Independent Predictor Of Late Recurrence Research Articles

Sex-based differences and outcomes in patients undergoing pulmonary vein isolation for atrial fibrillation

Abstract Introduction Some studies have suggested that the risk of atrial fibrillation (AF) recurrence after catheter ablation (CA) is greater in women than in men, which suggests that sex may be an independent risk factor for AF recurrence. However, the impact of gender on time to AF recurrence after CA is unknown. Methods Retrospective, single-centre study including all patients who underwent a first AF ablation procedure between 2017 and 2021. Late recurrence (LR) was defined as any AF recurrence at least 90 days after ablation, while early recurrence (ER) occurred <90 days after ablation. The effect of sex on the cumulative freedom from LR was estimated using the Kaplan-Meier method and compared using the log-rank test and Cox proportional hazards model. In a subgroup of patients, cardiac adipose tissue was quantified using cardiac computerized tomography (CT) scans. Results 656 patients were included, of whom 32% were women. Average follow-up after ablation was 26 months. In comparison to male patients, women undergoing CA were more likely to be older, have a higher body mass index and were more likely to have comorbid hypertension, thyroid dysfunction and valvular disease. After model adjustment, women had a greater risk of LR (HR 1.78, 95% CI 1.20-2.62). A reanalysis was conducted using a time-split at one year of follow-up, which showed that risk of LR was greater in women more than 12 months after CA (HR 2.70, 95% CI 1.60-4.57), but not during the first year after CA (HR 1.22, 95% CI 0.74-2.02). Persistent AF was also an independent predictor of LR (HR 2.05, 95% CI 1.45-2.91). In a subgroup of patients who underwent cardiac adipose tissue analysis (n = 348; 37% women), increased epicardial and pericardial adipose tissue volume was associated with an increased risk of LR in univariate analysis, but not after co-variate adjustment. Conclusions Women are referred later and less frequently to CA than men. LR after CA is more frequent in women, particularly after one year. Epicardial adipose tissue volume was associated with LR in women, but this effect was not maintained after model adjustment. Further studies are needed to better understand the mechanisms responsible for the increase in LR in women undergoing pulmonary vein isolation.

Using machine learning to enhance prediction of atrial fibrillation recurrence after catheter ablation.

Traditional risk scores for recurrent atrial fibrillation (AF) following catheter ablation utilize readily available clinical and echocardiographic variables and yet have limited discriminatory capacity. Use of data from cardiac imaging and deep learning may help improve accuracy and prediction of recurrent AF after ablation. We evaluated patients with symptomatic, drug-refractory AF undergoing catheter ablation. All patients underwent pre-ablation cardiac computed tomography (cCT). LAVi was computed using a deep-learning algorithm. In a two-step analysis, random survival forest (RSF) was used to generate prognostic models with variables of highest importance, followed by Cox proportional hazard regression analysis of the selected variables. Events of interest included early and late recurrence. Among 653 patients undergoing AF ablation, the most important factors associated with late recurrence by RSF analysis at 24 (+/-18) months follow-up included LAVi and early recurrence. In total, 5 covariates were identified as independent predictors of late recurrence: LAVi (HR per mL/m2 1.01 [1.01-1.02]; p < .001), early recurrence (HR 2.42 [1.90-3.09]; p < .001), statin use (HR 1.38 [1.09-1.75]; p = .007), beta-blocker use (HR 1.29 [1.01-1.65]; p = .043), and adjunctive cavotricuspid isthmus ablation [HR 0.74 (0.57-0.96); p = .02]. Survival analysis demonstrated that patients with both LAVi >66.7 mL/m2 and early recurrence had the highest risk of late recurrence risk compared with those with LAVi <66.7 mL/m2 and no early recurrence (HR 4.52 [3.36-6.08], p < .001). Machine learning-derived, full volumetric LAVi from cCT is the most important pre-procedural risk factor for late AF recurrence following catheter ablation. The combination of increased LAVi and early recurrence confers more than a four-fold increased risk of late recurrence.

Early recurrences predict late therapy failure after pulsed field ablation of atrial fibrillation.

Pulsed field ablation (PFA) is a new ablation technology for atrial fibrillation (AF). Data regarding early recurrences of atrial tachyarrhythmia (ERAT) after PFA-pulmonary vein isolation (PVI) are sparse. Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI. A dedicated catheter delivering bipolar energy (1.9-2.0 kV) was used. Late recurrence (LR) was defined as documented AF/atrial tachycardia (AT) lasting more than 30 s after a 90-day blanking period. Two hundred and thirty-one patients (42% female, age 69 ± 12, 55% paroxysmal AF [PAF]) were included in this analysis. Median follow-up time was 367 days (interquartile range: 253-400). Forty-six patients (21%) experienced ERAT after a median of 23 days (46% in PAF and 54% in persistent AF [persAF]). Kaplan-Meier estimated freedom of AF/AT was 74.2% at 1 year, 81.8% for PAF, and 64.8% for persAF (p = .0079). Of patients experiencing ERAT, an LR was observed in 54%. There was no significant difference of LR between those who presented with very early ERAT (0-45 days) and those with ERAT (46-90 days) (p = .57). In multivariate analysis, ERAT (hazard ratio [HR]: 3.370; 95% confidence interval [95% CI]: 1.851-6.136; p < .001) and female sex (HR: 2.048; 95% CI: 1.114-3.768; p = .021) were the only independent predictors for LR. ERAT could be recorded in 21% of patients after PFA-PVI and was an independent predictor for LR. We found no difference in the rate of LRs among patients experiencing ERAT before or after 45 days.

Early recurrences predict late therapy failure after pulsed field ablation of atrial fibrillation: midterm clinical outcome from a high-volume center

Abstract Funding Acknowledgements Type of funding sources: None. Background Pulsed field ablation (PFA) is a new myocardial-specific ablation technology for atrial fibrillation (AF). Direct current electric energy is applied to cells and disrupts cell membranes by creating pores. Data regarding midterm outcome are sparse. Purpose The aim of this single-center study was to report midterm clinical outcomes following PFA-based pulmonary vein isolation (PVI). Methods Consecutive patients with symptomatic AF were enrolled to undergo PFA-PVI based on the "5S Study" ablation strategy. Procedures were done between March 2021 and January 2022. A dedicated catheter with five splines delivering bipolar energy with a voltage of 1.8-2.0 kV was used. Arrhythmia recurrence was defined as documented AF/atrial tachycardia (AT) lasting more than 30 seconds after a 90 days blanking period (BP). Procedural and demographic data were analysed. Results 231 patients (42% female, age 69±12, 55% paroxysmal atrial fibrillation [PAF]) were included in this preliminary analysis. 901 pulmonary veins (PV) were identified, and all PVs could be isolated using solely the PFA device. 895 (99.3 %) PVs were isolated with the first application. 32±4 applications per patient were delivered. The overall complication rate was 3.5% (vascular access complication: 2.2%, stroke: 0.9%, tamponade: 0.4%). Median follow-up time was 323 days. 22% of patients experienced a recurrence during the BP after a median of 23 days. Kaplan Meier estimated freedom of AF/AT out of the BP was 75% at one year, 83% for PAF and 64% for persistent atrial fibrillation (persAF, p&amp;lt; 0.0036). In a multivariate analysis blanking recurrence (p&amp;lt;0.001) and female sex (p=0.002) were the only independent predictors for late recurrence. Conclusions This study indicates high acute efficacy of PFA based PVI. 75% of patients are free of AF at one year. Blanking recurrence is an independent predictor for late recurrence after PFA-PVI: further studies are required to better define the duration of the BP after PFA PVI.

Timing of clinically relevant recurrence or true blanking period?

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The Ministry of Health and Welfare of Korea The National Research Foundation of Korea (NRF) which is funded by the Ministry of Science, ICT &amp; Future Planning (MSIP) Background Although early recurrence (ER) within 3 months after atrial fibrillation catheter ablation (AFCA) is reportedly considered as a reliable predictor of late recurrence (LR), those ERs are still counted as benign events. There is no large-scale study showing the time limit of true blanking period, nor the potential mechanisms of clinically relevant recurrences within 3 months. Purpose To explore temporal association of ERs with LRs and the presence of extra-pulmonary vein (ExPV) triggers. Methods This retrospective, single center study included 2,788 patients undergoing de novo AFCA (median 60 years old, 37.4% persistent AF [PeAF]) with isoproterenol provocation at the procedures. ER and LR were defined as any documented atrial arrhythmia &amp;gt;30s occurring (≤3 months), (&amp;gt;3months) after AFCA respectively. We evaluated the risk factors for ER and LR and compared the risk for LR and existence of ExPV triggers according to different timing of ER. Results ER was detected in 783 (28.1%) patients. During a median follow-up of 40 months, LR occurred in 945 (33.9%) patients. PeAF (OR 1.79, 95% CI 1.36-2.34), a larger left atrial (LA) diameter (OR 1.03 per 1 mm increase, 95% CI 1.00-1.05), and the existence of ExPV-triggers (OR 3.02, 95% CI 2.08-4.38) were independently associated with ER. ER (HR 2.55, 95% CI 2.15-3.03); the existence of ExPV-triggers (HR 1.63, 95% CI 1.28-2.08), PeAF (HR 1.39, 95% CI 1.16-1.66), and a larger LA diameter (HR 1.02 per 1 mm increase, 95% CI 1.01-1.04) were independent predictors for LR. When stratified according to the days of ER occurrence, ER occurring earlier showed trends toward higher rates of LR (P for trend=0.047) (Figure 1A). Patients with ER occurring within 1 month after AFCA had a higher incidence of LR than those with ER occurring between 2 and 3 months after AFCA (57.5% vs. 49.6%; log-rank P=0.020) (Figure 2B). ER occurring within 1 month after AFCA, compared with no ER, was independently associated with the existence of ExPV triggers (OR 3.99, 95% CI 2.65-6.02) whereas ERs occurring at different timing were not (Figure 1B). Conclusions ER, regardless of the timing, and the existence of Ex-PV triggers were independently associated with long-term AF recurrence. Especially, ER occurring earlier within 1 month after AFCA, which was associated with Ex-PV triggers, had the worst rhythm outcome.

Clinical relevance of the blanking period on late recurrence after catheter ablation of atrial fibrillation.

Recurrence of atrial fibrillation (AF) within the blanking period after catheter ablation (CA) is traditionally classified as a transient and benign event. However, recent findings suggest that early recurrence (ER) is associated with late recurrence (LR), challenging the predefined "blanking period". We aimed to determine the clinical and procedural predictors of ER and LR after CA and establish the risk of LR in patients who experience ER. Retrospective single-centre study including all patients who underwent a first procedure of AF CA between 2017 and 2019. ER was defined as any recurrence of AF, atrial flutter or atrial tachycardia >30 s within 90 days after CA and LR as any recurrence after 90 days of CA. A total of 399 patients were included, 37% women, median age of 58 years [49-66] and 77% had paroxysmal AF. Median follow-up was 33 months (from 13 to 61). ER after CA was present in 14% of the patients, and LR was reported in 32%. Among patients who experienced ER, 84% also had LR (p < .001). Patients with ER had a higher prevalence of moderate/severe valvular heart disease, persistent AF, previous electrical cardioversion, a larger left atrium, higher coronary artery calcium score, and higher rates of intraprocedural electrical cardioversion and cardiac fibrosis on eletroanatomical mapping compared with patients without ER. After covariate adjustment, ER and female sex were defined as independent predictors of LR (hazard ratio [HR] 4.69; 95% confidence interval [CI], 2.99-7.35; p < .001 and HR 2.73; 95% CI, 1.47-5.10; p = .002, respectively). The risk of LR after an index procedure of CA was significantly higher in patients with ER (five-fold increased risk). These results support the imperative need to clarify the clinical role of the blanking period.

Surface ECG-based complexity parameters for predicting outcomes of catheter ablation for nonparoxysmal atrial fibrillation: efficacy of fibrillatory wave amplitude.

Catheter ablation (CA) is a well-established therapy for rhythm control in atrial fibrillation (AF). However, CA outcomes for persistent AF remain unsatisfactory because of the high recurrence rate despite time-consuming efforts and the latest ablation technology. Therefore, the selection of good responders to CA is necessary. Surface electrocardiography (sECG)-based complexity parameters were tested for the predictive ability of procedural termination failure during CA and late recurrence of atrial arrhythmias (AA) after CA. A total of 130 patients with nonparoxysmal AF who underwent CA for the first time were investigated. A 10-second sECG of 4 leads (leads I, II, V1, and V6) was analyzed to compute the fibrillatory wave amplitude (FWA), dominant frequency (DF), spectral entropy (SE), organization index (OI), and sample entropy (SampEn). The study endpoints were procedural termination failure during CA and late (≥1 year) AA recurrence after CA. In the multivariate analysis, FWA in lead V1 and DF in lead I were independent predictors of successful AF termination during CA (P <.05). The optimal cut-off values for FWA in lead V1 and DF in lead I were 60.38 μV (area under the curve [AUC], 0.672; P = .001) and 5.7 Hz (AUC, 0.630; P = .016), respectively. The combination of FWA of lead V1 and DF of lead I had a more powerful odds ratio for predicting procedural termination failure (OR, 8.542; 95% CI, 2.938–28.834; P < .001). FWA in lead V1 was the only independent predictor of late recurrence after CA. The cut-off value is 65.73 μV which was 0.634 of the AUC (P = .009).These sECG parameters, FWA in lead V1 and DF in lead I, predicted AF termination by CA in patients with nonparoxysmal AF. In particular, FWA in lead V1 was an independent predictor of late recurrence of AA after CA.

The mitral inflow E/A ratio before the procedure may predict late recurrence after pulmonary vein isolation using second-generation cryoballoon

Abstract Funding Acknowledgements Type of funding sources: None. Background The left ventricular (LV) diastolic dysfunction (DD) increases the risk of atrial fibrillation (AF) development. Some studies investigated whether a relationship between DD and late recurrence after catheter ablation for AF, but they found conflictory results. Such studies had relatively short follow-up duration and they did not have a standard ablation protocol. Some patients were taken to PVI only, while additional linear lesions in localizations such as the left atrial (LA) roof, LA isthmus, and cavotricuspid isthmus were added in others. Purpose The mitral inflow E/A ratio is a simple and practical method commonly used to evaluate LV DD. We aimed to investigate whether the E/A ratio before the procedure was predictive for late recurrence in patients with AF undergoing pulmonary vein isolation (PVI) with cryoballoon (CB). Methods A total of 100 patients undergoing AF ablation for the first time using second-generation CB were included. Only patients with paroxysmal AF and sinus rhythm the day before the procedure, and with pre-procedural pro-B natriuretic peptide levels within normal limits were included. The patients with and without late recurrence were compared in terms of basal characteristics and procedural features. Any atrial tachyarrhythmia episode longer than 30 s after the blanking period was defined as late recurrence. Results The patients [age: 58.0 (50.2-62.0) years, 53 female] were followed up for a median of 44.5 (14.2-62.7) months and late recurrence developed in 25 patients. Female gender (72.0% vs 46.7%), hypertension (72.0% vs 48.0%), and the frequency of early recurrence (20.0% vs 4.0%) were found to be higher in patients with late recurrence than in those without it (p =0.028, 0.037 and 0.022, respectively). The CHA2DS2-Vasc score was higher [2.0 (1.0-3.0) vs 1.0 (0-2.0)], AF duration was longer (27.8 ± 9.4 vs 22.0 ± 8.4 months) and the E/A ratio was lower [0.5 (0.4-1.2) vs 1.4 (0.6-1.7)] in patients with late recurrence than in those without it (p=0.014, 0.006 and 0.001, respectively) (Figure 1). The groups were similar in terms of precedural features. A multivariate analysis showed that female gender (HR: 4.46, 95%CI: 1.24-15.97, p=0.021), early recurrence (HR: 10.22, 95% CI: 2.49-41.99, p=0.001), and E/A ratio (HR: 0.25, 95%CI: 0.11-0.57, p=0.001) were independent predictors for late recurrence (Figure 2). Receiver operating characteristic analysis showed that the optimal cut-off level of the E/A ratio was 0.84. Any ATa free survival rate was significantly lower in patients with E/A ratio &amp;lt;0.84 than in those with ≥0.84 (56.1% vs 88.1%, log-rank p&amp;lt;0.001). Conclusions Female gender, early recurrence, and E/A ratio are independent predictors of late recurrence in patients with AF undergoing PVI using second-generation CB. Measuring the E/A ratio in patients with sinus rhythm before AF ablation may help to predict future recurrences.

Long Atrial Fibrillation Duration and Early Recurrence Are Reliable Predictors of Late Recurrence After Radiofrequency Catheter Ablation.

BackgroundRecurrence after atrial fibrillation (AF) ablation is still common.ObjectiveThis study aimed to evaluate the predictive abilities of AF duration and early recurrence (ER) to discriminate high-risk patients for recurrence.MethodsWe enrolled 1,763 consecutive patients with AF who were scheduled to receive the index radiofrequency catheter ablation (RFCA) from January 2016 to August 2021 in Dalian, China. Long AF duration (LAFD) was considered if the course of AF lasted for ≥ 12 months. ER was defined as any atrial tachycardia (AT) or AF event longer than 30 s occurring within a 3-month post-RFCA.ResultsLate recurrence occurred in 643 (36.5%) of the 1,763 patients at a median of 35 months after RFCA. Multivariate analysis identified LAFD (hazard ratio (HR): 1.80, 95% confidence interval (CI): 1.38–2.35, p < 0.001) and ER (HR: 2.34, 95% CI: 1.82–3.01, p < 0.001) as strong independent predictors of late recurrence in non-paroxysmal AF. Similarly, LAFD (HR: 1.48, 95% CI: 1.20–1.84, p < 0.001) and ER (HR: 3.40, 95% CI: 2.68–4.30, p < 0.001) were significantly associated with late recurrence in paroxysmal AF. Receiver operating curve analyses revealed that the CAAP-AF (CAD, Atrial diameter, Age, Persistent or longstanding AF, Antiarrhythmic drugs failed, Female) had the highest predict power [area under ROC curve (AUC) 0.586]. The addition of ER and LAFD to the CAAP-AF score significantly improved risk discrimination for late recurrence after AF ablation from 0.586 to 0.686.ConclusionLong AF duration and ER were independently associated with late recurrence. The prediction performance of the CAAP-AF model for recurrence was improved by the addition of LAFD and ER.

Early and late recurrences in lymph node-negative gastric cancer: a retrospective cohort study.

BACKGROUND: Predictors of recurrence in patients with lymph node-negative gastric cancer (GC) who have undergone curative resection have been widely investigated, but not the effects of predictors on timing of recurrence.OBJECTIVE: Determine the factors associated with early and late recurrence in patients with node-negative GC.DESIGN: Retrospective cohort.SETTING: Academic tertiary care center.PATIENTS AND METHODS: The study included patients with node-negative GC after curative resection between 2008 and 2018 at two institutions. Early and late recurrences were determined using a minimum P value approach to evaluate the optimal cutoff for recurrence-free survival (RFS). A competing risk model and landmark analysis were used to analyze factors associated with early and late recurrences.MAIN OUTCOME MEASURES: Recurrence-free survival and factors associated with survival.SAMPLE SIZE: 606.RESULTS: After a median follow-up of 70 months, 50 (8.3%) patients experienced recurrent disease. The optimal length of RFS for distinguishing between early (n=26) and late recurrence (n=24) was 24 months (P=.0013). The median RFS in the early and late recurrence groups was 11 and 32 months, respectively. Diffuse tumors (hazard ratio 3.358, P=.014), advanced T stage (HR 8.804, P=.003), perineural invasion (HR 10.955, P<.001), and anemia (HR 2.351, P=.018) were independent predictors of early recurrence. Mixed tumor location (HR 5.586, P=.002), advanced T stage (HR 5.066, P<.001), lymphovascular invasion (HR 5.902, P<.001), and elevated CA19-9 levels (HR 5.227, P<.001) were independent predictors of late recurrence. Similar results were obtained in the landmark analysis.CONCLUSIONS: Individualized therapeutic and follow-up strategies should be considered in future studies because of distinct patterns in predictors of early and late recurrence.LIMITATIONS: Retrospective design, small sample size.CONFLICT OF INTEREST: None.

Predictors of early and late recurrence of atrial fibrillation after catheter ablation: two sides of the same coin?

Abstract Background Recurrence of atrial fibrillation (AF) after catheter ablation (CA) is estimated to be between 20% and 45%. Recurrent AF early after ablation is generally classified as benign as a part of a blanking period, but recently has been associated with later recurrent AF. The prediction of early and late AF recurrence after CA remains challenging as well as the predictive value of early AF recurrence in the blanking period. Purpose We aimed to determine the clinical and procedural factors associated with early and late recurrence of AF after CA. Methods Single-centre retrospective study that included all patients who underwent AF CA between January 2017 and October 2019. Ablation procedures included radiofrequency and second-generation cryoballoon CA. Early recurrence of AF (ERAF) was defined as any recurrence of AF &amp;gt;30 seconds within 90 days after CA and late recurrence (LR) was defined as any recurrence of AF &amp;gt;30 seconds after 90 days of CA. The independent association between clinical and procedural variables and AF recurrence was evaluated with logistic regression analysis. Results We included 399 patients, 64,7% male, with a mean age of 56,8±11,6 years, most of them had paroxysmal AF with a mean duration until CA of 3,5±3,4 years. Early recurrence of AF occurred in 51 patients (12,8%). After multivariate logistic regression, we identify left atrium (LA) diameter [odds ratio (OR) 1,1, 95% confidence interval (CI) 1,03–1,18; p=0,007] as the only independent predictor associated with recurrent AF. Late recurrence of AF was observed in 104 patients (26,1%), on average, 12,8±8,7 months after CA. After multivariable adjustment, LA diameter (OR 1,1, 95% CI 1,01–1,12; p=0,032) and intraprocedural electric cardioversion (OR 1,8, 95% CI 1,03–3,12; p=0,040) were independently associated with recurrent AF. Regarding patients with ERAF, most of them also had late recurrent AF (64,7%), whereas in patients without ERAF, only 20,4% had LR (p&amp;lt;0,001). After including ERAF in the multivariate logistic regression, we identify ERAF as the only independent predictor of late recurrence of AF (OR 5,23, 95% CI 2,56–10,72; p&amp;lt;0,001). Conclusions In our cohort, late recurrence of AF after catheter ablation was significantly higher in patients with recurrence within the blanking period, which was the only independent predictor of AF late recurrence. Funding Acknowledgement Type of funding sources: None.

Early arrhythmia recurrence after catheter ablation for persistent atrial fibrillation: is it predictive for late recurrence?

BackgroundEarly recurrence of atrial tachyarrhythmia (ERAT) is common after radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF), but its clinical significance in patients with persistent AF remains unclear. We sought to determine the predictive value of ERAT for rhythm outcome after RFCA for persistent AF.MethodsThe study included 207 consecutive patients (mean age 66.4 ± 10.7 years, male 66.2%) with persistent and long-standing persistent AF undergoing de novo pulmonary vein isolation (± atrial substrate ablation). All patients remained off antiarrhythmic drugs. ERAT was defined as any atrial arrhythmia ≥ 30 s occurring within the first 30 days. Late recurrence (LR) was determined during follow-up visits scheduled 1, 3, 6 and 12 months post-ablation using 7-day Holter ECGs.ResultsERAT occurred in 143/207 (69.1%) patients as AF (60%) or atrial tachycardia (40%) and was persistent in 82% of cases. During a median follow-up of 22.2 months, LR occurred significantly more often in patients with ERAT than in patients without ERAT (92.3 vs. 43.8%, P < 0.001). The only independent predictors for LR were ERAT (OR 16.8, 95% CI 6.184–45.797, P < 0.001) and intraprocedural termination to sinus rhythm (OR 0.052, 95% CI 0.003–0.851, P = 0.038). Extending the blanking period from 30 to 90 days did not impact LR rates.ConclusionERAT following ablation of persistent AF is strongly associated with late arrhythmia recurrence, which challenges the assumption that ERAT represents merely a transient phenomenon. While limiting the blanking period to 30 days seems justified, the benefit of early re-ablations remains to be addressed in future studies.Graphic abstract

Prevalence and outcome of early recurrence of atrial tachyarrhythmias in the Cryoballoon vs Irrigated Radiofrequency Catheter Ablation (CIRCA-DOSE) study.

Early recurrence of atrial tachyarrhythmia (ERAT) is common after pulmonary vein isolation (PVI) and has been associated with an increased risk of late atrial fibrillation (AF) recurrence. The purpose of this study was to determine the incidence and outcomes of patients experiencing ERAT after PVI using advanced-generation ablation technologies. This is a prespecified substudy of the CIRCA-DOSE (Cryoballoon vs Irrigated Radiofrequency Catheter Ablation: Double-Short vs Standard Exposure Duration) trial, a prospective, randomized, multicenter study comparing PVI with contact force-guided radiofrequency ablation to secondary-generation cryoballoon ablation for paroxysmal AF. All study patients received an implantable cardiac monitor to allow continuous rhythm monitoring. ERAT was defined as any recurrent atrial tachyarrhythmia within the first 90 days after AF ablation. ERAT occurred in 61% of the 346 patients at a median of 12 days (range 1-90 days) after ablation. ERAF was a significant predictor of late recurrence (60.1% with ER vs 25.9% without ER; P <.001) and symptomatic atrial tachyarrhythmia (31.6% with ERAF vs 6.7% without ERAF; P <.001). Receiver operating curve analyses revealed a strong correlation between ERAT timing and burden and late recurrence. Multivariate analysis identified ER timing (hazard ratio [HR] 2.90; 95% confidence interval [CI] 1.41-5.95; P = .004) and burden (HR 1.05 per 1% ER burden; 95% CI 1.04-1.07; P <.001) as strong independent predictors of late recurrence. Incidence rate, timing, burden, and prognostic significance of ER did not differ between the study groups. ERAT remains common after PVI despite use of advanced-generation ablation technologies. Early AF recurrence beyond 3 weeks after ablation is associated with increased risk of late recurrence.

Long-term assessment of recurrence of hepatocellular carcinoma in patients with chronic hepatitis C after viral cure by direct-acting antivirals.

Background and AimEarly hepatocellular carcinoma (HCC) recurrence is common, even after achieving hepatitis C virus (HCV) cure. This study was carried out to assess the long‐term trends and predictors of recurrence after HCV cure by direct‐acting antivirals (DAAs).MethodsThis retrospective, multicenter cohort study enrolled 365 consecutive patients with chronic hepatitis C who required HCC treatment following sustained viral response (SVR) by DAA administration. Patients with HCC recurrence before SVR were excluded. Late HCC recurrence and its predictors beyond the post‐treatment early phase (24 weeks after SVR) were evaluated.ResultsThe data of 326 patients were available for the final analysis. The median follow‐up duration from SVR determination was 2.7 years. Median age was 74, and 220 (67.5%) were 70 or over. The corresponding 5‐year cumulative HCC recurrence rates of previous curative and palliative treatment groups were 45.4% and 65.7%, respectively (log‐rank test: P < 0.001). Cox regression multivariable analysis revealed that cirrhosis (hazard ratio [HR] 1.85, P = 0.021), the number of HCC nodules (≥ 2) (HR 1.52, P = 0.031), and previous palliative HCC treatment (HR 1.71, P = 0.012) were independent predictors of late recurrence, in addition to the predictors of early recurrence; AFP > 7 ng/mL at 12 weeks after DAA administration, time from HCC complete response (CR) to DAA initiation (< 1 year), and the number of HCC treatments necessary to achieve CR (≥ 2).ConclusionsThe evaluation of fibrosis and characteristics of the previous HCC would allow for better HCC recurrence stratification, which would be helpful for developing long‐term surveillance strategies.

A novel predictive model for late recurrence after catheter ablation for atrial fibrillation using left appendage volume measured by cardiac computed tomography

Larger left atrial appendage (LAA) volume is associated with a higher risk of late recurrence (LR) in patients undergoing radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF). However, it is unclear whether LAA volume predicts LR, independent of established risk factors. We sought to evaluate the value of LAA volume in predicting LR after RFCA for AF and to develop a score prediction model including LAA volume for these patients. We retrospectively studied 992 patients who underwent RFCA for AF and cardiac computed tomography before RFCA at a single center. At 3 years after RFCA, 362 patients (36.5 %) experienced recurrence. The multivariate Cox regression model showed that age ≥ 75 years (10 points), non-paroxysmal AF (9 points), diabetes mellitus (4 points), left atrial volume index (1 point per 10 ml/m2 rounded to the nearest integer), and the second (4.7 to < 7 ml/m2; 4 points) and third (≥ 7 ml/m2; 5 points) tertiles of the LAA volume index were independent risk factors LR. The above-mentioned risk factors were included in the integrated score model, and the C-index of the proposed score model was 0.715 (95 % confidence interval [CI] 0.679-0.752). LAA volume is an independent predictor of LR and the predictive model including LAA volume showed good discrimination power. These findings provide evidence for the inclusion of LAA volume in the risk stratification for AF recurrence in patients undergoing RFCA for AF.

Clinical characteristics and outcomes after pulmonary vein isolation in atrial fibrillation patients with complete right bundle branch block

Abstract Background Complete right bundle branch block (CRBBB) is one of the most frequent alterations of the electrocardiogram (ECG). Several studies have shown that CRBBB was a risk factor for cardiovascular diseases and the appearance of CRBBB in patients hospitalized for exacerbated heart failure (HF) was associated with a worse prognosis. Various alternations of ECG such as early repolarization pattern and intraventricular conduction disturbance were associated with high recurrence ratio of atrial fibrillation (AF) after pulmonary vein isolation (PVI). However clinical outcome after PVI in patients with CRBBB remains unclear. Methods We enrolled consecutive AF patients who underwent PVI from September 2014 to November 2018 rom Osaka Rosai Atrial Fibrillation (ORAF) registry. We excluded patients with other wide QRS (left bundle branch block, ventricular pacing and unclassified intraventricular conduction disturbance) and divided into 2 groups; CRBBB (QRS duration ≥120msec) group and no-CRBBB (QRS duration &amp;lt;120) group. We compared the clinical characteristics including age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, paroxysmal AF (PAF), renal function, plasma brain natriuretic peptide (BNP) level and echocardiographic parameters including left ventricular end-diastolic diameter (LVDd), left ventricular end-systolic diameter (LVDs), left atrial diameter (LAD) and left ventricular ejection fraction (LVEF) between the 2 groups. We also compared the incidence of late recurrence of AF/atrial tachycardia (AT) between the 2 groups. We investigated whether CRBBB was an independent predictor of late recurrence of AF/AT after PVI by multivariate Cox analysis. Results We enrolled 736 consecutive AF patients who underwent PVI. CRBBB patients comprised 55 patients (7.5%). There were no significant differences of age, gender, hypertension, diabetes mellitus, history of heart failure, history of stroke, CHADS2Vasc score, PAF, renal function, plasma BNP level and echocardiographic parameters (LVDd, LVDs, LVEF and LAD) between the 2 groups. Incidence of AF/AT recurrence after PVI was significantly higher in CRBBB group than no-CRBBB group (Figure). CRBBB was an independently and significantly associated with late recurrence of AF/AT after PVI by multivariate Cox analysis (hazard ratio: 1.923, 95% CI: 1.190–2.961, p=0.009) in addition to female (p&amp;lt;0.001), no-PAF (p=0.005) and left atrial diameter (p=0.042). Conclusion CRBBB may be a strong predictor of AF/AT late recurrence after PVI. AF/Ar recurrence after PVI Funding Acknowledgement Type of funding source: None

Noninvasive electrocardiography monitoring for very early recurrence predicts long-term outcome in patients after atrial fibrillation ablation.

BackgroundAtrial fibrillation (AF) is the most common sustained arrhythmia, and catheter ablation has been shown to be a highly effective treatment for patients with symptomatic AF. Very early recurrence (VER) of AF within 7 days after catheter ablation is common, but the clinical significance of VER remains unclear. We have examined the usefulness of the noninvasive electrocardiography monitor for the detection of VER and the relationship between VER and late recurrence (LR).MethodsEighty‐eight patients with paroxysmal or persistent atrial fibrillation were retrospectively included. All patients underwent primary catheter ablation at a large general hospital between March 2016 and August 2018. All patients were followed up in atrial fibrillation clinic at an interval of every 3 months for late recurrence of AF. VER was evaluated by one‐lead continuous noninvasive electrocardiography monitoring device for 7 days after ablation. The association between VER and LR was analyzed by univariate and multivariate Cox regression model.ResultsMean age was 62.9 ± 9.7 years, and 39.8% were female. Thirty‐two patients (36.4%) experienced VER. After a mean follow‐up of 539.36 ± 211.66 days, 17 patients (19.3%) experienced LR. Multivariate Cox regression analysis revealed VER was an independent predictor of LR: HR 3.6 (95% CI, 1.2–10.8), p = .020. In addition, diabetes was also associated with LR of atrial fibrillation.ConclusionsNoninvasive electrocardiography monitoring was a useful tool for detecting VER and VER after catheter ablation was associated with LR.

Burden and Long Firing of Premature Atrial Contraction Early After Catheter Ablation Predict Late Recurrence of Atrial Fibrillation.

Associations between characteristics of premature atrial contraction (PAC) 6 months after catheter ablation (CA) and later recurrence are not known. We investigated the effects of PAC characteristics on long-term outcomes of initially successful atrial fibrillation (AF) ablation.Methods and Results:In all, 378 patients (mean age 61 years, 21% female, 67% paroxysmal AF) who underwent initial radiofrequency CA for AF without recurrence up to 24-h Holter monitoring 6 months after the procedure were reviewed retrospectively. The calculated number of PAC/24 h and the length of the longest PAC run during Holter recording were analyzed. After 4.3±1.2 years (mean±SD) follow-up, 123 (32.5%) patients experienced late recurrence. Patients with recurrence had significantly more PAC/24 h (median [interquartile range] 110 [33-228] vs. 42 [16-210]; P<0.01) and a longer longest PAC run (5 [2-8] vs. 3 [1-5]; P<0.01) than those without. Receiver operating characteristic curve analysis indicated 58 PAC/24 h and a longest PAC run of 5 were optimal cut-off values for predicting recurrence. After adjusting for previously reported predictors of late recurrence, frequent PAC (≥58/24 h) and longest PAC run ≥5 were found to be independent predictors of late recurrence (hazard ratios [95% confidence intervals] 1.93 [1.24-3.02; P<0.01] and 1.81 [1.20-2.76; P<0.01], respectively). Six months after successful AF ablation, both frequent PAC and long PAC run are independent predictors of late recurrence.

Early recurrences of atrial tachyarrhythmias post pulmonary vein isolation.

To investigate the significance of early recurrence (ER) of atrial tachyarrhythmias after pulmonary vein isolation (PVI) on the development of late recurrence (LR) and to redefine the blanking period during which an ER is considered nonspecific. Data of 713 patients undergoing their first PVI for paroxysmal or persistent atrial fibrillation between January 2012 and December 2017 were included. All patients were followed-up for 12 months according to clinical and outpatient routine and were screened for any atrial tachyarrhythmia lasting >30 seconds occurring during the first 3 months postablation (ER) and after the 3 months blanking period (LR). Patients with ER compared to those without ER had significantly more LR (74.5% vs 16.5% vs, P < .001). The occurrence of ER during the first, second and third months showed increasing LR rates of 35.2%, 67.9%, and 94.8%, respectively (P < .001). Receiver operator characteristic analysis revealed a blanking period of 46 days with the highest sensitivity (68.1%) and specificity (96.5%). Later timing and longer time span of ER were independent predictors for LR in multivariable analysis. ER is a strong predictor for LR. Our study advocates a shortening of the post-PVI blanking period followed by a "gray zone" up to 3 months where individualized therapeutic decisions based on additional risk factors should be considered. We suggest that the ER time span might serve as such a predictor identifying patients at the highest risk for LR.

P1920Long-term outcomes of pulmonary vein isolation using second-generation cryoballoon during atrial fibrillation ablation: A single-center large-scale study

Abstract Background Currently available second-generation cryoballoon (CB2) is accepted as an effective and safe tool for pulmonary vein isolation (PVI). Although much more data exists about 1-year outcomes of CB2 ablation, data on long-term outcomes are scarce. Objective: We aimed to assess the long-term outcomes of PVI using CB2 in a large-scale symptomatic AF population at our tertiary referral center. Methods In this non-randomized prospective observational study, a total of 486 patients with paroxysmal (71%) or persistent (29%) AF who underwent index PVI using CB2 at our hospital between January 2013 and June 2017 were enrolled. Atrial tachyarrhythmia (ATa) free survival was defined as absence of AF, atrial flutter or atrial tachycardia recurrence &gt;30 s following 3-months blanking period. Predictors of recurrence were evaluated by univariate and multivariate Cox proportional hazards regression models. Results Acute procedural success rate was 99.8% (1898/1902 PVs). Mean procedural and fluoroscopy time were 64.9±9.2 and 12.1±2.6, respectively. At median 39 (IQR: 26–56) months follow-up, ATa free survival was 78.6% after a single procedure (280/345 [81.2%] for paroxysmal AF vs 102/141 [72.3%] for persistent AF, p=0.019) and 84.4% after a mean 1.48±0.42 ablations.Cox regression analysis showed that left atrium diameter, duration of AF history and early ATa recurrence were found as the independent predictors of late recurrence. PNP was observed in 17 (3.5%) patients. Figure 1 Conclusions Second-generation CB based PVI is effective to maintain sinus rhythm in a significant proportion of paroxysmal and early persistent AF patients with an acceptable complication rates at long-term follow-up.