Success Rate Of Atrial Fibrillation Ablation Research Articles

Role of high-density voltage map guiding parosysmal atrial fibrillation ablation

Abstract Background High-density mapping of the pulmonary vein antra has been demonstrated to improve the detection of conduction gaps in wide antral catheter ablation (WACA) approach for the treatment of paroxysmal atrial fibrillation (AF). Purpose We aimed to compare the AF recurrencies in patients treated with WACA for pulmonary veins isolation (PVI) guided by high-density bipolar voltage map (BVM) vs WACA guided by a standard 20-pole circumferential mapping catheter (CMC-20). Methods This prospective study included patients scheduled for AF ablation in a single center. In group A (85 patients) PVI was achieved with a conventional approach using CMC-20; in group B (96 patients) high density BVM was acquired by sequential multielectrode mapping through Pentaray Catheter (Biosense Webster). More than 1000 voltage points per map were acquired. Acute PVI was defined as an entrance and exit block after ≥ 20 min waiting period. In both groups WACA was perfomed using a contact force sensing catheter targeting an interlesion distance ≤6 mm and ablation index ≥400 at posterior wall and ≥550 at anterior wall. The primary endpoint was the AF recurrencies in the two groups. Results A total of 181 patients were included (mean age 64.9±10.6 years, 33.1% female): in 85 patients AF ablation was guided by CMC-20, in 96 patients AF ablation was guided by BVM; WACA PVI was achieved in all patients. There were no significant differences in the clinical characteristics of the two groups (table 1). At 12-month follow-up, AF recurrencies were significantly lower in the BVM group compared with CMC-20 group [11/96 (11.4%) vs 19/85 (22.3%) respectively, p=0.01]. Conclusions High-density BVM might increase success rate of AF ablation compared with a conventional 20-pole circumferential mapping approach.

Radiofrequency ablation of atrial fibrillation: A 14 years' experience at a tertiary care center in Thailand.

The result of atrial fibrillation (AF) ablation varies across centers. Most data are derived from the Western world, while data from Southeast Asian countries are lacking. We aimed to investigate the outcomes of AF ablation in Thailand. We performed a retrospective analysis of patients who underwent AF ablation in a tertiary care center, between the years 2006-2020. Details of AF ablation, including pulmonary vein isolation (PVI), and complex fractionated atrial electrogram (CFAE) ablation, were classified. The success rate of AF ablation is determined by freedom from AF beyond 3 months blanking period. Combined success rate of AF ablation was reported along with the success rate of each technique (PVI, CFAE, and combine PVI plus CFAE). We identified a total of 171 patients who underwent the first AF ablation. Ninety-four (55%) patients went through PVI, 55 (32%) patients for CFAE ablation, and 22 (13%) patients for PVI plus CFAE ablation. Overall freedom from AF was 73% at 12 months, 66% at 24 months, and 55% at 36 months. The success rate of PVI was 79% at 12 months, 74% at 24 months, and 59% at 36 months. The success rate of CFAE ablation was 63% at 12 months, 51% at 24 months, and 47% at 36 months. Catheter ablation of AF is proven safe and effective in Thai population.

PO-02-167 IMPACT OF OBESITY ON QUALITY OF LIFE AND CLINICAL OUTCOME IN PATIENTS WITH ATRIAL FIBRILLATION UNDERGOING PRIMO PULMONARY VEIN ISOLATION

Obesity is a major risk factor for the incidence and progression of atrial fibrillation (AF), negatively impacting AF ablation outcomes. Weight loss in obese patients prior to AF ablation may improve quality of life (QoL) and AF ablation success rates. To assess the impact of overweight and obesity on patient-reported outcomes (QoL scores) and clinical outcomes (AF recurrence) in patients undergoing index AF ablation procedure. This single-center cohort study retrospectively included 238 patients undergoing primo radiofrequency (RF) pulmonary vein isolation (PVI) who completed 1 year follow-up, including the Toronto AF Severity Scale (AFSS) questionnaire at baseline, 4-, and 12 months post-PVI for assessment of QoL (AF severity, AF burden, and global well-being). At baseline, patients were categorized by body mass index (BMI): normal (<25 kg/m2); overweight (≥25 - <30 kg/m2); and obese (≥30 kg/m2). AF recurrence was evaluated by either 24-h Holter monitoring, AliveCor KardiaMobile devices, or conventional electrocardiograms (ECG). Patients were divided based on BMI: 37.8% normal; 44.1% overweight; and 18.1% obese. Obese patients were more likely to be women (men 46.5%,p<0.01), and have diabetes mellitus (25.6%,p<0.01). AF recurrence rates detected during 12 months follow-up were similar among the three BMI groups: normal 27.8%, overweight 33.3%, and obese 30.2% (p=0.70). After AF ablation, all QoL scores in each BMI group improved, with no between-group differences (Table 1). Subgroup analysis showed significantly improved QoL scores in patients without AF recurrence independent of BMI category, however in patients with AF recurrence no significant improvement of AF severity and global well-being was found (Fig 1). Despite AF recurrence, self-reported AF burden significantly improved in the normal and overweight categories, but not in obese patients. A high BMI was not a major determinant of AF recurrence rates after a primo PVI. QoL after PVI was found to be determined by AF recurrence rather than BMI. This study suggests that obese patients might benefit from PVI to a similar extent compared to non-obese patients, though self-reported AF burden might differ between groups.

High-density mapping improves detection of conduction gaps after pulmonary vein isolation ablation with a circular mapping catheter.

High-density (HD) mapping of the pulmonary vein (PVs) has been hypothesized to improve the detection of conduction gaps in the radiofrequency ablation lesions set after pulmonary vein isolation (PVI) for the treatment of atrial fibrillation (AF). We aimed to compare the incidence of gaps after PVI with a standard 20-pole circumferential mapping catheter (CMC-20) and an HD mapping catheter (HD Grid). This prospective study included patients scheduled for high-power short-duration PVI. Acute PVI was defined as an entrance and exit block using the CMC-20 after ≥ 20min waiting period. The left atrium was then remapped using the HD Grid high-density mapping catheter to identify residual conduction gaps in the PVI lines by voltage and activation criteria. The primary endpoint was the number of gaps identified per patient by the HD Grid catheter. A total of 20 patients were included (mean age 59.9 ± 10.8years, 15% female, 70% paroxysmal AF). The new map with the HD Grid identified 6 gaps in 4 patients (20%) or 0.3 ± 0.7 gaps per patient (p = 0.055 when compared to CMC-20). Five gaps (83%) were located at the right PVs. There was no difference in mapping time (CMC-20 12.2 ± 2.6min vs HD Grid 11.7 ± 3.4min, p = 0.452); however, the number of points was significantly higher in the HD Grid map (1662.7 ± 366.1 vs 1171.6 ± 313.6, p < 0.001). HD mapping during AF ablation identified PVI gaps in 1 out of 5 patients. Therefore, HD mapping may have the potential to improve AF ablation success rates in the long term. ClinicalTrials.gov NCT04850508 on April 20, 2021.

We all know A and B, but what about C? Exploring the management of modifiable risk factors in patients with atrial fibrillation

Abstract Background The European Society of Cardiology (ESC) guidelines for the management of atrial fibrillation (AF) advise to treat AF according to the ABC pathway: A, anticoagulation, B, better symptom control, and C, comorbidities and cardiovascular risk factor management. Optimal treatment of comorbidities and risk factors slows AF progression and improves success rates of rhythm interventions for AF. However, several studies report underdiagnosis and therefore possible undertreatment for common cardiovascular comorbidities. Purpose This study aims to evaluate how common modifiable cardiovascular risk factors are managed in AF patients referred for catheter ablation. Methods This is a substudy of the ISOLATION study, a prospective cohort study including consecutive patients with paroxysmal or persistent AF referred for AF ablation. Screening for common modifiable risk factors for AF is structurally embedded in the work-up for AF ablation in the two participating centres. In the present study the prevalence of the following risk factors at this screening moment was assessed: (1) body mass index (BMI) above the target BMI for ablation (≥27 kg/m2), (2) hypertension, defined as on-site systolic blood pressure &amp;gt;130 mmHg and/or diastolic blood pressure &amp;gt;80 mmHg, (3) decreased glucose tolerance or diabetes mellitus, defined as HbA1c ≥6.5%, (4) dyslipidaemia, defined as low-density lipoprotein (LDL) ≥2.5 mmol/l, (5) regular alcohol consumption, defined as self-reported consumption of &amp;gt;15 standardized units/week, and (6) sleep disordered breathing (SDB), defined as apnoea-hypopnoea index (AHI) ≥15 assessed with home sleep tests (subset of patients). Results Among the 981 patients studied (median age 65 [59–71] years old, 64% male, 69% paroxysmal AF), previously diagnosed comorbidities were common (46% hypertension, 7% diabetes, 22% dyslipidaemia, 10% SDB), and a large proportion of patients received targeted treatment (Table 1). However, non-optimally managed risk factors remained significant (Figure 1). BMI ≥27 kg/m2 was present in 56% of patients. High systolic and diastolic blood pressure were present in 62% and 51% of patients, respectively, and any form of high blood pressure (either systolic or diastolic) was seen in 72% of patients. HbA1c was found to be above target ranges in 9% patients and LDL in 56%. A weekly alcohol consumption of ≥15 units was reported by 4% of patients. Screening for SDB was performed in a subset of patients (n=287), for whom AHI was ≥15 in 52%. Overall, 9% of patients had 4 or more non-optimally controlled modifiable risk factors, whereas the median number of modifiable risk factors was 2 [1–3]. Conclusions Structural screening revealed a high prevalence of non-optimally controlled modifiable cardiovascular risk factors in patients referred for AF catheter ablation. According to recent ESC guidelines, improving treatment of comorbidities may improve AF ablation success rates and even reduce mortality. Funding Acknowledgement Type of funding sources: None.

US hospital webpages on atrial fibrillation ablation: A potential source for misinformation.

Atrial fibrillation (AF)ablation is performed worldwide. To attract patients, hospitals frequently have webpages that tout the success of the procedure. The information disseminated to the public via these webpages has not been systematically reviewed. Our objective was to assess accuracy of information delivered to the public on hospital websites in regard to atrial AF ablation. From July 2019 to January 2020, we performed a Google search for all US hospitals registered with Medicare to see if they had a webpage describing AF ablation. Resulting hospital webpages were abstracted for data on AF ablation success rates and risks. Success rates over 86%, the highest success rate in the medical literature, were deemed exaggerated. Among 4805 hospitals, 487 had webpages describing AF ablation and 33 discussed success rates of AF ablation. Twelve percentagereported exaggerated success rates, 3% referred to ablation as a cure, and 2.8% referred to ablation as a tool to eliminate AF. Less than 10% of webpages describing AF ablation noted the potential need for a second ablation to achieve the stated success rate and merely 16% mentioned risks of the procedure. One percentage of webpages directly suggested AF ablation could reduce risk of stroke while others indirectly suggested it by discussing cessation of anticoagulation. Two webpages mentioned reduced mortality. US hospital webpages rarely discuss AF ablation. When discussed, there were concerning unsubstantiated claims regarding mortality, stroke prevention, and need for medical therapy. This could lead to some patients undergoing AF ablation based on faulty understanding.

Catheter ablation for atrial fibrillation in the elderly >75 years old: Systematic review and meta-analysis.

Atrial fibrillation (AF) ablation is increasingly performed worldwide. As comfort with AF ablation increases, the procedure is increasingly used in patients that are older and in those with more comorbidities. However, it is not well established whether AF ablation in the elderly, especially those >75 years old, has comparable safety and efficacy to younger populations. To compare the efficacy and safety profiles in patients older than 75 years undergoing AF ablation with younger patients. Databases from EMBASE, Medline, PubMed, and Cochrane, were searched from inception through September 2021. Studies that compared the success rates in AF catheter ablation and all complications rates between patients who were older vs under 75 years were included. Effect estimates from the individual studies were extracted and combined using random effect, generic inverse variance method of DerSimonian and Laird. Twenty-seven observational studies were included in the analysis consisting of 363,542 patients who underwent AF ablation. Comparing patients older than 75 years old to younger patients, there was no difference in the success of ablation rates between elderly and younger patients (pooled OR 0.85: 95% CI:0.69-1.05, p = .131). On the other hand, AF ablation in the elderly was associated with higher complication rates (pooled OR 1.42: 95% CI:1.21-1.68, p < .001). As AF ablation is expanded to elderly populations, our study found that AF ablation success rates were similar in both elderly and younger patients. However, older patients experience higher rates of complications that should be considered when offering the procedure and as a means to improve outcomes with future innovations.

Sleep apnea and atrial fibrillation: challenges in clinical and translational research

ABSTRACT Introduction Sleep-disordered breathing (SDB) is present in 21–74% of all patients with atrial fibrillation (AF). Treatment of SDB by positive airway pressure may help to prevent recurrence of AF after electrical cardioversion and help to improve AF ablation success rates in non-randomized studies. Areas covered In this review, the current understanding of the atrial arrhythmogenic pathophysiology of SDB is summarized, and diagnostic and therapeutic challenges in AF patients are discussed. Current international recommendations are presented, and a comprehensive literature search is undertaken. Expert opinion AF patients with SDB rarely report SDB-related symptoms such as daytime sleepiness. Therefore, systematic home sleep testing evaluation should be considered for all patients eligible for rhythm control strategy. A close interdisciplinary collaboration between the electrophysiologist/cardiologist, nurses and sleep-specialists are required for the management of SDB in AF patients. An arrhythmia-orientated assessment of SDB may better quantify SDB-related AF risk in an individual patient and may help to better guide targeted and personalized SDB treatment in AF patients as a component of rhythm and symptom control strategies. Finally, randomized controlled trials are needed to confirm the relationship between SDB and AF, and the benefits of routine testing and treatment of SDB in AF patients.

Success rate of one-stop procedure for atrial fibrillation ablation and its impact on cardiac function: a propensity-matched study

To investigate the effect of the combination of atrial fibrillation (AF) ablation and left atrial appendage closure (LAAC) on cardiac function and the success rate of AF ablation. We retrospectively analyzed the data of 56 patients with AF undergoing a one-stop procedure for AF ablation and LAAC in our hospital between May, 2015 and May, 2019. Propensity score matching (PSM) at the ratio of 1:1 was used to select 56 control patients undergoing AF ablation at high risk of stroke, for matching with the hybrid procedure group. The perioperative complications, thromboembolic events, recurrence of atrial arrhythmia and cardiac function were compared between the groups. The two groups of patients were comparable for age, gender, BMI, duration and type of AF, concomitant diseases, CHA2DS2-VASc and HAS-BLED scores (P > 0.05). The incidence of complications did not differ significantly between the hybrid procedure group and AF ablation group (17.9% vs 12.5%, P=0.430). Compared with the control patients with AF ablation alone, the patients undergoing the hybrid procedure had a lowered incidence of thromboembolic events, but the difference was not statistically significant (1.8%vs 3.6%, P=1.000). The hybrid procedure did not improve the success rate of AF ablation (OR: 1.338, 95%CI: 0.451-3.973, P= 0.600) but significantly improved the cardiac function parameters including NT-pro BNP (945.3±1401.6 pg/mL vs 1520.7±2089.1 pg/mL, P=0.010), LVEF[(60.8±7.0)% vs (58.6±7.8)%, P=0.044], and left atrial diameter (43.9±7.5 mm vs 45.6±6.3 mm, P=0.076); but the improvement of cardiac function was more obvious in the control patients undergoing AF ablation alone (P < 0.039). The combination of AF ablation and LAAC is safe but does not improve the success rate of AF ablation. The one-stop procedure can improve cardiac function of the patients, but AF ablation alone can achieve better improvement of cardiac function.

P457Incidence of LA fibrosis and substrate-based AF ablation success rates in HF patients

Abstract Funding Acknowledgements The author(s) received no specific funding for this work. Background In heart failure (HF) patients, sinus rhythm maintenance after catheter ablation for atrial fibrillation (AF) is mandatory to achieve better long-term outcome. Presence of left atrial (LA) fibrosis significantly attenuates ablation success rates. Incidence of LA fibrosis and the effect of an individualized substrate-based ablation concept on rhythm outcome in HF patients with AF is unclear. Methods This study investigated 103 patients (64 years, 69% men) with persistent AF (79%) and left ventricular (LV) dysfunction (EF 33% IQR [25; 38]) undergoing first time AF ablation. Identification of LA fibrosis and selection of ablation strategy were based on sinus rhythm voltage mapping. All patients received pulmonary vein isolation (PVI). LA fibrosis ablation was individualized by (i) homogenization of small areas, (ii) linear lesions connecting fibrosis and anatomical obstacles and (iii) linear lesions isolating large fibrotic areas. Rhythm outcome was measured by continuous device monitoring (AF detection ≥ 6 min) or Holter-ECG. A total post-procedural AF burden &amp;lt; 0.1% was defined as successful rhythm control. Results LA fibrosis in the overall cohort, in paroxysmal and persistent AF patients was detected in 39/103 (38%), 6/22 (27%) and 33/81 (41%), respectively. After 11 ± 5 months and 1.2 procedures/patient, freedom from AF recurrence was similar between patients with and without LA fibrosis (33/39 (84%) vs. 54/64 (84%); p = 0.485). With continuous monitoring, 73/87 (84%) patients recorded a total AF burden &amp;lt; 0.1%. There was no significant difference in AF burden outcome between patients with and without LA fibrosis (3.1% SD ±17.4 vs. 2.2% SD ±8.1; p = 0.4). No correlation between presence or extent of LA fibrosis and AF burden was found; p = 0.299. Conclusion A substantial number of HF patients with AF have no evidence of LA fibrosis. Among HF patients with LA fibrosis, individualized substrate-based AF ablation beyond PVI was able to achieve similar ablation success.

Efficacy of Ablation Lesion Sets in Addition to Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation: Findings From the SMASH - AF Meta-Analysis Study Cohort.

BackgroundThe objective was to explore the efficacy of ablation lesion sets in addition to pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation. The optimal strategy for catheter ablation of paroxysmal atrial fibrillation is debated.Methods and ResultsThe SMASH‐AF (Systematic Review and Meta‐analysis of Ablation Strategy Heterogeneity in Atrial Fibrillation) study cohort includes trials and observational studies identified in PubMed, Scopus, and Cochrane databases from January 1 1990, to August 1, 2016. We included studies reporting single procedure paroxysmal atrial fibrillation ablation success rates. Exclusion criteria included insufficient reporting of outcomes, ablation strategies that were not prespecified and uniform, and a sample size of fewer than 40 patients. We analyzed lesion sets performed in addition to PVI (PVI plus) using multivariable random‐effects meta‐regression to control for patient, study, and procedure characteristics. The analysis included 145 total studies with 23 263 patients (PVI‐only cohort: 115 studies, 148 treatment arms, 16 500 patients; PVI plus cohort: 39 studies; 46 treatment arms, 6763 patients). PVI plus studies, as compared with PVI‐only studies, included younger patients (56.7 years versus 58.8 years, P=0.001), fewer women (27.2% versus 32.0% women, P=0.002), and were more methodologically rigorous with longer follow‐up (29.5 versus 17.1 months, P 0.004) and more randomization (19.4% versus 11.8%, P<0.001). In multivariable meta‐regression, PVI plus studies were associated with improved success (7.6% absolute improvement [95% CI, 2.6–12.5%]; P<0.01, I 2=88%), specifically superior vena cava isolation (4 studies, 4 treatment arms, 1392 patients; 15.1% absolute improvement [95% CI, 2.3–27.9%]; P 0.02, I 2=87%). However, residual heterogeneity was large.ConclusionsAcross the paroxysmal atrial fibrillation ablation literature, PVI plus ablation strategies were associated with incremental improvements in success rate. However, large residual heterogeneity complicates evidence synthesis.

Secular trends in success rate of catheter ablation for atrial fibrillation: The SMASH-AF cohort

Approaches, tools, and technologies for atrial fibrillation (AF) ablation have evolved significantly since its inception. We sought to characterize secular trends in AF ablation success rates. We performed a systematic review and meta-analysis of AF ablation from January 1, 1990, to August 1, 2016, searching PubMed, Scopus, and Cochrane databases. Major exclusion criteria were insufficient outcome reporting and ablation strategies that were not prespecified and uniform. We stratified treatment arms by AF type (paroxysmal AF; nonparoxysmal AF) and analyzed single-procedure outcomes. Multivariate meta-regressions analyzed effects of study, patient, and procedure characteristics on success rate trends. Registered in PROSPERO (CRD42016036549). A total of 180 trials and observational studies with 28,118 patients met inclusion. For paroxysmal AF ablation studies, unadjusted success rate summary estimates ranged from 73.1% in 2003 to 77.1% in 2016, increasing by 0.9%/year (95% CI 0.4%-1.4%; P = .001; I2 = 90%). After controlling for study design and patient demographics, rate of improvement in success rate summary estimate increased (1.6%/year; 95% CI 0.9%-2.2%; P = .001; I2 = 87%). For nonparoxysmal AF ablation studies, unadjusted success rate summary estimates ranged from 70.0% in 2010 to 64.3% in 2016 (1.1%/year; 95% CI -1.3% to 3.5%; P = .37; I2 = 85%), with no improvement in multivariate analyses. Despite substantial research investment and health care expenditure, improvements in AF ablation success rates have been incremental. Meaningful improvements may require major paradigm or technology changes, and evaluation of clinical outcomes such as mortality and quality of life may prove to be important going forward.

Scar homogenization in AF ablation: Evolution and practice.

Laboratory studies, histology studies, image studies and the clinical studies all prove the positive correlation between atrial fibrillation and atrial fibrosis from different perspectives. Atrial fibrosis, by separating myocardial cell coupling, diminishing conduction velocity and promoting anisotropic conduction, produce the substrate to sustain atrial fibrillation (AF). These fibrotic areas can be translated into signal abnormalities (low voltage and complex electrgram), and be depicted by electroanatomic high density map. Ablation targeting these areas after circumferential pulmonary vein produces isolation as the additional substrate modification strategy has proved its beneficial results. However, the unified methodology regarding the scar definition, the mapping rhythm (AF or sinus rhythm) and the modification endpoint is yet to be negotiated. Large-scale clinical trials, long-term follow-up results are needed to prove its contribution to the overall success rate of AF ablation.

Update on Atrial Fibrillation

Atrial fibrillation (AF), the most prevalent cardiac arrhythmia, is categorized into 4 different groups on the basis of the duration of the arrhythmia episodes. If AF terminates spontaneously or with intervention within 7 days from onset, it is paroxysmal AF; AF of more than 7 days in duration is persistent AF; continuous AF of more than one year's duration is longstanding persistent AF; and permanent AF is the condition that ensues when the patient and his or her physician mutually decide not to pursue the restoration or maintenance of sinus rhythm by any means.1

What role for antiarrhythmic drugs today in patients with recurrent atrial fibrillation without relevant heart disease?

The efficacy of antiarrhythmic drugs (AADs) in the prevention of recurrent (paroxysmal or persistent) atrial fibrillation (AF) is rather low, since 1-year symptomatic recurrences are observed in ~50% of patients. New treatments have been suggested: upstream therapy does not appear to be effective in the prevention of AF recurrences, whereas catheter ablation has shown good results. Consistent data dealing with this procedure are available only in young patients, without relevant heart disease and with recurrent AF, refractory to AADs. In the present paper, an analysis of both systematic reviews of trials/meta-analyses and registries, which better express the real world, was carried out. The 1-year success rate of AF ablation in patients with the above mentioned characteristics was 70-80%. However, the 1-year single-procedure success rate, free of AADs, was only 47-57% in the trials and even lower in the real world (30-40%). The final success was increased by one or more repeated ablations, in 15-40% of patients, and by the use of AADs, ineffective before ablation, in ~40-50% of patients at 1-year and in ~60% at 2-year follow-up. AADs increased the success rate by ~15% in the trials and by a much higher percentage in the real world, even if not clearly definable. Considering that ~10-12% of patients have the first symptomatic recurrences only 1-2 years after ablation and others in the next years, AADs have still an important role in the management of patients with recurrent AF without relevant heart disease, not only as first-line treatment, but also in patients who underwent catheter ablation. Therefore, AF ablation appears to be more a supplementing procedure than a procedure alternative to AADs; in other words, the association ablation-AADs is more effective than AADs alone.

Left Atrial Appendage Ligation and Ablation for Persistent Atrial Fibrillation: The LAALA-AF Registry

ObjectivesThis study was intended to evaluate the impact of adding the left atrial appendage (LAA) closure system (LARIAT) procedure to conventional atrial fibrillation (AF) ablation in patients with persistent AF. BackgroundPercutaneous endoepicardial LARIAT may result in both mechanical and electrical exclusion of the LAA and aid in improving the outcomes of catheter ablation by eradicating the LAA triggers and altering the substrate. MethodsWe performed a prospective observational study of patients with persistent AF referred for AF ablation. Patients underwent LAA ligation with LARIAT procedure before undergoing AF ablation (LARIAT group). Age- and sex-matched persistent AF patients undergoing AF ablation during the same time frame were included in the control group (ablation-only group). ResultsA total of 138 patients were included in the study, with 69 patients in the LARIAT group. The mean age of the population was 67 ± 10 years, with 96 (70%) men. Left atrial (LA) size, CHADS2, CHADSVasc, and HAS-BLED scores were higher in the LARIAT group when compared with the ablation-only group. There were no differences in the type of lesions during AF ablation between the groups. The primary outcome of freedom from AF at 1 year off antiarrhythmic therapy after 1 ablation procedure was higher in the LARIAT group (45 [65%] vs. 27 [39%]; p = 0.002). More patients in the ablation-only group underwent repeat ablation because of AF recurrence (11 [16%] vs. 23 [33%]; p = 0.018). ConclusionsIn patients with persistent AF, addition of LAA ligation with the LARIAT device to conventional ablation appears to improve the success rate of AF ablation.

Detecting and monitoring arrhythmia recurrence following catheter ablation of atrial fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia prompting clinical presentation, is associated with significant morbidity and mortality. The incidence and prevalence of this arrhythmia is expected to grow significantly in the coming decades. Of the available pharmacologic and non-pharmacologic treatment options, the fastest growing and most intensely studied is catheter-based ablation therapy for AF. Given the varying success rates for AF ablation, the increasingly complex factors that need to be taken into account when deciding to proceed with ablation, as well as varying definitions of procedural success, accurate detection of arrhythmia recurrence and its burden is of significance. Detecting and monitoring AF recurrence following catheter ablation is therefore an important consideration. Multiple studies have demonstrated the close relationship between the intensity of rhythm monitoring with wearable ambulatory cardiac monitors, or implantable cardiac rhythm monitors and the detection of arrhythmia recurrence. Other studies have employed algorithms dependent on intensive monitoring and arrhythmia detection in the decision tree on whether to proceed with repeat ablation or medical therapy. In this review, we discuss these considerations, types of monitoring devices, and implications for monitoring AF recurrence following catheter ablation.

Catheter ablation of atrial fibrillation in patients with hypertrophic cardiomyopathy

Purpose: Atrial fibrillation (AF) is common in patients with hypertrophic cardiomyopathy (HCM) and known to predict adverse outcome. Radiofrequency catheter ablation represents a promising option to improve symptoms and outcome of these patients. The purpose of this study was to evaluate the long term effects of catheter ablation in AF patients with HCM. Methods: Twenty-five consecutive patients (19 male, age 53.4±8.0 years) with HCM undergoing pulmonary vein (PV) isolation with or without additional left atrial roof, mitral isthmus or cavotricuspid isthmus linear ablations for drug-refractory AF (16 paroxysmal AF) composed the HCM group of this study. Fifty non-HCM patients (38 male, age 53.5±8.3 years, 32 paroxysmal AF) matched for age, sex and types of AF were used as the control group. Ablation strategy used in control group was similar to that utilized in HCM group. Baseline characteristics, cardiac functional improvement and success rate of AF ablation during follow-up were compared. Results: All patients underwent ablation successfully without major complication. The left atrium (LA) was significantly larger in patients with HCM (47.38±7.51 vs. 40.36±7.98 mm in control group, P=0.001). Other baseline characteristics were comparable between two groups. AF-related symptoms were assessed by the European Heart Rhythm Association (EHRA) score which was 3.04±0.68 in HCM group and 2.54±0.68 in control group (P=0.003). Integrated long term follow-up data (3.39±1.17 years) were available in 20 patients of HCM group and 44 patients of non-HCM group. After an average of 1.1 procedures, sinus rhythm was retained in 9/20 (45%) patients with HCM and 32/44 (72.7%; p=0.032) patients without HCM. In HCM group, 8/9 patients were free from AF recurrence off anti-arrhythmic drug. Among patients in whom mitral isthmus (MI) linear ablation were performed, bidirectional isthmus block was achieved in 50% (4/8) of patients with HCM, comparing to 70.6% (12/17) in control group. After ablation, patients with HCM who maintained sinus rhythm showed remarkable improvement of NYHA cardiac functional categorization (1.1±0.3 vs. 1.6±0.5, P=0.035). Conclusions: AF-related symptoms are more severe in patients with HCM. Success rate of AF ablation remained low in this cohort. Restoration of sinus rhythm in HCM patients is associated with significant cardiac functional improvement.

Frequency, Patient Characteristics, Treatment Strategies, and Resource Usage of Atrial Fibrillation (from the Italian Survey of Atrial Fibrillation Management [ISAF] Study)

Atrial fibrillation (AF) is 1 of the most important healthcare issues and an important cause of healthcare expenditure. AF care requires specific arrhythmologic skills and complex treatment. Therefore, it is crucial to know its real affect on healthcare systems to allocate resources and detect areas for improving the standards of care. The present nationwide, retrospective, observational study involved 233 general practitioners. Each general practitioner completed an electronic questionnaire to provide information on the clinical profile, treatment strategies, and resources consumed to care for their patients with AF. Of the 295,906 patients screened, representative of the Italian population, 6,036 (2.04%) had AF: 20.2% paroxysmal, 24.3% persistent, and 55.5% permanent AF. AF occurred in 0.16% of patients aged 16 to 50 years, 9.0% of those aged 76 to 85 years, and 10.7% of those aged ≥85 years. AF was symptomatic despite therapy in 74.6% of patients and was associated with heart disease in 75%. Among the patients with AF, 24.8% had heart failure, 26.8% renal failure, 18% stroke/transient ischemic attack, and 29.3% had ≥3 co-morbidities. The rate control treatment strategy was pursued in 55%. Of the 6,036 patients with AF, 46% received anticoagulants. The success rate of catheter ablation of the AF substrate was 50%. In conclusion, in our study, the frequency of AF was 2 times greater than previously reported (approximately 0.90%), rate control was the most pursued treatment strategy, anticoagulants were still underused, and the success rate of AF ablation was lower than reported by referral centers.

Catheter Ablation Is Established as a Treatment Option for Atrial Fibrillation - Is Catheter Ablation Established as a Treatment Option of Atrial Fibrillation? (Pro) -

Atrial fibrillation (AF) is the most common arrhythmia in clinical practice and it has a significant impact on morbidity and mortality. Large randomized trials have failed to demonstrate a benefit for mortality of the pharmacological rhythm control strategy as compared with the rate control strategy, indicating that rate control may be an adequate treatment for AF. However, further study determined that the presence of AF at the time of study termination was a more potent predictor of mortality than the treatment strategy, suggesting the importance of sinus rhythm. On the other hand, catheter ablation recently has emerged as an alternative treatment option to pharmacological therapy for AF. Although AF ablation is an invasive strategy, over the past decade its efficacy has increased and the complication rate has decreased with the growing experience of operators and evolving technology. Moreover, the ablation methodology, such as pulmonary vein isolation based ablation, is consistent worldwide and the success rate of AF ablation, especially in paroxysmal AF, is similar. Therefore, catheter ablation is established as a treatment option for AF.