Atrial Tachyarrhythmias In Patients Research Articles

Transdermal bisoprolol for prevention of postoperative atrial fibrillation: A systematic review and meta‐analysis

AbstractBackgroundThe transdermal patch of bisoprolol available in Japan has been reported to demonstrate superior efficacy in preventing postoperative atrial fibrillation, possibly surpassing its oral counterpart. However, there has been no systematic review and meta‐analysis assessing the efficacy of transdermal bisoprolol.MethodsA comprehensive systematic literature search was conducted on PubMed, Embase, and Cochrane to identify all relevant studies assessing the efficacy of transdermal bisoprolol in preventing postoperative atrial fibrillation. The search covered studies from inception up to December 4, 2023. For data analysis, Review Manager (RevMan) 5.4 software was employed, using a random‐effects model to calculate risk ratios (RR) and 95% confidence intervals (CI).ResultsThree studies, comprising a total of 551 patients (transdermal bisoprolol 228 and control 323), were included. There was a decreased risk of postoperative atrial fibrillation or atrial tachyarrhythmias in patients treated with transdermal bisoprolol (RR 0.43, 95% CI 0.27–0.67, p = .0002, I2 = 0%).ConclusionTransdermal administration of bisoprolol has consistently shown efficacy, and this pooled analysis supports its effectiveness. The heterogeneity of the included studies limits certain interpretations. Future randomized clinical trials may elucidate the superiority of transdermal administration over oral administration.

Analysis of the endocardial stage of treatment of tachyarhythmias after open interventions for atrial fibrillation. Experience of one center

AIM: To study EFI parameters and features of recurrent atrial tachyarrhythmias in patients who underwent surgical correction of AF.
 MATERIALS AND METHODS: from January 2013 to December 2021, 447 combined interventions were performed to eliminate AF using the labyrinth-3 and left atrial labyrinth techniques with correction of CHD (congenital heart disease) and/or coronary artery disease.
 Rhythm disturbances were detected in 57 (12.7%) patients at various follow-up periods. Endovascular interventions were performed in 39 patients. The average follow-up period after the endocardial stage was 34.37 (standard deviation 24.32) months. The median age of patients was 64 (58–67) years, 21 (54%) were men. The patients were divided into 2 groups: group 1 — after the classic biatrial (BA) labyrinth-3 — 23 (59%) patients, group 2 — after the left-atrial variant (LA) labyrinth-3 — 16 (41%) patients.
 At the endocardial stage, electrophysiological studies (EFI) were performed to clarify the mechanism of arrhythmia, and ablation eliminated tachyarrhythmia. EFI protocol: revision of the pulmonary veins, determination of the isolation of the posterior wall of the LA assessment of atrial arrhythmia, elimination of arrhythmia, control induction of arrhythmia after ablation. After repeated intervention, patients were observed in the operating clinic every 3 months.
 RESULTS: After the endocardial stage, a regular rhythm was determined in 19 (82.6%) patients of the BA group, 13 (92.9%) patients of the LA group (p = 0.914). Relapses in the form of AF were noted in 5 patients (4 — group 1 and 1 — group 2) group (p = 0.306) All relapses of tachyarrhythmia with an irregular cycle (AF) were detected in patients with AF before the endovascular stage In both groups, there were cases of restoration of conduction in the pulmonary veins — 10 (43.5%) patients after BA ablation and 1 (5.3%) patient after LA ablation. There are no recurrences of atrial arrhythmia after ablation of atrial flutter (arrhythmia with a stable cycle).
 CONCLUSION: The endocardial stage is highly effective and demonstrates subsequent freedom from atrial arrhythmia in patients who have tachycardia with a regular cycle after both methods of surgical ablation of AF. Recurrent tachyarrhythmia in the form of AF (irregular cycle) is associated with a low probability of maintaining a regular atrial rhythm after a repeated endocardial procedure, due to the presence of structural and electrophysiological changes in the atrial myocardium.

A novel ablation strategy for recurrent atrial fibrillation: Fractionated signal area in the atrial muscle ablation 1-year follow-up.

Treatment of recurrent atrial fibrillation (AF) is sometimes challenging due to non-pulmonary vein (PV) foci. Fractionated signal area in the atrial muscle (FAAM) is a valid predictor of the location of non-PV foci. FAAM ablation has the potential to decrease the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF. We compared the clinical impact of FAAM ablation for recurrent AF, using 1 year follow up date. A total of 230 consecutive patients with symptomatic recurrent AF who underwent catheter ablation specifically targeting non-PV foci as FAAM-guided ablation (n = 113) and non-FAAM-guided ablation (n = 117) were retrospectively analyzed. FAAM was assigned a parameter (peaks slider, which indicates the number of components of fractionated signals), ranging from 1 to 15, indicating the location of the FAAM (1: largest, 15: smallest). FAAM-guided ablation was performed by ablating FAAM until none inducibility of non-PV foci. On the other hand, non-FAAM-guided ablation was performed via linear ablation, complex fractionated atrial electrogram ablation, superior vena cava isolation, and focal ablation according to the location of the non-PV foci. The RHYTHMIA system was used to perform all the procedures. The primary endpoints were AF recurrence, atrial flutter, and/or atrial tachycardia. After a 1-year follow up, freedom from atrial tachyarrhythmia was achieved in 90.3% and 75.2% of patients in the FAAM and non-FAAM groups, respectively (hazard ratio = 0.438 [95% confidence interval: 0.243-0.788], p = .005). FAAM ablation showed a promising decrease in the recurrence rate of atrial tachyarrhythmia in patients with recurrent AF during a 1-year follow-up.

PO-01-064 IMPROVED METHOD FOR VEIN OF MARSHALL ALCOHOL ABLATION: CASE SERIES

Vein of Marshall (VoM) alcohol ablation has emerged as a successful method to reduce recurrence of atrial fibrillation (AF) and atrial tachyarrhythmias in patients with persistent AF. Cannulation of the VoM close to the coronary sinus (CS) ostium with an IMA guiding catheter through an unsupported CS access catheter can be challenging; extending procedure/fluoroscopy time, contrast use, and increase the risk of complications. To describe new tools & techniques for VoM alcohol ablation that make the procedure easier. We describe here an improved method for VoM alcohol ablation in 4 patients following AF ablation. A baseline 3D left atrium voltage map was obtained to assess pre-existing scar (local bipolar voltage of <0.1 mV). The CS was cannulated via the right femoral vein with either a 6 French (F) decapolar catheter or a hand-shaped 6F multipurpose guiding catheter telescoped inside a long curved 9F inner diameter (ID) sheath. The sheath was then advanced into the CS body. Next, a 0.035 in Amplatz wire (short taper) was introduced through the sheath into the CS using a 5F outer diameter (OD) vein selector to provide extra support and facilitate easy re-cannulation of the CS in case the outer sheath disengaged. An occlusive venogram was conducted in RAO 20 view. After the identification of the VoM, a 5F vein selector was used to engage it and a 0.014 mm floppy wire was advanced. An over-the-wire angioplasty balloon (size 1.5 to 2mm x 6mm) was advanced in the VoM and dilated to occlude the vessel. Three ml of 98% ethanol were delivered over 1 minute. This process was repeated twice. The balloon was deflated, and the apparatus was retracted into the sheath. We then proceeded with repeat 3D voltage mapping to assess the ethanol-induced scar. Application of this workflow using these tools reduced the use of contrast, fluoroscopy time, and total procedural time in this case series. What is new: 1. The ID of the CS access sheath was increased to 9F. 2. An Amplatz (short taper) stabilizing/support wire was added to the CS access sheath. 3. The shape of the catheter used to engage the VOM was changed from IMA to vertebral. Application of these tools reduced the use of contrast, fluoroscopy time, and total procedural time.

Abstract 11726: Atrial Arrythmia Recurrence in Patients After Left Atrial Ablation is Associated With Epicardial Connections and Directly Correlated to Reduced Left Ventricular Ejection Fraction

Introduction: Heart Failure with Reduced Ejection Fraction has a positive association with atrial arrhythmia incidence and recurrence. However, this has not been studied in atrial fibrillation (AF) and atrial tachycardia (AT) patients who underwent left atrial radiofrequency ablation(RFA) and were subsequently found to have epicardial connections(EC). Hypothesis: Heart Failure with Reduced Ejection Fraction was associated with an increased recurrence of atrial tachyarrythmias in patients with epicardial connections. Methods: We studied 40 consecutive patients with persistent atrial arrhythmias who underwent RFA for AF and AT at our center. Epicardial connections were determined by high density mapping, missing isochrones and activation patterns. Clinical, echocardiographic and activation mapping pattern characteristics were collected. Results: Forty patients were found to have EC (Table 1). The association of EC and echocardiographic parameters were assessed. Reduced Left Ventricular Ejection Fraction was associated with an increased recurrence of atrial tachyarrhythmias in patients due to epicardial connections((HR:1.25(1.05-1.48)) (Table 2). Conclusions: Reduced Left Ventricular Ejection Fraction is positively correlated with atrial tachyarrythmia recurrence in patients due to epicardial connections.

Cryoballoon catheter ablation or drug therapy to delay progression of atrial fibrillation: A single-center randomized trial.

Delaying atrial fibrillation (AF) progression is a key goal in cardiovascular treatment. However, numbers of previously published studies on delayed AF progression are relatively limited. The purpose of this study was to determine whether a cryoballoon catheter ablation (CA) strategy could delay AF progression compared to anti-arrhythmic drug (AAD) treatment in patients with paroxysmal AF. A total of 204 subjects were enrolled in the trial, including 102 in the cryoballoon CA group and 102 in the AAD group. Participants were followed up with for 36 months. The primary study endpoint was the first occurrence of persistent atrial tachyarrhythmia, while secondary endpoints included the event rates of persistent atrial tachyarrhythmia at 1 and 2 years. The primary safety endpoint was serious adverse events. Overall, the 36-month follow-up was completed by 154 subjects (75.5%). At 3 years, documented progression from paroxysmal AF to persistent atrial tachyarrhythmia had occurred in 2 of the 102 patients assigned to undergo cryoballoon CA [2.203% (95% confidence interval (CI), 0.554-8.537)] and in 17 of the 102 patients assigned to receive AADs [20.223% (95% CI, 13.040-30.604)] [hazard ratio (HR), 0.107; 95% CI, 0.043-0.262; P < 0.001]. Lower rates of progression in the cryoballoon CA group compared to the AAD group were already obvious at 1 year [1.053% (95% CI, 0.149-7.238) vs. 5.284% (95% CI, 2.233-12.237)] [HR, 0.193; (95% CI, 0.039-0.956; P = 0.09)] and 2 years [2.203% (95% CI, 0.554-8.537) vs. 12.430% (95% CI, 7.066-21.371)] (HR, 0.169; 95% CI, 0.057-0.501, P < 0.001). Serious adverse events occurred in 7 of the 102 patients (6.9%) in the cryoballoon CA group and 9 of the 102 patients (8.8%) in the AAD group. Cryoballoon CA was superior to AAD therapy in preventing the occurrence of persistent atrial tachyarrhythmia in patients with paroxysmal AF who had not received prior rhythm control therapy. Serious adverse events were rare.

Usefulness of Prolonged PR Interval to Predict Atrial Tachyarrhythmia Development Following Surgical Repair of Tetralogy of Fallot

Atrial tachyarrhythmias (ATAs), which may occur after tetralogy of Fallot (TOF) surgery, can cause sudden cardiac death. However, ATAs may also develop in response to electrical substrates. This study aims to examine the predictive factors for ATAs by identifying electrical substrates in the atrium obtained from 12-lead electrocardiogram in patients who underwent TOF repair. A total of 144 patients aged >15 years (median, 31.6 years) who underwent TOF repair at Hokkaido University were enrolled. We investigated the correlation between the development of ATAs with age, time interval after initial corrective surgery, brain natriuretic peptide levels, cardiac magnetic resonance parameters (right ventricular end-diastolic volume index, right ventricular end-systolic volume index, right ventricular ejection fraction, right atrial volume index, left ventricular end-diastolic volume index, left ventricular ejection fraction), and 12-lead electrocardiogram parameters (P wave maximum voltage, PR interval, QRS width, number of fragmented QRS). Of the 144 patients, 44 patients (30.6%) developed ATAs. Multivariate analysis revealed time interval after initial corrective surgery (odds ratio 6.7, 95% confidence interval 1.78 to 12.6) and PR interval (odds ratio 2.7, 95% confidence interval: 1.17 to 4.20) as independent risk factors for the development of ATAs. The receiver operating characteristic curve revealed a PR interval cut-off value of >200 milliseconds as predictive of the development of ATAs in patients more than 15 years after initial corrective surgery (area under the curve, 0.658; sensitivity, 71.4%; specificity, 66.4%). The present study demonstrated that a prolonged PR interval is a simple and convenient predictor for the development of ATAs in patients who underwent TOF repair.

PentaRay® Multielectrode Mapping Catheter for Atrial Tachyarrhythmia in Adults With Congenital Heart Disease.

Ablation of atrial tachyarrhythmia in adults with congenital heart disease (ACHD) is challenging because of complex anatomy and high scar burden. We proposed that the addition of high-density mapping with the PentaRay® (Biosense Webster, Inc) mapping catheter (EAM+P) to 3-dimensional electroanatomic mapping (EAM) allows for rapid acquisition of high-resolution maps and shorter procedure times. In this single-center, retrospective cohort study of patients with ACHD who underwent atrial arrhythmia ablation, patients were divided those who underwent ablation with EAM and those who underwent ablation with EAM+P. Fifteen ablations were performed in 13 patients using standard EAM, and 11 ablations were performed in 10 patients using EAM+P. There was no difference in mean age or complexity of congenital heart disease. The procedure duration was 1.5 times longer in the EAM than in the EAM+P group (P = .015). The dose area product was 12 times higher in the EAM than in the EAM+P group (P = .001). A higher number of venous access sites were used for EAM cases than for EAM+P cases (P = .008). Acute success rates of ablation and recurrence rates at 1 year were similar in the 2 groups. There were no procedure-related complications in either group. This is the first study to evaluate the use of the PentaRay® high-density mapping catheter for ablation of atrial tachyarrhythmia in patients with ACHD. The use of the PentaRay® high-density mapping catheter results in shorter procedure time, decreased radiation exposure, and fewer venous access sites.

The role of landiolol in the management of atrial tachyarrhythmias in patients with acute heart failure and cardiogenic shock: case reports and review of literature.

Atrial tachyarrhythmias and worsening heart failure frequently coexist and potentially progress to a life threatening condition. Therapeutic approach requires simultaneous management of rapid ventricular response and heart failure symptom relief in order to improve haemodynamic stability and cardiac function. Landiolol is an ultra-short-acting b-adrenergic receptor blocker with high b1 selectivity incorporated in 2020 European Society of Cardiology guidelines for the management of atrial fibrillation. We provide a report of two cases with atrial fibrillation treated with landiolol in the acute setting of pulmonary oedema and cardiogenic shock, respectively. Additionally, we searched the international database PUBMED (MEDLINE, PubMed Central) to retrieve scientific evidence regarding its implementation in the treatment of atrial tachyarrhythmias in patients with cardiac dysfunction. Recent studies support the use of landiolol in patients with acute heart failure and atrial tachyarrhythmias. Compared to digoxin, landiolol proved to be more effective in controlling heart rate, with minimal adverse effects. Moreover, landiolol may be helpful in the conversion of atrial tachyarrhythmia to sinus rhythm. A more potent effect has been reported in patients with heart failure with preserved or mildly reduced ejection fraction, small left ventricular volume and high blood pressure. Likewise, administration of low doses of landiolol in patients with cardiogenic shock and atrial tachyarrhythmias reduced heart rate and pulmonary capillary wedge pressure and improved cardiac contractility without reducing blood pressure. Landiolol seems to be an attractive alternative in the acute management of patients with atrial tachyarrhythmias and cardiac dysfunction, though further clinical trials are needed to establish its role.

Cardioversion of Post-Ablation Atrial Tachyarrhythmia with Ibutilide and Amiodarone: A Registry-Based Cohort Study.

Patients with recurrence of atrial tachyarrhythmia after catheter ablation for atrial fibrillation or atrial flutter constitute a rapidly growing cohort, but study-driven treatment recommendations are lacking. The present study aimed to compare the cardioversion success of ibutilide and amiodarone in patients with post-ablation atrial tachyarrhythmia. We included all episodes of post-ablation atrial tachyarrhythmia in patients treated with either intravenous ibutilide or amiodarone at an academic emergency department from 2010 to 2018. The primary endpoint was the conversion to sinus rhythm. The conversion rates were stratified by arrhythmia type, and multivariable cluster-adjusted logistic regression was used to estimate the effect of ibutilide and amiodarone on cardioversion success, given as the odds ratio (OR) with 95% confidence intervals (95% CI). In total, 109 episodes of 72 patients were analyzed. The conversion rates were 37/49 (76%) for ibutilide and 16/60 (27%) for amiodarone. Compared to amiodarone, ibutilide was associated with higher odds of conversion (multivariable cluster-adjusted OR 5.6, 95% CI 1.3–24.3). The cardioversion success of ibutilide was the highest in atrial flutter (crude OR 19.5, 95% CI 3.4–112.5) and focal atrial tachycardia (crude OR 8.3, 95% CI 1.5–47.2), but it was less pronounced in atrial fibrillation (crude OR 4.5, 95% CI 1.2–17.2). Randomized trials are warranted to confirm our findings.

Capability of guideline-conform remote atrial high rate episode monitoring with a single-chamber implantable defibrillator with atrial sensing

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction Device-detected atrial high-rate episodes (AHRE) and their burden progression are associated with an increased risk for thromboembolic events in correlation with CHA2DS2-VASc score and AHRE burden. To allow timely initiation of anticoagulation therapy for the prevention of stroke, the European guidelines on atrial fibrillation (AF) recommend the monitoring of AHRE progression along pre-specified strata (6min…&amp;lt;1h, 1h…&amp;lt;24, ≥24h). We sought to assess the capability of a single-lead implantable cardioverter defibrillator (ICD), that is equipped with an atrial dipole for atrial sensing, to remotely detect and monitor AHRE burden progression in patients with standard indication to single-chamber ICD. Methods From the MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems) registry, we analyzed remotely transmitted, and electrogram (IEGM) AHREs in a subset of patients with remote transmissions and without history of long-standing AF at baseline. For each patient, we selected the first occurring episode per duration stratum and the first subsequent occurrence when progressing to a stratum of any longer duration. After episode adjudication by an independent electrophysiologist, we assessed the classification performance of the device (positive predictive value [PPV]) and analyzed AHRE onset and progression pathways. Results Of the MATRIX cohort, 1,746 patients matched the inclusions criteria (see table for patient characteristics) and 1,451 had no AF history. Of the 258 patients with AHREs (14.8%), 450 out of 465 evaluated episodes were correctly classified as AHRE. Reasons for misclassification were artifact (13) and R-wave oversensing (2). PPV was 96.8% (95% confidence interval 94.7%-98.2%). Grouped by stratum, PPV was 93.9%, 99.5% and 100% for 6min…&amp;lt;1h, 1h…&amp;lt;24 and ≥24h, respectively. Ninety six of 240 patients (40.0%) with a first episode according to the pre-specified strata were progressing to a stratum of longer duration and 9 patients (3.8%) had further progression (see Figure). In 119 out of 1,451 patients without AF history (8.2%), the device detected AHRE and 81 of them (4.6% of analysis set) had a mid to high risk for stroke and were not on anticoagulation therapy. In 121 out of 295 patients with known history of paroxysmal and persistent AF (41.0%), the arrhythmia was confirmed by the device. Discussion and Conclusion: The single-chamber ICD with atrial sensing capabilities correctly classified ≈97% of all adjudicated AHREs ≥6min. About 7% of patients had device-detected AHRE onset and/or progression and a mid to high stroke risk. These patients would potentially benefit the most from a guideline-conform AF monitoring strategy to timely initiate anticoagulation medication for stroke prevention.

Real-world experience on implantation and atrial signal detection of a SC ICD with atrial sensing capability: The MATRIX study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): BIOTRONIK, Berlin, Germany Introduction A single-lead implantable cardioverter-defibrillator (ICD) with atrial sensing dipole (the DX ICD system) can potentially give additive information concerning atrial diagnostics in patients requiring only a single-chamber ICD. We therefore report the real-world experience from large DX registry on implantation, atrial signal quality and detection and the long-term stability of the atrial signal. Methods The prospective, single-arm MATRIX (Management and Detection of Atrial Tachyarrhythmias in Patients Implanted With BIOTRONIK DX Systems, NCT01774357) registry study effectively enrolled 2041 patients at 119 sites in 24 countries. All patients had a DX system implanted for a single-chamber ICD indication for primary or secondary prevention of sudden cardiac death. Patients were followed for 24 months including remote monitoring. Implantation and follow-up data are reported for the whole patient set. For the analyses on atrial sensing amplitude values, remotely transmitted device measurements of patients without history of long-standing persistent or permanent AF at baseline were used. Results The mean follow-up period was 677±173 days. Implantation took place at 15±22 days before enrollment. Baseline and implantation data are shown in the table. Implantation procedure and lead insertion were rated as "easy" or "very easy" in 91.0% and 96.3% of assessments, respectively. At implantation, the investigators rated the quality of the atrial sensing amplitude as "sufficient" in 97% of the assessed cases. At enrollment (12-month/24-month follow-up), the atrial signal quality and detection were rated as "good" or "excellent" in 92.3% (89.8%/89.9%) and 92.4% (90.1%/91.3%) of assessments, respectively. For 1841 patients (90.2%), remotely transmitted device information was received. The median (mean ± SD, IQR) transmission rate was 92.5% (85.4±18.2%, 81.4-97.3%). 1746 patients (85.5%) matched the inclusion criteria for the quantitative analyses on atrial sensing. 95.6% of available RA sensing amplitude values were ≥1 mV. Based on each patient’s overall median value, the median (mean ± SD, IQR) RA sensing amplitude was 4.6 mV (4.4±2.0 mV, 2.8-6.2 mV). The time course of patient median values stratified by month is shown in the figure. Conclusion The study followed 2041 patients implanted with the DX ICD system for two years. In the vast majority of cases, investigators rated implantation as (very) easy and the atrial signal over 24 months as good/excellent. According to daily, automatic Home Monitoring data, the overall mean P-wave amplitude remained stable throughout the whole follow-up. The MATRIX study demonstrated functionality and clinical utility of the DX concept in an unselected, real-life setting.

Abstract 13581: Heart Rhythm versus Heart Rate Control Strategy in Patients With Pre-Capillary Pulmonary Hypertension and Atrial Arrhythmias

Introduction: Atrial tachyarrhythmias in patients with pre-capillary pulmonary hypertension are often poorly tolerated leading to increased morbidity and mortality. Sinus rhythm restoration seems to improve outcomes but a direct comparison between rate and rhythm control has not been investigated. We sought to determine any difference in effectiveness between the two strategies. Methods: We performed a retrospective study in 88 patients with pulmonary arterial hypertension (PAH) or chronic thromboembolic pulmonary hypertension (CTEPH) and new-onset atrial flutter or fibrillation seen in our centre from 2005-2020. Patients were divided into 3 groups based on management strategy: rate control (n=20), rhythm control with medication only (n=24) and rhythm control with DC cardioversion (DCCV) and medication (n=44) (Table 1). Differences in WHO functional class and incremental shuttle walk test distance (ISWTD) at arrhythmia onset and after treatment were measured. Results: Sinus rhythm was successfully restored in 42/44 (95%) of patients treated with DCCV and medication compared to 13/24 (54%) treated with amiodarone only (p&lt;0.001). Cardioverted patients reported a significant improvement in functional class compared to patients treated with rate control (p&lt;0.001). A similar improvement in ISWTD (≥15%) was also reported (p=0.004) (Table 2). No serious complications were reported with either strategy. Conclusions: A rhythm control strategy including DCCV and medication is a safe and effective way to restore sinus rhythm in patients with PAH/CTEPH and atrial tachyarrhythmias. Restoration and maintenance of sinus rhythm led to an improvement in their functional status.

Cryoablation versus anti-arrhythmic therapy for initial treatment of atrial fibrillation: a systematic review and meta-analysis

Abstract Introduction Atrial fibrillation is a common cardiac arrhythmia that affects approximately 2% of the overall population. Guidelines suggest the use of anti-arrhythmic agents as initial therapy in patients with symptomatic atrial fibrillation, however using cryoablation as a first line therapy might have increased efficacy. The safety and efficacy of cryoablation as initial therapy has not yet been established. Purpose We performed a systematic review and meta-analysis of randomized controlled trials to investigate the use of cryoballoon catheter ablation compared to anti-arrhythmic therapy as an initial intervention to prevent recurrence of atrial tachyarrhythmias in patients with atrial fibrillation. We also wanted to determine if using this initial ablative approach did not present increased adverse events. Methods A comprehensive search of multiple databases was performed to find randomized control trials that directly compared cryoablation therapy versus anti-arrhythmic therapy as initial treatment for patients with atrial fibrillation. A total of three RCTs met the inclusion criteria (724 patients) and were used in the meta-analysis. The primary outcome of our meta-analysis was recurrence of atrial tachyarrhythmias. The secondary outcome evaluated serious adverse events of each therapy. Results The results showed a statistically significant reduction of recurrence of atrial tachyarrhythmic events in patients receiving cryoablation compared to anti-arrhythmic therapy [Risk Ratio (RR): 0.60, 95% CI (0.49, 0.72), P&amp;lt;0.ehab724.03521, I2=0%]. There was no significant difference in serious adverse events between patients receiving cryoablation compared to patients receiving anti-arrhythmic therapy. [Risk Ratio (RR): 1.19, 95% CI (0.71, 2.00), P=0.52, I2=0%]. Conclusion Our meta-analysis showed that cryoablation therapy as an initial therapy is more efficacious than anti-arrhythmic therapy in patients with atrial fibrillation without an increased risk of serious adverse events. Funding Acknowledgement Type of funding sources: None.

Epidemiology of subclinical atrial fibrillation in patients with cardiac implantable electronic devices: a systematic review and meta-analysis

Abstract Background Sub-clinical atrial fibrillation (SCAF) and atrial high-rate episodes (AHREs), seen as high-frequency atrial tachyarrhythmias in patients with cardiac implantable electronic devices (CIEDs), have gained prominence as determinants of clinical atrial fibrillation (AF) and increased stroke risk. As a result, several studies investigating their role in predicting the onset of AF and AHRE-related outcomes have been conducted but uncertainty exists on the epidemiology of AHRE. Purpose To estimate the incidence of SCAF, according to presence of AHREs in patients with CIEDs, through a systematic review and meta-analysis of the available literature. Methods PubMed and EMBASE were searched from inception to 27th January 2021 for all studies documenting the incidence of AHREs in patients with CIEDs. We included all studies with ≥100 patients reporting data on AHREs incidence. Pooled prevalence and incidence rates were computed; we also performed meta-regressions for pooled incidence rates, according to relevant study-level characteristics. This study was registered in PROSPERO: CRD42019106994. Results Among the 2,515 results retrieved, we included 51 studies in the systematic review and meta-analysis, with a total of 68,414 patients. Meta-analysis of included studies showed a pooled prevalence of 28.2% (95% CI: 24.3–32.5%, I2=99%), with a pooled incidence rate (IR) of 15 new AHRE cases per 100 patient-years (95% CI: 12–19, I2=100%). Given the large heterogeneity showed in the pooled estimates we performed additional analyses. Regarding pooled prevalence, we performed several subgroup analyses, according to various studies baseline characteristics, which did not show any significant difference in any of the subgroups examined. Regarding IR, a multivariable meta-regression analysis showed that decreasing follow-up time and increasing age were the only factors significantly associated with AHRE incidence, explaining a large proportion of heterogeneity (R2=68%, p&amp;lt;0.001; Figure 1, Panel A and B respectively). Accordingly, the AHRE IR was highest at 1 year follow-up and in the oldest subjects. Presence of SCAF was significantly associated with older age, higher CHA2DS2-VASc score, and higher prevalence of hypertension, heart failure and history of cerebrovascular disease. Conclusions This systematic review and meta-regression demonstrated that SCAF is very common in patients with CIEDs, with an overall IR for AHREs of up to 15 per 100 patient-years; increasing with age and decreasing with longer follow-up time. Presence of SCAF was associated with an overall higher clinical risk profile compared to those subjects without SCAF. Funding Acknowledgement Type of funding sources: None. Figure 1. Meta-regression for AHRE Incidence

B-PO02-078 PROSPECTIVE RANDOMIZED MULTICENTER COMPARISON OF THIRD GENERATION CRYOBALLOON AND LASER BALLOON CATHETERS FOR PULMONARY VEIN ISOLATION ABLATION IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION

Cryoballoon (CB) and Laser balloon (LB) catheters have emerged as alternative modalities for pulmonary vein isolation (PVI) of patients with paroxysmal atrial fibrillation (PAF). To compare clinical efficacy, safety, and procedural characteristics of 3rd generation CB (Arctic Front Advance-Short Tip; CB3) and LB (Heartlight X3; LB3) catheters for first-time PVI in PAF patients. Symptomatic PAF patients were prospectively randomized 1:1 to undergo PVI with CB3 or LB3 catheters (CB3: n=115; LB3 n=115). Follow up included 3,6, and 12 month office visits. 14-day Holter monitoring guided by symptoms. Primary efficacy endpoint was defined as freedom from atrial tachyarrhythmia (AAT) between 91 to 365 days after first-ablation procedure. Secondary endpoints included procedural parameters and procedural complications. Procedure time, left atrial time, and fluoroscopy time were based on standard definitions. 230 PAF patients underwent PVI with CB3 (n=115) and LB3 (n=115). There were no significant differences in baseline characteristics between groups. Mean age was 65.3 + 12.3 for CB3 and 63.1 + 11.5 for LB3 (p=0.158). On 9 month follow up, 17.2% of CB and 11.4% of LB3 patients (p=0.939) had recurrence of AAT after 90-day blanking period. Procedure time was 91.7 + 33.8 for CB3 vs 91.1 + 27.7 mins for LB3 (p=0.87). LA dwell time was 68.9 + 26.1 for CB3 vs 74.2 + 22.2 min for LB3(p=0.11). Fluoroscopy time was 13.8 + 7.0 vs 8.7 + 5.7 min for CB3 and LB3 groups (p<0.001), respectively. Total therapy time per PV was 6.5 + 3.9 for CB3 vs 5.6 + 2.4 min for LB3(<0.001). Of the PVs treated, 98.7% (450/456) were isolated with CB3 and 99.1% (445/449) were isolated with LB3. First pass isolation rate was 78.0% (351/450) for CB3 vs 93.7% (417/445) for LB3 (p<0.001). Hematomas occurred in four CB3 and two LB3 patients (p=0.458), respectively. No phrenic palsy events were observed in either group. Third generation CB and LB catheters offer improved safety and comparable efficacy for treatment of AAT in patients with PAF. Although procedure and LA dwell time were similar between balloon catheters, PVI with LB3 was associated with lower fluoroscopy usage, higher first pass PV isolation rate, and shorter total therapy time to achieve isolation per PV.

Higher Pulmonary Arterial Pressure Was Related to Non-Pulmonary Vein Atrial Tachyarrhythmia.

Recurrence of atrial tachyarrhythmias (ATA) following catheter ablation for atrial fibrillation (AF) is often associated with the recovery of conduction into previously isolated pulmonary veins (PVs). Little evidence concerning repeat PV isolation (PVI) and non-PV ATA ablation has been reported. This study aimed to explore the clinical outcome of recurrent ATA ablation after PVI and the difference between patients with and without non-PV ATA.A total of 49 patients without structural heart diseases who received catheter ablation for recurrent AF between January 2014 and December 2018 were recruited (prior ablation with PVI only 71.4% and PVI with cavotricuspid isthmus line ablation 28.6%). Patients were divided into two groups according to the presence or absence of non-PV ATA.Most patients (53.1%) experienced very late recurrence with a median duration of 15 months. A total of 15 patients had non-PV ATA and received non-PV ATA ablation whereas 34 patients received only repeat PVI for reconnected PVs. A higher pulmonary arterial systolic pressure (PASP) was associated with non-PV ATA (odds ratio: 1.161; 95% confidence interval: 1.021-1.321; P = 0.023). During 4.7 ± 1 months, 4/15 (26.7%) and 1/34 (2.9%) patients with and without non-PV ATA, respectively, had ATA recurrence (P = 0.011). The cumulative incidence of ATA recurrence after repeat ablation was significantly lower in patients without non-PV ATA (P = 0.013).In our study, a high PASP was associated with non-PV ATA in patients with recurrent AF. Repeat PVI had a high rate of maintenance of sinus rhythm in patients without non-PV ATA.

Catheter ablation of complex atrial tachyarrhythmias in adult patients with cor triatriatum.

Reports concerning clinical characteristics of cor triatriatum and approaches for catheter ablation of complex atrial tachyarrhythmias remain limited. Here, we describe successful catheter ablation treatments for complex atrial tachyarrhythmias in patients with cor triatriatum and address the clinical caveats. Demographic characteristics, electrophysiologic findings, and ablation results in four patients with cor triatriatum were described. Catheter ablation was performed in four patients with cor triatriatum (three sinister and one dexter) and complex atrial arrhythmias (three with persistent atrial fibrillation (AF) and one with atypical left atrial flutter). A transseptal puncture was selectively directed into the accessory compartment containing the pulmonary veins. A comprehensive preview involving transthoracic echocardiography, transesophageal echocardiography, and computed tomography of the pulmonary veins was critical for proper positioning of ablation catheters. The pulmonary veins remain the major triggers or initiators for AF, and four pulmonary vein isolation procedures were sufficient to achieve successful results with negative inducibility test in the patients with AF. Heterogeneous conduction and complex fractionated signals were observed on the fibromuscular membrane. Atypical flutter was terminated during ablation over the connection between membrane and left atrial roof. The procedure was successfully performed on all patients without complications. No acute recurrences of atrial tachyarrhythmias were observed in any of the patients during short-term follow-up. Catheter ablation is a feasible and efficient therapeutic strategy for treating complex atrial tachyarrhythmias in patients with cor triatriatum. Atrial remodeling due to anatomical obstruction or heterogeneous conduction of the fibromuscular membrane may serve as an arrhythmic substrate.

Recurrent persistent atrial fibrillation after effective pulmonary vein isolation: What else?

Pulmonary vein isolation (PVI) is the mainstay of every atrial fibrillation (AF) ablation procedure. However, it is still debated in the literature whether PVI alone is sufficient to achieve long-term freedom from atrial tachyarrhythmias in patients with non-paroxysmal AF. Hereby, we discuss the hypothetical clinical scenario of a patient with AF relapse 6 months after PVI in whom all pulmonary veins are electrically silent at the time of repeat ablation.

Efficacy and safety of new-generation atrial antitachycardia pacing for atrial tachyarrhythmias in patients implanted with cardiac resynchronization therapy devices

BackgroundAtrial tachyarrhythmias (ATAs) have a significant negative impact on the prognosis of patients implanted with cardiac resynchronization therapy (CRT) devices. New-generation atrial antitachycardia pacing (Reactive ATP, Medtronic Inc., Minneapolis, MN, USA) is effective in managing ATAs in patients implanted with pacemakers. The purpose of this study was to evaluate the efficacy and safety of Reactive ATP in patients implanted with CRT devices. MethodsThis was a single-center retrospective study involving 72 CRT patients with a history of ATAs [44 patients with a device capable of Reactive ATP (ATP group) and 28 patients with a device without ATP function (Control group)]. The atrial fibrillation (AF) burden, the biventricular pacing rate, and clinical outcomes were compared between the two groups. ResultsAt baseline, there was no significant difference in the AF burden and biventricular pacing rate between the ATP and Control groups. During the 832±489 days of the follow-up period, 23 of the 44 patients (52%) received a total of 2862 ATP deliveries and the median ATP success rate was 23.6% (interquartile range: 12.5–50.0%) in the ATP group. The AF burden was significantly decreased only in the ATP group 6 months after ATP was programmed (from 6.1±18.2% to 2.0±5.4%, p=0.0083) and maintained low throughout the follow-up period. Moreover, there were no Reactive ATP-related complications observed. Patients in the ATP group showed a significantly lower incidence of heart failure (HF) hospitalization (log-rank, p=0.041) and ventricular arrhythmias (log-rank, p=0.039) than those reported in the Control group. ConclusionsReactive ATP successfully and safely reduced AF burden, and was associated with a lower incidence of HF hospitalization in patients implanted with CRT devices.