Catheter Ablation Procedures Research Articles

Effect of acupuncture on quality of life in atrial fibrillation: study protocol for a randomised controlled trial

IntroductionAtrial fibrillation (AF) is the prevalent cardiac arrhythmia and can significantly impair the quality of life (QoL). Although catheter ablation (CA) is an established treatment for AF,post-procedural complications or perceived...

Strategy Optimization for a Combined Procedure in Patients With Atrial Fibrillation: The COMBINATION Randomized Clinical Trial.

The optimal strategy of combining left atrial appendage occlusion (LAAO) with catheter ablation (CA) in patients with atrial fibrillation (AF) during a single procedure remains unclear. To determine the effects of ablation-first vs occlusion-first strategies on long-term clinical outcomes among patients with atrial fibrillation undergoing a combined LAAO and CA procedure. The prospective, multicenter COMBINATION randomized clinical trial was conducted in 14 high-volume centers in China. Enrollment of patients with nonvalvular AF referred for the combined procedure began on July 24, 2020, and concluded on January 20, 2022. Patients were randomly assigned to either the ablation-first group or the occlusion-first group. Outcomes of LAAO using an occlusion device and CA using a contact force-sensing catheter following different combination strategies during long-term follow-up were evaluated. The primary end point was a composite of thromboembolic events including stroke or transient ischemic attack, device-related thrombus (DRT), clinically relevant bleeding, and cardiovascular rehospitalization or death. Freedom from AF or atrial tachyarrhythmia (ATA) after a single procedure without antiarrhythmic drugs, at both 1 year and long-term follow-up, was also evaluated. Of the 202 patients enrolled, 194 (96.0%) completed the trial (97 in the ablation-first group and 97 in the occlusion-first group). The mean (SD) age of the cohort was 67.3 (9.2) years, and 110 patients (56.7%) were male. All procedures achieved acute successful LAAO and restoration of sinus rhythm, with similar incidences of periprocedural complications. Compared with the ablation-first group, the occlusion-first group exhibited significantly higher event-free survival of the primary end point (83.5% vs 71.1%; hazard ratio [HR], 0.53 [95% CI, 0.29-0.95]; log-rank P = .04) during the median 2.5 (IQR, 2.3-2.8) years of follow-up. Subgroup analysis indicated that male patients and those with higher CHA2DS2-VASc scores (a composite of factors associated with stroke risk; higher scores indicate higher risk) were at lower risk of thromboembolic events. Rates of long-term freedom from AF (77.3% vs 63.5%; HR, 0.58 [95% CI, 0.34-0.97]; log-rank P = .04) and from ATA (70.1% vs 55.7%; HR, 0.62 [95% CI, 0.39-0.99]; log-rank P = .04) were higher in the occlusion-first group vs the ablation-first group. Additionally, a higher incidence of chronic peridevice leak (15 [15.5%] vs 5 [5.2%]; P = .03) and DRT (8 [8.2%] vs 1 [1.0%]; P = .04) was observed in the ablation-first group vs the occlusion-first group. In this randomized clinical trial, the occlusion-first approach was superior due to its higher event-free survival of the primary end point and long-term freedom from ATA. These findings suggest that the occlusion-first approach should be recommended for combined procedures with plug-like device implantation. Chinese Clinical Trial Registry Identifier: ChiCTR2000031486.

Analysis of the left atrial appendage function by intracardiac echocardiography in patients with atrial fibrillation

Abstract Introduction Intracardiac echocardiography (ICE) is frequently performed during catheter ablation procedures in order to guide the transseptal puncture and has been recently used to evaluate the morphology of the LAA. Purpose The objective of this study was to evaluate the feasibility of using an ICE catheter placed in the coronary sinus (CS) to delineate the LAA function during catheter ablation for atrial fibrillation. Methods We included 21 consecutive patients (age 62±9 years, 5 women, 6 paroxysmal AF) who underwent catheter ablation for AF. An 8-Fr phased-array ICE catheter was used to obtain images of the LAA, while in sinus rhythm. The LAA was visualized with the ICE probe placed sequentially in the left atrium (LA, Figure A), with the ultrasound section plane parallel to the long axis of the left ventricle (LV), and in the CS, with the ultrasound section plane perpendicular to the LV long axis (Figure B). LAA emptying flow velocity, and LAA fractional area change (FAC) were used to evaluate LAA function. There were no procedural complications. Results ICE imaging was possible in all cases. The LAA peak flow velocity was similar when the ICE catheter was placed in the LA and in the CS (64±7 cm/s and 62±5cm/s respectively, P=NS). The LAA FAC was significantly lower when the ICE catheter was placed in the CS when compared to an LA location (14±6% vs 36±14%; P<0.001). The LAA FAC measured from the LA correlated with the mitral annular plane systolic excursion while the LAA FAC measured from the CS did not. Thus, LAA contraction in a plane perpendicular to the LV long axis is independent of the LV longitudinal contraction. These results suggest that in our patient group most of the LAA contraction was due to the longitudinal movement of the LV base during systole and diastole. Conclusions Imaging of LAA using an ICE probe positioned in the LA and CS was feasible in all cases. The LV longitudinal contraction appears to impact the LAA function.

Strategy optimization for the combined procedure of left atrial appendage occlusion plus catheter ablation in patients with atrial fibrillation (COMBINATION): a multi-center, randomized study

Abstract Background The long-term efficacy and safety of combining left atrial appendage closure (LAAC) plus catheter ablation (CA) in patients with atrial fibrillation (AF) in a single procedure have been established. However, the optimal combining strategy has not been well elucidated. Objective To determine the impact of different combining strategies on long-term clinical outcomes. Methods In this prospective multicenter study, patients with non-valvular AF referred for the combining procedure were randomly assigned to the ablation-first or occlusion-first groups at a 1:1 ratio. We evaluated the outcomes of LAAC with a Watchman device and CA using a contact-force sensing catheter during long-term follow-up. Results Of the 202 randomized patients, 194(96.0%) completed the trial with 97 patients in each group. Baseline characteristics were comparable between groups. All procedures were accomplished with acute successful LAAC and restoration of sinus rhythm. Incidences of periprocedural complications were similar. Higher chronic peri-device leak (PDL, 15.5% vs 5.2%, P=0.031) and device-related thrombus (DRT, 8.2% vs 1.0%, P=0.035) rates were observed in the ablation-first group. The event-free survival rate of the primary endpoint (composite of stroke/transient ischemic attack, thromboembolism, clinically-relevant bleeding, cardiovascular rehospitalization/death) was significantly higher in the occlusion-first group (83.5% vs 71.1%, log-rank P=0.036, HR 0.53, 95%CI 0.29-0.95) during a median 2.5-year follow-up. Patients with male gender and higher CHA2DS2-VASc score were at lower risk in the subgroup analysis. Long-term freedoms from AF (77.3% vs 63.5%, log-rank P=0.039) and atrial tachyarrhythmias (70.1% vs 55.7%, log-rank P=0.044) were higher in the occlusion-first group, respectively. Conclusions The occlusion-first approach is recommended for combined procedures where a plug-like device is implanted due to its superior long-term clinical benefits.Flowchart of the COMBINATION trialIncidences of primary endpoint

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.

Risk of death, thromboembolic events, and bleeding in elderly patients with Atrial Fibrillation and Clinical Complexity who are not taking oral anticoagulation

Abstract Background Patients with Atrial Fibrillation (AF) often exhibit Clinical Complexity (CC), defined as ≥2 features, i.e. patients aged ≥75 years plus a body mass index (BMI) < 23/kg/m2 and/or bleeding history and/or chronic kidney disease. No data are available about the clinical course of patients with Atrial Fibrillation (AF) and CC who are not taking oral anticoagulation (OAC). Purpose To assess the risk of thrombotic and hemorrhagic events in patients with Atrial Fibrillation (AF) and CC who are not taking OAC. Methods Retrospective study with a health care research network (TriNetX). Based on the ICD-10-CM codes entered between 2011-2022 from 85 health care organizations mainly located in the United States, AF patients ≥75 years with CC were categorized into two groups based on the use of OAC during the last year before the study period. The primary outcomes were the one-year risk of death, major cardiovascular events ([MACE]: heart failure, stroke, and myocardial infarction), and major bleeding (central nervous system, gastrointestinal, internal bleeding, and hypovolemic shock). Secondary outcomes were each component of the primary outcome and catheter ablation. Cox regression analyses were used to calculate hazard ratios (HRs) and 95% CIs following propensity score matching 1:1. Results Overall, we identified 271,402 AF CC patients not on OAC (80.1±6.8 years, 46.5% females) and 87,101 AF CC patients on OAC (79.8±6.5 years, 47.6% females). Before PSM, AF CC patients not on OAC showed no significant differences in cardiovascular and bleeding risk factors but were less treated with pharmacological treatment than AF CC patients on OAC. After PSM, no significant differences were found between the two groups, but AF CC not on OAC were at higher risk of all-cause death (HR 1.54, 95%CI 1.50-1.57), MACE (HR 1.13, 95%CI 1.11-1.16), and major bleeding (HR 1.34, 95%CI 1.31-1.38), when compared to AF CC on OAC. AF CC patients not on OAC were associated with a higher risk of each component of the primary outcome and with a lower use of catheter ablation procedures (HR 0.48, 95%CI 0.43-0.54) (Table 1). The risk of the composite outcomes was the highest in those with all the three CC components. A progressive increase in OAC prescription was observed during the follow-up period, with increasing of NOACs and lower use of warfarin being observed. There was a clear temporal relationship between increasing OAC prescription and incidence of bleeding in CC patients (Figure 1) Conclusions AF CC patients not on OAC have a high risk of all-cause death, thrombotic and hemorrhagic events. Over time, increasing NOAC use was associated with more bleeding in CC patients. New antithrombotic approaches aimed at reducing thrombotic risk without increasing bleeding risk are needed in these patients.Figure 1 OAC new prescriptions

Machine-learning models to predict the risk of recurrent VT following catheter ablation in patients with structural heart disease

Abstract Background Ventricular tachycardia (VT) is a life-threatening arrhythmia that can complicate structural heart disease. While catheter ablation is effective in treating this condition, the recurrence of VT after the procedure continues to be a concern. Consequently, there is a need for a reliable system to evaluate the likelihood of arrhythmia recurrence following an ablation. Objective To predict recurrence or repeat ablation after a VT catheter ablation procedure using machine learning (ML) models. Methods We conducted a single-center, retrospective study of all patients undergoing catheter ablation for scar-related VT between 2012 and 2022. Data collected included demographics, comorbidities, medications, relevant laboratory abnormalities, electrocardiograms, echocardiograms, detailed procedural characteristics, and outcomes. Python version 3.8.5 for exploratory data analysis (EDA) and visualization. Using six different ML models from the training set (90:10 split), we used 34 variables to predict the primary outcome, including VT recurrence or repeat catheter ablation. The accuracy of these models was compared using ROC curves based on their performance on the test set. Results Out of 508 VT ablation procedures, 261 experienced a recurrence. Support Vector Classifier (SVM) performed the best, having an AUC of 0.73, followed by logistic regression at 0.69 (Figure A). SVM yielded sensitivity, specificity, positive and negative predictive values of 0.73, 0.73, 0.79, and 0.67, respectively. The F1 score was 0.70. Among the factors with the highest feature importance in the model, the most influential variable was the proceduralist’s experience level, followed by QRS width at baseline, LVEF, and patient’s age (Figure B). Conclusion Our model can predict recurrent VT after ablation with reasonable accuracy, outperforming the existing clinical risk scores significantly. Larger training sample sizes will help achieve more robust ML models and improve predictive accuracy further.Figure A: ROC curve depicting the AUROCB. Feature importance graph

Impact of adjacent thoracic structures in negative left atrial remodelling in atrial fibrillation

Abstract Background Previous work has suggested that compression from external structures can promote negative atrial remodelling in atrial fibrillation (AF) [1]. This is mechanistically plausible, with many recognised risk factors in developing AF (age, hypertension, obesity, obstructive sleep apnoea, etc.) related through activation of the autonomic nervous system with an associated increase in atrial pressure and chronic elevation in wall stress [2,3]. Such negative remodelling contributes to the existence of arrhythmogenic atrial substrate [4]. This is highly significant when we consider catheter ablation of extrapulmonary vein targets. Purpose This study aims to investigate the relationship between abnormal conduction patterns indicative of potential AF drivers and their proximity to structures adjacent to the left atrium (LA). Methods Eight patients with paroxysmal or persistent AF, scheduled for an elective catheter ablation procedure using a charge density mapping (CDM) system [5] underwent pre-procedural cardiac MRI. 3D surface mesh reconstructions of individuals’ LA and adjacent structures (ascending aorta [AoA], descending aorta [AoD], and spine) were produced from 2D MRI slices using a proprietary graphical interface tool developed in MATLAB (Figure 1A & B) [6]. MRI derived LA geometries were registered with their CDM counterparts by the Iterative Closest Point algorithm (Figure 1C); this enabled integration of MRI LA geometries into the CDM system. Subsequently, non-contact intrachamber voltage measurements from individuals’ procedures were used to derive cardiac activation directly onto MRI LA geometries. Abnormal conduction patterns representing possible AF drivers (focal firing, rotational propagation, and pivoting propagation) [5] were quantified as occurrences per second at each vertex of MRI LA geometries (Figure 1D). These conduction patterns could then be visualised and assessed in the context of adjacent structures (Figure 1E), with the Euclidean distance between each vertex of the MRI LA geometries and the closest point to their adjacent structures being calculated. Results Mean age was 65±9 years; 4 patients (50%) were male; AF was paroxysmal in 3 (37%) and persistent in 5 (63%); median time since AF diagnosis was 1 (1-3.8) years; ablation type was de novo in 5 (63%) and retreatment in 3 (38%). Frequencies of pivoting and rotational propagation were notably higher in regions of the LA closer to the AoA, and lower near the AoD and spine (Figure 2A & B). Conversely, focal firing showed a less prominent trend, being more frequent in LA regions nearer the AoD and distant from the AoA (Figure 2C). Conclusions Compression from the ascending aorta may promote anterior LA remodelling in AF, leading to increased pivoting and rotational AF drivers. Clinically, this suggests a potential target for ablation therapy with an anterior seatbelt line connecting the right superior pulmonary vein to the mitral annulus.

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

Temporal trends of catheter ablation procedures in patients with atrial fibrillation and atrial flutter: A nationwide cohort study

BackgroundCatheter ablation is a well-established treatment to prevent atrial fibrillation (AF) and atrial flutter (AFL) recurrences and to relieve symptoms, whereas pacemaker implantation and atrioventricular node (AVN) ablation is used for rate control when medical therapy fails. AimsWe investigated temporal trends and patient characteristics in catheter ablation procedures for AF, AFL and AVN in Finland between 2012–2018. MethodsFinnish AntiCoagulation in Atrial Fibrillation (FinACAF) is a registry-based study including all patients with AF or AFL in Finland between 2012–2018. ResultsThe number of patients with AF or AFL diagnosis in Finland increased from 185057 to 243802 between 2012–2018 and a total of 8954 first-time catheter ablation procedures were performed. Of them, 4909 (54.8 %) were AF ablations, 2731 (30.5 %) AFL ablations and 1314 (14.7 %) AVN ablations. The procedural numbers increased from 457/year to 934/year for AF, from 223/year to 553/year for AFL and from 114/year to 238/year for AVN. Altogether, 0.65% of all patients with diagnosed AF or AFL underwent AF, AFL or AVN ablation in 2018. The mean age of the patients increased in all ablation groups. Patients undergoing AF and AFL ablations were predominantly men (69.7 % and 74.6 % respectively) whereas patients undergoing AVN ablation were more often women (56.9%). ConclusionsThe use of catheter ablation more than doubled during 2012–2018 and the increase was particularly seen in the elderly patients. Nevertheless, only a minority of AF and AFL patients were treated with catheter ablations.

Combined left atrial appendage occlusion and catheter ablation procedure for left atrial arrhythmias: A real-world, propensity-matched analysis.

Real-world studies comparing safety and efficacy of combined percutaneous left atrial appendage occlusion (LAAO) and catheter ablation (CA) to LAAO alone are limited. Patients from a large US hospital system undergoing combined LAAO and left-atrial CA from 8/2020 to 2/2024 were retrospectively analyzed and compared to a control group undergoing LAAO alone. Controls were identified using a 1:2 propensity score match based on LAAO device type (Watchman FLX vs. Amulet), CHA2D2-VASc and Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio [INR], Elderly, Drugs/alcohol (HAS-BLED) scores and compared for safety, sealing performance and clinical outcomes at 6 months. Patients were younger in the combined (n = 72) than in the control group (n = 144, 70.2 ± 7.3 vs. 76.7 ± 6.9 years, p < 0.001) but otherwise comparable with a mean CHA2D2-VASc score of 4.2 ± 1.1 and 4.4 ± 1.2 (p = 0.26) and HAS-BLED score of 2.2 ± 0.8 and 2.3 ± 0.7 (p = 0.34). Successful LAAO implantation rates were the same (95.8% vs. 95.8%, p = 0.99) with longer procedure times seen in the combined group (156.5 ± 53 vs. 56 ± 26 min, p < 0.001). Both major (1.4% vs. 2.1%, p = 0.72) and minor (27.8% vs. 19.4%, p = 0.17) in-hospital complications were similar between the combined and control group, respectively. At 45 days, presence of peri-device leak (18.3% vs. 30.4%, p = 0.07) and device related thrombosis (4.5% vs. 4.5%, p = 0.96) on transesophageal echocardiogram did not differ. Finally, all-cause mortality (0% vs. 1.4%, p = 0.99), thromboembolic (0% vs. 0%, p = 0.99) and bleeding (6.1% vs. 4.4%, p = 0.73) events during follow-up were comparable. This large, real-world analysis indicates comparable safety and efficiency of combined LAAO and CA when compared with LAAO alone.

Charge density mapping demonstrates superiority in catheter ablation of post-surgical atrial tachycardias.

Atrial tachycardia (AT) frequently occurs after cardiac surgery or surgical ablation procedures. The novel charge density-based mapping system (CDM) provides global chamber mapping and can detect crucial pathways of conduction; therefore, it has potential added value in catheter ablation (CA) of post-surgical ATs. We aimed to test the hypothesis that CDM-guided CA procedures are safe, feasible, and may improve outcome compared to conventional sequential 3D mapping (CARTO)-based CA. Consecutive patients undergoing CA for post-surgical AT guided by CDM or CARTO were enrolled. Procedural safety and efficiency were analyzed. Acute success, one-year outcome was assessed. A total of 35 patients (mean age 60.8 ± 10.6 years, 42.9% female) underwent CA of AT using CDM (n = 20) and CARTO (n = 15). A total of 61 ATs were mapped (35 in CDM and 26 in CARTO group). Four patients had focal ATs, 22 macro re-entrant, and 8 patients had ATs with both mechanisms. No differences were found in procedural complication (CDM 3 vs. CARTO 1 patient, p = 0.61). There were no differences in procedure duration (185.9 vs. 147.9 min, p = 0.09), fluoroscopy dose (165.0 vs. 155.0 mGy, p = 0.31), RF application number (28.0 vs. 18.0, p = 0.17) or duration (1,251.5 vs. 1,060.0 s, p = 0.54). Acute success was 95.0% in CDM and 73.3% in CARTO group (p = 0.14). Cumulative AT recurrence rates were lower in CDM group compared to CARTO group (10.0% vs. 46.7%, p = 0.02). The CDM system is feasible. Our data suggest that patients treated with CDM-guided CA developed fewer AT recurrences as compared to CARTO-guided procedures.

Early LAAO device migration after combined atrial fibrillation ablation and left atrial appendage occlusion.

The combined procedure of catheter ablation and percutaneous left atrial appendage occlusion for patients with atrial fibrillation has been shown to be safe and feasible using radiofrequency energy or cryoballoon.

Outcomes of atrial fibrillation ablation in community hospitals with and without onsite cardiothoracic surgery availability.

Limited data exist on outcomes of atrial fibrillation (AF) catheter ablation based on hospital setting and, specifically, the availability of onsite cardiothoracic surgery (CTS). We aimed to describe the characteristics and outcomes of catheter ablation for AF performed at a facility with and without CTS. This was a retrospective study of consecutive patients who underwent catheter ablation for AF at hospital with (CTS) and without cardiothoracic surgery (N-CTS) from January 2011 through December 2019. Clinical and procedural characteristics, complications, and 1-year outcomes, including clinical events and AF recurrence, were collected. There were 326 unique patients who underwent an index AF ablation procedure: 206 CTS patients and 120 N-CTS patients. There were no differences inoverall cardiac complications (2.5% vs. 5.8%), including mapping catheter entrapment requiring open-heart surgery (0% vs. 0.5%), pericardial effusion requiring pericardiocentesis (0.8% vs. 0.5%), hemopericardium (1.7% vs. 0.5%), acute myocardial infarction (0% vs. 1.0%), and sinus node injury (0% versus 0.5%) (all P values > .05)between N-CTS and CTS patients. Likewise, overall noncardiac complications (20.7% vs. 19.8%, P = .85), including bleeding, cerebrovascular accident, and phrenic or vagus nerve injury, were similar between N-CTS and CTS hospitals. Also, 1-year cumulative Kaplan-Meier estimates of overall AF recurrence (11.6% vs. 16.4%; log-rank P = 0.21; HR 1.47; 95% CI, 0.79-2.74) were not statistically significant between N-CTS and CTS hospitals. Catheter ablation procedure is safe and effective regardless of onsite CTS presence, and there were no significant differences between the two hospital settings.

Thirty-day mortality risk in patients following radiofrequency and cryoballoon ablation for atrial fibrillation across the entire nation of Poland: An 8-year analysis from the National Health Fund of Poland.

Atrial fibrillation (AF) is the most common sustained arrhythmia, and catheter ablation (CA) is a primary therapeutic option. However, the 30-day all-cause mortality risk associated with CA for AF may be underestimated due to selection bias. Our study aimed to assess 30-day mortality in an unselected cohort of patients. Data from the National Health Fund-Poland covered over 99% of nationwide radiofrequency ablation (RF) or cryoballoon ablation for AF, with 100% recorded deaths. The study included consecutive CA procedures in adult patients between 2012 and 2019. Thirty-day mortality rates were calculated for each age group. A total of 31 214 CAs for AF were performed on 26 767 patients (34.8% female). Forty-four percent of patients had hypertension, 31.2% had coronary artery disease, 14.4% had heart failure, 11% had diabetes mellitus, 5.6% had malignant neoplasms, 2.7% had a previous myocardial infarction, 2.5% had a previous stroke, and 2.2% had kidney disease. Thirty-two deaths (0.1%) occurred within 30 days, with the highest mortality in the oldest age group (>80 years). Statistical analysis revealed higher incidences of kidney disease (p < 0.001) and heart failure (p = 0.001) in patients who died within 30 days. Mortality risk did not significantly differ between cryoballoon and RF ablation, as well as first and subsequent ablation for AF. The risk of death within 7 days postablation for AF was 1 in 2750 procedures, while the risk of death on the same day postablation was 1 in 6250 procedures. The 30-day mortality rate in a large, unselected AF ablation cohort, covering 99% of procedures in the country, is low except for the oldest patients. This factor should be taken into consideration when offering CA for AF.

Left Atrial Wall Thickness Estimated by Cardiac CT: Implications for Catheter Ablation of Atrial Fibrillation.

Atrial wall thickness (AWT) is a significant factor in understanding the pathological physiological substrate of atrial fibrillation, with a potentially substantial impact on the outcomes of catheter ablation procedures. Precise measurements of the AWT may provide valuable insights for categorising patients with AF and planning targeted interventions. Objectives: The purpose of this study was to evaluate the characteristics of the left atrium (LA) using non-invasive multidetector computed tomography (MDCT) scans and subsequent three-dimensional (3D) image post-processing using novel software designed to calculate atrial thickness dimensions and mass. Methods: We retrospectively analysed 128 consecutive patients (33.6% females; mean age 55.6 ± 11.2 years) referred for AF ablation (37 with persistent AF and 91 with paroxysmal AF) who underwent preprocedural MDCT. The images were post-processed and analysed using the ADAS software (Galgo Medical), automatically calculating the LA volume and regional wall thickness. In addition, the software employed a regional semi-automatic LA parcellation feature that divided the atrial wall into 12 segments, generating atrial wall thickness (AWT) maps per segment for each patient. Results: This study demonstrated considerable variability in the average thickness of LA walls, with the anterior segments being the thickest across the cohort. Distinct sex-specific differences were observed, with males exhibiting greater anterior and septal wall thickness than females. No significant associations were identified between the average AWT and body mass index, LA volume, or sphericity. Survival analysis conducted over 24 months revealed a meaningful relationship between mean anterior wall thickness and recurrence-free survival, with increased thickness associated with a lower likelihood of AF-free survival. No such relationship was observed for the indexed LA volume. Conclusions: The variability in AWT and its association with recurrence-free survival following AF ablation suggest that AWT should be considered when stratifying patients for AF management and ablation strategies. These findings underscore the need for personalised treatment approaches and further research on the interplay of the structural properties of the left atrium as factors that can serve as important prognostic markers in AF treatment.

Ventricular arrhythmias originating from different portions of the communicating vein of the left ventricular summit: electrocardiographic characteristics and catheter ablation

BackgroundIdiopathic ventricular arrhythmias (IVAs) arising from different portions of the communicating vein of the left ventricular summit (summit-CV) are not a rare phenomenon. Whereas its electrocardiographic (ECG) and electrophysiological characteristics are not fully investigated.ObjectiveThis study aimed to identify distinct ECG and electrophysiological features of IVAs originating from different portions of summit-CV.MethodsNineteen patients confirmed arising from summit-CV were included in this study.ResultsThe 19 patients were divided into proximal and distal portion groups based on their target sites in summit-CV. In the proximal portion group, 100% (11/11) VAs showed dominant negative (rs or QS) waves in lead I, while in the distal portion group, 87.5% (7/8) showed dominant positive waves (R, Rs or r) (p < 0.000). In lead V1, 100% (11/11) of the proximal portion group showed dominant positive waves (R or Rs), while 62.50% (5/8) of the distal portion group showed positive and negative bidirectional or negative waves (RS or rS) (p < 0.005). RI>4mV, SI<3.5mV, RV1<13mV, SV1>3.5mV, RI/SI>0.83, and RV1/SV1< 2.6 indicated a distal portion of summit-CV with the predictive value of 0.909, 1.000, 0.653, 0.972, 0.903, 0.966, respectively. A more positive wave in lead I and a more negative wave in lead V1 indicated more distal origin in summit-CV. Target sites in proximal and distal summit-CV groups showed similar electrophysiological characteristics during mapping.ConclusionsThere were significant differences in ECG characteristics of VAs at different portions of summit-CV, which could aid pre-procedure planning and facilitate radiofrequency catheter ablation (RFCA) procedures.

Atrial fibrillation fact sheet in Korea 2024 (part 3): treatment for atrial fibrillation in Korea: medicines and ablation

BackgroundAtrial fibrillation (AF) is a prevalent cardiac arrhythmia associated with significant morbidity and mortality, posing a considerable burden on healthcare systems. In Republic of Korea, the prevalence and incidence of AF have increased in recent years. There have also been significant changes in the trends of antiarrhythmic drug (AAD) use and procedural treatments for AF.ObjectivesThis study aims to review the trends in AF treatment strategies in Republic of Korea, particularly focusing on the utilization of antiarrhythmic drugs and catheter ablation.MethodsThe Korean National Health Insurance Service (K-NHIS) data were used to identify AF patients from 2013 to 2022. AAD usage and catheter ablation procedures were analyzed annually. AADs were classified into Class IC and III drugs. Trends in beta-blockers, calcium channel blockers, and digoxin prescriptions were also examined. The primary endpoint was the trend of AAD use and AF catheter ablation (AFCA) over 10 years.ResultsIn 2022, 940,063 patients had a prior diagnosis of AF. From 2013 to 2022, the use of AADs increased from 12.1 to 16.4% among prevalent AF patients. Beta-blockers were the most commonly prescribed rate control medication, while the use of calcium channel blockers and digoxin declined. The frequency of AFCA procedures also increased, from 0.5% of prevalent AF patients in 2013 to 0.7% in 2022. Younger patients, males, and those with lower CHA2DS2-VASc scores were more likely to receive AFCA. Regional variations in treatment patterns were observed, with Seoul exhibiting higher rates of procedural treatments and AAD prescriptions.ConclusionsOver the past decade, there has been a significant increase in the use of AADs and AFCA procedures in Republic of Korea. These trends reflect recent advancements in AF management advocating a refined rhythm control strategy.

Remote technical support of nurse-lead electro-anatomic mapping during complex catheter ablation procedures.

Remote technical support of nurse-lead electro-anatomic mapping during complex catheter ablation procedures.

Safety and feasibility of cardiac electrophysiology procedures in ambulatory surgery centers

BackgroundDespite their improved safety, by and large, cardiac electrophysiology procedures including catheter ablation (CA), are presently performed in hospital outpatient departments. ObjectiveThis large multicenter study investigated the safety and outcomes associated with various cardiac electrophysiology procedures performed at 6 ambulatory surgery centers (ASCs), primarily during the coronavirus disease 2019 pandemic under the Center for Medicare and Medicaid Services Hospitals Without Walls program. MethodsWe retrospectively analyzed the outcomes from consecutive electrophysiology procedures performed in ASCs with same-day discharge, including transesophageal echocardiography, cardioversion, cardiac implantable electronic device (CIED) implantation, electrophysiology studies, and CA for atrial fibrillation (AF), atrial flutter (AFL)/supraventricular tachycardia, ventricular premature complexes (VPCs), and atrioventricular node. ResultsAltogether, 4037 procedures were performed, including 779 transesophageal echocardiography/cardioversion procedures (19.3%), 1453 CIED implantation procedures (36.0%), 26 electrophysiology studies (0.6%), and 1779 CA procedures (44.1%) for AF (75.4%), AFL/supraventricular tachycardia (18.8%), VPC (4.7%), and atrioventricular node (1.1%). Overall, 80.2% of CA procedures were for left-sided atrial arrhythmias (AF/atypical AFL) requiring transseptal catheterization. Left-sided VPC ablation procedures (42.2%) were performed using a transseptal/retrograde approach. Adverse event rates were low, but comparable between CIED implantation and CA (0.76% vs 0.73%; P = .93), as were the incidences of urgent/unplanned postprocedure hospitalization (0.48% vs 0.45%; P = .89), respectively. Moreover, the adverse event rates in ASCs vs hospital outpatient departments did not differ for CIED (0.76% vs 0.65%; P = .71) or CA (0.73% vs 0.80%; P = .79). ConclusionThe results from this large multicenter study suggest that ASCs represent a safe and effective setting to perform a variety of cardiac electrophysiology procedures including CA. These findings bear important implications for healthcare delivery and policy.