrence without a significant increase in procedure time, fluoroscopy time, or complication rate.

The anticoagulation one year after ablation of atrial fibrillation in patients with atrial fibrillation (ALONE-AF) trial: Study protocol

BackgroundThe ideal long-term antithrombotic strategy for patients after successful catheter-based atrial fibrillation (AF) ablation is still uncertain. Presently, practices vary, and the advantages of oral anticoagulation (OAC) for the post-ablation population are not clearly established. To date, no randomized trials have addressed this therapeutic question. This study aimed to evaluate whether no OAC therapy is superior to apixaban in reducing the risk of stroke, systemic embolism, or major bleeding among patients without apparent recurrent atrial arrhythmias for at least 1 year after their AF ablation procedure. MethodsThe ALONE-AF trial is a prospective, multicenter, open-label, randomized study with blinded outcome assessment. Patients with AF who have at least one non-gender stroke risk factor (as determined by the CHA2DS2-VASc score) and no documented recurrences of atrial arrhythmia for at least 12 months post-ablation will be randomly assigned to apixaban 5 mg b.i.d. or no OAC therapy. The primary endpoint is a composite outcome of stroke, systemic embolism, and major bleeding. Key secondary outcomes include clinically relevant non-major bleeding, all-cause mortality, myocardial infarction, transient ischemic attack, quality of life, and frailty analysis. Participants will be followed for a period of 2 years. The estimated total sample size is 840 subjects, with 420 subjects in each arm. ConclusionThe ALONE-AF trial aims to provide robust evidence for the optimal anticoagulation strategy for patients with stroke risk factors following successful AF ablation.

Adjunctive left atrial posterior wall isolation for atrial fibrillation: An updated systematic review and meta-analysis.

Posterior left atrial wall isolation (PWI) plus traditional pulmonary vein isolation (PVI) has been proposed as a promising intervention to decrease atrial fibrillation (AF) recurrence. We aim to investigate the efficacy and safety of adding PWI to the traditional PVI in patients with AF. A systematic review and meta-analysis was conducted using synthesizing randomized controlled trials (RCTs) retrieved by systematically searching PubMed, Web of Science, SCOPUS, EMBASE, and Cochrane through June 14, 2023. We used Stata version 17 to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023446227). We included 11 RCTs with a total number of 1534 patients. Combined ablation with PWI + PVI was not associated with any significant difference over PVI only regarding the recurrence of clinical AF (RR: 0.86 with 95% CI [0.70-1.06]), all atrial arrhythmia (RR: 0.93 with 95% CI [0.82-1.07]), nonatrial fibrillation arrhythmia (RR: 1.22 with 95% CI [0.97-1.53]), early AF (RR: 0.89 with 95% CI [0.62-1.27]), and antiarrhythmic drugs at discharge (RR: 0.83 with 95% CI [0.67-1.04]). However, it was associated with increased total ablation duration (minutes) (MD: 12.58 with 95% CI [6.80-18.37]) and total procedure duration (minutes) (MD: 16.77 with 95% CI [9.63-23.91]), without any significant difference regarding adverse events (RR: 1.05 with 95% CI [0.63-1.74]). While the pooled data from PWI + PVI using point-by-point radiofrequency did not suggest a benefit in the recurrence of various atrial arrhythmias compared to PVI alone, PWI+PVI using direct posterior wall ablation, especially with cryoballoon, demonstrated a significant reduction in recurrence of AF/atrial arrhythmias. Also, PWI + PVI significantly increased the ablation and total procedure durations.

Efficacy and safety of a novel hexaspline pulsed field ablation system in patients with paroxysmal atrial fibrillation: the PLEASE-AF study.

Pulsed field ablation (PFA) is an emerging non-thermal ablative modality demonstrating considerable promise for catheter ablation of atrial fibrillation (AF). However, these PFA trials have almost universally included only Caucasian populations, with little data on its effect on other races/ethnicities. The PLEASE-AF trial sought to study the 12-month efficacy and the safety of a multi-electrode hexaspline PFA catheter in treating a predominantly Asian/Chinese population of patients with drug-refractory paroxysmal AF. Patients underwent pulmonary vein (PV) isolation (PVI) by delivering different pulse intensities at the PV ostium (1800 V) and atrium (2000 V). Acute success was defined as no PV potentials and entrance/exit conduction block of all PVs after a 20-min waiting period. Follow-up at 3, 6, and 12 months included 12-lead electrocardiogram and 24-h Holter examinations. The primary efficacy endpoint was 12-month freedom from any atrial arrhythmias lasting at least 30 s. The cohort included 143 patients from 12 hospitals treated by 28 operators: age 60.2 ± 10.0 years, 65.7% male, Asian/Chinese 100%, and left atrial diameter 36.6 ± 4.9 mm. All PVs (565/565, 100%) were successfully isolated. The total procedure, catheter dwell, total PFA application, and total fluoroscopy times were 123.5 ± 38.8 min, 63.0 ± 30.7 min, 169.7 ± 34.6 s, and 27.3 ± 10.1 min, respectively. The primary endpoint was observed in 124 of 143 patients (86.7%). One patient (0.7%) developed a small pericardial effusion 1-month post-procedure, not requiring intervention. The novel hexaspline PFA catheter demonstrated universal acute PVI with an excellent safety profile and promising 12-month freedom from recurrent atrial arrhythmias in an Asian/Chinese population with paroxysmal AF. ClinicalTrials.gov Identifier: NCT05114954.

Real-world evidence demonstrates an appropriate atrial fibrillation population for hybrid convergent approach versus stand-alone cryoballoon ablation: A long-term safety and efficacy study.

A hybrid convergent approach (endocardial and epicardial ablation) demonstrated superior effectiveness in a recent randomized study for long-standing persistent atrial fibrillation (LSPAF). Yet, there is a lack of real-world, long-term evidence as to which patients are best candidates for a hybrid convergent approach compared to standard endocardial cryoballoon pulmonary vein isolation (CB PVI). This single-center, retrospective analysis spanning from 2010 to 2015 compared two distinctly different atrial fibrillation (AF) cohorts; one treated with stand-alone cryoablation and one treated with a hybrid convergent approach. Baseline characteristics described candidates for each approach. The following criteria were utilized to determine CB PVI candidacy: (1) paroxysmal AF (PAF) (stage 3A) with failed class I/III antiarrhythmic drug (AAD) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD unwilling to undergo hybrid procedure. Selection criteria for the hybrid procedure included: (1) PAF refractory to both class I/III AAD and prior CB PVI (stage 3D) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD agreeable to hybrid procedure. Prior sternotomy was excluded. Serial electrocardiograms and continuous monitoring evaluated primary efficacy outcome of time-to-first recurrence of atrial arrhythmia after a 90-day blanking period. Secondary outcomes were procedure-related complications and AAD use (at discharge, 12, and 36 months). Kaplan-Meier methods evaluated arrhythmia recurrence. Of 276 patients, 197 (64.2 ± 10.6 years old; 66.5% male; 74.1% 3A-PAF; 18.3% 3B/3D-persistent AF; 1.0% 3C-LSPAF; 6.6% undetermined) underwent CB PVI and 79 (61.4 ± 8.1 years old; 83.5% male; 41.8% 3D-PAF; 45.5% 3B/3D-persistent AF; 12.7% 3C/3D-LSPAF) underwent hybrid procedure. Arrhythmia freedom through 36 months was 55.2% for CB PVI and 50.4% for hybrid (p = .32). Class I AAD utilization at discharge occurred in 38 (19.3%) patients in the CB PVI group and 5 (6.3%) patients in the hybrid group (p = .01). CB PVI class I AAD utilization at 12 months occurred in 14 (9.0) patients versus 0 patients for hybrid convergent (p = .004). Patients with one or more adverse event were as follows: two (1.0%) in the CB PVI group (both transient phrenic nerve palsy) and three (3.7%) in the hybrid group (two with significant bleeding and one with wound infection) (p = .14). This study demonstrated that patients with more complex forms of AF (3D-PAF or 3B/3C/3D-persistent/LSPAF) could be well managed with a convergent approach. In a real-world evaluation, outcomes match safety and efficacy thresholds achieved for patients with earlier, less complex AF etiologies treated by CB PVI alone.

Meta-analysis of high-power short-duration versus cryoballoon ablation for atrial fibrillation.

The existing literature regarding the treatment strategy for high-power short-duration (HPSD) ablation in patients diagnosed with atrial fibrillation (AF) is currently insufficient. The objective of this study is to perform a comparative analysis evaluating the effectiveness, safety, and procedural efficiency of HPSD versus cryoballoon ablation (CBA) for AF. A comprehensive search was conducted in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify trials comparing HPSD with CBA for AF from their inception until December 25, 2023. Treatment effect measures were expressed as odds ratio (OR), mean difference (MD), accompanied by a 95% confidence interval (CI). The analysis comprised six eligible trials involving a total enrollment of 2481 patients. No statistically significant disparities were observed in recurrent atrial arrhythmia (OR 0.90; 95% CI, 0.71-1.16) or total complications (OR 0.65; 95% CI, 0.38-1.12) between the two ablation techniques examined in this study. However, HPSD technique exhibited a significantly prolonged procedure time (MD 27.42; 95% CI, 19.03 to 35.81). Conversely, no significant differences were observed between the two modalities in terms of total fluoroscopy duration (MD -4.37; 95% CI -10.70 to 1.96) and ablation time (MD 7.95; 95% CI -3.97 to 19.88). Furthermore, HPSD demonstrated significantly higher odds of extrapulmonary vein (PV) trigger ablation compared to CBA (OR 18.86; 95% CI, 5.12-69.49). The subgroup analyses revealed that CBA continued to exhibit superior procedure time (except for the paroxysmal AF subgroup: [MD 29.52; 95% CI -4.25 to 63.60]), while no significant differences in safety and efficacy (except for the HPSD ≥ 70W subgroup: [OR 0.44, 95% CI 0.20-0.97]) outcomes were still observed. Among patients undergoing ablation therapy for AF, both HPSD and CBA demonstrate comparable efficacy and safety profiles; however, HPSD is associated with longer procedural time and higher rates of extra-PV trigger ablation.

The Value of Adjunctive Left Atrial Posterior Wall Isolation on Clinical Outcomes in Atrial Fibrillation Patients: A Systematic Review and Meta-Analysis.

Although pulmonary vein isolation (PVI) remains the mainstream way of atrial fibrillation (AF) ablation. The left atrial posterior wall (LAPW) may contributes to the development of AF as an arrhythmogenic substrate. The efficacy of additional left atrial posterior wall isolation (LAPWI) beyond PVI is in AF patients remains undefined. This study explored the influence of posterior wall isolation (PWI) on clinical outcomes in AF patients. PubMed, EMBASE, and Cochrane Library databases were searched for studies comparing the outcomes of AF with and without PWI. The efficacy outcomes were recurrence of all atrial arrhythmia (AA), atrial fibrillation (AF), and atrial flutter (AFL)/atrial tachycardia (AT). The safety outcomes were mainly focused on procedural adverse events. A total of 16 studies (7 randomized controlled trials (RCTs), 3 prospective studies and 6 retrospective analyses) with 3340 AF patients were enrolled (1550 patients in PVI with PWI group and 1790 in PVI alone group). 12 studies included persistent atrial fibrillation patients, 3 studies with paroxysmal AF patients and 1 study with paroxysmal AF and persistent AF concurrently. Mean follow-up period was 16.56 months. In AF patients, adjunctive PWI obviously reduced the recurrence of all atrial arrhythmias (risk ratio (RR) 0.78 [95% CI 0.64-0.95], = 79%, p = 0.01) and the recurrence of AF (RR 0.68 [95% CI 0.53-0.88], = 75%, p = 0.004); Meanwhile, additional PWI left no impact substantially on lower recurrence of AFL/AT (RR 1.23 [95% CI 0.94-1.60], = 49%, p = 0.12). The results seemed to be no significant differences in occurrence rate of procedural complications between the PVI only and PWI+PVI (RR 1.19 [95% CI 0.80-1.79], = 0%, p = 0.39). In subgroup analyses, the benefit of adjunctive PWI compared with PVI only was more distinct in persistent AF group and cryoballoon ablation group. Notably, adjunctive PWI with radiofrequency ablation may induce a slight increase of recurrent AFL/AT compared with PVI only (RR 1.56 [95% CI 1.02-2.39], = 30%, p = 0.04). Compared with PVI alone, additional PWI to PVI appeared to be associated with decreased recurrence of AF and atrial arrhythmias without an increased occurrence of procedural complications, especially in persistent AF patients. Cryoballoon ablation seemed more suitable for PWI compared with radiofrequency ablation. More RCTs are needed to verify the conclusion.

Comparison of anterior mitral line and mitral isthmus line for ablation of mitral annular flutter.

Mitral annular flutter (MAF) is the most common left atrial macro-reentrant arrhythmia following catheter ablation of atrial fibrillation (AF). The best ablation approach for this arrhythmia remains unclear. This single-center, retrospective study sought to compare the acute and long-term outcomes of patients with MAF treated with an anterior mitral line (AML) versus a mitral isthmus line (MIL). Acute ablation success, complication rates, and long-term arrhythmia recurrence were compared between the two groups. Between 2015 and 2021, a total of 81 patients underwent ablation of MAF (58 with an AML and 23 with a MIL). Acute procedural success defined as bidirectional block was achieved in 88% of the AML and 91% of the MIL patients respectively (p = 1.0). One year freedom from atrial arrhythmias was 49.5% versus 77.5% and at 4 years was 24% versus 59.6% for AML versus MIL, respectively (hazard ratio [HR]: 0.38, confidence interval [CI]: 0.17-0.82, p = .009). Fewer patients in the MIL group had recurrent atrial flutter when compared to the AML group (HR: 0.32, CI: 0.12-0.83, p = .009). The incidence of recurrent AF, on the other side, was not different between both groups (21.7% vs. 18.9%; p = .76). There were no serious adverse events in either group. In this retrospective study of patients with MAF, a MIL compared to AML was associated with a long-term reduction in recurrent atrial arrhythmias driven by a reduction in macroreentrant atrial flutters.

Impact of the timing of early recurrences during the blanking period in patients after cryoballoon ablation: insights from the COMPARE CRYO study using continuous rhythm monitoring

Abstract Background Early recurrences (ER) during the blanking period after pulmonary vein isolation (PVI) are common. While many of those correlate to late recurrences (LR) after the blanking period, some do not. The impact of the timing of ER is difficult to assess with non-invasive Holter monitoring due to under sampling. Purpose To evaluate the impact of the timing of ER after cryoballoon ablation using continuous rhythm monitoring by means of an implantable cardiac monitor (ICM). Methods This is a prespecified sub study of the COMPARE-CRYO study. The trial enrolled patients with paroxysmal atrial fibrillation and compared PVI with the PolarX cryoballoon and the ArcticFront cryoballoon. All patients underwent ICM implantation at the end of the PVI. ER was defined as recurrence of any atrial arrhythmia &amp;gt; 30 seconds between days 0-90 after PVI. LR was defined as recurrence of any atrial arrhythmia &amp;gt; 30 seconds between days 91-365. Results ER occurred in 116 of 201 patients (58%). A total of 5330 episodes occurred, 4210 in patients with LR and 1120 in patients without LR (Figure 1A). Median time to the latest episode of ER in the blanking period was 18 days (IQR 8.5-36.5) in patients with no LR and 80 days (IQR 27-89) in patients with LR (p&amp;lt;0.001). The latest episode of ER occurred between days 0-30, 31-60 and 61-90 in 41%, 13% and 46% of patients respectively. Freedom from recurrence of atrial arrhythmias 1 year after the PVI was 81% in patients without ER and 37% in patients with ER (p&amp;lt;0.001, Figure 1B). When patients were classified according to their latest episode of ER occurring between days 0-30, 31-60 and 61-90, freedom from any atrial arrhythmia at 1 year was 60%, 53% and 11% (p&amp;lt;0.001, Figure 1C) respectively. ROC analyses revealed a strong correlation of LR with the timing of the latest episode of ER in the blanking period (AUC=0.81, p&amp;lt;0.001) with an optimal cutoff value at 61 days (SN 64%, SP 88%). Median AF burden in the blanking period was 0% (IQR 0-0) in patients with ER but no LR and 0.2% (IQR 0-2) in patients with ER and LR (p&amp;lt;0.001). This was similarly true for all individual months (0-30 days: 0% vs. 1.8%, p&amp;lt;0.001, 31-60 days: 0% vs. 0.1%, p&amp;lt;0.001, 61-90 days: 0% vs. 0.1%, p p&amp;lt;0.001). There were no differences in the duration of ER episodes or in clinical characteristics between patients with and without LR Conclusion ER after cryoballoon PVI is common. While ER during the first and second month after PVI disappear in the majority of patients, presence of ER in the third month after PVI are highly predictive for ablation failure.

Long-term outcomes of catheter ablation for atrial fibrillation in octogenarians

Abstract Background Catheter ablation is superior to standard medical therapy in controlling atrial fibrillation (AF). There is limited data on the long-term outcomes of AF ablation in octogenarians. Purpose This study aims to rigorously evaluate the efficacy and safety of AF catheter ablation in octogenarians, compared to non-octogenarians. Methods In this retrospective, multicentre, international study in 13 centres in the United Kingdom, France, and Switzerland, the long-term outcomes of 473 consecutive octogenarian patients undergoing catheter ablation for AF were compared to 473 propensity-matched non-octogenarian controls (median age 81.3 [80.0, 83.0] vs 64.4 [56.5, 70.7] years, 54.3% vs 35.1% females; p-value for both &amp;lt;0.001). The primary endpoint was the recurrence of atrial arrhythmia during 365 days' follow-up after an initial blanking period of 90 days (median follow-up time 322 [153, 365] days. Results Acute success of the ablation was achieved in 97% of octogenarians. When comparing non-octogenarians vs octogenarians, there were more complications in the octogenarians group (11.4% vs 7.0%, p=0.018), with the most common adverse events being vascular complications (3.8% vs 2.7%). The median follow-up time was 322 [153, 365] days. Through day 365, 131 (27.7%) octogenarians had a recurrence of atrial arrhythmia as compared to 111 (23.5%) non-octogenarians (odds ratio 1.49; 95% confidence interval 1.16-1.92; p=0.002). In a multivariable regression model including gender, previous AF ablation, vascular disease, chronic kidney disease, CHA2DS2-VASc score, left atrial dilatation, and indwelling cardiac implantable electronic device, age above 80 remained an independent predictor of recurrence of atrial arrhythmias throughout 365 days' follow-up. Conclusion Age over 80 is associated with higher rates of recurrence of atrial arrhythmia on 365 days' follow-up post-catheter ablation for atrial fibrillation. Arrhythmia recurrence on follow-up

Electrogram dispersion mapping for repeat ablation in patients with persistent atrial fibrillation

Abstract Background/Introduction While pulmonary vein isolation (PVI) is a key guideline endpoint for atrial fibrillation (AF) ablation, strategies for repeat ablation are debated, particularly when PVs are isolated. Electrogram dispersion mapping identifies dynamic substrates using existing catheters, remote from the PVs and may confer benefit to additional ablation. Purpose To describe the outcome of repeat ablation using electrogram mapping to identify areas of mechanistic significance in persistent AF patients. Methods Patients undergoing repeat ablation for persistent AF were recruited from two international centers. A five spline catheter was used to mark areas of electrogram dispersion before any ablation using previously described criteria. After confirming PVI, or re-isolation of PVs if necessary, ablation of all dispersion areas was performed. If termination to atrial tachycardia (AT) occurred, this was mapped using conventional methods. Patients who terminated to sinus underwent reinduction pacing protocols to map any further AT or AF inducible. Patients were followed up at 12 months with continuous event monitors, and beyond 12 months based on local guidelines. Results In total, 167 AF patients were enrolled: age 66 ± 8 yrs; 32% female; mean LA diameter 4.8 cm. PVI was present in 108 (64%) of patients. All patients underwent LA mapping, and 75 (45%) underwent right atrial (RA) mapping. Patients had an average of 3.2 LA and 1.4 RA ablation sites. The total number of dispersion sites in patients was similar in patients with and without PVI, (4.1 ± 2 and 3.6 ± 1 respectively). AF terminated in 144 patients (86%), with an overall conversion to sinus rhythm obtained by ablation in 42% of the patients. Patients were followed for an average of 2.92 ± 0.9 years. At 12 months, 159 (95%) patients were AF free, and 124 (74%) remained free of atrial arrhythmia. Of those patients, only 8 (5%) had AF, with 35 (21%) recurring with AT or atrial flutter (AFL). Of the 70 patients who terminated to sinus with repeat ablation, only 2 (2.9%) recurred with AF and 26 (37.1%) had recurrence of atrial arrhythmia (AF/AT/AFL) as a whole throughout the entire follow-up period (P&amp;lt;0.05). Patients with and without PVI at redo procedure did not have a statistically significant difference in recurrence of AF (Figure 1, P = 0.80) nor recurrence of atrial arrhythmia (Figure 2, P = 0.63) during total follow up time by log rank test. Conclusions In a difficult to treat population of persistent AF patients requiring a repeat ablation procedure, electrogram mapping led to rates of freedom from AF at 12 months similar to first time ablation series. Additionally, those with PVI present at time of procedure had similar benefit from this approach compared to those with reconnected veins. This is the largest demonstration of a technique that confers benefit in a PVI isolated subgroup of purely redo ablations for persistent AF.Figure 1:Percent AF FreeFigure 2:Percent AF/AT/AFL Free

Long-term impact of multiple freezes during cryoballoon pulmonary-vein isolation on atrial arrhythmia recurrence

Abstract Background Cryoballloon pulmonary vein isolation (CryoPVI) is well established for atrial fibrillation (AF) ablation. Nevertheless, it is still important to identify possible periprocedural factors influencing its efficacy. With difficult anatomical conditions it is currently unclear whether the number of cryoballoon applications needed to achieve complete vein isolation has an impact on the long-term effectiveness of CryoPVI. Methods We prospectively analyzed AF patients who underwent first-time CryoPVI in a single center cohort between 2018-2023. The group allocation depended on the number of cryo applications until complete isolation was achieved. CryoPVI was performed in a standardized procedure. Follow-up was performed after 3, 6, 12, 18, 24 and 36 months post CryoPVI. Efficacy endpoint was the occurrence of symptomatic atrial arrhythmia. Results A total of 1170 patients were included in the study. Of these, in 610 patients received only one cryoballoon application per pulmonary vein to achieve complete isolation. Gender distribution (56.7% male vs. 43.3% male p=0.09) and AF phenotype (38.5% persistent AF vs. 61.5% paroxysmal AF, p=0.23) did not differ significantly between the two groups, patients who received only cryoballoon application were older (70.1 vs. 68.5, p=0.006) and accordingly had higher CHADS-VASc (2.86 vs. 2.62, p=0.006). After 36 months no difference in the efficacy endpoint was observed between the two groups (47.6% vs. 43.2%, p=0.53). Complications included three major access complications (0.5% vs. 0.5%) and one stroke within the first 30 days after the procedure (0.2% vs. 0.2%) in each group. No pericardial tamponade occurred. Conclusion Multiple- freezes during CryoPVI have no influence on atrial arrhythmia recurrence.

Arrhythmia-induced versus arrhythmia-superimposed cardiomyopathy: outcome in patients with atrial fibrillation and heart failure undergoing cryoballoon pulmonary vein isolation

Abstract Introduction The outcome in patients with arrhythmia-induced cardiomyopathy (AIC) compared with that in patients with arrhythmia-mediated/superimposed cardiomyopathy (AMC) undergoing cryoballoon pulmonary vein isolation (cryo-PVI) is also poorly defined. Methods In this retrospective observational study, we analysed patients with AF and reduced left ventricular ejection fraction (LVEF &amp;lt; 50%) who underwent cryoballoon ablation between 2014 and 2020. Patients with LVSD were divided into AIC and AMC. AIC was diagnosed ex juvantibus during first year after ablation at 3- and 12-month follow-up when LVEF recovered to &amp;gt; 50% and by more than 10% after ablation and a different aetiology for reduced LVEF was excluded. AMC was diagnosed when structural heart disease was responsible for LVSD and AF had likely exacerbated pre-existing LVSD. For identification of independent predictors of LVEF non-improvement after ablation, univariate and multivariate logistic regression analyses were performed. LVEF non-improvement was defined when LVEF neither increased by more than 10% nor increased over absolute 50% at 12-month follow-up. The first documented &amp;gt; 30-s atrial arrhythmia recurrence after a 3-month blanking period during the one-year follow-up was compared by Kaplan-Meier analysis. Results Out of 1293 consecutive patients who underwent cryoballoon ablation, 113 AF patients with reduced LVEF (&amp;lt;50%) were identified. After 1-year follow-up these patients were divided into AIC (N= 77) and AMC (N = 36) groups. The prevalence of persistent AF was comparable in both groups (85.7% vs. 77.8 %, p = 0.435). LVEF, left atrial (LA) enlargement, and left ventricular end diastolic diameter (LVEDD) were similar between the groups. After one year, the median LVEF improved significantly in the AIC group from 42% (IQR: 35-45%) to 60% (IQR: 58-63%; p &amp;lt; 0.0001) and in the AMC group from 42% (IQR: 33-45%) to 47.5% (IQR= 43-53%; p=0.015). At follow-up LVEF was significantly higher in the AIC than in the AMC cohort (p &amp;lt; 0,001). After univariate and multivariate analysis, the following parameters were associated with non-LVEF improvement: LVEDD (OR = 1.12, p = 0.012) and atrial arrhythmia recurrence (OR = 5.87, p = 0.031; Figure 1). In the AIC group LA area decreased from 25.6 cm2 (IQR: 22.4-29.5 cm2) to 21.8 cm2 (IQR: 18.3-25.2 cm2; p = 0.012). In AMC patients LA enlargement did not change with respect to baseline. Kaplan-Meier curves demonstrated no difference in recurrence-free survival rate between the groups during the 12-month follow-up (75.3% vs. 75%, log-rank P = 0.89; Figure 2). Conclusions LVEDD and arrhythmia recurrence were identified as predictors of non-LVEF improvement after cryo-PVI. The LVEF increased in both groups after ablation, but in AIC group more than in AMC group. In the AIC group LA atrial area decreased compared to the AMC group. Atrial arrhythmia recurrence rates were comparable between AIC and AMC groups after 12 months.Figure 1Figure 2

Intraprocedural and outcome findings in repeat left atrial procedures after pulsed field ablation for pulmonary vein isolation in paroxysmal and persistent atrial fibrillation

Abstract Background Pulsed Field Ablation (PFA) has emerged as a promising novel technique for pulmonary vein isolation (PVI) in the setting of atrial fibrillation. First outcome data revealed comparable success rates to radiofrequency and cryoablation. However, data on lesion dimensions and reconnection of PV after PFA potentially causing recurrence of AF is sparse. We, therefore report on pivotal reconnection sites and ablation extend after PFA-PVI. Methods All patients after PFA-PVI for paroxysmal or persistent AF at our center between September 2021 and October 2023 were included in this retrospective analysis. Baseline characteristics, procedural and outcome data were obtained. Furthermore, in all redo procedures of these patients lesion dimensions and the occurrence and location of PV gaps were evaluated. Results A total of 123 patients with atrial fibrillation underwent successful PFA-PVI during index procedure. The study cohort comprised [n= 52; 42%] paroxysmal and [n= 71; 58%] persistent atrial fibrillation cases. After a median follow-up of 123 (IQR 93-150) days recurrence of atrial arrhythmia (all AF) occurred in 9 [14. 5%] patients. Of these, 6 [9.6%] patients underwent a redo procedure due to recurrence of atrial fibrillation (3 PAF and 3 persAF [50%]; p=1). All left atrial maps and 24 PVs were analyzed. All 6 [100%] patients exhibited electrical reconnection of one or more pulmonary vein. Analysis of redo procedures revealed that the dimensions of PFA-induced lesions varied among patients: The right inferior pulmonary vein (RIPV) showed reconnection in all redo-patients (100%). Also frequent reconnection was observed for the RSPV (3 pts [50%]) and LIPV (2 pts [33%]). The gap size was 66±40% of the circumference in the reconnected RPVs and 61±31% in the reconnected LPVs. A roof-line lesion set was performed in 4 out of 6 pts (67%) due to the initially antral PV lesions affecting the posterior wall and LA roof potentially creating an isthmus for roof-dependent atrial tachycardia (AT). Conclusion Outcome data for PFA-PVI are comparable to other energy sources used for PVI. However, reconnection of PV also occurs after PFA-PVI. This retrospective analysis of redo procedures after initially successful PVI identified the RIPV as pivotal for reconnection. Furthermore, map analysis revealed that reconnection gaps extend to up to 2/3 of the initial circumferential PV ablation area. Furthermore, PFA seems to create new critical isthmuses potentially causing AT. No difference in reconnection was seen comparing PAF and persAF.

Effectiveness of photoplethysmography-based rhythm monitoring after atrial fibrillation ablation using a smartphone application

Abstract Introduction Recurrence of atrial fibrillation (AF) after AF ablation is frequent. Monitoring recurrence is essential for attributing patient symptoms and for assessing both AF burden and treatment effectiveness. The conventional approach relies on periodic (long-term) electrocardiograms (ECG) and is constrained by limited monitoring time, measurement dispersion, and cost. Furthermore, patients are unable to prioritize measurements based on symptoms. Photoplethysmography (PPG) emerges as a technology that could potentially transform any smartphone into a rhythm monitoring device, thereby mitigating the limitations associated with current practices. Selected applications leveraging this technology have demonstrated excellent usability and accuracy for the detection of AF. However, the effectiveness of PPG-based follow-up remains uncertain. Purpose To compare the effectiveness of digital follow-up utilizing a PPG-based smartphone application with conventional ECG-based follow-up for the detection of atrial arrhythmia recurrence after ablation. Methods Patients undergoing AF ablation were consecutively enrolled and monitored using a 24h-ECG at 3-6-12 months on top of ECGs conducted for clinical indications (conventional follow-up). Additionally, patients were instructed to perform PPG measurements twice daily or whenever symptoms were perceived, over the course of one year (digital follow-up). The primary outcome was recurrence of atrial arrhythmia. Results In total, 96 patients (69% male, mean age 64 [58 – 68] years) performed 39,895 PPG measurements. The compliance rate (n performed/prescribed) was 92.6% for ECG and 78.2% for PPG recordings. After one year follow-up, atrial arrhythmia recurrence was detected by conventional follow-up in 17.9% and in 38.5% of patients by digital follow-up (odds ratio, 3.4; 95% CI: 1.7-7.1). The confidence interval lower limit exceeded the predefined non-inferiority margin (p for non-inferiority &amp;gt; 0.001). Hence, superiority was tested (p for superiority = 0.001). The negative predictive value of digital follow-up for atrial arrhythmia detected with conventional follow-up was 98.3% (95% CI: 90.1-99.9%). Symptoms were reported in 81.1% of PPG-detected atrial arrhythmias and episodes sustained for 3.9 [1.1 – 22.7] hours. Conclusions Among patients with AF ablation, digital PPG-based rhythm monitoring with a smartphone, was non-inferior in the detection of atrial arrhythmia recurrence after ablation. Moreover, the detection of atrial arrhythmia was significantly increased compared to conventional ECG-based monitoring.

Impact of age on atrial arrhythmia recurrence following cryoballoon pulmonary-vein isolation

Abstract Background Age is a major risk factor for development of atrial fibrillation (AF) and associated with increased recurrence rates in the setting of rhythm control. Current data tend to support catheter ablation in elderly patients, but it remains unclear whether there is an age limit for ablation and whether the potential benefits of catheter ablation justify the potentially increased complication rate in elderly. Objective To prospectively analyze the impact of age on efficacy and safety of cryoballoon ablation (CBA). Methods ; We prospectively analyzed consecutive patients who underwent CBA in a single-center cohort between 2018 and 2023. Patients were stratified by age (&amp;lt;75yrs versus ≥75yrs) and AF type. Primary efficacy endpoint was recurrence of atrial arrhythmia after 90-day blanking period. Linear and spline regression were used to assess the association between age and primary efficacy endpoint. Safety endpoints were death, stroke or procedure-related complications. Results 873 patients underwent CBA (525 paroxysmal, 348 persistent AF). Median follow-up was 18-months. At 1-year, primary efficacy endpoint occurred in 19.6% (71/363) of young (&amp;lt;75yrs) versus 27.8% (45/162) of elderly (≥75yrs) patients with paroxysmal AF (HR 0.62; 95%CI, 0.41-0.92; P=0.019; fig. 1A) and in 25.0% (57/228) of young versus 39.2% (47/120) of elderly patients with persistent AF (HR 0.57; 95%CI, 0.37-0.85; P=0.006; fig. 1B). A significant linear relationship between age and primary efficacy endpoint occurrence was found for both paroxysmal (P=0.01) and persistent AF (P=0.002; fig.2) while spline regression was non-significant (P=0.45/ P=0.12). No difference was observed regarding the incidence of safety endpoints between young and elderly patients (P=0.76). Conclusion Atrial arrhythmia recurrence rate after CBA increases linearly with age (thus not allowing determination of a clear "cut-off-age") and is highest in elderly patients (≥75 yrs) with persistent AF. Safety of CBA in elderly is comparable to patients of younger age.