Circumferential Pulmonary Vein Research Articles

Unipolar Voltage for Better Characterizing Left Atrium Substrates: Comparing the Predictive Efficacy for Recurrence Post Atrial Fibrillation Ablation in a Post Hoc Analysis of STABLE-SR-III Trial.

While bipolar voltage (BV) is acknowledged as an indicator of viable cardiomyocyte activation, unipolar recording has emerged as an alternative technique due to its advantage of providing a wider field of view. This study aims to compare the efficacy of unipolar voltage (UV) versus BV in predicting ablation recurrence in atrial fibrillation patients. In Substrate Ablation in the Left Atrium during Sinus Rhythm Trial III, 375 patients completed the follow-up with preserved mapping data were included in the analysis. For each patient, the mean UV and BV was obtained from the electrograms sampled in left atrium (LA). Totally 301 patients experience the primary endpoint within 23.0 ± 9.2 months. While both low UV and BV had significant associations with long-term recurrence of atrial tachyarrhythmia (ATa), only mean UV was independently associated with the outcome. The model by UV with ablation feature had higher discriminatory power to predict ATa recurrence compared with BV model (area under the curve [AUC]: 0.858 vs. 0.757, p < 0.001). In subgroup analysis, UV reveals more powerful predictive efficacy compared with BV, with the AUC 0.843 versus 0.751 (p < 0.001) in circumferential pulmonary vein isolation (CPVI) alone cohort and 0.882 versus 0.750 (p < 0.001) in CPVI plus cohort, respectively. UV exhibits higher efficacy for predicting long-term ATa recurrence after ablation compared with BV in elderly patients with atrial fibrillation regardless of whether the patient accepts substrate modification. The outcome suggests that unipolar recording may better characterize LA fibrosis by capturing more comprehensive transmural features than bipolar signals. ClinicalTrials.gov; URL: https://www. gov. Unique Identifier: NCT03462628.

Recurrent atrial flutter after radiofrequency ablation for atrial fibrillation in a patient with hypertrophic obstructive cardiomyopathy undergoing repetitive transcoronary ablation of septal hypertrophy

IntroductionWe described the clinical characteristics of a patient with hypertrophic obstructive cardiomyopathy (HOCM) who had undergone transcoronary ablation of septal hypertrophy (TASH) twice and developed atrial flutter after radiofrequency ablation for atrial fibrillation (AF) due to pulmonary vein reconnection. This case of HOCM is unique because of its complex complications and multiple complex atrial arrhythmias. The treatment of HOCM was successful and the postoperative follow-up results was good.Methods and resultsA 71-year-oldfemale, developed exertional dyspnea with palpitations 12 years ago, with a valid diagnosis of HOCM according to the echocardiography which showed an absolute increase in the interventricular septum thickness (22.8 mm). She underwent two rounds of TASH and only the second round was successful. During a visit due to recurrent palpitations, the patient was diagnosed with AF based on electrocardiographic examination. Circumferential pulmonary vein isolation (CPVI) was performed to treat AF. However, the recurrence of atrial flutter was detected on her electrocardiograms (ECGs) three years after the operation. Since the patient had an interstitial lung injury, there were relative contraindications for antiarrhythmic drugs. Due to restrictive use of antiarrhythmic drugs and continuous palpitation, the patient agreed to receive a second radiofrequency ablation. Left-sided macroreentrant circuits were identified via high-density mapping and successful ablation was performed at the isthmus.ConclusionsPerforming catheter ablation and TASH respectively in patients with HOCM associated with AF would be tricky. But taking such a comprehensive and respective clinical treatment would be beneficial to patients in the long term.

The Safety and Efficacy of Left Atrial BOX Ablation in Persistent Atrial Fibrillation: A Meta-Analysis.

Circumferential pulmonary vein isolation (CPVI) has a high recurrence rate in managing persistent atrial fibrillation (AF). While some studies suggest that augmenting CPVI with additional left atrial BOX ablation can diminish this recurrence rate among patients with persistent AF, this approach remains controversial. This meta-analysis assesses the safety and efficacy of adjunctive left atrial BOX ablation in treating persistent atrial fibrillation. We conducted a comprehensive literature search across China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, and Cochrane Library, focusing on randomized controlled trials. The primary outcome was the recurrence rate of any atrial arrhythmias (AAs) within one-year post-treatment, with the secondary outcome being the frequency of adverse events related to the surgery. The combination of CPVI and left atrial BOX ablation did not lead to a significant reduction in the overall recurrence rate of atrial arrhythmias (risk ratios (RR) = 0.86, 95% confidence interval (CI) = 0.73-1.02, I2 = 35%). However, subgroup analyses revealed that this therapeutic approach significantly decreased the recurrence rates of all atrial arrhythmias (RR = 0.67, 95% CI = 0.49-0.92, I2 = 15%) and specifically atrial fibrillation (RR = 0.53, 95% CI = 0.37-0.77, I2 = 0%) in patients with a left atrial diameter ≤44 mm. Notably, there was no significant increase in the incidence of procedure-related adverse events (RR = 1.04, 95% CI = 0.56-1.94, I2 = 0%). However, the durations of both the ablation (mean difference (MD) = 19.77, 95% CI = 15.84-23.70, I2 = 0%) and the overall procedure (MD = 15.64, 95% CI = 6.99-24.29, I2 = 0%) were longer due to the additional ablation steps. In patients with smaller left atrial diameters, augmenting CPVI with left atrial BOX ablation significantly lowers the recurrence rates of atrial arrhythmias and atrial fibrillation without elevating surgical risk levels.

An unexpected culprit of haemoptysis: Bronchial varices and review of literature.

Bronchial varices, characterized by dilated and tortuous vessels within the bronchial tree, are a rare entity often presenting as massive or recurrent haemoptysis. Multiple aetiologies have been described in the literature including congenital or acquired pulmonary vein stenosis secondary to surgical or radiofrequency ablation or other cardiac interventions. We present a case of a 60-year-old female with a history of systemic hypertension, hypothyroidism and sick sinus syndrome, who presented with intermittent episodes of dry cough and haemoptysis. A diagnostic workup revealed circumferential bronchial thickening and pulmonary vein stenosis on contrast-enhanced chest computed tomography (CT). Bronchoscopic findings confirmed the presence of bronchial varices, which was secondary to the Radiofrequency ablation she underwent 7 years ago. This case highlights the diagnostic challenge posed by bronchial varices and underscores the importance of a comprehensive approach in managing such rare presentations.

Multiomics analysis of canine myocardium after circumferential pulmonary vein ablation: Effect of neuropeptide Y on long-term reinduction of atrial fibrillation.

Catheter ablation (CA) is an essential method for the interventional treatment of atrial fibrillation (AF), and it is very important to reduce long-term recurrence after CA. The mechanism of recurrence after CA is still unclear. We established a long-term model of beagle canines after circumferential pulmonary vein ablation (CPVA). The transcriptome and proteome were obtained using high-throughput sequencing and TMT-tagged LC-MS/LC analysis, respectively. Differentially expressed genes and proteins were screened and enriched, and the effect of fibrosis was found and verified in tissues. A downregulated protein, neuropeptide Y (NPY), was selected for validation and the results suggest that NPY may play a role in the long-term reinduction of AF after CPVA. Then, the molecular mechanism of NPY was further investigated. The results showed that the atrial effective refractory period (AERP) was shortened and fibrosis was increased after CPVA. Atrial myocyte apoptosis was alleviated by NPY intervention, and Akt activation was inhibited in cardiac fibroblasts. These results suggest that long-term suppression of NPY after CPVA may lead to induction of AF through promoting cardiomyocyte apoptosis and activating the Akt pathway in cardiac fibroblasts, which may make AF more likely to reinduce.

Combination of Epicardial Adipose Tissue and Left Atrial Low-Voltage Areas Predicting Atrial Fibrillation Recurrence after Radiofrequency Ablation.

Atrial fibrillation (AF) is a common arrhythmia, with radiofrequency catheter ablation (RFCA) being first-line therapy. However, the high rate of post-ablation recurrence necessitates the identification of predictors for recurrence risk. Left atrial low-voltage areas (LA-LVASs), reflecting atrial fibrosis, have been confirmed to be related to recurrence of AF. Recently, epicardial adipose tissue (EAT) has been studied due to its role in initiating and maintaining AF. In this study, we try to evaluate the significance of the combined use of left atrial epicardial adipose tissue (LA-EAT) and percentage of LA-LVAs (LA-LVAs%) for predicting the recurrence of AF. A total of 387 patients with AF who had undergone RFCA for the first time were followed up for 1, 3, 6, and 12 months. They were divided into two groups: the recurrence group (n = 90) and the non-recurrence group (n = 297). Before the ablation, all patients underwent computed tomography angiography examination of the left atrium, and the LA-EAT was measured using medical software (Advantage Workstation 4.6, GE, USA). After circumferential pulmonary vein isolation, a three-dimensional mapping system was used to map the LA endocardium and evaluate the LA-LVAs in sinus rhythm. After a median follow-up of 10.2 months, 90 patients developed AF recurrence after RFCA. Compared to patients without recurrence, the volume of LA-EAT (33.45 ± 13.65 vs. 26.27 ± 11.38; p &lt; 0.001) and the LA-LVAs% (1.60% [0%, 9.99%] vs. 0.00% [0%, 2.46%]; p &lt; 0.001) was significantly higher. Multivariate analysis indicated that PersAF, LA-EAT volume, and LA-LVAs% were independent predictors. Compared to PersAF (AUC 0.628; specificity 0.646; sensitivity 0.609), LA-EAT volume (AUC 0.655; specificity 0.675; sensitivity 0.586), or LA-LVAs% (AUC 0.659; specificity 0.836; sensitivity 0.437), the combined use of LA-EAT volume and LA-LVAs% offers higher accuracy for predicting AF recurrence after ablation (AUC 0.738; specificity 0.761; sensitivity 0.621). The combined LA-EAT and LA-LVAs% can effectively predict the risk of AF recurrence after radiofrequency ablation.

Posterior wall isolation in patients with persistent atrial fibrillation: a single center comparative study between ablation index and very high power short duration radiofrequency ablation protocol

Abstract Background Circumferential pulmonary veins ablation (CPVA) with posterior wall isolation (PWI) using radiofrequency catheter ablation (RFCA) is gaining increasing interest in terms of safety and efficacy. Purpose To compare procedural data and efficacy between two radiofrequency ablation protocols for the treatment of persistent atrial fibrillation (PersAF): very high power-short duration (vHPSD) ablation using a novel temperature-controlled ablation catheter and Ablation Index (AI) guided RFCA using traditional contact-force catheter. Methods This single center prospective study enrolled 75 consecutive patients (Group 1) with symptomatic PersAF undergoing RFCA using a novel contact-force catheter optimized for temperature-controlled ablation with microelectrodes and 6 thermocouples for real-time temperature monitoring during ablation. The vHPSD algorithm modulates power to maintain target temperature during these lesions (90 Watts, 4 s) in the posterior wall. RF delivery in anterior regions was performed in a temperature guided setting (1-45W, 45°C) to achieve a 500-550 AI. These patients were compared to 75 propensity matched patients (Group 2) undergoing PersAF ablation with traditional AI-guided ablation. Procedural data were compared between the two groups (Table 1). Procedural outcome was considered as loop recorder documented atrial arrhythmias recurrences and compared between the two groups. Results Seventy-five patients (69% male, 63.1±11.2 years old) underwent ablation with vHPSD protocol (Group 1). CPVA and PWI was achieved in all patients with total procedure and fluoroscopy times of 67.5±28.8 min and 4.5±2.8 min, respectively. After 12-month median follow-up, 57/75 patients (76%) were free from AF. Seventy-five propensity matched patients (69% male, 60.7±9.9 years old) have undergone ablation with standard contact-force catheter. CPVA and PWI was achieved in all patients with total procedure and fluoroscopy times of 81.99±20.5 min and 5.7±2.1 min, respectively. After 12-month median follow-up, 55/75 patients (73%) were free from AF. Procedural and fluoroscopy times were significantly lower in in Group 1 than in Group 2 (Table 1). AF recurrencies were comparable between the two groups as assessed with survival analysis (Figure 1, log-rank 0.509). There were no deaths or other severe periprocedural complications. Conclusions PWI on top of CPVA is effective in limiting arrhythmic recurrences following RFCA of PersAF. Compared to standard AI guided ablation, vHPSD protocol significantly reduces procedural time and fluoroscopy exposure. Clinical outcomes between the two protocols are similar.Figure 1

Left ventricular wall thickening predicts left atrial low voltage areas in patients undergoing catheter ablation for atrial fibrillation

Abstract Background The success rate of circumferential pulmonary vein isolation (CPVI) remains suboptimal in patients with paroxysmal and persistent atrial fibrillation; moreover, the detection of low voltage areas (LVA) in the left atrium does predict an even higher recurrence rate of atrial tachyarrhythmias after the procedure. Left ventricular wall thickening (LVWT) is known to correlate with left atrial volume; however, no data is available whether LVWT is predictive of the presence of left atrial LVA. Purpose The aim of this study was to investigate whether LVWT is predictive of left atrial LVA and to verify that the presence of LVA confer a higher arrhythmia recurrence rate after catheter ablation for atrial fibrillation. Methods A total of 374 patients who undervent CPVI with the use of 3D electroanatomical mapping system as a primary procedure were enrolled in the study. Transthoracic echocardiography was performed in all patients prior the procedure with measurement of the thickness of the septum and the posterior wall. Patients were classified based on LVWT as normal (females:≤9mm, males:≤10mm), borderline (females:10-11mm, males: 11-12mm) and increased (females:≥12mm, males:≥13mm). A detailed left atrial voltage map was obtained in all patients prior to ablation with the identification of LVA (bipolar voltage &amp;lt;0.5mV with an area &amp;gt;5cm2). Arrhythmia recurrence was defined as documented atrial fibrillation or atrial tachycardia lasting for at least 30 seconds. Results Among 374 patients (mean age: 59.0±10.2 years, 131 females) 94, 195 and 85 were considered to be normal, borderline and increased based on LVWT, respectively. LVA were found in 29.9% (112/374) of patients. According to LVWT, LVA were detected in 16.0% (15/94), 31.3% (61/195) and 42.4% (36/85) in patients with normal, borderline and increased wall thickness, respectively, p=0.005. Patients with left atrial LVA had a higher [60.7% (68/112)] arrhythmia recurrence compared to those without low voltage areas [35.1% (92/262)] during a mean follow-up of 2.1±1.9 years, p&amp;lt;0.0001. Conclusions Left ventricular wall thickening predicts the presence of left atrial low voltage areas in patients undergoing catheter ablation for atrial fibrillation. Low voltage areas confer a higher arrhyhtmia recurrence rate during follow-up.

Higher recurrence rate after ablation of persistent atrial fibrillation in patients with prolonged P-wave negativity in lead V1

Abstract Background Several ECG P-wave parameters, such as duration, amplitude and morphology reflect the electromechanical condition of the atria. P-wave features mainly served to identify patients prone to atrial fibrillation (AF) or to predict recurrence of paroxysmal AF after ablation. Purpose We sought to investigate which specific features derived from the P-wave might help identify patients with persistent atrial fibrillation (peAF) unresponsive to wide circumferential pulmonary veins isolation (WPVI). Methods 41 patients (63±10 y) with peAF (sustained duration 11±7 months) underwent a de-novo WPVI. A second WPVI was performed in patients with recurrent AF in order to provide complete PV disconnection. We defined "success" as patients who remained in sinus rhythm (SR) after one or two procedures, and "failure" otherwise. The average duration and amplitude of the P-waves on ECG lead II, and the duration and amplitude of positive and negative deflections on ECG lead V1 were extracted during SR after cardioversion at the end of the index WPVI. P-wave terminal force in V1 (PTFV1) was computed as the product of negative amplitude and duration in lead V1. Results Over a mean follow-up of 32±9 months, 24 patients remained free from AF (success group), while 11 patients had AF recurrence after 2 WPVIs (failure group). Six patients were lost to follow-up or declined the second WPVI. 45% (5/11) were ON antiarrhythmic drugs (AAD) during follow-up in the failure group, while 0.04% (1/24) were ON AAD in the success group (p&amp;lt;0.05). Other clinical characteristics (e.g. age, body mass index, left atrial volume or duration in sustained AF) were similar. The figure displays P-wave metrics of patients ON and OFF AAD during follow-up. No significant differences were found in P-wave duration (lead II; Panel A1), in PTFV1 (Panel A2), and in duration of V1 positive deflection (Panel A3). Interestingly, the failure group displayed longer duration of the negative deflection in V1 (76±17ms) than that of the success group (68±18ms, p&amp;lt;0.05; Panel A4). Panel B shows that the differences remained after exclusion of patients ON AAD during follow-up. No differences were found in P-wave amplitude in lead II or in amplitude of positive and negative deflections in lead V1 (data not shown). Conclusion Our results show that prolonged negativity in lead V1, which is indicative of left atrial electromechanical remodeling, is associated with failure to restore long-term sinus rhythm after WPVI of peAF.

Extended period rhythm outcomes of posterior box isolation of left atrium during pan-spectrum of atrial fibrillation catheter ablation in 4 randomized clinical trials

Abstract Background Catheter-based electrical posterior box isolation (POBI) in addition to circumferential pulmonary vein isolation (CPVI) did not improve rhythm outcome of atrial fibrillation (AF) catheter ablations (AFCA). We analyzed the long-term rhythm outcomes of previously conducted our 4 randomized controlled trials (RCTs) comparing CPVI vs. additional POBI by intention to treat. Methods We analyzed 575 AF patients who were included in 4 RCTs (PAF [paroxysmal AF], PEACEFUL [persistent to paroxysmal AF]; POBI [persistent and long-standing persistent AF]; and RILI [repeat procedures] trials) comparing the usefulness of additional POBI after further long-term protocol-based rhythm follow-up. We compared the primary endpoint as clinical recurrence after index procedure and major adverse cardiac event, and the secondary endpoint as procedure time, procedure-related complication rate, recurrence as atrial tachycardia (AT), and cardioversion or repeat procedure rates. We also conducted Cox regression analysis to evaluate the efficacy of POBI. Results After a median follow-up of 48months, there was no significant difference in the clinical recurrence (42.9% vs. 41.3%; log-rank P=0.855) and major adverse cardiac event (4.5% vs. 3.7%; log-rank P=0.675). Procedure time was significantly longer (p=0.003) and AT recurrence rate was higher (6.6% vs. 12.6%; log-rank P=0.014) in the additional POBI group. In patients who experienced clinical recurrence, there were no significant differences in the rates of cardioversion (33.9% vs. 46.6%, P=0.059) or the need for a repeat procedure (30.4% vs. 31.7%, P=0.955) between the two groups. Catheter-based POBI did not improve AFCA outcomes (HR 1.07 [0.81~1.40], P=0.655), regardless of paroxysmal, persistent to paroxysmal, persistent AFs, or the 2nd procedures. In the redo mapping after RCTs (n=64), PV reconnection rate did not differ, but reentrant AT was more common in POBI than in CPVI alone group (46.7% vs. 10.7%, P=0.007), while extra-PV trigger was more common in CPVI alone than in POBI group (29% vs. 3.0%, P=0.012). Conclusions Additional-POBI to CPVI did not improve long-term rhythm outcomes. Additional-POBI to CPVI is related to the increase of AT recurrence and the decrease of extra-PV trigger.

Efficacy of Shensong Yangxin capsule combined with dronedarone in paroxysmal atrial fibrillation after ablation.

To investigate whether postoperative administration of Shensong Yangxin capsules (SSYX) and dronedarone for atrial fibrillation (AF) can reduce the recurrence of paroxysmal AF after radiofrequency ablation, thus providing a more optimal choice of antiarrhythmic medication during the blank period. We included 120 patients with paroxysmal AF who underwent radiofrequency ablation at our hospital between July 2020 and July 2022. They underwent routine circumferential pulmonary vein ablation and, subsequently, left and right atrial pressure monitoring to assess sinoatrial node recovery time under burst 400/300 ms stimulation. Postoperatively, the patients were randomly divided into 2 groups (60 patients each). The control group was administered dronedarone orally for 3 months and the study group was treated with SSYX combined with dronedarone. This study aimed to compare differences in clinical efficacy of the treatment between the 2 groups. The left and right atrial pressures in both groups were higher than those in the preoperative period (P < .05), with no statistically significant differences between the 2 groups (P > .05). Sinoatrial node recovery time under burst 400/300 ms stimulation showed no statistical difference between the 2 groups (P > .05). At 3 months and 1 year postoperatively, the AFEQT scale scores for both groups were lower than those before treatment (P < .05), with the study group scoring lower than the control group at 3 months (P < .05). However, no statistically significant difference was observed between the 2 groups at 1 year postoperatively (P > .05). At 3 months postoperatively, the sinus rhythm maintenance rate and heart rate were higher in the intervention group than in the control group (P < .05); however, these differences between the 2 groups were not statistically significant at 1 year postoperatively (P > .05). The combination of SSYX and dronedarone could effectively reduce the early recurrence of paroxysmal AF after radiofrequency ablation, increase heart rate, and improve the quality of life.

Using computed tomogram atrial myocardial thickness maps in high-power short-duration radiofrequency pulmonary vein isolation: UTMOST AF.

High-power short-duration (HPSD) ablation creates wide, shallow lesions using radiofrequency (RF) heating. It is uncertain if adjusting RF energy based on atrial wall thickness provides extra benefits. We studied the safety and effectiveness of tailored HPSD energy based on left atrial (LA) wall thickness (LAWT) for circumferential pulmonary vein isolation (CPVI) in patients with paroxysmal atrial fibrillation (PAF). We enrolled 212 patients (68.4% male, mean age: 59.5 ± 11.0 years) and randomly assigned them to two groups: LAWT-guided CPVI (WT, n = 108) and conventional CPVI (control, n = 104). Both groups used an open irrigated-tip deflectable catheter to apply 50 W for 10 s to the posterior LA, while controls used 60 W for 15 s on other LA regions. RF delivery time in WT was titrated (15 s at LAWT > 2.1 mm, 13 s at 1.4-2.1 mm, and 11 s at <1.4 mm) according to the computed tomogram-myocardial thickness color map. After a mean follow-up of 13.4 ± 7.0 months, the WT and control groups showed no significant difference regarding clinical recurrence rate (13.9% vs. 5.8%, respectively; p = .061) and major complication rate (4.6% vs. 3.8%, respectively; p > .999). The total procedure time, cardioversion rate, and post-procedural AAD prescription rates did not significantly differ between the groups. The LAWT-guided energy titration strategy did not result in improved procedural safety and efficacy compared to the conventional 50-60 W-HPSD CPVI in patients with PAF.

Sex difference in atrial scar prevalence: What can we learn from the STABLE-SR-III trial?

BackgroundFemale sex has long been recognized to present a higher risk of stroke and atrial fibrillation (AF) recurrence after circumferential pulmonary vein isolation (CPVI) than in males. However, the underlying mechanisms and benefits of additional low-voltage area (LVA) modification in women remain unknown. ObjectiveThe purpose of this study was to investigate differences in atrial substrate and efficacy of additive LVA ablation between sex subgroups. MethodsPatients with paroxysmal atrial fibrillation (PAF) aged 65–80 years were randomly assigned to either CPVI plus LVA modification (STABLE-SR) group or CPVI alone group. The primary outcome was freedom from atrial arrhythmias after a single ablation procedure. ResultsOf 414 patients included in STABLE-SR-III, 204 (49.3%) were women (mean age 70.5 ± 4.7 years). Women demonstrated significantly higher LVA prevalence (51.5% vs 32.9%; P <.001) and LVA burden (6.5% vs 2.9%; P <.001) than men. In the STABLE-SR group, additional LVA ablation was associated with a 63% reduction in recurrence for women compared with the CPVI alone group (10.8% vs 29.4%; adjusted hazard ratio 0.37; 95% confidence interval 0.18–0.75; P for interaction = .040). However, this finding was not observed in men (18.7% vs 18.5%). In the female subgroup, both group 1 (CPVI + LVA modification) and group 3 (CPVI alone in females without LVA) had similar clinical outcomes, which were much better than in Group 2 (CPVI alone in women with LVA) (90% vs 83.8% vs 63.6%; P = .003). ConclusionIn older patients with PAF, women demonstrated more advanced atrial substrate, including higher prevalence and burden of LVA compared with men. Women may receive greater benefit from additional LVA modification than men.

Changes in Heart Rate Variability Parameters Following Radiofrequency Ablation in Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis.

Radiofrequency (RF) ablation is a prevalent treatment for atrial fibrillation (AF), targeting triggers within the pulmonary vein (PV) for elimination. This study evaluated heart rate variability (HRV) parameter changes at three intervals post-RF ablation: short-term (immediately to 1 month), medium-term (1 to 6 months), and long-term (6 months to 1 year). We compared two ablation techniques: circumferential PV isolation (CPVI) and segmental PV isolation (SPVI). A thorough search of databases, including PubMed, Embase, Scopus, Web of Science, and Cochrane, in 2022 yielded 835 pertinent studies. After inclusion criteria were applied, 22 studies were analyzed. Results showed a marked decline in HRV parameters post-AF ablation, with LF/HF as an exception. These reductions persisted in short- and long-term evaluations up to a year post-procedure. Subgroup analysis revealed significant HRV declines, with distinct LF/HF values post-SPVI. This meta-analysis suggests the potential of decreased HRV as an indicator of autonomic denervation, necessitating further exploration to optimize therapeutic strategies and enhance patient outcomes.

Association between P-wave terminal force in lead V1 and extent of left atrial low-voltage substrate in older patients with paroxysmal atrial fibrillation.

The P-wave terminal force in lead V1 (PTFV1) is a marker of cardiomyopathy and risk of atrial fibrillation (AF). Low-voltage area (LVA) in the left atrium (LA), which indicates underlying atrial fibrosis, could predict AF recurrence. This study aimed to investigate the correlation between PTFV1 and LVA in older patients with paroxysmal AF. From May 1, 2020, to October 31, 2021, a total of 162 patients aged 65-80years with paroxysmal AF who underwent index ablation procedures were enrolled. PTFV1 was measured in sinus rhythm (SR) using 12-lead electrocardiograms prior to the ablation. Abnormal PTFV1 was defined as a ≥ 4 mVms depression. Additional LVA ablation beyond circumferential pulmonary vein isolation (CPVI) was performed if LVAs were found. Among the 162 patients, 88 had a normal PTFV1 and 74 had an abnormal PTFV1 prior to ablation. There was a significant difference in LVA in patients with and without an abnormal PTFV1 (LVA, 11.0 vs. 5.1 cm2, P < 0.001; LVA burden, 8.9% vs. 4.5%, P < 0.001). PTFV1 and PTAV1 were highest in the upper tertile with extensive LVAs (P < 0.001). Multivariate analysis revealed that abnormal PTFV1 was an independent predictor of LVAs (β = 4.961; 95% CI, 2.135-7.788; P < 0.001). After a median follow-up of 23months, the AF-free survival rate was similar between the normal PTFV1 group and the abnormal PTFV1 group (13/88 vs. 12/74, hazard ratio [HR], 0.933 [95% CI, 0.425-2.047]; P = 0.861). Abnormal PTFV1 at baseline was independently associated with the extent of LVA in older patients with paroxysmal AF.

General anesthesia enhances lesion quality and ablation efficiency of circumferential pulmonary vein isolation.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. General anesthesia (GA) resolves the problem of pain intolerability and provides regular respiratory mode which might improve the catheter maneuverability of AF ablation. This study aims to compare the procedural performance of PVI under GA versus conscious sedation (CS) from multiple perspectives. A total of 36 consecutive patients undergoing first AF ablation under GA were enrolled in GA group. Another 109 patients receiving AF ablation under CS in the same period were selected as the control group. After propensity score matching, 29 matched pairs with similar baseline characteristics were available for further analysis. The AIFV (using AI to analyze the raw data from CARTO3 system) system was used to evaluate six procedural parameters in each PVI procedure. Compared with CS, PVI under GA had a significantly shorter total PVI time (51.4 min vs. 67.8 min; p = .003) and higher radiofrequency ratio (62.6% vs. 55.8%; p = .032). The number of gaps (1.0 vs. 3.0; p < .001) and the rate of break point were significantly lower in the GA group. GA was also associated with a higher effective ablation-index ratio (87.5% vs. 74.1%; p < .001) and effective force-over-time ratio (85.3% vs. 69.2%; p = .001). After a medium follow-up time of 24 months, 12/29 (41.4%) patients in the CS group and 6/29 (20.7%) patients in the GA group suffered from AF recurrence (p = .156). GA improves the lesion quality and procedural efficiency of PVI from multiple perspectives evaluated by the AIFV system.

Comparison of Long-Term Clinical Outcomes Between Segmental and Circumferential Pulmonary Vein Isolation in Patients Undergoing Repeat Atrial Fibrillation Ablation.

Circumferential pulmonary vein isolation (CPVI) has supplanted segmental PVI (SPVI) as standard procedure for atrial fibrillation (AF). However, there is limited evidence examining the efficacy of these strategies in redo ablations. In this study, we investigated the difference in recurrence rates between SPVI and CPVI in redo ablations for PV reconnection.Methods and Results: This study retrospectively enrolled 543 patients who had undergone AF ablation between 2015 and 2017. Among them, 167 patients (30.8%, including 128 male patients and 100 patients with paroxysmal AF) underwent redo ablation for recurrent AF. Excluding 26 patients without PV reconnection, 141 patients [90 patients of SPVI (Group 1) and 51 patients of CPVI (Group 2)] were included. The AF-free survival rates were 53.3% and 56.9% in Group 1 and Group 2, respectively (P=0.700). The atrial flutter (AFL)-free survival rates were 90% and 100% in Group 1 and Group 2, respectively (P=0.036). The ablation time was similar between groups, and there no major complications were observed. For redo AF ablation procedures, SPVI and CPVI showed similar outcomes, except for a higher AFL recurrence rate for SPVI after long-term follow-up (>2 years). This may be due to a higher probability of residual PV gaps causing reentrant AFL.

Catheter ablation of persistent atrial fibrillation: circumferential pulmonary vein ablation with or without a linear lesion at the left atrial roof for (12-year follow-up)

Abstract Background Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation. Circumferential pulmonary vein ablation is still the standard approach in these patients. However, the results are not very favourable and more complex ablation strategies are the subject of current controversy. Therefore, we have evaluated the effect of an additional linear lesion at the roof of the left atrium on the long-term outcome. Methods A total of 300 patients (155 men, 145 women; mean age 72 years (SD ± 18 years)) with symptomatic persistent atrial fibrillation underwent a circumferential pulmonary vein ablation procedure in combination with an additional linear lesion at the roof of the left atrium (group A). After discharge, patients were scheduled for repeated visits at the arrhythmia clinic at 1, 3, 6, 12, 24, 36, 48, 60, 72, 84, 96, 102, 108, 120, 132, 138 and 144 months after the ablation procedure. The long-term follow-up data was compared to 300 patients who underwent circumferential pulmonary vein ablation without an additional linear lesion at the roof of the left atrium (group B). Results The ablation procedure could be performed as planned in all patients. Sixfty-six out of 300 patients (22.0 %) in group A and 69 out of 300 patients (23.0 %) in group B experienced an arrhythmia recurrence within the first 3 months after ablation requiring an electrical cardioversion. At 144-month follow-up, analysis of a 168-hour ECG recording revealed no evidence for an arrhythmia recurrence in 171/300 patients (57.0 %) in group A and in 141/300 patients (47.0 %) in group B. In 87/300 patients (29.0 %) in group A and 78/300 patients (26.0 %) in group B, only short episodes of paroxysmal atrial fibrillation were documented. In 42 patients (14.0 %) in group A, a recurrence of persistent atrial fibrillation (&amp;gt; 48 hours) was revealed by the long-term recordings (group B: 81 patients (27.0 %)). The lower arrhythmia recurrence rate in group A was partially due to a lower incidence of atypical atrial flutter after catheter ablation. The rate of repeat ablation procedures was significantly lower in group A than in group B. There were no major complications. Conclusions Catheter ablation of persistent atrial fibrillation comprising a circumferential pulmonary vein ablation and an additional linear lesion at the roof of the left atrium provides more favourable results than circumferential pulmonary vein ablation alone. The effect is more pronounced during long-term than during short-term follow-up.

Catheter ablation of atrial fibrillation: three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pre-interventioal pulmonary vein imaging (8-year follow-up)

Abstract Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 240 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 110 patients, persistent AF: 130 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 230/240 patients (95.8 %). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.9 (cryo group), 3.9 (radiofrequency catheter ablation group)). At 96-month follow-up, 64.6 % of all patients were free from an arrhythmia recurrence (cryo group: 70.0 %, Carto group: 60.0 %). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Left atrial fibrosis-guided ablation in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials

Abstract Background Left atrial fibrosis is related to atrial fibrillation (AF) recurrence after AF ablation. However, the benefit of patient-specific substrate modification guided by fibrosis delineated on voltage mapping or magnetic resonance imaging (MRI) is conflicting. Objective To compare the efficacy and safety of additional modification of left atrial fibrosis [identified by low-voltage area (LVA) or late gadolinium-enhancement on MRI] vs. circumferential pulmonary vein isolation (PVI) with or without stepwise ablation not targeting fibrosis in AF. Methods A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was performed from inception to November 2022. Only randomized studies investigating the utility of fibrosis-guided substrate modification beyond conventional PVI were included. The primary outcome was a recurrence of any atrial arrhythmia. Major adverse events and procedural, fluoroscopic, and total ablation time were defined as secondary outcomes. We calculated pooled estimates of the outcomes by a random-effect model and reported them as risk ratio (RRs) and 95% confidence interval (CI). Results A total of 9 studies (8 randomized controlled clinical trials and 1 randomized design within a prospective study) and 2135 patients with AF were included. The atrial arrhythmia recurrence was lower in the additional fibrosis-guided ablation group (RR 0.82; 95% CI 0.71-0.94; p=0.006) (Figure 1A). No differences were found between fibrosis-guided substrate modification and conventional PVI group in major adverse events [RR 1.25 (0.55-2.81), p=0.598)] and mean differences of procedural time [-2.88 (-40.34 to 34.57) min], fluoroscopic time [1.82 (-1.86 to 5.49) min], and total ablation time [-14.28 (-48.70 to 20.14) min]. In the stratified analyses, there were no interactions of the lower atrial arrhythmia recurrences within the modality of fibrosis identification (LVA vs. delayed enhancement on MRI), type of AF (paroxysmal vs. persistent), the burden of LVA (no or low vs. high), and strategy of the control group (PVI only vs. PVI plus stepwise ablation) (Figure 1B). Conclusion By incorporating two modalities of left atrial substrate evaluation – voltage mapping and MRI – we conclude that the individually tailored fibrosis-guided ablation in AF is associated with a lower recurrence after catheter ablation.