Atrial Fibrillation Recurrence In Patients Research Articles

A multicenter evaluation of repeat ablation for atrial fibrillation in patients with isolated pulmonary veins: a Netherlands Heart Registration study

Abstract Background Of the 25-50% atrial fibrillation (AF) ablation patients who undergo repeat ablation, approximately 15-30% have all pulmonary veins (PVs) isolated at the repeat procedure. Currently, there is limited evidence and a lack of consensus on the appropriate treatment strategy for patients with isolated PVs. Purpose Our aim was to characterize and compare the effectiveness of repeat AF ablation strategies to reduce AF recurrences in patients with isolated PVs using a real-world multicenter registry. Methods All AF patients referred for repeat AF ablation with all PVs isolated at 8 hospitals in the Netherlands were included (Netherlands Heart Registration; 2016-2019). Medical record reviews were conducted for all patients referred for repeat AF ablation to determine study eligibility, the presence of PV reconnection, ablation strategy used, and the outcome of AF recurrence. Patients referred for repeat AF ablation, with PVI only conducted during previous ablations, and all PVs isolated were eligible. Effectiveness of repeat AF ablation strategies were assessed with multivariable Cox models comparing individual ablation strategies, number of ablation strategies performed, and presence of persistent AF. Results Of 2,311 repeat AF ablations performed, 274 (11.9%) were eligible and had all PVs isolated (Figure 1). Patients with isolated PVs were a median age of 66 (IQR 58-70) years, 44.2% were women, 45.6% had persistent or long-standing persistent AF, and the median CHA2DS2-Vasc score was 2 (IQR 1-3). Ablation was not performed in 33 (12.0%) patients with isolated PVs (Figure 2a). A single ablation strategy was performed most often (41.2%; Figure 2a). Posterior box ablation was the most frequent (58.4%) ablation strategy performed, followed by antralization of the PVs (26.3%). Over a median follow-up of 2.0 (1.0-3.3) years, 147 (59.8%) patients with isolated PVs had an AF recurrence >3 months after repeat ablation and 30 (12.7%) patients had another repeat AF ablation within 1 year of repeat procedure. After multivariable adjustment, no difference in AF recurrences was detected between ablation strategies [p>0.05 for all; Figure 2b]. Further, there was no difference detected in AF recurrences for the number of ablation strategies performed (Figure 2c), the individual ablation strategy conducted, and persistent AF (p>0.05 for all). Among patients with isolated PVs, patients with larger left atrial size had a higher risk of AF recurrences [adjusted HR 1.03 (95% CI 1.01-1.05)]. Conclusion Among the 2,311 repeat AF ablations performed, 11.9% had all PVs isolated. Despite multiple ablation strategies performed for isolated PVs, 59.8% of patients had an AF recurrence over follow-up and no difference in the incidence of AF recurrences was detected between repeat ablation strategies. Further evidence is warranted to determine an effective treatment strategy to reduce AF recurrences in AF patients with isolated PVs.

Difference between cryoballoon and radiofrequency ablations for atrial fibrillation based on electroanatomical mechanisms

Abstract Backgrounds Cryoballoon pulmonary vein isolation (PVI; Cryo-PVI) has comparable results to conventional radiofrequency PVI (RF-PVI) in patients with atrial fibrillation (AF). However, Cryo-PVI using a 28-mm cryoballoon has limitations for wide circumferential PVI or extra-pulmonary vein (PV) trigger (ExPVT) ablations. We compared long-term outcomes of Cryo-PVI and RF-PVI in patients without ExPVT and explored the potential electroanatomical mechanisms. Methods We identified 2,160 patients who underwent de novo AF ablation. After propensity score matching for age, sex, AF type, and left atrial (LA) diameter for patients without ExPVT (female 24.6%, mean 61.8years old, paroxysmal AF 53.2%), we compared rhythm outcomes between 403 Cryo-PVI and 403 RF-PVI procedures, considering AF type and LA size. We determined the LA diameter cutoff which best differentiated rhythm outcomes between RF-PVI and Cryo-PVI using a maximum likelihood approach based on the Cox proportional hazard model and investigated the relationship between PVI level and LA mass reduction through computational modeling. Results During the 24 months of median follow-up, Cryo-PVI showed poorer rhythm outcomes to RF-PVI (Log-rank p=0.009) in overall patients. However, Cryo-PVI showed comparable overall rhythm outcomes to RF-PVI (Log-rank p=0.370) in patients with paroxysmal AF. Cryo-PVI showed higher AF recurrence in patients with larger LA size (LA diameter≥40mm; hazard ratio [HR] 1.55 [1.04-2.30]; log-rank p=0.030) or with persistent AF (log-rank p=0.001). In the computational modeling, PV antrum was likely to be covered by Cryo-PVI in patients with small LA, but not in those with large LA. Conclusions Cryo-PVI showed inferior rhythm outcomes than RF-PVI in patients with higher LA diameter or with persistent AF.

Strategies for recurrent atrial fibrillation in patients despite durable pulmonary vein isolation

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone in treatment of atrial fibrillation (AF). Despite initially successful PVI patients experience recurrence of AF mostly due to reconnection of pulmonary veins (PVs). However, a certain number of patients presents with recurrent AF despite durable PVI. The optimal ablation strategy for these patients has yet to be discerned. Aim The aim of this study was to compare outcomes for different ablation strategies for recurrent AF despite persistent PVI. Methods All redo procedures for recurrence of AF from 01/2016 – 6/2022 at our center were analyzed. Only patients with proven durable PVI (entrance/exit block and high density (HD) mapping) were included. Patients were excluded, if re-PVI or right atrial ablation was necessary. In all procedures (HD) 3-D mapping and radiofrequency ablation were performed. Ablation strategy was at operators’ discretion. A 12-month follow up (FU) was obtained. Results A total of 405 left-atrial procedures for the recurrence of AF were analyzed. In 85 (21.0%) procedures all PVs were still isolated. Of these 30 patients (35.3 %) were female and 70 patients (82.4 %) suffered from persistent AF. In 49 patients (57.6 %) LA scar was detectable (85.7 % persAF). The ablation strategies consisted of: roof line (n=9; 10.6 %), left atrial anterior line (n=8, 9.4 %), roof line and left atrial anterior line (n=8, 9.4%), roof line and left atrial inferior line (n=18, 21.2 %), box lesion (n=6, 7.1 %), other left atrial ablation lines (n=20, 23.5 %) and substrate modification (CFAE and substrate encirclement) (n=16, 18.8 %). In patients with PAF (n=15), 3 patients received a roof line (20.0 %), 3 patients received the latter and left atrial inferior line (20.0 %), 5 patients received other left atrial ablation lines (33.3 %) and 4 patients received substrate modification (CFAE and substrate encirclement) (26.7 %). After a mean follow up of 401 +/- 125 days 55.3 % (n=47) of patients were free from any atrial arrhythmia (roof line 77.8 +/- 15 %, left atrial anterior line 87.5 +/- 13 %, roof line and left atrial anterior line 37.5 +/- 18 %, roof line and left atrial inferior line 50 +/- 12 %, box lesion 83.3 +/- 17 %, other left atrial ablation lines 45.0 +/- 11 %, substrate modification (CFAE and substrate encirclement) 43.8 +/- 13 %, p=0.122), 35.3 % (n=30) showed recurrence of AF (p=0.287) and 9.4 % (n=8) showed atrial tachycardia (AT) (p=0.693). None of the ablation strategies led to a significantly superior outcome. Conclusion In patients suffering from recurrence of AF despite durable pulmonary vein isolation different substrate modification strategies did not show any superiority for one or the other. Despite the necessity of additional ablation beyond PVI the optimal ablation strategy needs to be yet determined to improve outcome for redo procedures.

Catheter-based pulmonary vein isolation fails to prevent transient atrial arrhythmogenic changes related to acute obstructive respiratory events in a porcine model.

Pulmonary vein isolation (PVI) is the corner stone of modern rhythm control strategies in patients with atrial fibrillation (AF). Sleep-disordered breathing (SDB) is prevalent in more than 50% of patients undergoing AF ablation and studies have indicated a greater recurrence rate after PVI in patients with SDB. Herein, we study the effect of catheter-based PVI on AF in a pig model for SDB. In 11 sedated spontaneously breathing pigs, obstructive apnoeas were simulated by 75 seconds of intermittent negative upper airway pressure (INAP) applied by a negative pressure device connected to the endotracheal tube. INAPs were performed before and after PVI. AF-inducibility and atrial effective refractory periods (aERP) were determined before and during INAP by programmed atrial stimulation. PVI prolonged the aERP by 48 ± 27 ms in the right atrium (RA) (p < 0.0001) and by 40 ± 34 ms in the left atrium (LA) (p = 0.0004). Following PVI, AF-inducibility dropped from 28 ± 26% to 0% (p = 0.0009). INAP was associated with a transient aERP-shortening (ΔaERP) in both atria, which was not prevented by PVI (INAP indued ΔaERP after PVI in the RA: -57 ± 34 ms, p = 0.0002; in the LA: -42 ± 24 ms, p < 0.0001). INAP was associated with a transient increase in AF-inducibility (from 28 ± 26% to 69 ± 21%; p = 0.0008), which was not attenuated by PVI (INAP-associated AF-inducibility after PVI: 58 ± 33% (p = 0.5)). Transient atrial arrhythmogenic changes related to acute obstructive respiratory events are not prevented by electrical isolation of the pulmonary veins, which partially explains the increased AF recurrence in patients with SDB after PVI procedures.

Notched P‐wave on digital electrocardiogram predicts the recurrence of atrial fibrillation in patients who have undergone catheter ablation

AbstractBackgroundA notched P‐wave is associated with the occurrence of atrial fibrillation (AF). However, the association between a notched P‐wave and AF recurrence in patients who have undergone a catheter ablation for AF is unclear.MethodsWe enrolled 100 subjects who underwent catheter ablation for AF (paroxysmal AF: 60 cases; persistent AF: 40 cases). Twelve‐lead electrocardiography (ECG) was conducted, and the peak‐to‐peak distance in the M shape was calculated automatically using a 12‐lead ECG analysis system. A notched P‐wave was defined as a P‐wave with an M‐shape and a peak‐to‐peak distance of ≥20 ms in lead II. We compared the recurrence of AF in the patients with notched P‐wave and the others.ResultsThe mean follow‐up period was 12 ± 8 months, and a recurrence of AF was observed in 28 patients. The recurrence of AF in the notched P‐wave group was significantly higher than that in the controls (log rank 5.14, p = .023). A notched P‐wave was a significant predictor of the recurrence of AF after adjustment for age, gender, history of heart failure, history of catheter ablation, persistent AF, use of antiarrhythmic drugs, and the left atrial volume index (hazard ratio 2.470, 95% confidence interval 1.065–5.728, p = .035).ConclusionsAutomatically identified notched P‐waves with peak‐to‐peak distance ≥20 ms were associated with AF recurrence in patients who had undergone catheter ablation.

Association between triglyceride–glucose index trajectories and radiofrequency ablation outcomes in patients with stage 3D atrial fibrillation

BackgroundThis study investigates the relationship between triglyceride-glucose (TyG) index trajectories and the results of ablation in patients with stage 3D atrial fibrillation (AF).MethodsA retrospective cohort study was carried out on patients who underwent AF Radiofrequency Catheter Ablation (RFCA) at the Cardiology Department of the Fourth Affiliated Hospital of Zhejiang University and Taizhou Hospital of Zhejiang Province from January 2016 to December 2022. The main clinical endpoint was determined as the occurrence of atrial arrhythmia for at least 30 s following a 3-month period after ablation. Using a latent class trajectory model, different trajectory groups were identified based on TyG levels. The relationship between TyG trajectory and the outcome of AF recurrence in patients was assessed through Kaplan-Meier survival curve analysis and multivariable Cox proportional hazards regression model.ResultsThe study included 997 participants, with an average age of 63.21 ± 9.84 years, of whom 630 were males (63.19%). The mean follow-up period for the participants was 30.43 ± 17.75 months, during which 200 individuals experienced AF recurrence. Utilizing the minimum Bayesian Information Criterion (BIC) and the maximum Entropy principle, TyG levels post-AF RFCA were divided into three groups: Locus 1 low-low group (n = 791), Locus 2 low-high-low group (n = 14), and Locus 3 high-high group (n = 192). Significant differences in survival rates among the different trajectories were observed through the Kaplan-Meier curve (P < 0.001). Multivariate Cox regression analysis showed a significant association between baseline TyG level and AF recurrence outcomes (HR = 1.255, 95% CI: 1.087–1.448). Patients with TyG levels above 9.37 had a higher risk of adverse outcomes compared to those with levels below 8.67 (HR = 2.056, 95% CI: 1.335–3.166). Furthermore, individuals in Locus 3 had a higher incidence of outcomes compared to those in Locus 1 (HR = 1.580, 95% CI: 1.146-2).ConclusionThe TyG trajectories in patients with stage 3D AF are significantly linked to the outcomes of AF recurrence. Continuous monitoring of TyG levels during follow-up may help in identifying patients at high risk of AF recurrence, enabling the early application of effective interventions.

Atrial Functional Substrates for the Prediction of Atrial Fibrillation Recurrence After Pulmonary Vein Isolation

Low-voltage areas have been used as atrial structural substrates in estimating fibrotic degeneration in patients with atrial fibrillation (AF). The high-resolution maps obtained by recently developed mapping catheters allow the visualization of several functional abnormalities. We investigated the association between left atrial (LA) functional abnormal findings on a high-resolution substrate map and AF recurrence in patients who underwent pulmonary vein isolation without any additional LA substrate ablation. This observational study included 100 consecutive patients who underwent second ablation for AF (paroxysmal, 48%; persistent, 52%). Patients with extra-pulmonary-vein LA substrate ablation during the initial and second ablation were excluded. LA mapping was performed using a 64-pole mini-basket catheter on the Rhythmia mapping system. Patients were followed for 2 years. AF recurrence developed in 39 (39%) patients. On the high-resolution substrate map, AF recurrence was associated with the presence of the following findings: low-voltage areas (<1.0 mV, >5cm2; hazard ratio [HR]=2.53; 95% confidence interval [CI]=1.30-4.93; p<0.006), fractionated-electrogram areas (≥5 peaks, >5cm2; HR=2.15, 95%CI=1.10-4.19; p=0.025), LA conduction time of >130 msec (HR=3.11, 95%CI=1.65-5.88, p<0.0001), deceleration zone (≥5 isochrones/cm2; HR=1.97, 95%CI=1.04-3.37, p=0.039), and multiple septal breakout points (HR=3.27, 95%CI=1.50-7.16, p=0.003). Accumulation of these risk factors increased AF recurrence in a stepwise manner, with an HR=1.90, 95%CI=1.44-2.52, p<0.00001 for each additional risk factor. In conclusion, high-resolution map revealed new LA functional substrates associated with AF recurrence. Implementation of functional substrates may improve the prediction of AF recurrence after ablation, and possibly aid the development of tailored AF ablation strategies.

Efficacy and Safety of High-power Short-duration Radio Frequency Ablation in the Treatment of Atrial Fibrillation: A Meta-analysis of Prospective Study

Background: Radiofrequency ablation is a critical therapeutic method used in the management of atrial fibrillation (AF). This study systematically evaluates the effectiveness and safety of two catheter radio frequency ablation approaches: high-power short-duration (HPSD) and traditional low-power long-duration (LPLD), in treating AF. Methods: Four databases were searched for prospective studies (eight cohort studies and three randomised controlled trials) that evaluated the effect of HPSD treatment on AF recurrence, occurrence rate of complications and procedural time in patients with AF from the establishment of the databases to March 2023. We utilised RevMan 5.20 and Stata 11.0 statistical software to conduct a meta-analysis, and publication bias was assessed using funnel plots and Egger's test. The effect estimates were synthesised as relative risks (RRs) or standardised mean differences (SMDs) along with their corresponding 95% confidence intervals (CIs). Results: A total of 536 relevant studies were retrieved, and 11 prospective studies were collected. The combined value of the estimated effect of HPSD versus LPLD treatment on AF recurrence in patients with AF had an RR of 0.59 (95% CI: 0.45–0.78; p &lt; 0.001), the effects of HPSD versus LPLD treatment on procedural time in patients with AF had an SMD of –1.17 (95% CI: –1.56– –0.77; p &lt; 0.001), and the effect of HPSD versus LPLD treatment on oesophageal thermal injury in patients with AF had an RR of 0.84 (95% CI: 0.22–3.28; p = 0.80). Notably, the estimated combined effects of HPSD and LPLD on other major complications (steam pop) in patients with AF had an RR of 0.57 (95% CI: 0.22–1.47; p = 0.24). Conclusions: HPSD is more effective than traditional LPLD and has a lower AF recurrence rate after surgery. Meanwhile, HPSD treatment can improve surgical efficiency and has a shorter procedural time than LPLD treatment.

Association between baseline glycated hemoglobin level and atrial fibrillation recurrence following cryoballoon ablation among patients with and without diabetes

ObjectivesThe study aims to assess the effect of baseline glycated hemoglobin (HbA1c) levels on atrial fibrillation (AF) recurrence following cryoballoon ablation in patients with and without diabetes.MethodsConsecutive AF patients receiving first cryoballoon ablation between April 2018 and April 2021 were included. AF recurrence and other clinical outcomes were recorded for a minimum of 12 months post-ablation, with regular assessments at 3, 6, and 12 months, followed by annual check-ups. The primary outcome was AF recurrence after ablation at longest follow-up. Multivariate Cox proportional hazards regression models were utilized to calculate the hazard ratio (HR) and 95% CI per standard deviation (SD) increase of baseline HbA1c level.Results335 patients were included in the analysis. The mean age was 61.7 years, 61.8% were male. 12.8% had type 2 diabetes, and 81.7% of patients had paroxysmal AF. The median level of HbA1c was 5.3%, and the mean CHA2DS2-VASc score was 1.8. All cryoballoon ablation procedures, utilizing a 28-mm balloon, achieved successful pulmonary vein isolation. Over a median follow-up of 18 months, 105 patients (31.3%) experienced AF recurrence. In multivariate Cox proportional hazards analysis, a higher HbA1c level, persistent AF (HR 1.91, 95% CI 1.08 to 3.39, P = 0.026), alcohol consumption (HR 2.67, 95% CI 1.33 to 5.37, P = 0.006), and Nadir RSPV (HR 1.04, 95% CI 1.00 to 1.08, P = 0.005) were significant predictors of AF recurrence. Per-SD increase of HbA1c was associated with a 1.75-fold increase risk of AF recurrence (HR 1.75, 95% CI 1.39 to 2.21, P < 0.001). Subgroup analysis revealed that a higher HbA1c level was associated with a higher risk of AF recurrence in patients with and without diabetes, and in patients with paroxysmal and persistent AF.ConclusionBaseline HbA1c level was an independent predictor of AF recurrence following cryoablation, both in patients with and without diabetes.

Association between preablation and postablation neutrophil-lymphocyte ratio and atrial fibrillation recurrence: A meta-analysis.

Atrial fibrillation (AF) recurrence has become common in patients who have undergone catheter ablation. High neutrophil lymphocyte ratios (NLR) have been linked to an increased risk of recurrent AF. The research is, however, not conclusive. This meta-analysis addressed the value of easily accessible and affordable pre- and postablation NLR levels as indicators of AF recurrence in patients who had undergone ablation. We searched PubMed, SCOPUS, and Google Scholar for pertinent studies through May 2023. Using random effects models, the aggregated odds ratio (OR) of pre- and post-NLR and AF recurrence was estimated. Inter-study heterogeneity was described using I 2 statistics and leave-one-out sensitivity analysis. A p-value < .05 was considered statistically significant. The literature search yielded 270 studies, seven of which were included in this meta-analysis of 1923 patients who experienced AF recurrence after undergoing ablation. There are five retrospective and two prospective studies with a mean follow-up of 20.5 months. The unadjusted odds ratio (OR) of AF recurrence for preablation NLR was 1.33 (95% CI: 1.04-1.71, p < .01, I 2 = 95.49%), while the adjusted OR was 1.45 (95% CI: 0.87-2.43, p < .01, I 2 = 95.1%). The unadjusted odds ratio (OR) for postablation NLR was 1.21 (95% CI: 1.09-1.36, p < .01, I 2 = 85.9%), and the adjusted odds ratio (OR) was 1.28 (95% CI: 0.93-1.76), demonstrating significant heterogeneity (I 2 = 95.32%) with a p-value < .01. NLR was significantly associated with AF recurrence prediction. To detect AF recurrence, we recommend that clinicians add a simple NLR blood test to their diagnostic modalities.

Increased EHRA Score Predicts Atrial Fibrillation Recurrence in Paroxysmal Atrial Fibrillation Patients Undergoing Cryoablation

Abstract Aim: Atrial fibrillation (AF) recurrence occurs in 20-30% of patients despite cryoablation treatment. We aimed to investigate the importance of CHA2DS2-VASc, TIMI-AF, ATRIA, HASBLED and EHRA scoring systems in identifying patients with late-stage AF recurrence in patients who received cryoablation due to paroxysmal AF (PAF). Materials and Methods: This cross-sectional study included 300 patients who received cryoablation because of PAF. EHRA, CHA2DS2-VASc, TIMI AF, ATRIA and HASBLED scores used in the clinic were calculated for AF burden, stroke and bleeding risk in patients. AF recurrence was defined as detection of AF in 12-lead electrocardiography or observation of AF attack for at least 30 seconds in Holter ECG recording. Patients were divided into 2 groups as patients with and without AF recurrence. Results: In the follow-up of patients who underwent cryoablation due to PAF, AF recurrence was detected in 47 (16%) patients. CHA2DS2-VASc, ATRIA, HASBLED and EHRA scores were significantly higher in the patient group with AF recurrence (p&lt;0.05 for each). TIMI-AF score was similar between the two groups. When logistic regression analysis was performed to identify patients with AF recurrence, variables of HT (OR:3.322, 95% CI:1.659 – 6.620, p=0.001), BMI (OR:1.087, 95% CI:1.011 – 1.169, p=0.024) and EHRA scoring system (OR:3.503, 95% CI:1.680 – 7.306, p=0.001) were determined as independent markers for AF recurrence. Conclusion: The results of our study showed that EHRA scoring system should be used for AF ablation decision, as well as its ability to predict AF recurrence, would be clinically useful.

Long-term serial changes in left atrial volume and function after catheter ablation for atrial fibrillation

Abstract Background Catheter ablation for atrial fibrillation (AF) is an effective method to restore and maintain sinus rhythm. The value of left atrial (LA) volume and reservoir function at short-term after ablation have been shown to associate with clinical outcomes. However, data regarding serial changes in LA size and function after the ablation remain scarce. Purpose The purpose of this study was to investigate the serial changes in LA volume and function, and their relationship to the AF recurrence in patients who underwent primary ablation for AF and had preserved left ventricular ejection fraction (LVEF). Methods We retrospectively reviewed 1,204 patients (age: 72±10 years, male: 72%, LVEF: 62±4%, paroxysmal AF: 66%) for whom both pre- and post-procedural serial echocardiographic data were available. Echocardiography was performed at pre-, 1-year, 2-year and 3-year after the ablation procedure. The association between AF recurrence and changes in echocardiographic parameters were evaluated by A repeated measures ANOVA with a Greenhouse-Geisser correction and Bonferroni tests. The AF recurrence was defined as any documented atrial arrhythmia of &amp;gt; 30 seconds after a single ablation procedure. Results During the mean follow-up of 1725±713 days, AF recurrence was observed in 418 patients (34.7%) and persistent AF at last follow-up was 41 patients (3.4%). Patients with AF recurrence had significantly larger LA volume index (LAVI) and lower LA emptying fraction (LAEF) at baseline than those without (50.0±15.5 vs 41.4±14.4 mL/m2, P&amp;lt;0.001, and 31.2±14.9 vs 37.7±14.0 %, P&amp;lt;0.001, respectively) and these differences were maintained thereafter during the follow-up. The trend of LAVI decreased until 6 months later and then remained unchanged regardless of the AF recurrence. These trends were maintained in patients divided into initial paroxysmal and persistent AF. The trend of LAEF increased until 6 months later and then gradually decreased regardless of the AF recurrence. These trends were maintained in patients with persistent AF, however, LAEF continued to decline in patients with paroxysmal AF. (Figure) Conclusions The catheter ablation was associated with significant reduction in LAVI and improvement of LAEF in patients with persistent AF regardless of recurrent AF. In contrast, LAEF decreased gradually in patients with paroxysmal AF. These findings may suggest LA function in patients with AF declines gradually, even when they are maintained in sinus rhythm. However, both LAVI and LAEF in paroxysmal AF were better than persistent AF, suggesting that catheter ablation may be more effective in the paroxysmal AF stage.

Abstract 17589: Efficacy of Sacubitril-Valsartan Compared With Angiotensin-Converting Enzyme Inhibitor or Angiotensin-Receptor Blocker for Preventing Atrial Fibrillation Recurrence After Catheter Ablation: A Systematic Review and Meta-Analysis

Introduction: Among patients with atrial fibrillation (AF) who underwent catheter ablation, it is unclear whether AF recurrence is lower in those who receive Sacubitril-Valsartan (SV) than in those who receive ACEi (angiotensin-converting enzyme inhibitor) or ARB (angiotensin-receptor blocker). Hypothesis: Is SV more effective than ACEi/ARB in decreasing AF recurrence after catheter ablation? Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating the efficacy of SV for preventing AF recurrence in patients who underwent catheter ablation. The outcomes of interest were AF recurrence and structural remodeling, assessed by Left Ventricular Ejection Fraction (LVEF) and Left Atrial Volume Index (LAVi). Statistical analysis was performed using RevMan 5.1.7. Heterogeneity was assessed with I 2 statistics. Results: We included 2 RCTs and 1 PMC, comprising 517 patients, of whom 256 were treated with SV, 101 received ARB, and 155 ACEis. AF recurrence was significantly lower in the SV group (RR 0.50; 95% CI 0.37-0.68; p&lt;0.00001; I 2 =0%; Figure 1A), even considering only RCTs (RR 0.55; 95% CI 0.34-0.91; p=0.03; I 2 =0%). Also, SV was associated with a significant decrease in LAVi (MD -5.34 mL/m 2 ; 95% CI -8.77 to -1.91; p=0.002; I 2 =57%; Figure 1B) compared to ARB. LVEF was similar between groups (MD 1.24 %; 95% CI -0.12 to 2.60; p=0.07; I 2 =0%). Conclusions: SV therapy was associated with a decreased risk of AF recurrence compared to ACEi or ARB, and was superior to ARB in attenuating atrial structural remodeling in patients submitted to catheter ablation.

Abstract 12590: Association of Iron Deficiency With the Recurrence of Atrial Fibrillation After Pharmacological Cardioversion

Introduction: Anemia and iron deficiency (ID) are common conditions in patients with atrial fibrillation (AF). The presence of anemia may be associated with worse outcome in patients with AF. The potential role of ID in the development of AF has been discussed recently, however the issue is considered only in the context of anemia. Thus, information on the direct impact of ID on AF development and on the sinus rhythm maintenance remains limited. Methods: The purpose of this article is to study the effects of ID on the frequency of recurrence of AF within 12 months in patients with paroxysmal AF after pharmacological cardioversion with amiodarone.198 patients (120 men) with nonvalvular paroxysmal AF with successful pharmacological cardioversion were included in the study between 2019-2021 years. The Me of the patients age is 71 (63,2–77) year. ID is assumed to be present when serum ferritin &lt;100 ng/mL or 100 ng/mL ≤ serum ferritin ≤299 ng/mL with transferrin saturation (TSAT) &lt;20%. The primary outcome was AF recurrence within 12 months after pharmacological cardioversion. AF recurrence is statistically tested by the Kaplan-Meier test. Results: The patients were divided into 2 groups: group 1 - 116 patients with ID, group 2 - 82 patients without ID. The groups did not differ in the main clinical parameters, comorbidities and medications. After cardioversion, all patients received treatment according to the current guidelines. The significant difference in AF recurrence was observed between groups. Within 12 months of observation, AF recurrence was developed in 49 (42.2%) patients in group 1 and in 16 (19.5%) patients in group 2 (p=0.0008). The RR of the recurrence of AF in patients with ID is 2.64 [95% CI: 1.5-4.65] (p=0.0003). Conclusion: ID is associated with the higher chances of AF recurrence within 12 months after pharmacological cardioversion. ID increases the risk of AF recurrence by 2,64 times within 12 months after pharmacological cardioversion.

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF). Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4±8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow-up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%). Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC.

Comparison of pulmonary vein isolation using cryoballoon, high-power short-duration, and conventional radiofrequency ablation for atrial fibrillation: a propensity score-weighted study.

The comparative efficacy, saftey, and heart rate variability (HRV) parameters after pulmonary vein isolation using cryoballoon (Cryo-PVI), high-power short-duration (HPSD-PVI), and conventional radiofrequency ablation (conventional-PVI) for atrial fibrillation (AF) is unclear. In this propensity score-weighted, retrospective analysis of a single-center cohort, we analyzed 3,395 patients (26.2% female, 74.5% paroxysmal AF) who underwent AF catheter ablation without an empirical left atrial ablation. Procedural factors, recurrence rates, complication rates, and the post-procedural HRV parameters were compared across the Cryo-PVI (n = 625), HPSD-PVI (n = 748), and conventional-PVI (n = 2,022) groups. Despite the shortest procedural time in the Cryo-PVI group (74 min for Cryo-PVI vs. 104 min for HPSD-PVI vs. 153 min for conventional-PVI, p < 0.001), the major complication (p = 0.906) and clinical recurrence rates were similar across the three ablation groups (weighted log-rank, p = 0.824). However, the Cryo-PVI group was associated with a significantly lower risk of recurrent AF in patients with paroxysmal AF [weighted hazard ratio (WHR) 0.57, 95% confidence interval (CI) 0.37-0.86], whereas it was associated with a higher risk of recurrent AF in patients with persistent AF (WHR 1.41, 95% CI 1.06-1.89, p for interaction of <0.001) compared with the conventional-PVI group. In the subgroup analysis for the HRV, the Cryo-PVI group had the highest low-frequency-to-high-frequency ratio at 1-year post-procedure, whereas the HPSD-PVI group had the lowest low-frequency-to-high-frequency ratio at 1-year post-procedure (p < 0.001). The Cryo-PVI group had better rhythm outcomes in patients with paroxysmal AF but worse rhythm outcomes in patients with persistent AF and a higher long-term post-procedural sympathetic nervous activity and sympatho-vagal balance compared with the conventional-PVI group.

Atrial Fibrillation Recurrence in Patients With Transient New-Onset Atrial Fibrillation Detected During Hospitalization for Noncardiac Surgery or Medical Illness : A Matched Cohort Study.

Atrial fibrillation (AF) is often detected for the first time in patients who are hospitalized for another reason. Long-term risks for AF recurrence in these patients are unclear. To estimate risk for AF recurrence in patients with new-onset AF during a hospitalization for noncardiac surgery or medical illness compared with a matched population without AF. Matched cohort study. (ClinicalTrials.gov: NCT03221777). Three academic hospitals in Hamilton, Ontario, Canada. The study enrolled patients hospitalized for noncardiac surgery or medical illness who had transient new-onset AF. For each participant, an age- and sex-matched control participant with no history of AF from the same hospital ward was recruited. All participants left the hospital in sinus rhythm. 14-day electrocardiographic (ECG) monitor at 1 and 6 months and telephone assessment at 1, 6, and 12 months. The primary outcome was AF lasting at least 30 seconds on the monitor or captured by ECG 12-lead during routine care at 12 months. Among 139 participants with transient new-onset AF (70 patients with medical illness and 69 surgical patients) and 139 matched control participants, the mean age was 71 years (SD, 10), the mean CHA2DS2-VASc score was 3.0 (SD, 1.5), and 59% were male. The median duration of AF during the index hospitalization was 15.8 hours (IQR, 6.4 to 49.6 hours). After 1 year, recurrent AF was detected in 33.1% (95% CI, 25.3% to 40.9%) of participants in the transient new-onset AF group and 5.0% (CI, 1.4% to 8.7%) of matched control participants; after adjustment for the number of ECG monitors worn and for baseline clinical differences, the adjusted relative risk was 6.6 (CI, 3.2 to 13.7). After exclusion of participants who had electrical or pharmacologic cardioversion during the index hospitalization (n = 40) and their matched control participants and limiting to AF events detected by the patch ECG monitor, recurrent AF was detected in 32.3% (CI, 23.1% to 41.5%) of participants with transient new-onset AF and 3.0% (CI, 0% to 6.4%) of matched control participants. Generalizability is limited, and the study was underpowered to evaluate subgroups and clinical predictors. Among patients who have transient new-onset AF during a hospitalization for noncardiac surgery or medical illness, approximately 1 in 3 will have recurrent AF within 1 year. Peer-reviewed grants.

Catheter ablation using pulmonary vein isolation with versus without left atrial posterior wall isolation for persistent atrial fibrillation: an updated systematic review and meta-analysis.

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation of atrial fibrillation (AF); however, the results are suboptimal for persistent AF. The left atrial posterior wall (LAPW) is thought to be a major additional area in initiation and perpetuation of persistent AF. Therefore, adjunctive ablation of the posterior wall may reduce AF recurrence in patients with persistent AF. The objective of this study was to compare outcomes of catheter ablation in patients with persistent AF using PVI alone versus a combination of PVI and LAPW isolation. Literature search was conducted in PubMed, PubMed Central, Scopus, and Embase since inception to February 2023. Screening of studies was done via Covidence software. Risk of bias assessment was done using appropriate tools. Data extraction and a narrative synthesis were carried out accordingly. Ten studies were included, of which five were randomized controlled trials. PVI with LAPW ablation group had significantly lower recurrence of overall atrial tachyarrhythmia (OR 0.47, CI 0.32-0.70) and AF (OR 0.39, CI 0.23-0.69). In sensitivity analysis, freedom from atrial arrhythmias was noted to be significantly higher in the PVI with LAPW ablation group (OR 2.22, CI 1.36-3.64). However, there was no significant difference in occurrence of atrial flutter (OR 1.36, CI 0.86-2.14) or with periprocedural adverse events (OR 1.10, CI 0.60-1.99). LAPW ablation, in addition to PVI, significantly improves the rates of arrhythmia freedom and reduces the recurrence of overall atrial tachyarrhythmia. There was no significant difference in atrial flutter or periprocedural adverse events.

Quantification of epicardial adipose tissue by computed tomographic scanning as a prognostic criterion of atrial fibrillation recurrence after catheter ablation.

Aim This study focused on a systematic review and meta-analysis on the predictive role of quantifying the epicardial adipose tissue (EAT) volume using data of computed tomography (CT) in patients after catheter ablation for atrial fibrillation (AF).Material and methods We performed a search in PubMed and Google Scholar for studies that examined the predictive value of EAT volume measured by CT for AF recurrence in patients after undergoing pulmonary venous isolation. Risk ratio (RR) values from studies, where similar scoring criteria were available, were pooled for the meta-analysis.Results Eighteen studies were selected from 901 publications for these systematic review and meta-analysis. In total, 4087 patients were included in this analysis (mean age, 59.0 years; mean follow-up duration, 14.9 mos). Patients with recurrent AF after ablation had higher left atrial EAT volume compared to patients without relapse (weighted mean difference, 5.99 ml; 95% CI: -10.04 to -1.94; p = 0.004). An increase in left atrial EAT volume per ml was significantly associated with the development of AF recurrence after ablation (RR 1.08; 95% CI: 1.01 to 1.16; p=0.03). Patients with recurrent AF after ablation also had higher total EAT values than patients without relapse (difference in weighted values, 11.67 ml; 95% CI: -19.81 to -3.54; p = 0.005). However, no significant association was found between the total EAT volume and the risk of AF relapse (RR 1.00; 95% CI: 1.00 to 1.01; p=0.06).Conclusions The volume of left atrial EAT measured by CT has a significant predictive value in AF patients after catheter ablation and can be used for stratification of the risk for recurrent AF.

Total Atrial Conduction Time as a Predictor of Atrial Fibrillation Recurrence: A Systematic Review and Meta-Analysis.

This systematic review and meta-analysis aims to evaluate the predictive value of total atrial conduction time (TACT) assessed by tissue Doppler echocardiography (PA-TDI) in atrial fibrillation (AF) recurrence in patients following a rhythm-control strategy. A systematic approach following Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines was applied in electronic databases (Pubmed, Cochrane Library, and Web of Science), supplemented by scanning through studies' references. TACT was compared using a random-effects model and presented as a difference in means (MD). The primary endpoint was AF recurrence. Seven publications were included in this systematic review. The mean age of the patients ranged from 55 years to 72 years. Prolonged TACT was associated with AF recurrence [MD, 23.12 msec; 95% confidence interval (CI), 11.54-34.71; I2 = 95%]. Subgroup analysis showed that prolonged TACT was strongly associated with AF recurrence in persistent AF cohorts undergoing electrical cardioversion (MD, 26.56; 95% CI, 15.51-37.6; I2 = 86%), while in patients with paroxysmal AF (PAF) undergoing catheter ablation, the results were not statistically significant (MD, 11.48; 95% CI, -1.19 to 24.14; I2 = 90%). The summary area under the curve (sAUC) using a random-effects model was 0.89 (95% CI, 0.80-0.99). TACT is a valuable echocardiographic parameter that can predict AF recurrence in patients following a rhythm-control strategy. Protocol registration:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022353018.