Atrial Fibrillation Undergoing Catheter Ablation Research Articles

Adverse outcomes of atrial fibrillation ablation in heart failure patients with and without cardiac amyloidosis: a Nationwide Readmissions Database analysis (2015-2019).

Atrial fibrillation (AF) in patients with cardiac amyloidosis (CA) has been linked with a worse prognosis. The current study aimed to determine the outcomes of AF catheter ablation in patients with CA. The Nationwide Readmissions Database (2015-2019) was used to identify patients with AF and concomitant heart failure. Among these, patients who underwent catheter ablation were classified into two groups, patients with and without CA. The adjusted odds ratio (aOR) of index admission and 30-day readmission outcomes was calculated using a propensity score matching (PSM) analysis. A total of 148 134 patients with AF undergoing catheter ablation were identified on crude analysis. Using PSM analysis, 616 patients (293 CA-AF, 323 non-CA-AF) were selected based on a balanced distribution of baseline comorbidities. At index admission, AF ablation in patients with CA was associated with significantly higher adjusted odds of net adverse clinical events (NACE) [adjusted odds ratio (aOR) 4.21, 95% CI 1.7-5.20], in-hospital mortality (aOR 9.03, 95% CI 1.12-72.70), and pericardial effusion (aOR 3.30, 95% CI 1.57-6.93) compared with non-CA-AF. There was no significant difference in the odds of stroke, cardiac tamponade, and major bleeding between the two groups. At 30-day readmission, the incidence of NACE and mortality remained high in patients undergoing AF ablation in CA. Compared with non-CA, AF ablation in CA patients is associated with relatively higher in-hospital all-cause mortality and net adverse events both at index admission and up to 30-day follow-up.

The timing of pericardial drainage catheter removal and restart of the anticoagulation in patients suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran: Experiences from 20 cases

Objective: To investigate the timing of pericardial drainage catheter removal and restart of the anticoagulation in patients with atrial fibrillation (AF) suffered from perioperative pericardial tamponade during atrial fibrillation catheter ablation and uninterrupted dabigatran. Methods: A total of 20 patients with pericardial tamponade, who underwent AF catheter ablation with uninterrupted dabigatran in Beijing Anzhen Hospital from January 2019 to August 2021, were included in this retrospective analysis. The clinical characteristics of enrolled patients, information of catheter ablation procedures, pericardial tamponade management, perioperative complications, the timing of pericardial drainage catheter removal and restart of anticoagulation were analyzed. Results: All patients underwent pericardiocentesis and pericardial effusion drainage was successful in all patients. The average drainage volume was (427.8±527.4) ml. Seven cases were treated with idarucizumab, of which 1 patient received surgical repair. The average timing of pericardial drainage catheter removal and restart of anticoagulation in 19 patients without surgical repair was (1.4±0.7) and (0.8±0.4) days, respectively. No new bleeding, embolism and death were reported during hospitalization and within 30 days following hospital discharge. Time of removal of pericardial drainage catheter, restart of anticoagulation and hospital stay were similar between patients treated with idarucizumab or not. Conclusion: It is safe and reasonable to remove pericardial drainage catheter and restart anticoagulation as soon as possible during catheter ablation of atrial fibrillation with uninterrupted dabigatran independent of the idarucizumab use or not in case of confirmed hemostasis.

10-Year Outcomes of Patients With Non-Paroxysmal Atrial Fibrillation Undergoing Catheter Ablation.

Radiofrequency catheter ablation (RFCA) is commonly performed in patients with non-paroxysmal atrial fibrillation (AF), but because very long-term follow-up results of RFCA are limited, we investigated the 10-year RFCA outcomes of non-paroxysmal AF. We retrospectively enrolled 100 patients (89 men, mean age 53.5±8.4years) with drug-refractory symptomatic non-paroxysmal AF who underwent 3D electroanatomic-guided RFCA. Procedural characteristics at index procedures and clinical outcomes were investigated. In the index procedures, all patients had pulmonary vein isolation, 56 (56.0%), 48 (48.0%), and 32 (32.0%) underwent additional linear, complex fractionated atrial electrogram (CFAE) and non-pulmonary vein (NPV) foci ablations, respectively. After 124.1±31.7 months, 16 (16%) patients remained in sinus rhythm after just 1 procedure (3 with antiarrhythmic drugs [AAD]) and after multiple (2.1±1.3) procedures in 53 (53.0%) patients (22 with AAD). Left atrial (LA) diameter (hazard ratio HR 1.061; 95% confidence interval (CI) 1.020 to 1.103; P=0.003), presence of NPV triggers (HR 1.634; 95% CI 1.019 to 2.623; P=0.042) and undergoing CFAE ablation (HR 2.003; 95% CI 1.262 to 3.180; P=0.003) in the index procedure were independent predictors for recurrent atrial tachyarrhythmia. The 10-year outcomes of single RFCA in non-paroxysmal AF were unsatisfactory. Enlarged LA, presence of NPV triggers, and undergoing CFAE ablation in the index procedure independently predicted single-procedure recurrence. Multiple procedures are required to achieve adequate rhythm control.

Same-day discharge following catheter ablation and venous closure with VASCADE MVP: A postmarket registry.

Early and safe ambulation can facilitate same-day discharge (SDD) following catheter ablation, which can reduce resource utilization and healthcare costs and improve patient satisfaction. This study evaluated procedure success and safety of the VASCADE MVP venous vascular closure system in patients with atrial fibrillation (AF). The AMBULATE SDD Registry is a two-stage series of postmarket studies in patients with paroxysmal or persistent AF undergoing catheter ablation followed by femoral venous access-site closure with VASCADE MVP. Efficacy endpoints included SDD success, defined as the proportion of patients discharged the same day who did not require next-day hospital intervention for procedure/access site-related complications, and access site sustained success within 15 days of the procedure. Overall, 354 patients were included in the pooled study population, 151 (42.7%) treated for paroxysmal AF and 203 (57.3%) for persistent AF. SDD was achieved in 323 patients (91.2%) and, of these, 320 (99.1%) did not require subsequent hospital intervention based on all study performance outcomes. Nearly all patients (350 of 354; 98.9%) achieved total study success, with no subsequent hospital intervention required. No major access-site complications were recorded. Patients who had SDD were more likely to report procedure satisfaction than patients who stayed overnight. In this study, 99.7% of patients achieving SDD required no additional hospital intervention for access site-related complications during follow-up. SDD appears feasible and safe for eligible patients after catheter ablation for paroxysmal or persistent AF in which the VASCADE MVP is used for venous access-site closure.

Omnipolar Versus Bipolar Electrode Mapping in Patients With Atrial Fibrillation Undergoing Catheter Ablation.

Peak-to-peak bipolar voltage varies with electrode orientation, fractionation, and collision events. Novel, omnipolar mapping is less dependent on electrode orientation but has limited data in humans. This study sought to compare bipolar peak-to-peak voltage with omnipolar maximum voltage (Vmax) during sinus rhythm in the left atrium of patients with persistent (PerAF) or paroxysmal atrial fibrillation (PAF). Baseline voltage maps were generated with bipolar and omnipolar mapping in 20 patients undergoing de novo catheter ablation for PerAF or PAF and 9 patients with known scar from prior cardiac surgery, to validate voltage-based scar approximations. Low voltage was defined as<0.5mV and scar<0.1mV. Mean voltage was compared with unpaired t testing. Percent low voltage and scar were compared with chi-square testing. A point-to-point comparison was performed with Bland-Altman analysis. The mean age was 62.2 ± 9.9 years, 34% were women, and 41% had heart failure. Omnipolar mappingidentified significantly higher mean voltage than bipolar mapping and classified less points as low voltage (PerAF: 32.90% vs 43.40%; PAF: 19.20% vs 25.60%) and scar (PerAF: 7.72% vs 12.10%; PAF: 4.03% vs 6.07%) (all P< 0.0001). Omnipolar Vmax displayed significant disagreement with bipolar by Bland-Altman analysis. Scar and low-voltage approximations were validated in atria with known scar, in which bipolar mapping overestimated the extent of low voltage (P< 0.0001) and scar (P< 0.0001). Omnipolar mapping identifies higher voltage and has greater specificity for the detection of low voltage and scar than conventional bipolar mapping in patients with PerAF or PAF.

Abstract 15839: Complication and Readmission Outcome of Atrial Fibrillation Catheter Ablation Among Cancer Patients

Introduction: Catheter ablation (CA) has been increasingly utilized among patients with atrial fibrillation (AF) as a guideline-supported treatment. However, limited data is available regarding its safety among cancer patients. Hypothesis: Patients with a cancer diagnosis has worse outcome following AF CA Methods: We queried the 2016 to 2019 United State Nationwide Readmission database to identify all patients with (active cancer or a history of cancer) or without cancer diagnosis who underwent AF CA. Hospital outcome and 30 days readmission rate were analyzed. Multivariate logistic regression or Cox proportional hazards regression analysis was employed when appropriate adjusting for comorbidities as well as patient and hospital-level factors. Results: A total of 46,461 AF CAs were included in the analysis, among which 800 (1.72%) patients were diagnosed with active cancer and 5,133 (11.04%) patients had a history of cancer. Compared to non-cancer patients, patients with a cancer diagnosis were older and more likely to be female (Table 1). Patient with cancer diagnosis also has a higher burden of comorbidities, stroke risk, and bleeding risk as evidenced by Charlson Comorbidity Index, CHA 2 DS 2 -VASc score, and ATRIA score (Table1). As a result, patient with active cancer has higher inpatient hospital mortality, procedural complication rate, and all-cause readmission rate. After adjusting for confounders, active cancer diagnosis but not a history of cancer was associated with increased hospital mortality (Odds ratio: 2.72[1.18-6.24] p=0.018 vs noncancer) In contrast, only a history of cancer was associated with a small increased risk of 30 days readmission following CA (Hazard ratio: 1.19 [1.04-1.37) p=0.009 vs noncancer). There was no difference in procedural risk between cancer and non-cancer patients. Conclusions: Active cancer but not a history of cancer was associated with increased in-hospital mortality among AF patients who underwent CA.

Abstract 11139: Role of Esophageal Cooling in the Prevention of Esophageal Injury in Atrial Fibrillation Catheter Ablation: A Systematic Review and Meta-Analysis of Randomized Controlled Studies

Introduction: Trials evaluating the role of esophageal cooling in the prevention of esophageal injury in patients undergoing atrial fibrillation (AF) catheter ablation have yielded mixed results. The aim of our study is to evaluate the efficacy of esophageal cooling in the prevention of esophageal injury in patients undergoing AF catheter ablation. Methods: Comprehensive search of MEDLINE, EMBASE, and Cochrane databases through April 2022 for randomized controlled trials (RCTs) evaluating the role of esophageal cooling compared with control in the prevention of esophageal injury during AF catheter ablation. The study's primary outcome was the incidence of total esophageal injury. Secondary outcomes included the incidence of severe esophageal injury, the incidence of mild to moderate esophageal injury, procedural duration, posterior wall duration, total radiofrequency (RF) time, acute reconnection incidence, and ablation index. Results: The meta-analysis included 4 RCTs with total of 294 patients. There was no significant difference in the incidence of total esophageal injury between esophageal cooling and control (15% vs. 19%; Relative Risk [RR] 0.86; 95% confidence interval [CI] 0.31 - 2.41; I 2 = 63%). However, compared with control, esophageal cooling showed lower risk of severe esophageal injury (0.01% vs. 0.09%; RR 0.21; 95% CI 0.05 - 0.80). There were no significant differences among the two groups in mild to moderate esophageal injury (13.6% vs. 12.1%; RR 1.09; 95% CI 0.28 - 4.23), procedure duration (standardized mean difference [SMD] -0.03; 95% CI -0.36 - 0.30), posterior wall duration (SMD 0.27; 95% CI -0.04 - 0.58), total RF time (SMD -0.50; 95% CI -1.15 - 0.16), acute reconnection incidence (RR 0.93; 95% CI 0.02 - 36.34), and ablation index (SMD 0.16; 95% CI -0.33 - 0.66). Conclusions: Among patients undergoing AF catheter ablation, esophageal cooling did not show a significant difference in the incidence of total esophageal injury. However, it has shown a significant decrease in the risk of severe esophageal injury without affecting the ablation process. This can help decrease the progression to atrial-esophageal fistula. Further large RCTs are needed to better evaluate the role of esophageal cooling in the prevention of esophageal injury.

Comparison of Interrupted and Uninterrupted Anticoagulation Therapy for Patients With Atrial Fibrillation Undergoing Catheter Ablation: A Meta-Analysis.

Adequate periprocedural anticoagulation is important to prevent complications like transient ischemic attack, stroke, severe esophageal injury, and pulmonary vein stenosis. The aim of this meta-analysis was to compare uninterrupted anticoagulation therapy with interrupted anticoagulation therapy for patients with arrhythmias undergoing catheter ablation. The current meta-analysis followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Several online databases were searched, such as PubMed, Cochrane Library, and Embase, to search for relevant randomized controlled trials (RCTs). The primary outcome included thromboembolic events. Secondary outcomes included major bleeding events and minor bleeding events. A total of eight RCTs were included in the current meta-analysis, encompassing a total of 3893 patients. No significant differences were reported in relation to thromboembolic events (RR: 2.39, 95% CI: 0.41-13.97, p-value: 0.33), major bleeding events (RR: 0.99, 95% CI: 0.50-1.96, p-value: 0.98) and minor bleeding events (RR: 1.55, 95% CI: 0.56-4.30, p-value: 0.40) between the two study groups.This meta-analysis did not find any conclusive evidence for the absence of any difference between the two strategies.

Predictors of AF recurrence in patients with paroxysmal AF undergoing catheter ablation: new predictors coming?

Abstract Introduction Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45% and the prediction of recurrence AF in patients (pts) with paroxysmal AF undergoing CA remains challenging. Purpose To determine the clinical and procedural predictors of recurrence AF after CA in pts with paroxysmal AF. Methods Single-centre retrospective study that included all pts with paroxysmal AF who underwent AF CA between 2017 and 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. All pts underwent cardiac computed tomography prior the procedure. AF recurrence was defined as any recurrence of AF, atrial flutter or atrial tachycardia &amp;gt;30 seconds (recorded in 12-lead electrocardiogram or Holter) after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with Cox regression analysis. Results We included 351 pts, 63,5% male and with a mean age of 57,1±11,4 years. CHADSVASCscore ≥2 points were present in 43,7% of the pts, median duration of AF prior the intervention was 3 years (IQR 1–6) and most pts were treated with some antiarrhythmic drug at the time of CA (56,9%). Overall, median follow-up was 27 months (IQR 19–39). AF recurrence was present in 96 pts (27,4%), on average, 15,2±10,4 months after CA. Univariate logistic regression identified female gender, thyroid disease, left atrium (LA) enlargement (defined as LA indexed volume &amp;gt;34 mL/m2 or LA diameter &amp;gt;38mm for female or &amp;gt;40mm for male), coronary calcium score &amp;gt;100, epicardial adipose tissue volume, number of previous electric cardioversions, treatment with antiarrhythmic drugs prior CA and the extent of CA (only pulmonary vein isolation (PVI) or PVI and ablation of other lesions) as predictors of recurrence AF after CA in pts with paroxysmal AF (p&amp;lt;0,05 for all). Cox regression analysis identified female gender (OR 1,615, 95% CI 1,005–2,597; p=0,008), LA enlargement (OR 2,084, 95% CI 1,207–3,596; p=0,008) and coronary calcium score &amp;gt;100 (OR 1,958, 95% CI 1,133–3,385; p=0,016) as independent predictors of AF recurrence. Conclusions In our cohort, AF recurrence was significantly higher in pts with LA enlargement, with coronary calcium score &amp;gt;100 and female gender pts. Funding Acknowledgement Type of funding sources: None.

Outcomes of patients with heart failure with preserved ejection fraction undergoing catheter ablation of atrial fibrillation

Limited real-world data exist on early outcomes in patients with heart failure with preserved ejection fraction (HFpEF) undergoing atrial fibrillation (AF) ablation. The purpose of this study was to examine and compare rates of index procedural complications and 30-day readmissions after AF ablation in patients with HFpEF, with heart failure with reduced ejection fraction (HFrEF), and without heart failure. Using the Nationwide Readmissions Database (NRD), we examined 50,299 admissions of adults with heart failure undergoing AF catheter ablation between 2010 and 2014. Using ICD-9-CM codes, we identified procedural complications and causes of readmission after AF ablation. From 2010 to 2014, the prevalence of HFpEF among patients undergoing AF ablation increased from 3.05% to 7.35% (P for trend <.001). Compared to patients without heart failure, patients with HFpEF had significantly increased procedural complications and index mortality (8.4% vs 6.2% and 0.30% vs 0.08%, respectively; P = .016 and P = .010, respectively). Index complication rates between patients with HFpEF and HFrEF were similar. All-cause 30-day readmissions occurred in 18.3% of patients with HFpEF compared to 9.5% of patients without heart failure (P <.001). Compared to no heart failure, the presence of HFpEF was independently associated with all-cause readmissions (adjusted odds ratio 1.52; 95% confidence interval 1.15-1.96; P = .002), but not with procedural complications, cardiac readmissions, or early mortality. Rates of 30-day readmissions after AF ablation are high in patients with HFpEF. However, after adjustment for age and comorbidities, complications and early mortality after AF ablation between patients with HFpEF and those without heart failure are comparable.

A prediction model of atrial fibrillation recurrence after first catheter ablation by a nomogram: HASBLP score.

BackgroundAt present, catheter ablation is an effective method for rhythm control in patients with atrial fibrillation (AF). However, AF recurrence is an inevitable problem after catheter ablation. To identify patients who are prone to relapse, we developed a predictive model that allows clinicians to closely monitor these patients and treat them with different personalized treatment plans.Materials and methodsA total of 1,065 patients who underwent AF catheter ablation between January 2015 and December 2018 were consecutively included in this study, which examines the results of a 2-year follow-up. Patients with AF were divided into development cohort and validation cohort. Univariate and multivariate analyses were carried out on the potential risk factors. Specific risk factors were used to draw the nomogram according to the above results. Finally, we verified the performance of our model compared with CHADS2 and CHA2DS2-Vasc scores by receiver operating characteristic (ROC) curve and calibration curve and plotted the decision analysis curve (DAC).ResultsA total of 316 patients experienced AF recurrence. After univariate and multivariate analyses, AF history (H), age (A), snoring (S), body mass index (BMI) (B), anteroposterior diameter of left atrial (LA) (L), and persistent AF (P) were included in our prediction model. Our model showed a better performance compared with CHADS2 and CHA2DS2-Vasc scores, and the area under ROC curve (95%CI) was 0.7668 (0.7298–0.8037) vs. 0.6225 (0.5783–0.6666) and 0.6267 (0.5836–0.6717).ConclusionWe established a nomogram (HASBLP score) for predicting AF recurrence after the first catheter ablation at a 2-year follow-up, which can be used as a tool to guide future follow-up of patients. However, its usefulness needs further validation.

Outcome of catheter ablation for paroxysmal atrial fibrillation in patients with stable coronary artery disease.

Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. This study aimed to assess the long-term outcome of catheter ablation in patients with paroxysmal AF and SCAD. In total, 12,104 patients with paroxysmal AF underwent catheter ablation in the Chinese Atrial Fibrillation Registry between 2011 and 2019 were screened. A total of 441 patients with SCAD were matched with patients without SCAD in a 1:4 ratio. The primary endpoint was AF recurrence after single ablation. The composite secondary endpoints were thromboembolism, coronary events, major bleeding, all-cause death. Over a mean follow-up of 46.0±18.9 months, the recurrence rate in patients with SCAD was significantly higher after a single ablation (49.0%vs. 41.9%, p=.03). The very late recurrence rate of AF in the SCAD group was also significantly higher than that in the control group (38.9%vs. 31.2%;p=.04). In multivariate analysis, adjusted with the female, smoking, duration of AF, previous thromboembolism, COPD, and statins, SCAD was independently associated with AF recurrence (adjusted HR, 1.19 [1.02-1.40], p=.03). The composite secondary endpoints were significantly higher in the SCAD group (12.70%vs. 8.54%, p=.02), mainly due to thromboembolism events (8.16%vs. 4.41%, p<.01). SCAD significantly increased the risk of recurrence after catheter ablation of paroxysmal AF. The incidence of thromboembolic events after catheter ablation of paroxysmal AF in the patients with SCAD was significantly higher than that in those without SCAD.

Differences in outcomes among patients with atrial fibrillation undergoing catheter ablation with versus without intracardiac echocardiography

BackgroundIntracardiac echocardiography (ICE) use can lead to early detection of periprocedural complications and may improve patient outcomes by providing real‐time visualization of catheter location and the treatment area during cardiac ablation (CA) for atrial fibrillation (AF).ObjectiveExamine complications and 12‐month healthcare use among patients with AF undergoing CA with versus without ICE use during the procedure in a real‐world setting.MethodsThe 2015–2020 IBM MarketScan® Database was used to identify non‐elderly adults (age 18–64 years) undergoing CA for AF. Patients were classified into ICE/non‐ICE groups based on the presence or absence of ICE procedure codes. Patients in each group were matched on study covariates using propensity scores. Peri‐procedural complications, 12‐month cardiovascular (CV) or AF‐related inpatient admission, repeat CA, and cardioversion were compared using a Cox proportional hazard model.Results1371 patients were identified in each study cohort (ICE and non‐ICE) after propensity matching. Patients who had CA with ICE had a significantly lower rate of complications than those without (2.9% vs. 5.8%; p < .001). The risk of complications was 50% lower with ICE use (hazard ratio [HR] 0.50; 95% confidence interval [CI] 0.34–0.72). For assessment of 12‐month healthcare utilization, 1250 patients were identified in each cohort after propensity matching. ICE use was associated with a 36% lower risk of 12‐month repeat ablation (HR 0.64; 95% CI 0.49–0.83). No differences in CV‐ or AF‐related inpatient admission and cardioversion were observed.ConclusionAmong patients with AF, the use of ICE during an ablation procedure was associated with lower incidence of complications and repeat ablation.

Prediction of Left Atrial Fibrosis and Success of Catheter Ablation by Speckle Tracking Echocardiography in Patients Imaged in Persistent Atrial Fibrillation.

BackgroundNon-invasive evaluation of left atrial structural and functional remodeling should be considered in all patients with persistent atrial fibrillation (AF) to optimal management. Speckle tracking echocardiography (STE) has been shown to predict AF recurrence after catheter ablation; however in most studies, patients had paroxysmal AF, and STE was performed while patients were in sinus rhythm.AimThe aim of this study was to evaluate the ability of STE parameters acquired during persistent AF to assess atrial fibrosis measured by low voltage area, and to predict maintenance of sinus rhythm of catheter ablation.MethodsA total of 94 patients (69 men, 65 ± 9 years) with persistent AF prospectively underwent measurement of Global Peak Atrial Longitudinal Strain (GPALS), indexed LA Volume (LAVI), E/e′ ratio, and LA stiffness index (the ratio of E/e′ to GPALS) by STE prior to catheter ablation, while in AF. Low-voltage area (LVA) was assessed by electro-anatomical mapping and categorized into absent, moderate (>0 to <15%), and high (≥15%) atrial extent. AF recurrence was evaluated after 3 months of blanking.ResultsMultivariable regression showed that LAVI, GPALS, and LA stiffness independently predicted LVA extent after correcting for age, glomerular filtration rate, and CHA2DS2-VASc score. Of all the parameters, LA stiffness index had the highest diagnostic accuracy (AUC 0.85), allowing using a cut-off value ≥0.7 to predict moderate or high LVA with 88% sensitivity and 47% specificity, respectively. In multivariable Cox analysis, both GPALS and LA stiffness were able to significantly improve the c statistic to predict AF recurrence (n = 40 over 9 months FU) over CHARGE-AF (p < 0.001 for GPALS and p = 0.01 for LA stiffness) or CHA2DS2-VASc score (p < 0.001 for GPALS and p = 0.02 for LA stiffness). GPALS and LA stiffness also improved the net reclassification index (NRI) over the CHARGE-AF index (NRI 0.67, 95% CI [0.33–1.13] for GPALS and NRI 0.73, 95% CI [0.12–0.91] for LA stiffness, respectively), and over the CHA2DS2-VASc score (NRI 0.43, 95% CI [−0.14 to 0.69] for GPALS and NRI 0.52, 95% CI [0.10–0.84], respectively) for LA stiffness to predict AF recurrence at 9 months.ConclusionSTE parameters acquired during AF allow prediction of LVA extent and AF recurrence in patients with persistent AF undergoing catheter ablation. Therefore, STE could be a valuable approach to select candidates for catheter ablation.

Higher coronary calcium score is associated with increased risk of atrial fibrillation recurrence

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with atrial fibrillation (AF) referred for catheter ablation routinely undergo cardiac computed tomography (CCT) for procedure planning. An opportunistic evaluation of coronary artery calcium score (CACS) can be an important tool to improve clinical care. It is already known that CACS is associated with a high risk of AF development, particularly if values are above 100, but few data are available regarding the impact of CACS in AF recurrence after ablation. Purpose To assess the impact of CACS on atrial fibrillation recurrence following catheter ablation. Methods Retrospective, single-centre cohort study of consecutive patients with AF undergoing CCT for ablation procedure planning, from 2017 to 2019. Baseline clinical and demographical data were collected. Patients with known history of coronary artery disease (CAD) and moderate to severe valvular heart disease were excluded. CACS was assessed using the Agatston method. Recurrence was defined as any documented episode of AF, atrial flutter or atrial tachycardia after 3 months from procedure. Patients were stratified in CACS&amp;lt;100 and CACS≥100. Explorative analysis incorporated Kaplan-Meier survival curves and Cox regression. Results A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. More than half of the patients had a CACS&amp;gt;0 (n=185, 52%) and 63 patients (18%) had a CACS≥100. Patients with CACS≥100 were older (63 ± 7 vs 54 ± 12 years, p&amp;lt;0.001), had higher prevalence of hypertension (68% vs 43%, p&amp;lt;0.001) and diabetes mellitus (21% vs 10%, p=0.012) and higher left atrial volume (39 ± 9 vs 35 ± 9 ml/m2, p=0.018). After a median observation time of 34 months (IQR 24-43), 117 patients (33%) had AF recurrence. CACS≥100 was associated with increased risk of AF recurrence (unadjusted Cox regression: hazard ratio [HR] 1.85; 95% confidence interval [CI], 1.23-2.79, p=0.003) (Fig. 1). After covariate adjustment (age, gender, hypertension, diabetes mellitus, obesity, thyroid disease, AF type and left atria enlargement) CACS≥100 remained an independent predictor of the risk of AF recurrence (HR, 1.68; 95% CI, 1.05-2.70, p=0.03) as well as persistent AF (HR, 1.91; 95% CI, 1.23-3.00, p=0.004) (Fig. 2). Conclusion In patients with AF undergoing catheter ablation, without previous history of CAD, a CACS≥100 was independently associated with a 68% increase in the risk of AF recurrence.

Association of epicardial adipose tissue and coronary artery calcium score in patients with atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Both coronary artery calcium (CAC) and epicardial adipose tissue (EAT) had been implicated in coronary artery disease (CAD) and risk of future adverse cardiovascular events. There are scarce data regarding the assessment and association of EAT volume and CAC score (CACS) in atrial fibrillation (AF) patients. Purpose To assess the association between EAT volume and the presence and severity of CAC in patients with AF. Methods Retrospective and single-centre study including consecutive patients with AF undergoing contrast-enhanced cardiac computed tomography for catheter ablation planning, from 2017 to 2019. Patients with known history of CAD and moderate to severe valvular heart disease were excluded. Baseline clinical and demographical data were collected, as well as their cardiovascular risk, based on the SCORE (Systematic Coronary Risk Evaluation) system and cardiovascular risk categories. We assessed CACS (Agatston method) and EAT volume and analysed their association. EAT was defined as the adipose tissue accumulated between the visceral pericardium and the myocardium and was semi-automatically reconstructed by manually tracing the pericardium. Patients were split into three groups according to CACS: 0, 1-99 and ≥100. A logistic regression (LR) analysis was performed to explore the relationship between EAT volume and the presence of CAC (CACS&amp;gt;0), adjusted for age, gender, obesity, diabetes mellitus and hypertension. Results A total of 354 patients were included, with a mean age of 56 ± 12 years, 66% male and 21% with persistent AF. A CHA2DS2-VASc score ≥2 was present in 130 (37%) patients and most patients had low to moderate cardiovascular risk (n=213, 82%). More than half of the patients had a CACS&amp;gt;0 (n=185, 52%), of which 63 patients (18%) had a CACS≥100. The mean EAT volume was 79 ± 39 ml. There was a significant association between EAT volume and the presence of CAC: CACS=0 69 ± 34 ml vs CACS 1-99 84 ± 38 ml vs CACS ≥100 95 ± 45 ml (p&amp;lt;0.001) (Fig. 1). After covariate adjustment (LR model R2 = 0.373, p &amp;lt;0.0001), the presence of CAC was not associated with EAT volume (OR 1.00, 95%CI 1.00 - 1.01, p=0.2) or obesity, and only with higher age, male gender, hypertension and diabetes mellitus (Fig. 2). Conclusion In our cohort of patients with AF undergoing catheter ablation we observed an association between EAT and CACS. Nevertheless, EAT volume was not an independent predictor of CACS and only the classical cardiovascular risk factors remained significant.

Association of Postprocedural Left Atrial Volume and Reservoir Function with Outcomes in Patients with Atrial Fibrillation Undergoing Catheter Ablation

The value of left atrial (LA) volume and reservoir function (ResF) after ablation for atrial fibrillation for predicting overall outcomes needs further investigation, particularly in large cohorts. The aim of this study was to test the hypothesis that abnormal LA volume and ResF after ablation are associated with adverse outcomes. Patients who underwent primary atrial fibrillation ablation between 2007 and 2016 and had available measurements of maximum LA volume index (LAVImax) and minimum LA volume index (LAVImin) and LA ResF (LA emptying fraction and LA expansion index) at 3-month echocardiographic examination after ablation were included in this analysis. The primary endpoint was the composite of cardiac hospitalization for heart failure or acute ischemic events, stroke or transient ischemic attack, and all-cause death; secondary endpoints were cardiac hospitalization and all-cause death. A total of 792 patients were studied (mean age, 60±10years). Over a median of 7.5years (interquartile range, 3.0-9.7years) of follow-up, 96 patients experienced adverse events. After adjustment for several parameters, including age, comorbidities, and left ventricular structure and function, increased LA volumes and impaired ResF were each independently associated with the primary endpoint (LAVImax > 34mL/m2: adjusted hazard ratio [HR], 2.37 [95% CI, 1.49-3.76; P=.0003]; LAVImin ≥ 20.5mL/m2: adjusted HR, 3.21 [95% CI, 1.97-5.24; P<.0001]; LA emptying fraction < 40%: adjusted HR, 2.00 [95% CI, 1.29-3.10; P=.002]; LA expansion index < 66%: adjusted HR, 1.91 [95% CI, 1.22-2.98; P=.005]) as well as with the secondary endpoints of cardiac hospitalization (P<.05 for adjusted HR for all LA parameters) and all-cause death (P<.05 for adjusted HR for LAVImin, LA emptying fraction and LA expansion index). ResF measures were incremental to LAVImax (P<.05 for all), but not to LAVImin. In patients with normal LA (LAVImax ≤ 34mL/m2; n=403), those with higher LAVImin (≥17mL/m2) were at 4 times higher risk for primary endpoint events (age-adjusted HR, 4.32; 95% CI, 1.90-9.81; P=.0005). All these findings were independent of atrial tachyarrhythmia recurrence. Enlarged left atrium and impaired ResF at 3months after ablation for atrial fibrillation are strongly associated with long-term outcomes, independent of left ventricular function or cardiac rhythm at follow-up. LAVImin showed the strongest associations and even identified a high-risk subgroup among patients with nondilated left atria.

Adding six short lines on pulmonary vein isolation circumferences reduces recurrence of paroxysmal atrial fibrillation: Results from a multicenter, single-blind, randomized trial.

Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) is associated with a non-negligible long-term recurrence rate. The purpose of this study was to investigate whether PVI combined with 6 short ablation lines on the PVI circumferences (PVI+6L group) yields higher success rates than PVI alone (PVI group). In this multicenter, single-blind, randomized trial, a total of 390 patients with paroxysmal AF were randomly assigned to the PVI group (n = 193) or the PVI+6L group (n = 197). The primary endpoint was freedom from AF/atrial tachycardia recurrence between 91 and 365 days. Secondary endpoints included AF burden, procedural parameters, and complications. Freedom from atrial tachyarrhythmia was achieved in 160 of 197 patients (81.2%) in the PVI+6L group and 142 of 193 patients (73.6%) in the PVI group (hazard ratio 0.61; 95% confidence interval 0.39-0.97; P = .040). Mean AF burden tended to be lower in the PVI+6L group compared to the PVI group (1.95% vs 0.53%, P = .097). Procedural and ablation times were slightly longer in the PVI+6L group than in the PVI group (130 ± 25 minutes vs 121 ± 28 minutes; P = .002; and 46 ± 14 minutes vs 41 ± 16 minutes, P = .001, respectively). X-ray exposure was similar (60 ± 54 seconds vs 61 ± 60 seconds; P = .964). Complications occurred in 3 patients (1.6%) in the PVI group and 3 patients (1.5%) in the PVI+6L group. In patients with paroxysmal AF undergoing catheter ablation, adding 6 short ablation lines on the PVI circumferences could reduce the AF recurrence rate.

Machine Learning-Predicted Progression to Permanent Atrial Fibrillation After Catheter Ablation.

IntroductionWe developed a prediction model for atrial fibrillation (AF) progression and tested whether machine learning (ML) could reproduce the prediction power in an independent cohort using pre-procedural non-invasive variables alone.MethodsCohort 1 included 1,214 patients and cohort 2, 658, and all underwent AF catheter ablation (AFCA). AF progression to permanent AF was defined as sustained AF despite repeat AFCA or cardioversion under antiarrhythmic drugs. We developed a risk stratification model for AF progression (STAAR score) and stratified cohort 1 into three groups. We also developed an ML-prediction model to classify three STAAR risk groups without invasive parameters and validated the risk score in cohort 2.ResultsThe STAAR score consisted of a stroke (2 points, p = 0.003), persistent AF (1 point, p = 0.049), left atrial (LA) dimension ≥43 mm (1 point, p = 0.010), LA voltage <1.109 mV (2 points, p = 0.004), and PR interval ≥196 ms (1 point, p = 0.001), based on multivariate Cox analyses, and it had a good discriminative power for progression to permanent AF [area under curve (AUC) 0.796, 95% confidence interval (CI): 0.753–0.838]. The ML prediction model calculated the risk for AF progression without invasive variables and achieved excellent risk stratification: AUC 0.935 for low-risk groups (score = 0), AUC 0.855 for intermediate-risk groups (score 1–3), and AUC 0.965 for high-risk groups (score ≥ 4) in cohort 1. The ML model successfully predicted the high-risk group for AF progression in cohort 2 (log-rank p < 0.001).ConclusionsThe ML-prediction model successfully classified the high-risk patients who will progress to permanent AF after AFCA without invasive variables but has a limited discrimination power for the intermediate-risk group.

2021 Korean Heart Rhythm Society Guidelines for Catheter or Surgical Ablation of Atrial Fibrillation

Rhythm control therapy is used in atrial fibrillation (AF) management to improve AF-related symptoms along with rate control. AF catheter ablation is effective in maintaining sinus rhythm and has an acceptable complication rate. Compared with antiarrhythmic drugs, AF catheter ablation is superior with respect to arrhythmia-free survival and improvement in the quality of life. Therefore, AF ablation is recommended for rhythm control after the failure of antiarrhythmic drugs and is sometimes considered a first-line therapy for AF patients. Radiofrequency and cryoballoon ablation show similar efficacy, with slightly different complication profiles. Surgery for AF is also an effective rhythm control therapy and should be considered in patients undergoing cardiac surgery or in those with failed catheter ablation. For patients undergoing AF catheter ablation, performing ablation under uninterrupted warfarin or non-vitamin K oral anticoagulant treatment is recommended for periprocedural stroke risk management. Here, we review existing data and discuss the general principles of AF catheter and surgical ablation in patients with AF.