Atrial Fibrillation Free Survival Research Articles

P202Identification of predictors for atrial fibrillation-free survival after catheter ablation of persistent atrial fibrillation-results from a large prospective cohort

P202Identification of predictors for atrial fibrillation-free survival after catheter ablation of persistent atrial fibrillation-results from a large prospective cohort

Integrated Care Management in Atrial Fibrillation is associated with improved outcomes – a systematic review and meta-analysis

Introduction : Atrial fibrillation (AF) is a global epidemic and a major public health burden with an estimated 33.5 million patients globally in 2010, and evidence suggests that these figures are continuing to rise. AF contributes to a significant burden on the health care system mainly due to AF hospitalisations with an annual cost of $3.46 billion in Australia alone. AF management is highly fragmented and integrated care management has been recognised as a way to reorganise AF treatment. Theory/methods : A systematic review of Pubmed, Embase and CINAHL databases until February, 2016 was undertaken. Studies were deemed suitable for inclusion if they incorporated integrated multidisciplinary care, focussed on the holistic management of AF with at least a six month follow up period. Studies were excluded if they focussed on one aspect of AF management (e.g. anticoagulation) or were not published in English. Results : Three studies with a total of 1383 participants were identified for inclusion. Mean age was 67 ± 15 years and 50% were female. Two studies reported on all-cause mortality, odds ratio (95% confidence interval): 0.51 (0.32-0.80), p=0.003. Three studies reported on cardiovascular hospitalizations: 0.58 (0.44-0.77), p=0.0002; two studies reported on AF related hospitalisations: 0.82 (0.56-1.19), p=0.29; and three studies reported on cerebrovacular events: 1.00 (0.48-2.09), p=1.00. Discussion : A crucial aspect of integrated care in AF is the management of AF risk factors like hypertension, diabetes mellitus, obesity, sleep apnoea, smoking and alcohol intake, as these are established to result in the substrate predisposing to the development and progression of AF. From the studies included in our analysis it is apparent that AF risk factor management is often not integrated in AF practice. In prior research from our group we demonstrated that aggressive risk factor management is associated with a significant reduction in AF symptom burden and significant improvement of AF free survival. Conclusion : Outcomes in patients with AF have demonstrated significant improvements with the use of the integrated care approach in AF management. Lessons learned : Integrated Care in AF should include: a comprehensive treatment approach including AF risk factor management steered by Evidence Based Guidelines; a patient-centred approach with active patient involvement in the care process; well prepared, proactive, multidisciplinary treatment teams; and dedicated smart software to guide decision making in the treatment team. Limitations : Aside from one trial, all studies have been limited to single centre sites and not yet replicated in larger randomised controlled studies. Future studies need to address the optimal methods, settings and components of delivering integrated care to the AF population. Suggestions for future research : Therefore we propose to integrate the evidence in AF specific and risk factor management to extend the Integrated Care approach to AF management. We will perform a multi-centre, randomised controlled trial to evaluate this approach involving sites in Australia and New-Zealand.

P894Identification of predictors for atrial fibrillation-free survival after catheter ablation of persistent atrial fibrillation-results from a large prospective cohort

P894Identification of predictors for atrial fibrillation-free survival after catheter ablation of persistent atrial fibrillation-results from a large prospective cohort

216-71: Reduction of recurrence of atrial fibrillation after electrical cardioversion by Dabigatran-etexilate

Background: Electrical cardioversion (ECV) is a fast and secure method to establish sinus rhythm immediately in patients with symptomatic atrial fibrillation (AF). Unfortunately recurrence rate of AF after ECV is still high. Different agents such as antiarrhythmic or antiinflammatory drugs can improve the long term rhythm outcome. The direct thrombin inhibitor, dabigatran-etexilate, has a pleiotropic mechanism of action, with potential antioxidative, antiinflammatory and antifibroblastic growth effect. Its influence on recurrence after ECV has not yet been studied. Methods: We performed an analysis of 142 patients (98 men, mean age 65 ± 10 years, 57% on antiarrhythmic therapy, 49% persistent AF) who underwent ECV and were anticoagulated with either dabigatran-etexilate (n = 78) or phenprocoumon (n = 64). Results: During the mean follow up of 19 ± 8 months an AF recurrence was observed in 65 patients (45.8%). Baseline characteristics of both patient groups were similar despite the fact, diabetes mellitus (28.5% vs. 7.8%, p = 0.003) was more frequent in the dabigatran group (Table 1). Although persistent AF was more frequent in patients with dabigatran (73% vs. 20%, p < 0.001) the mean AF free survival was significantly longer in this group (17 ± 1 months vs. 10 ± 2 months, p < 0.001) (Figure 1).In the multivariate analysis including all baseline characteristics the use of dabigatran was associated with improved rhythm outcome (HR 0.30, CI 95% 0.18-0.51, p < 0.001). Conclusion: The results suggest a positive effect of dabigatran on preventing recurrence of AF after successful ECV. This effect may derive from its pleiotropic mechanism of action. Further clarification of potential mechanisms and evaluation in larger multicenter trials is needed.

Holter Monitor Recordings in a Man Who Snores

Electrocardiographic rhythm strips were recorded over a 24-hour period in a 49-year-old man who snored but had no prior cardiac history and no rhythm disturbances while awake. A modified lead II strip recorded at 4:06 am showed marked sinus arrhythmia and second-degree AV block (Figure 1a). The AV block increased when the sinus rate slowed, suggesting increased vagal tone affecting both the sinus and the AV nodes. The fourth QRS was slightly wider than the others and may have been junctional escape complex; its T wave was considerably wider than the others and probably contained a sinus P wave. A modified lead II strip recorded 3 minutes later showed normal sinus rhythm throughout (Figure 1b). Modified V1 rhythm strips recorded at 11:52 pm showed marked slowing of the sinus rate accompanied by sudden high-grade AV block with ventricular asystole of 5.46 seconds that was terminated by a ventricular escape complex (with a sinus P wave in its ST segment). Afterwards, there was a slight increase in the sinus rate accompanied by marked first-degree AV block. Again, sudden, transient high-grade AV block accompanying slowing of the sinus rate suggested increased vagal tone (Figure 1c). Figure 1. Electrocardiograms over a 24-hour period. Modified lead II strips showing (a) marked sinus arrhythmia and second-degree AV block at 4:06 am and (b) normal sinus rhythm at 4:09 am. (c) Continuous modified V1 rhythm strips recorded at 11:52 pm showing marked ... In addition to its association with bradyarrhythmias, obstructive sleep apnea has been associated with ventricular ectopy, including nonsustained ventricular tachycardia, atrial fibrillation, and atrial flutter (1–3). Obstructive sleep apnea is also associated with sudden cardiac death (4). The arrhythmias occur predominantly or, as in this patient, exclusively during sleep. Relief of the upper airway obstruction has reduced the frequency and severity of rhythm disturbances (1). Continuous positive airway pressure (CPAP) reduces the arrhythmia recurrence rate following pulmonary vein isolation for atrial fibrillation in patients with obstructive sleep apnea and increases atrial fibrillation-free survival off antiarrhythmic drugs or repeat ablation. Pulmonary vein isolation appears to offer limited value to patients with obstructive sleep apnea not treated with CPAP (5).

Increased arterial stiffness is an independent predictor of atrial fibrillation in hypertensive patients.

Atrial fibrillation is the most common arrhythmia, and confers a high risk of stroke and heart failure. Hypertension and ageing are two important risk factors of incident atrial fibrillation and are both associated with increased arterial stiffness. The possible relationship between arterial stiffness and atrial fibrillation is insufficiently documented and is probably complex. We tested these relations in a cohort of hypertensive patients. The population belongs to a registry which includes patients referred before administration of antihypertensive treatment and fulfilling the following criteria: office blood pressure (BP) above 140/90 mmHg, essential hypertension, no history of cardiovascular events, type 1 diabetes or atrial fibrillation, 24-h ambulatory measurement of BP coupled with the measurement of timing of Korotkoff sounds to assess arterial stiffness [indexed theoretical value of QKD interval for a SBP of 100 mmHg, at heart rate (HR) of 60 b.p.m., indexed for height and QRS duration (QKDh)]. An echocardiographic examination was carried out at baseline in the majority of patients. Atrial fibrillation-free survival was analysed with a Cox model including sex, diabetes, smoking, hypercholesterolaemia, QKDh, average 24-h pulse pressure and mean BP, mean 24-h HR, BMI and left atrial diameter (LAD), when available. We included 853 patients and recorded 67 new onsets of atrial fibrillation (mean follow-up = 102 ± 62 months). Analysis found three variables significantly and independently linked to the occurrence of atrial fibrillation: age, QKDh and 24-h average HR. When LAD was introduced (n = 480, 35 incident atrial fibrillation), three variables were linked to incident atrial fibrillation: age, QKDh and LAD. Arterial stiffness is a strong predictor of future atrial fibrillation in hypertensive patients, independently of age, 24-h pulse pressure and LAD.

A long-term evaluation of cryoballoon ablation in 205 atrial fibrillation patients: a single center experience.

Atrial fibrillation is the most prevalent cardiac arrhythmia with significant healthcare impact with regards to treatment costs, morbidity, and mortality. Many of the focal electrical activities that initiate and sustain atrial fibrillation have been found to reside within or near the pulmonary veins. Consequently, pulmonary vein isolation by catheter ablation has emerged as an effective method to eliminate the focal triggers associated with atrial fibrillation. In this single-center study, 205 patients were ablated for atrial fibrillation using a cryoballoon catheter and followed-up long-term by retrospective chart examination to evaluate their post-procedural freedom from atrial fibrillation. Patients were followed for up to 6 years with a cohort median of 3 years of post-ablation evaluation. Overall, at 12, 24, and 36 months post-ablation, 71, 49, and 31% of evaluated patients were free of atrial fibrillation, respectively. We found the type of atrial fibrillation (paroxysmal vs. persistent) as an independent predictor for arrhythmia recurrence (HR 1.97; 95% CI: 1.24-3.13, P = 0.006). The cohort median atrial fibrillation-free survival time was 24 months (27 months for paroxysmal atrial fibrillation patients and 14 months for persistent atrial fibrillation patients). There were a total of 37 (18%) complications, 8 (3.9%) were categorized as major complications, all without permanent sequels. The most common complication was phrenic nerve palsy which occurred in 14 (6.8%) patients. Long-term outcomes in this study suggest that the pulmonary vein isolation using the cryoballoon technique is relatively an effective method especially in the treatment of paroxysmal atrial fibrillation.

5A.05

Objective: Atrial fibrillation (AF) is certainly the most common arrhythmia and confers a high risk of stroke and cardiac failure. Hypertension and ageing are two important risk factors of incident AF and are both associated with increased arterial stiffness (AS). The possible relationship between AS and AF are insufficiently documented and probably complex. We tested these relations in hypertensive patients. Design and method: The patients included in this study belong to the Bordeaux cohort of hypertensive, a registry started in 1984 in which are included patients referred to our centre before administration of antihypertensive treatment and fulfilling the following criteria: Office BP > 140/90 on at least 2 occasions, Essential hypertension, no cardiovascular events or pathology likely to affect the prognosis, no type 1 diabetes. no history of AF, 24 h ambulatory measurement of BP coupled with the measurement of QKD interval inversely linked to AS (QKD100–60 (value for a systolic BP 100 mmHg and heart rate 60 bpm, corrected for patient's height and QRS duration and expressed as % of normal value = QKDh). An echocardiography was also performed at baseline in the majority of patients. AF free survival was analyzed according to the Cox model including sex, diabetes, smoking, hypercholesterolemia, QKDh, average 24 h PP and mean BP, mean 24 h HR, body mass index and left ventricular mass index (LVMI) and Left atrial Diameter (LAD) when available. Results: 853 have been recruited 67 new on-set of AF have been noticed with a mean follow up of 102 ± 62 months. Cox analysis found 3 variables significantly and independently linked to the occurrence of AF: age, QKDh and 24 h average HR Results remained unchanged when LVMI was introduced. When LAD was introduced (n = 480, 35 incident AF), 3 variables were significantly and independently linked to the occurrence of AF: age, QKDh and LAD.HaRa: Hazard ratio, CI: 95% confidence interval Conclusions: Arterial stiffness is a strong predictor of future AF in hypertensive patients, independently of age, 24 h pulse pressure, LVMI and LAD.

A new circular mapping-guided approach for endoscopic laser balloon pulmonary vein isolation

BackgroundPulmonary vein isolation (PVI) for atrial fibrillation (AF) is performed with the endoscopically assisted laser balloon ablation system (EAS). We hypothesized that placement of a circular mapping catheter (CMC) in the pulmonary vein (PV) distal to the laser balloon during ablation is feasible and safe. MethodsOut of 58 included patients, 37 underwent mapping-guided EAS PVI, with the CMC inside the PV during laser ablation, and 21 patients underwent standard EAS PVI, with the CMC outside the PV during laser ablation. ResultsMean age was 56years and 81% had paroxysmal AF. In the mapping-guided ablation group, 91% of PVs were isolated with the CMC in the PV during EAS ablation, isolation was completed in 9% of PVs after the CMC was removed from the PV. After passing a learning curve in 18 patients, a significant drop in unsuccessfully isolated PVs was observed in the mapping guided EAS PVI group (15% to 4%, P=0.020). No major complications were seen in the mapping-guided EAS PVI group. However, in the standard EAS PVI group, laser ablation was complicated by a temporary phrenic nerve palsy in 1 patient. After a median follow-up of 16.7months, there was no statistical difference in AF free survival among treatment groups (mapping-guided: 56% vs. 52%, P=0.875). ConclusionMapping guided EAS PVI with a distal CMC in the PV during laser ablation is feasible and seems safe as the standard EAS PVI approach.

Pulmonary vein orientation assessment: Is it necessary in patients undergoing contact force sensing guided radiofrequency catheter ablation of atrial fibrillation

PurposeWe hypothesized that pulmonary vein (PV) orientation influences tissue contact of the contact force (CF) sensing radiofrequency ablation catheter (CFC) and therefore atrial fibrillation (AF) free survival after pulmonary vein isolation (PVI). The aim of this study was to determine the association between PV orientation, CF and AF free survival in patients undergoing CFC PVI. MethodsSixty consecutive patients undergoing CFC PVI were included. ECG-triggered cardiac CT scans were obtained in all patients before PVI, and the PV orientation was measured at the insertion in the LA for all PVs in both the transverse and frontal plane. PVs were assigned to 1 of 4 orientation groups: ventral–caudal, dorsal–caudal, ventral–cranial and dorsal–cranial. ResultsMean age was 59years, 88% had paroxysmal AF. AF free survival off anti-arrhythmic drugs after a median follow-up of 12months was 58% after a single PVI procedure. No association was found between PV orientation and CF. Furthermore, no association was found between PV orientation and AF free survival. In univariate analysis, the number of lesions with a mean CF of 10g was associated with AF free survival. However, in multivariate analysis, only the AF duration was significantly associated with AF free survival. ConclusionsThis study shows that in patients undergoing PVI with the CFC ablation system, PV orientation does not affect CF and is not associated with AF free survival. PV orientation assessment does not appear to be necessary in patients undergoing CFC PVI.

Correlation of atrial fibrillation cycle length and fractionation is associated with atrial fibrillation free survival

AimsFractionation of electrograms in atrial fibrillation (AF) is associated with structural and electrical remodeling. We hypothesized that fractionation can also be associated with the AF cycle length (AFCL). This study was aimed at calculating the mean AFCL to fractionation correlation coefficient (mAFCC) and assessing its association with AF free survival after pulmonary vein isolation (PVI). MethodsIn twenty-eight patients, 15-second electrograms during AF were recorded with a twenty-polar catheter at the left and right atrial appendages. The AFCL was determined manually and the number of activations per second was automatically calculated into a fractionation score. The correlation between AFCL and fractionation was assessed with the mAFCC. ResultsMean age was 53±8years and 86% had paroxysmal AF. 64% of patients were AF free after a median follow-up of 5.5years. Baseline characteristics, mean AFCL and fractionation score were not associated with AF free survival after PVI. The mAFCC assessed at the left atrial appendage predicted long-term AF free survival (area under the curve: 0.871. P=0.002), but the mAFCC recorded at the right atrial appendage did not (0.690, P=0.131). ConclusionThe mean AFCL mAFCC recorded at the left atrial appendage was a significant predictor of long-term AF free survival. Although not a significant predictor of AF free survival, there was a significant association between mAFCC recorded at the right atrial appendage and AF free survival.

Acute conversion of persistent atrial fibrillation during dofetilide loading does not predict long-term atrial fibrillation-free survival.

Pharmacologic conversion of atrial fibrillation and flutter (AF/AFl) is common with dofetilide. We determined whether pharmacologic conversion with dofetilide predicts long-term arrhythmia-free survival. We retrospectively studied a cohort of 264 consecutive patients who initiated dofetilide during persistent AF/AFl between 2008 and 2013. Patients were excluded if dofetilide was discontinued prior to five doses or electrical cardioversion was performed prior to four doses. Incidence of and characteristics associated with pharmacologic conversion were determined. Patients were followed for long-term AF/AFl recurrence. Predictors of recurrence were identified using multivariate Cox modeling. Of 205 patients meeting study criteria, 92 (44.9%) converted to sinus rhythm during dofetilide loading. Female gender, history of AFl, greater number of prior catheter ablations, shorter duration of current AF/AFl, and presentation in AFl were all associated with acute pharmacologic conversion (p = 0.001, 0.05, 0.001, 0.003, and 0.003, respectively). In multivariate modeling, longer time since first AF/AFl diagnosis (hazard ratio (HR) = 1.07 per 1-year increase, 95% confidence interval (CI) 1.03-1.10, p < 0.001), longer duration of current AF/AFl episode (HR = 1.01 per 1-month increase, 95% CI 1.00-1.01, p = 0.003) and greater number of failed antiarrhythmic drugs (HR = 1.43 per one drug increase, 95% CI 1.20-1.70, p < 0.001) were independently associated with shorter time to AF/AFl recurrence. Pharmacologic conversion was not significantly associated with time to AF/AFl recurrence (HR = 0.79, 95% CI 0.57-1.10, p = 0.2). Acute pharmacologic conversion of persistent AF/AFl to sinus rhythm frequently occurs during dofetilide loading. Nevertheless, acute pharmacologic conversion does not predict long-term arrhythmia control, which was moderate at best.

Association between pulmonary vein orientation and atrial fibrillation-free survival in patients undergoing endoscopic laser balloon ablation.

Obtaining optimal pulmonary vein (PV) occlusion with the endoscopic laser balloon ablation system (EAS) can be difficult, hypothetically influenced by PV geometry. The aim of this study was to determine the impact of PV orientation on atrial fibrillation (AF)-free survival after PV isolation (PVI) using the EAS. Forty-three patients undergoing a single EAS PVI were included. Left atrial electrocardiogram -triggered computed tomography was performed in all patients prior to PVI. Of all four PVs, the orientation at the insertion in the left atrium was measured in both the transverse and frontal plane and assigned to one of the four orientation groups: ventral-caudal, dorsal-caudal, ventral-cranial, and dorsal-cranial. Mean age was 56 years; 86% had paroxysmal AF. Overall, AF-free survival after a median follow-up of 18.2 months was 51.2%. AF-free survival varied between 21 and 88% depending on left upper PV orientation (P = 0.045). Furthermore, AF-free survival varied between 21 and 86% depending on left lower PV orientation (P = 0.010) and AF-free survival varied between 29 and 88% depending on right lower PV orientation (P = 0.053). No association was found between right upper PV orientation and AF-free survival after EAS PVI (P = 0.794). In multivariate analysis, only left lower PV orientation was associated with AF-free survival [hazards ratio (HR) 10.4, P = 0.019]. PV orientation is associated with AF-free survival after EAS PVI. PV orientation assessment may be useful for selecting the most suitable patients for EAS PVI.

Conventional radiofrequency catheter ablation compared to multi-electrode ablation for atrial fibrillation

BackgroundLimited data is available on long-term atrial fibrillation (AF) free survival after multi-electrode catheter pulmonary vein isolation (PVI). The aim of this study was to compare point-by-point PVI to multi-electrode PVI in terms of procedural characteristics and long-term AF free survival. Methods and results460 consecutive patients were randomly allocated: 230 patients underwent conventional, point-by-point ablation with a radiofrequency ablation catheter (cPVI group) and 230 patients underwent multi-electrode, phased radiofrequency ablation (MER group). Median follow-up was 43months. Mean age was 56years, 82% of patients had paroxysmal AF. Baseline characteristics did not differ among catheter groups. Acute electrical PVI was achieved in 99.7% of pulmonary veins, with no differences among catheter groups. Procedure time and ablation time were significantly shorter in the MER group. There were significantly less complications in the MER group (4.8% vs. 1.3%, P=0.025). After a mean of 1.5 procedures, AF free survival without the use of antiarrhythmic drugs was 74% at 1year and 46% at 5years follow-up and did not differ among catheter groups (cPVI group 45%, MER group 48%, P=0.777). In multivariate analysis, BMI, AF duration and CHADSVASc score were predictors of AF free survival. ConclusionMulti-electrode ablation was superior in procedure duration and ablation time, with less complications. However, both conventional point-by-point PVI and multi-electrode PVI achieved a high acute PVI success rate and showed a comparable long-term AF free survival.

Pulmonary vein isolation with radiofrequency ablation followed by cryotherapy: a novel strategy to improve clinical outcomes following catheter ablation of paroxysmal atrial fibrillation

Pulmonary vein (PV) isolation for atrial fibrillation (AF) often requires repeat procedures due to PV reconnection. We hypothesized that wide area cicumferential ablation using radiofrequency energy (RFA) followed by ostial PV ablation with a cryoablation balloon would reduce the rate of AF recurrence compared with either approach alone. A retrospective study compared outcomes in the first 25 consecutive patients undergoing PV isolation for paroxysmal AF using the combined approach, to consecutive controls using either approach alone. Demographic and procedural data were collected from a prospective database. Kaplan-Meier curves were used to analyse AF free survival and curves were compared using the log-rank test. Twenty-five patients were included in each group. There were no major complications. Minor complications included two transient phrenic nerve palsies and a haematoma in both the combined groups and the cryoablation alone groups. In the RFA group the only complication was a grounding plate burn. Follow-up was 2.2 years in the RFA group, 1.0 years in the cryoablation group, and 1.4 years in the combined group. All recurrences but one occurred within one year. Freedom from AF was significantly greater in the combined group (80%) compared with the RFA alone group (52%) and the cryoablation alone group (56%, both P < 0.05). The combined approach was safe and increased single procedure efficacy of PV isolation for AF compared with either technique alone.

Role of Preoperative Atorvastatin Administration in Protection Against Postoperative Atrial Fibrillation Following Conventional Coronary Artery Bypass Grafting

Atrial fibrillation (AF) is one of the most common postoperative arrhythmias in patients who undergo coronary artery bypass grafting (CABG). The aim of this study was to evaluate the effect of preoperative atorvastatin on postoperative atrial fibrillation following coronary artery bypass grafting with cardiopulmonary bypass (CCABG). One hundred consecutive patients undergoing elective CCABG, without history of AF or previous statin treatment, were enrolled and randomly assigned to a statin group (atorvastatin 20 mg/d, n = 49) or a control group (placebo, n = 51) starting 7 days preoperatively. The primary endpoint was the occurrence of postoperative AF. C-reactive protein (CRP) levels were assessed in all selected patients before surgery and every 24 hours postoperatively until discharge from hospital. Atorvastatin significantly reduced the incidence of postoperative AF and postoperative peak CRP level versus placebo (18% versus 41%, P = 0.017; 129.3 ± 24.3 mg/L versus 149.3 ± 32.5 mg/L, P < 0.0001). Kaplan-Meier curves confirmed a significantly better postoperative atrial fibrillation-free survival in the statin group (χ(2) = 7.466, P = 0.006). Logistic regression analysis showed preoperative atorvastatin treatment was an independent factor associated with a significant reduction in postoperative AF (OR = 0.235, P = 0.007), whereas high postoperative CRP levels were associated with increased risk (OR = 2.421, P = 0.015). Preoperative atorvastatin administration may inhibit inflammatory reactions to prevent atrial fibrillation following coronary artery bypass grafting with cardiopulmonary bypass.

Hybrid Therapy of Radiofrequency Catheter Ablation and Percutaneous Transvenous Mitral Commissurotomy in Patients With Atrial Fibrillation and Mitral Stenosis

The rhythm control of atrial fibrillation (AF) associated with mitral stenosis (MS) is often difficult using antiarrhythmic drugs (AADs), even after a percutaneous transvenous mitral commissurotomy (PTMC). Few studies have examined the efficacy and safety of simultaneously performing radiofrequency catheter ablation (RFCA) and a PTMC in patients with MS and AF. Twenty consecutive patients with drug-resistant AF and rheumatic MS underwent RFCA combined with a PTMC (n = 10; persistent AF-8, long-lasting [>1 year] persistent AF-2; RFCA group) or transthoracic direct cardioversion (DC) following a PTMC (n = 10; persistent AF-7, long-lasting persistent AF-3; DC group). In all patients, the mitral valve morphology was amenable to a PTMC, and more than 2 AADs had been ineffective in maintaining sinus rhythm (SR). In the RFCA group, a segmental pulmonary vein isolation (PVI) was performed in the initial 5 patients, and an extensive PVI was performed in the remaining 5. During a mean follow-up period of 4.0 +/- 2.7 years, 8 patients (80%) in the RFCA group were maintained in SR, as compared to 1 (10%) in the DC group (hazard ratio, 0.16; 95% confidence interval, 0.03 to 0.75; P = 0.008 by the log-rank test). The prevalence of the concomitant use of class I and/or class III AADs was comparable between the 2 groups (P = 0.70). No complications occurred during the procedure or follow-up period in either group. The hybrid therapy using RFCA and a PTMC was safe and feasible, and significantly improved the AF free survival rate compared to DC following a PTMC.

Image Integration‐Guided Catheter Ablation of Atrial Fibrillation: A Prospective Randomized Study

Several studies have provided details of left atrial anatomy by means of the image integration techniques, particularly focusing on the atypical patterns of the pulmonary veins. To compare, in a prospective, randomized fashion, the conventional method of pulmonary vein disconnection and the image integration-guided approach. Two hundred and ninety consecutive patients (290 patients, mean age 55 +/- 11 years) with drug-refractory paroxysmal or persistent atrial fibrillation were enrolled in the study and were divided into two treatment groups: group 1 (145 patients) undergoing an imaging integration-guided (CartoMerge TM) ablation; group 2 (145 patients) treated by a conventional radiofrequency catheter ablation procedure. The arrhythmia was refractory to at least two antiarrhythmic drugs (IC, amiodarone). Electrical disconnection of all identified pulmonary veins was obtained in all patients of both groups. Bidirectional block of the cavotricuspid isthmus was achieved in 34 group 1 patients and in 40 group 2 patients. Left mitral isthmus ablation was attempted in 52 group 1 patients and in 56 group 2 patients. At a mean follow-up of 14 +/- 12 months, the atrial fibrillation-free survival rate was significantly higher in group 1 patients compared with group 2 patients (88% vs 69%, P = 0.017). The analysis for the subset of patients with previously ineffective ablation (98 patients: 52 group 1 patients and 46 group 2 patients) showed a significantly lower recurrence rate in group 1 versus group 2 (19% vs 48%, P < 0.01). Our data indicate a superior efficacy of the image-integration guided catheter ablation of atrial fibrillation over the long term.

Risk of atrial fibrillation in dipper and nondipper sustained hypertensive patients

The risk of atrial fibrillation (AF) in sustained hypertensive patients with different circadian blood pressure (BP) patterns is unknown. We investigated the risk of new onset AF in dipper and nondipper sustained hypertensive patients. The occurrence of AF was evaluated in 1141 patients aged > or = 40 years with sustained hypertension (clinic BP > or = 140 and/or 90 mmHg and daytime BP > or = 135 and/or 85 mmHg). Among these patients, 783 had night-time systolic BP fall > or = 10% (dippers) and 358 had night-time BP decline <10% (nondippers). During the follow-up (6.1+/-3.2, range 0.5-12.9 years), AF occurred in 43 patients. The AF rate per 100 patient-years in dippers and nondippers was 0.38 and 1.13, respectively. AF free survival was significantly different between the groups (P=0.0002). After adjustment for other covariates, including left atrial enlargement or left ventricular hypertrophy (these variables were analyzed in separate models because of a strong association between them) and 24-h BP, Cox regression analysis showed that the risk of AF was significantly higher in nondippers than in dippers [nondippers vs. dippers, relative risk (RR) 2.02, 95% confidence interval (CI) 1.08-3.79, P=0.028 in the model including left atrial enlargement, and RR 1.97, 95% CI: 1.05-3.69, P=0.035 in the model including left ventricular hypertrophy]. This study shows that nondipper sustained hypertensive patients have a two-fold greater risk of developing AF than dipper ones. This aspect could partly contribute to explain the higher cardiovascular risk previously observed in nondipper hypertensive patients.

Pretreatment with verapamil in patients with persistent or chronic atrial fibrillation who underwent electrical cardioversion

OBJECTIVESTo evaluate, in a prospective and randomized fashion, the efficacy of a pretreatment with verapamil (V) in reducing recurrences of atrial fibrillation (AF) after electrical cardioversion (C).BACKGROUNDThe increased vulnerability for AF recurrence is probably due to AF-induced changes in the electrophysiologic properties of the atria. This electrical remodeling seems to be due to intracellular calcium overload.METHODSOne hundred seven patients with persistent or chronic AF underwent external and/or internal C. All patients received oral propafenone (P) (900 mg/day) three days before and during the entire period of follow-up (three months). In the first group, patients received only the P. In the second group, in adjunct to P, oral V (240 mg/day) was initiated three days before C and continued during the follow-up. Finally, in the third group, oral V was administered three days before and continued only for three days after electrical C.RESULTSDuring the three months of follow-up, 23 patients (23.7%) had AF recurrence. Mantel-Haenszel cumulative chi-square reached a significant level only when comparing AF free survival curves of group I versus group II and group III (chi-square = 5.2 and 4, respectively; p < 0.05). Significantly, 15 (65.2%) AF relapses occurred during the first week after cardioversion with a higher incidence in group I (10/33 patients, 30.3%) than group II (2/34 patients, 5.9%; p = 0.01) and group III (3/30 patients, 10%; p = 0.04).CONCLUSIONSSix days of oral V administration centered on the C day, combined with P, significantly reduce the incidence of early recurrences of AF compared with P alone.