Atrial Tachyarrhythmia Recurrence Research Articles

Early repeat catheter ablation in patients with early recurrent arrhythmia

Abstract Background Repeat catheter ablation reduces adverse cardiovascular endpoints in patients with recurrent atrial tachyarrhythmia after index ablation. However, when to proceed with re-ablation in patients with early recurrent arrhythmia is unknow. Objective In this study, we aim to access the effectiveness of early repeat ablation on cardiovascular outcomes in early recurrent atrial tachycardia patients. Methods A total of 502 post-ablation patients, who experienced early atrial tachyarrhythmia recurrence within 6 months outside the blank period post index ablation and had undergone a repeat ablation, were consecutively enrolled from China AF registry from January 2012 to December 2018. Early repeated ablation (ERA) was defined as patients underwent a subsequent catheter ablation procedure within early recurrent period, then late repeated ablation (LRA) referred to a redo procedure that performed after 6 months since the de novel ablation. Cox proportional hazard models were used to estimate the effect of early re-ablation on primary endpoint (a composite of cardiovascular death, stroke and cardiovascular rehospitalization) and secondary endpoint (each component of primary outcome and AF/AT recurrence). Results The median follow-up time was 26 months after the redo-AF/AT ablation. First primary composite outcome occurred in 39 of the patients received early re-ablation (24.38 per 100 person-years) and in 136 of the patients performed with late re-ablation (39.77 per 100 person-years) (HR = 0.55, 95% CI = 0.38-0.79; P0.001). Cardiovascular re-hospitalization (hazard ratio 0.52 95% confidence interval [0.36; 0.73]) and AF recurrence occurred less often (hazard ratio 0.76, 95% confidence interval [0.58; 0.98]) in the ERA group. No significant difference between the two groups was found in terms of cardiovascular death, stroke and major bleeding events. Conclusion Early initiation of redo-ablation conveys better clinical benefit in patients with early arrhythmia recurrence.

Impact of conduction velocity in left atrium assessing with omnipolar technology in patients with atrial fibrillation

Abstract Background There is increased interest in exploring substrate of atrial fibrillation (AF) and recent studies have shown that atrial conduction velocity (CV) reflects the electrophysiological phenomena and plays key role in perpetuating AF. The novel omnipolar technology (OT) use three unipolar and two orthogonal bipolar signals allow us to analyze the voltage, activation direction, and CV independent of catheter position. Objective The purpose of the present study was to evaluate if the left atrium (LA) CV which assessed by OT predict the any atrial tachy-arrhythmia (AT) recurrence after initial AF ablation. Methods We enrolled 58 consecutive patients who underwent initial pulmonary vein isolation (PVI) for drug refractory AF. (mean age: 68.2±10.2 years old, 32 male(55.1%), 32 persistent AF(55.1%), CHADS2 score:1.6±0.6). After electrical PVI was achieved and remained in sinus rhythm, the LA was mapped with high density mapping catheter (Advisor HD Grid, Abott USA) utilizing with the novel OT combined with Ensite X system (Abott, USA). The conduction distance and conduction times were measured from the earliest activation site to the latest activation site in LA (Figure 1). Each conduction velocity in anterior, posterior, and septal area were also calculated as conduction distance divided by conduction time. The LA voltage was also measured. Results During a mean follow up period of 316±143 days, the recurrence of AT after initial PVI was observed in 9 (15.5%) patients. There were no significant differences in baseline demographics between AT recurrence and non-recurrence group (mean age:66±13.3 vs 68.5±10.5 years old P=0.66, CHADS2 score: 1.5±0.57 vs 1.68±0.62 P=0.59, proportion of persistent AF: 15.4% vs 15.5% P=0.82, LA volume: 102±35.9 vs 93.6±37.3ml P=0.63). The earliest activation site in LA were identified in 3 areas including anterior site of right pulmonary vein (51.7%), Bachmann bundle area (41.4%), and antero-septal area (6.89%) (Figure 2). In patients with AT recurrence, the CV in LA was significantly slower than those without AF recurrence(0.61±0.21 vs 0.81±0.16 m/s, P=0.036) whereas the whole LA voltage was not (1.52±0.75 vs 2.22±1.06 mv, P=0.28). The CV in each LA portion are similar between recurrence and non-recurrence AT group. (anterior:0.57±0.24 vs 0.81±0.23 m/s, P=0.18, posterior: 0.87±0.18 vs 1.2±0.49 m/s P=0.36, septal: 0.89±0.76 vs 1.15±0.39 m/s, P=0.41). Conclusion The earliest activation site in LA was varied in each case. The whole CV in LA is a predictor of AF recurrence after PVI whereas the CV of each LA portion and LA voltage was not.

Posterior wall isolation for persistent atrial fibrillation catheter ablation: an updated systematic review and meta-analysis

Abstract Background The ability of catheter ablation (CA) to prevent arrhythmic recurrences in patients with persistent atrial fibrillation (PeAF) remains suboptimal. In this context, the results of studies conducted with both thermal and non-thermal technologies, that evaluated the effect of adding electrical isolation of the posterior wall of the left atrium (PWI) to isolation of the pulmonary veins alone (PVI) have provided conflicting data. Purpose To compare the efficacy and safety of an ablative strategy with the addition of PWI to PVI versus PVI alone in patients with PeAF undergoing a first ablation procedure. Methods We searched electronic databases for observational studies and randomized controlled trials (RCTs) comparing PVI+PWI versus PVI alone as first CA procedure for PeAF, regardless of the technologies used. The efficacy outcomes were recurrence of any atrial tachyarrhythmias lasting more than 30 seconds, recurrence of atrial fibrillation (AF) and atrial flutter/atrial tachycardia (AFlu/AT). The safety outcome was relevant procedural complications defined as a composite of vascular complications, pericardial effusion or tamponade, phrenic nerve palsy, stroke, atrio-esophageal fistula, and death. The procedural time was compared between the ablation strategies studied. The software RevMan 5.4 was used to estimate the risk ratio (RR) and mean difference (MD) with the relative confidence intervals (CI), using a random-effect model. Results Thirteen studies (8 RCTs and 5 observational studies) counting a total of 2994 PeAF patients (1304 treated with PVI+PWI and 1690 with PVI alone; 1847 RF, 600 cryo and 547 PFA) were included in the analysis. Mean age was 65.2±4.1 years, and 26% were female. Mean follow-up period was 14.5±4.8 years. There were no significant differences in the risk of recurrence of any atrial tachyarrhythmias (RR 0.88; 95% CI 0.68-1.14) between the ablation strategies studied. Patients treated with PWI+PVI experienced a reduced risk of recurrence of AF (RR 0.67; 95% CI 0.48-0.94; p = 0.02) balanced by a trend towards increased risk of AFlu/AT (RR 1.74; 95% CI 0.99-3.06; p = 0.06) as compared with PVI alone strategy. No statistically significant differences in the risk of relevant procedural complication were identified between the studied groups (RR 0.94; 95% CI 0.50-1.78 – Fig. 2A). Procedural time was longer in the PWI+PVI group as compared with PVI alone (MD 30.63 min; 95% CI 8.60-52.65 min; p=0.006 – Fig. 2B). Conclusions Our metanalysis shows that, in patients with PeAF treated for the first time with CA, PWI+PVI versus PVI alone was not associated with a reduction of atrial tachyarrhythmias recurrence and required longer procedural times. Nonetheless, a reduction in the risk of AF recurrence and a trend towards an increased risk of AFlu/AT were identified. No differences in the risk of relevant procedural complications were found between the ablation strategies studied.Figure 2

Long-term efficacy of concomitant surgical ablation for atrial fibrillation with cardiac surgery

Abstract Background Concomitant surgical ablation (SA) is recommended at the time of cardiac surgery in patients with atrial fibrillation (AF) but it is only performed in the minority due to perceived barriers such as increased risk, longer procedure duration and additional technical skills required [1,2]. Furthermore, long-term outcome reporting is limited to only a few high-volume centres. Purpose We sought to report on our centre’s 11-year experience with cardiac surgery and concomitant SA. Methods This was a retrospective observational study on 625 patients with AF who underwent SA in addition to other cardiac surgery at our centre between April 2011 and March 2022. Patients undergoing standalone SA were excluded. Complications were recorded up to 30 days post-procedure. Freedom from atrial tachyarrhythmias (ATA) was determined by electrocardiography, Holter monitoring and pacemaker interrogation at various time points, if available, with or without additional therapies for AF. Results Mean age was 69 +/- 9.9 years and the median duration of AF was 1.2 years (interquartile range 0.4-3.8), persistent in 79% of patients. The median left atrial volume index (LAVI) was 55 ml/m2 (interquartile range 43-71). Concomitant surgery included coronary artery bypass grafting (26%), mitral (68%), aortic (27%), tricuspid (21%) and/or other (5%). Biatrial Cox-Maze IV was performed in 51% of patients and the left atrial appendage was occluded in 74%. Major complications included 30-day mortality (3%), stroke (3%) and pacemaker implantation (4%). Freedom from ATAs was 80% (312/391), 64% (154/240), 53% (76/144) and 44% (33/75) at 1, 3, 5 and 7 years, respectively (Figure 1). Cox regression demonstrated diabetes mellitus, AF duration, persistent AF and LAVI as predictors of 7-year ATA recurrence. Conclusion Concomitant SA for AF has good early and acceptable longer-term rhythm outcomes with no significantly increased complication rate, which should encourage greater uptake of the procedure.

A negative relationship between first-pass pulmonary vein isolation and body mass index in ablation index–guided pulmonary vein isolation

BackgroundWe previously reported the relationship between first-pass pulmonary vein isolation (FPI) and pulmonary vein isolation (PVI) durability in ablation index–guided atrial fibrillation ablation. Obesity is a worsening factor for atrial tachyarrhythmia (AT) recurrence. However, the impact of obesity on FPI has been scarcely reported. General anesthesia (GA) facilitates completing PVI by preventing airway obstruction caused by sedative drug use. However, the impact of GA on the relationship also has not been elucidated. ObjectiveThe study sought to evaluate the impact of obesity and its relationship with GA on FPI. MethodsWe retrospectively studied 2187 consecutive patients undergoing ablation index–guided first atrial fibrillation ablation (conscious sedation in 1969 and GA in 218). We divided them into 4 groups according to body mass index (BMI): underweight (BMI < 18.5 kg/m2) (n = 80), normal (18.5 kg/m2 ≤ BMI < 25 kg/m2) (n = 1,160), overweight (25 kg/m2 ≤ BMI < 30 kg/m2) (n = 763), and obesity (BMI ≥30 kg/m2) (n = 184). ResultsFPI rate decreased as BMI increased in both conscious sedation (68.1% in underweight, 61.5% in normal, 48.7% in overweight, and 39.0% in obesity; P < .001) and GA (87.5%, 67.1%, 61.3%, and 44.7%, respectively; P = .01). Multivariate analysis revealed overweight (odds ratio 0.65, 95% confidence interval [CI] 0.53–0.79, P < .001, vs normal) and obesity (OR 0.44, 95% CI 0.31–0.62 P < .001, vs normal) as independent predictors for FPI and obesity as an AT recurrence predictor (hazard ratio 1.35, 95% CI 1.01–1.81, P = .04). ConclusionBMI increase was negatively related to the FPI rate. Notably, the FPI rate in obese patients, even under GA, was low, which might be related to their high AT recurrence.

Concomitant ablation for non-paroxysmal atrial fibrillation: combined energy versus cryoablation alone.

Surgical ablation of atrial fibrillation has been the most efficient treatment for atrial fibrillation (AF). Combined energy (CE) ablation and cryoablation alone (CA) are the most common energy modes used for ablation, however, comparative data is lacking. To compare the efficacy of CE ablation with CA in the setting of concomitant biatrial ablation for non-paroxysmal AF. A retrospective analysis of 453 patients with non-paroxysmal AF undergone concomitant biatrial ablation from November 2007 to December 2022 during elective cardiac surgery using either combined bipolar radiofrequency with cryoenergy or cryoenergy alone was performed. Propensity score matching was conducted to balance the covariates in the groups. There were 157 patients per group after matching. CE ablation was associated with lower odds of atrial tachyarrhythmia recurrence (OR = 0.13, 95% CI 0.02-0.91, p = 0.040), a significantly lower rate of hospital readmissions due to rhythm disruption (HR = 0.34, 95% CI 0.18-0.65, p < 0.001), and lower cumulative incidence of stroke (SHR = 0.38, 95% CI 0.15-0.97, p = 0.043). No significant difference in permanent pacemaker implantation was observed between the two groups. In the setting of concomitant biatrial ablation for non-paroxysmal AF, combined bipolar radiofrequency and cryoablation appear to be a superior treatment modality compared to cryoablation alone in achieving long-term freedom from atrial arrhythmias, in reducing arrhythmia-related hospital readmissions and ischemic strokes.

Segmental evaluation of predictive value of left atrial epicardial adipose tissue following catheter ablation for atrial fibrillation

BackgroundLeft atrial epicardial adipose tissue (LA-EAT) is associated with the recurrence of atrial tachyarrhythmias (AF/AT) after catheter ablation for atrial fibrillation (AF). However, no previous studies have assessed the predictive value of segment-specific LA-EAT volumes for AF/AT recurrence. This study aimed to assess the relationship between segmental LA-EAT volume and AF/AT recurrence. MethodsThis study included 350 consecutive patients who underwent initial AF ablation (53.7 % paroxysmal AF (PAF)). Preoperative multidetector row computed tomography assessed LA-EAT, categorized into three segments: anterior-EAT, posterior-EAT, and interatrial septal adipose tissue (IAS-AT). ResultsDuring a mean follow-up period of 351 ± 109 days, 56 patients (16.0 %) experienced AF/AT recurrence. The mean LA-EAT volume was 20.7 ± 11.1 ml and LA-EAT ≥26.8 ml was an independent risk factor for AF/AT recurrence (HR 2.21, 95 % confidence interval (CI): 1.24–3.93, P = 0.007). Receiver operating characteristic analyses revealed the area under the curve for IAS-AT was 0.669 (95 % CI: 0.596–0.743) with an optimal cut-off point of 1.3 ml (sensitivity 76.8 %; specificity 50.0 %), significantly outperforming the anterior- and posterior-EAT in predicting recurrent AF/AT. Multivariate analysis indicated IAS-AT was an independent predictor of AF/AT recurrence in patients with persistent AF (PeAF) (HR 3.52, 95 % CI: 1.52–8.13, P = 0.003), but not in patients with PAF. ConclusionsLA-EAT predicts AF/AT recurrence after AF ablation, with IAS-AT proving significantly more effective than other LA-EAT segments in predicting recurrence. Notably, IAS-AT emerged as an independent predictor of AF/AT recurrence in patients with PeAF but not in those with PAF.

Short- and long-term outcomes in isolated vs. hybrid thoracoscopic ablation in patients with atrial fibrillation: a systematic review and reconstructed individual patient data meta-analysis.

Both isolated thoracoscopic and hybrid thoracoscopic atrial fibrillation (AF) ablation techniques have demonstrated favourable outcomes in the management of patients with (long-standing) persistent AF, as compared with catheter ablation. However, it is currently unknown whether there is a difference in short- and long-term outcomes when comparing these two minimally invasive surgical AF ablation procedures. Therefore, a systematic review and meta-analysis were performed to investigate these two techniques, with a specific emphasis on long-term freedom from atrial tachyarrhythmias (ATAs). A systematic search through PubMed, EMBASE, and the Cochrane Library databases was performed. All studies reporting on short-term outcomes were included in the meta-analysis. A pooled analysis of long-term freedom from ATA was performed based on Kaplan-Meier (KM) curve-derived individual patient data. Reconstructed individual time-to-event data were analysed in a multivariable Cox frailty model with adjustments for age, sex, type of AF, duration of AF history, and study variable (frailty term in the frailty Cox model). In total, 53 studies were included in the meta-analysis, encompassing 4950 patients. There were no differences in major short-term outcomes (mortality or stroke) between isolated thoracoscopic and hybrid thoracoscopic ablation. A total of 18 studies reported KM curves for long-term freedom from ATA, comprising 2038 patients. Adjusted analysis revealed that hybrid ablation was significantly associated with greater freedom from ATA [adjusted hazard ratio (aHR) = 0.59, 95% confidence interval (CI): 0.43-0.83, P < 0.001] compared with isolated thoracoscopic ablation. Additionally, older age (aHR = 1.07, 95% CI: 1.03-1.12, P = 0.002) and a higher percentage of male patients (aHR = 1.02, 95% CI: 1.01-1.03, P < 0.001) were significantly associated with lower long-term freedom from ATA recurrence. Hybrid thoracoscopic AF ablation is associated with a greater long-term freedom from ATA when compared with isolated thoracoscopic ablation, without differences in complications.

Ethanol infusion into the vein of Marshall reduced atrial tachyarrhythmia recurrence during catheter ablation: A systematic review and meta-analysis

Ethanol infusion into the vein of Marshall reduced atrial tachyarrhythmia recurrence during catheter ablation: A systematic review and meta-analysis

Shortened radiofrequency delivery time to optimize efficiency and safety of pulmonary vein isolation with the radiofrequency balloon: insights from the COLLABORATE registry.

Previous clinical studies on pulmonary vein isolation (PVI) with a radiofrequency balloon (RFB) reported safe and effective procedures using conventional ablation settings with 20/60 s RF delivery via posterior/anterior (PST/ANT) electrodes. The latest evidence suggests that reducing the application time to 15 s (s) on the posterior wall when facing the oesophageal region is as effective as applying 20 s. To prospectively assess whether reducing RF time on PST/ANT segments to 15/45 s can ensure sufficient quality of lesion metrics and compare the new shortened ablation settings with the conventional one in terms of safety, and effectiveness at 1-year. A total of 641 patients from seven European centres were enrolled in a collaborative registry, with 374 in the conventional RF delivery group and 267 in the shortened RF delivery group. Procedural outcomes, lesion metrics, and safety profiles were assessed and compared between the groups. Freedom of any atrial tachycarrythmias at one year was 85.4% and 88.2% in the SHRT and CONV groups, respectively. The shortened RF delivery strategy was associated with significantly shorter procedure times (median 63.5 vs. 96.5 min, P < 0.001) and shortened fluoroscopy exposure (median 10.0 vs. 14.0 min, P < 0.001) compared to conventional delivery. Efficacy metrics, including first-pass isolation rates and time to isolation, were comparable between groups. Shortened RF delivery was associated with a lower incidence of procedural complications (1.4% vs. 5.3%, P = 0.04) and optimized thermal characteristics. Analyses from the COLLABORATE registry demonstrate that shortening RF energy delivery times to 15/45 s (PST/ANT) during PVI with the RFB resulted in comparable freedom from recurrent atrial tachyarrhythmia compared to conventional delivery times with comparable efficiency and safety.

Atrial tachyarrhythmia prevention by Shensong Yangxin after catheter ablation for persistent atrial fibrillation: the SS-AFRF trial.

Despite advances in technology and techniques, the recurrence rate of persistent atrial fibrillation (AF) following catheter ablation remains high. The Shensong Yangxin (SSYX) capsule, a renowned traditional Chinese medicine formula, is used in the treatment of cardiac arrhythmias. This trial aimed to investigate whether the SSYX can improve clinical outcomes in patients who have undergone catheter ablation for persistent AF. A multi-centre, randomized, double-blind, placebo-controlled clinical trial was conducted at 66 centres in China among 920 patients with persistent AF undergoing first ablation. Participants were randomized to oral SSYX, 1.6 g (.4 g/granule) thrice daily (n = 460), or matched placebo (n = 460) for 12 months. The primary endpoint was recurrent atrial tachyarrhythmias lasting for ≥30 s following a blanking period of 3 months. Secondary endpoints included time to first documented atrial tachyarrhythmias, AF burden, cardioversion, stroke/systemic embolism, changes in echocardiographic parameters, and quality-of-life (QoL) score. Analyses were performed according to the intention-to-treat principle. A total of 920 patients underwent randomization (460 assigned to SSYX group and 460 assigned to placebo group). During the follow-up of 12 months, patients assigned to SSYX had a higher event-free rate from recurrent atrial tachyarrhythmias when compared with the placebo group (12-month Kaplan-Meier event-free rate estimates, 85.5% and 77.7%, respectively; hazard ratio, .6; 95% confidence interval .4-.8; P = .001). Patients assigned to receive SSYX had a better QoL score at 12 months compared to those randomized to placebo. There was no significant difference in the incidence of serious adverse events between the two groups. Treatment with SSYX following radiofrequency catheter ablation for persistent AF reduced the incidence of recurrent atrial tachyarrhythmias and led to clinically significant improvements in QoL during a 12-month follow-up in a Chinese population.

Clinical impact of cryoballoon posterior wall isolation using the cross-over technique in persistent atrial fibrillation.

Successful left atrial posterior wall isolation (LAPWI) using only the cryoballoon (CB) is technically challenging for the treatment of atrial fibrillation (AF). This study aimed to evaluate the efficacy of the cross-over technique, wherein an overlapped ablation is performed by placing the CB from both directions in contact with the LAPW. This was a single-center, retrospective, observational study of 194 consecutive patients with persistent atrial fibrillation (PerAF) who underwent a first-time procedure of pulmonary vein isolation (PVI)+PWI (108 patients) or PVI-only (86 patients) using the CB. The cross-over technique was applied in all LAPWI. For ablation of the LA roof and bottom, respectively, a mean of 8.6±1.0 (right to left [R→L] 4.3±1.1 and left to right [L→R] 4.3±1.1) and 9.1±1.2 (R→L 4.6±1.6 and L→R 4.5±1.2) CB applications were delivered. LAPW was successfully isolated solely using the CB in 99.1% of patients. Although the PVI+PWI group had significantly longer procedure time, no severe adverse events were observed in either group. During a median follow-up of 19 months, freedom from recurrence of all atrial tachyarrhythmias was achieved in 93.5% of the PVI+PWI group and 72.9% of the PVI-only group (p=.011). LAPWI performed solely with the CB using the cross-over technique is feasibly, safe, and was independently associated with a significantly higher freedom from recurrence of atrial tachyarrhythmias compared with PVI alone in patients with PerAF.

Comparative Analysis of Clinical Outcomes of High-power, Short-duration Ablation versus Low-power, Long-duration Ablation Strategy in Patients with Atrial Fibrillation: A Comprehensive Umbrella Review of Meta-analyses.

Atrial fibrillation (AF) affects around 33 million people worldwide, rendering it a common cardiac arrhythmia. Catheter ablation (CA) has evolved as a leading therapeutic intervention for symptomatic AF. This umbrella review systematically evaluates existing systematic reviews and meta-analyses to assess the safety, efficacy, and potential of high-power, short-duration (HPSD) ablation as an alternative therapy option for AF. A thorough exploration was undertaken across PubMed, the Cochrane Library, and Embase to identify pertinent studies for inclusion in this umbrella review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was employed to assess the overall certainty of the evidence comprehensively, and the quality of the incorporated reviews was meticulously evaluated through use of the AMSTAR 2 tool, the Cochrane Collaboration tool, and the Newcastle-Ottawa scale. In this study, we initially identified 35 systematic reviews and meta-analyses, narrowing them down to a final selection of 11 studies, which collectively integrated data from 6 randomized controlled trials and 26 observational studies. For primary efficacy outcomes, the HPSD approach led to a non-significant decrease in the risk of atrial tachyarrhythmia recurrence (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.70-1.12; I 2 = 90%; P = .31) and a significantly reduced risk of AF recurrence (RR, 0.53; 95% CI, 0.42-0.67; I 2 = 0%; P < .00001) compared to the low-power, long-duration (LPLD) approach. In terms of primary safety outcomes, the HPSD approach significantly reduced the risk of esophageal thermal injury (ETI) (RR, 0.71; 95% CI, 0.61-0.83; I 2 = 0%; P < .00001) and facilitated a non-significant decrease in the risk of other major complications (RR, 0.87; 95% CI, 0.73-1.03; I 2 = 0%; P = .10). In conclusion, HPSD therapy is safer and more effective than LPLD therapy, facilitating decreased AF recurrence rates along with reductions in ETI, total procedure duration, ablation number, ablation time, fluoroscopy time, and acute pulmonary vein reconnection.

Influence of ABC stroke score on late recurrence of paroxysmal atrial fibrillation following radiofrequency catheter ablation

BackgroundIn this study we investigated the impact of ABC stroke score on the recurrence of paroxysmal atrial fibrillation (PAF) following radiofrequency catheter ablation (RFCA).MethodsA total of 132 patients with PAF who underwent RFCA from October 2018 to September 2019 were included in this study. During the first phase of this study the patients were categorized into two groups based on late recurrence of atrial fibrillation after RFCA. In the second phase, the patients were further divided into two groups based on whether their ABC stroke score was ≥ 6.5.ResultThe univariate analysis indicated that the risk factors for late recurrence of PAF included early recurrence, ABC stroke score, CHA2DS2-VASc score, and NT-proBNP (P < 0.05). Cox multivariate regression analysis revealed that ABC stroke score (P = 0.006) and early recurrence (P = 0.000) were independent predictors of late recurrence, and ABC stroke score ≥ 6.5 was a risk for predicting recurrence of PAF after RFCA with a sensitivity of 66.7% and specificity of 65.7%. After the completion of the 1:1 matching, the univariate Cox analysis indicated that an elevated score of ABC stroke (≥ 6.5) was an independent predictor of late recurrence of PAF (HR = 2.687, 95% CI: 1.036–6.971, P = 0.042). However, using an ABC stroke score cut off at 6.4 predicted the recurrence of atrial tachyarrhythmia with 85% sensitivity and 58.5% specificity.ConclusionAn ABC stroke score ≥ 6.4 is a predictor for late recurrence of PAF after RFCA.

Long-term clinical impact of early recurrence of atrial tachyarrhythmia after cryoballoon ablation in patients with atrial fibrillation.

The impact of early recurrence of atrial tachyarrhythmia (ERAT) within the 90-day blanking period on long-term outcomes in atrial fibrillation (AF) patients undergoing cryoballoon ablation (CBA) is controversial. This study aimed to assess the relationship between ERAT and late recurrence of atrial tachyarrhythmia (LRAT) post-CBA. Utilizing data from a multicenter registry in Korea (May 2018 to June 2022), we analyzed the presence and timing of ERAT (<30, 30-60, and 60-90 days) and its association with LRAT risk after CBA. LRAT was defined as any recurrence of AF, atrial flutter, or atrial tachycardia lasting more than 30 s beyond the 90 days. Out of 2636 patients, 745 (28.2%) experienced ERAT post-CBA. Over an average follow-up period of 21.2 ± 10.3 months, LRAT was observed in 874 (33.1%) patients. Patients with ERAT had significantly lower 1-year LRAT freedom compared to those without ERAT (42.6% vs. 85.5%, p < .001). Multivariate analysis identified ERAT as a potential predictor of LRAT, with a hazard ratio (HR) of 3.98 (95% confidence interval [CI], 3.47-4.57). Significant associations were noted across all examined time frames (HR, 3.84; 95% CI, 3.32-4.45 in <30 days, HR, 5.53; 95% CI, 4.13-7.42 in 30-60 days, and HR, 4.29; 95% CI, 3.12-5.89 in 60-90 days). This finding was consistently observed across all types of AF. ERAT during the 90-day blanking period strongly predicts LRAT in AF patients undergoing CBA, indicating a need to reconsider the clinical significance of this period.

Prevalence, timing, and impact of early recurrence of atrial tachyarrhythmias after pulsed field ablation: A secondary analysis of the PULSED AF trial

BackgroundEarly recurrence of atrial tachyarrhythmias (ERAT) within 3 months of thermal ablation for atrial fibrillation (AF) is common and often considered transient. Pulsed field ablation (PFA) is a nonthermal energy source in which ERAT is not well described. ObjectiveThe purpose of this study was to analyze ERAT in patients with AF undergoing PFA in the Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF (PULSED AF) trial. MethodsThis analysis included 154 (52.4%) paroxysmal AF and 140 (47.6%) persistent AF who had ≥10 rhythm assessments during the 90-day blanking period. ERAT was defined as any instance of ≥30 seconds of AF, atrial flutter, or atrial tachycardia on transtelephonic monitoring (weekly and symptomatic) or ≥10 seconds on electrocardiography (at 3 months), both within 90 days. Late recurrence of atrial tachyarrhythmias (LRAT) was defined as observed atrial tachyarrhythmias between 90 days and 12 months. ResultsThe overall prevalence of ERAT was 27.1% in patients with paroxysmal AF and 31.6% in patients with persistent AF. In patients with ERAT, 73% had ERAT onset within the first month of the procedure. The presence of ERAT was associated with LRAT in patients with paroxysmal AF (hazard ratio 6.4; 95% confidence interval 3.6–11.3) and patients with persistent AF (hazard ratio 3.8; 95% confidence interval 2.2–6.6). Yet, in 29.4% of patients with paroxysmal AF and 34.3% of patients with persistent AF with ERAT, LRAT was not observed. LRAT was positively correlated with the number of ERAT observations. ConclusionERAT after PFA predicted LRAT in patients with paroxysmal and persistent AF. However, the concept of a blanking period after PFA is still valid, as approximately one-third of patients with ERAT did not continue to have LRAT during follow-up and may not need reablation.

Pulsed field vs very high-power short-duration radiofrequency ablation for atrial fibrillation: Results of a multicenter, real-world experience

BackgroundPulsed field ablation (PFA) and very high-power short-duration (vHPSD) radiofrequency ablation are the most recently introduced technologies for atrial fibrillation (AF) ablation. The procedural performance, safety, and effectiveness of PFA vs vHPSD are currently unknown. ObjectiveThe study aimed to compare PFA with vHPSD for the treatment of paroxysmal or persistent AF. MethodsWe conducted an observational, multicenter study enrolling 534 consecutive patients (63 ± 9 years; 36% female) with paroxysmal (n = 368 [69%]) or persistent (n = 166 [31%]) AF undergoing ablation by either PFA (Farapulse; n = 192) or vHPSD (90 W/4 seconds; QDOT Micro; n = 342) between 2020 and 2023. Atrial tachyarrhythmia recurrence after a 1-month blanking period was the primary efficacy end point and was assessed both overall and in propensity score–matched patients. The primary safety end point was a composite of procedure-related complications. ResultsSuccessful pulmonary vein isolation was achieved in all patients, with shorter procedure duration (PFA,70 minutes; vHPSD, 100 minutes; P < .001) but longer fluoroscopy time (PFA, 15 minutes; vHPSD, 7 minutes; P < .001) in the PFA group. PFA was associated with more frequent use of general anesthesia (P < .001). Primary safety outcome events occurred in 19 patients (3.5%), with similar prevalence in both groups (PFA, 4%; vHPSD, 3%; P = .745). After a median follow-up of 12 (9–12) months, survival free from recurrent atrial tachyarrhythmia was similar between the PFA and vHPSD groups, both overall (12-month estimate: PFA, 75%; vHPSD, 76%; log-rank P = .73) and in propensity score–matched patients (n = 342; 12-month estimate: PFA, 75%; vHPSD, 77%; log-rank P = .980). ConclusionIn a large, multicenter experience, PFA was associated with more common use of general anesthesia, shorter procedural times, and longer fluoroscopy exposure compared with vHPSD ablation, with both techniques displaying superimposable safety and efficacy.

Hybrid ablation versus repeated catheter ablation in persistent atrial fibrillation: long-term results of the HARTCAP-AF trial

Abstract Background The HARTCAP-AF study compared the efficacy and safety outcomes in forty-one ablation-naive patients with persistent atrial fibrillation (AF) randomized to thoracoscopic hybrid ablation (HA) or stand-alone catheter ablation (CA). One-year results have shown that thoracoscopic HA has superior rhythm outcomes than CA, without increasing complications. Purpose Here, we evaluated the efficacy, safety and quality of life (QOL) of thoracoscopic HA and CA within a long-term follow-up (FU) duration of three years. Methods Efficacy outcomes included freedom from atrial tachyarrhythmia (ATA) recurrences ≥5 minutes off and allowing antiarrhythmic drugs (AAD) after 24 and 36 months. Safety outcomes, including serious adverse events (SAEs), and QOL, measured by the EHRA AF symptom score, were evaluated after 36 months. Results After a mean FU duration of 25±3 and 38±3 months, freedom from ATA recurrences was higher in the HA group compared to the CA group off AAD (68.4% vs. 22.7%, P=0.002 and 57.0% vs. 22.7%, P=0.005) and allowing AAD (73.7% vs. 22.7%, P=0.001 and 63.2% vs. 22.7%, P=0.001) (Figure 1, Table 1). The number of redo catheter procedures was higher in the CA arm than the HA arm (n=15 vs. n=3, P=0.021). The total number of SAEs was low and did not differ between groups (HA: n=6 vs. CA: n=7, P=0.989). Moreover, QOL measured by the EHRA AF-symptom score improved for both groups post-procedure (3.2±0.7 and 1.6±0.78, P&amp;lt;0.001) and were better for HA than CA after 3 years (1.3±0.7 and 1.9±0.8, P=0.029). Conclusion After three years, (thoracoscopic) HA continues to have superior rhythm outcomes compared to CA with a comparable long-term safety profile. While both procedures resulted in a reduction in AF symptoms, EHRA scores were more favorably scored by patients in the HA arm. Therefore, in experienced centers thoracoscopic HA should be considered as a first-line treatment to percutaneous approaches for ablation-naive patients with persistent AF.Figure 1Table 1

Impact of interatrial septal thickness and interatrial conduction time on cryoballoon ablation outcome

Abstract Introduction Interatrial septal thickness (IAST) is an indirect measure of interatrial septal fat which is anatomic extension of epicardial fat. Interatrial conduction time (IACT) reflects altered conduction between atria. Both parameters are associated with left atrial (LA) fibrosis and atrial fibrillation (AF). However, limited data exist regarding the influence of IAST and IACT on the outcomes of cryoballoon ablation (CBA). In this study, we aimed to analyze possible effect of IAST and IACT on atrial tachyarrhythmia (ATA) free survival after CBA. Methods and results Sixty five patients (34/65, 52.3% male, 53.3±11.0 years old) undergoing first time CBA for pulmonary vein isolation were enrolled. Pre-procedural TEE images were analyzed and bicaval view was used to visualize SVC rim for IAST measurement (Figure 1). IACT was measured from the onset of surface P wave to atrial EGM recorded by distal coronary sinus electrode. After 3 months blanking period all anti-arrhythmic drugs were discontinued. Clinical endpoint was ATA recurrence including AF, flutter or tachycardia lasting more than 30 seconds. After 11.2±4.1 months of follow-up 8 patients (12.3%) had ATA recurrence. IAST (4.4±1.1 vs 3.3±0.6 mm, p=0.007) and LA volume index (37.4±8.0 vs 30.1±12.4 mL/m2, p=0.03) were greater in patients with ATA recurrence than those without. In contrast, patients with and without had similar IACT (85.8±31.1 vs 62.2±23.9 ms, p=0.10). Conclusion Pre-procedural measurement of IAST using TEE may provide prognostic information in CBA patients. Increased IAST was found to be associated with ATA recurrence after CBA based PVI and warrants further study.Interatrial septal thickness measurement

Different predictors of AF recurrence after pulmonary vein isolation with cryoballoon and radiofrequency ablation: insights from clinical and electroanatomical mapping data of the NO-PERSAF study

Abstract Background Pulmonary vein isolation (PVI) with cryobaloon ablation (CBA) and radiofrequency ablation (RFA) lead to a similar outcome of freedom from atrial tachyarrhythmia (ATA) during follow-up as showed by the NO-PERSAF study. Analyses of ATA recurrence for these two techniques based on data of electroanatomical mapping (EAM) are scarce from randomized clinical trials. Purpose This study aimed to evaluate and compare clinical outcomes and EAM data recorded in the left atrium (LA) during CBA and RFA procedures in patients with persistent atrial fibrillation (AF). Methods For the NO-PERSAF study, 101 patients (mean 63.2±8.6 years, 80 male, 21 female) with persistent AF (77 persistent AF, 24 long-standing persistent AF) referred to PVI were randomized (1:1) to CBA or RFA and followed for 12 months. A prolonged 3-year follow-up was carried out. EAM was performed by a circular mapping catheter with a 3-dimensional mapping system in all patients. EAM data were recorded and analyzed off-line. The areas of the LA, posterior wall, low-voltage (&amp;lt;0.5mV) and complex fractionated electrogram (cycle length &amp;lt;120 ms) were measured and corrected by body surface area (BSA). EAM data from 90 patients were qualified for further analysis and the others (5 in CBA and 6 in RFA) excluded because of disqualification or technical failure of recording. Correlation between clinical results of 3-year follow-up and the EAM data were analyzed using univariate cox regression. Results After 3-year follow-up, freedom from ATA was achieved in 51 (50.5%) of the 101 patients, 28 (54.9%) out of 51 patients in the CBA group and 23 (46.0%) out of 50 patients in the RFA group and no difference was found (p=0.327). RFA compared with CBA resulted in larger ablation lesions in the LA (23.9% vs. 21.3%; p=0.037) and particularly in the posterior wall (44.2% vs 31.8%; p&amp;lt;0.001). Compared between the patients with and without recurrence, there was no difference with respect to age, gender, AF history, body mass index, heart disease and CHA2DS2-vasc score. For EAM data, the area of the LA and low voltage were significantly higher in ATA recurrent patients in CBA group, but not in RFA group (Table 1). Univariate cox regression analyses suggested that 3-year follow-up outcomes were associated with the size of the LA and the amount of low voltage corrected by BSA. The criteria of the LA area &amp;gt;55 cm2/m2 or low voltage area &amp;lt;19 cm2/m2 could predict ATA recurrence after CBA, but not after RFA procedure (Figure 1). Conclusions The size of the LA and the amount of low voltage corrected by BSA was associated with the outcomes of PVI during follow-up and could be employed as predictors of ATA recurrence for CBA, but not for RFA procedure.Table 1Figure 1K-M curves after CBA and RFA