Left Ablation Research Articles

Predictors of left ventricular reverse remodeling after catheter ablation for atrial fibrillation: sub analysis of a randomized controlled EARNEST-PVI trial

Abstract Background Atrial fibrillation (AF) is widely known to cause heart failure. The catheter ablation for AF improves left ventricular function in many patients with heart failure. However, the predictors of left ventricular reverse remodeling are not well established. Purpose The purpose of this study was to examine the predictor of left ventricular reverse remodeling in patients with persistent AF. Methods The predictors of left ventricular reverse remodeling was examined using data from EARNEST-PVI trial which compared 12-month rhythm outcomes between persistent AF patients allocated to pulmonary vein isolation (PVI) alone and those allocated to PVI followed by left atrial linear ablation or complex fractionated electrograms ablation. Left ventricular reverse remodeling in this study was defined as a 15% reduction of left ventricular systolic diameter at transthoracic echocardiogram 12 months after initial ablation compared to preoperative echocardiogram. Results Of the 512 patients enrolled in the EARNEST-PVI trial, 453 patients with preoperative and 12-month postoperative echocardiogram data were analyzed. Median age was 67 [60. 73] years and 75.7% were male. Recurrence of AF was observed in 106 patients (23.4%) during 12 months after the ablation. LVEF before the initial ablation was 44 [39, 47]% and LVEF 12 months after the initial ablation was 60 [55, 63]% (P<0.001), and LVDs before the initial ablation was 30 [27, 34] mm and LVDs after the initial ablation was 29 [27, 31] mm (P<0.001). Left ventricular reverse remodeling was observed in 78 patients (17.2%). Multivariate linear regression analysis showed age (Odds ratio 0.967 [95%CI=0.939-0.996], P=0.025), preoperative hear rate (Odds ratio 1.032 [95%CI=1.018-1.047], P<0.001) and the use of β-blocker (Odds ratio 2.119 [95%CI=1.235-3.638], P=0.006) were independently associated with left ventricular reverse remodeling but AF recurrence was not (Odds ratio 0.532 [95%CI=0.425-1.561], P=0.538). Conclusion Patients with persistent AF showed improvement of LVEF and left ventricular reverse remodeling 12 months after the catheter ablation. Age, heart rate before the initial ablation and the use of β-blocker were predictive factors for the left ventricular reverse remodeling after the ablation regardless of AF recurrence.

Regional levels of tenascin- C in patients with heart failure and atrial fibrillation

Abstract Background Tenascin-C (TNC) is an extracellular matrix glycoprotein that is upregulated at high levels during active tissue remodeling. The serum concentration of TNC has been reported to be increased in patients with several cardiac diseases. The aim of this study was 1) to measure the TNC plasma level in heart failure (HF) and atrial fibrillation (AF) patients compared to patients without structural heart disease and 2) to search for a local production in the heart. Methods This study included 13 patients with HF who underwent CRT- implantation (CRT- group), 13 patients with persistent AF who underwent left atrial catheter ablation (AF- group) and 13 patients without structural heart disease or AF, who underwent electrophysiological study (Control- group). Blood was collected at the beginning of the procedures from the coronary sinus (CS), superior vena cava (SVC) and aorta (Ao). Level of TNC-B (ng/dl) in the CS (TNC-CS), SVC (TNC-SVC) and aorta (TNC-Ao) was measured. Results Patients characteristics: CRT- group: mean age 74y, 8 male, LV- EF 32%, 3 with a history of atrial fibrillation. AF- group: mean age 68y, 9 male, LV- EF 55%. Control- group: mean age 54y, 9 male, LV- EF 65%. The TNC level in the SVC was in the CRT group significant elevated (6125 ± 2030 ng/ml vs 475 ± 238 ng/ml in controls (p<0.01). In the AF group the TNC level in the SVC as well was significantly higher 4983 ± 1814 ng/ml vs 475 ± 238 ng/ml in controls (p<0.01). The TNC level of the CRT- and the AF- group were not significant different (p= 0.219) (Figure 1). No significant differences were noted at the various collection sites (CS, SVC and aorta) between the 3 groups (p = 0.38). Discussion The TNC serum levels in HF- and AF- patients are elevated compared to a control group without structural heart disease and without a history of AF. We could not determinate, the source of serum TNC, differences in the level of TNC between CS and SVC and aorta were not visible. Whether an effective treatment of HF and AF will lower TNC levels and slow the disease progression needs to be evaluated in further studies.

A novel designed atrial septum linear ablation method (Icho line) for non-pulmonary vein triggers originating from atrial postero-septum and crista terminalis

Abstract Background Therapeutic strategy for non-pulmonary vein (PV) trigger of atrial fibrillation (AF) has not been well established although they are the major cause of AF recurrence after PV isolation. The atrial postero-septum or right atrial crista terminalis (CT) are the common non-PV trigger sites of AF. For them, a focal ablation is often insufficient due to a regional arrhythmogenicity. We devised an original linear ablation method, named "Icho Line". Icho means ginkgo in Japanese. Methods Eight hundred and thirty-two AF ablation patients were retrospectively studied. An AF induction test was conducted after each PV isolation procedure. Non-PV triggers from the postero-septum or CT that initiate AF were analyzed. Premature atrial contractions that did not initiate AF were excluded. A linear ablation was designed horizontally from the anterior right PV isolation line to fossa ovalis in the left atrium. In the right atrium, the opposite side of the left atrial ablation and CT were continuously ablated like the shape of a ginkgo leaf (Figure 1). Results A hundred and fifteen non-PV triggers were detected in 104 patients (12.5%), among which Icho line ablation was performed in 39 patients (37.5%) with documented triggers from the postero-septum or CT (Figure 1). Atrial tachyarrhythmia recurrence free rate in the Icho line group and other non-PV ablation patients were 61.8% and 45.4%, respectively (P=0.54, Figure 2). Conclusions A novel designed Icho line is a feasible and effective ablation strategy covering non-PV triggers from the atrial septum and CT.Icho Line Figure 1Icho Line Figure 2

Abstract 15925: Comparative Mortality, Safety, and Cost Among Stroke Patients Who Received Implantable Loop Records Compared to Continuous External Cardiac Monitors

Background: Implantable loop recorders (ILR) are increasingly used to screen for atrial fibrillation (AF) among patients with stroke, but real-world outcomes are lacking. Goal: To determine comparative effectiveness, safety, and costs of ILR compared with continuous external monitors (CEM) and Holter monitors in a real-world setting of patients with stroke. Methods: This retrospective cohort analysis used the Optum Labs Data Warehouse, which contains longitudinal, de-identified administrative claims. The cohort included patients with recent stroke who received cardiac monitoring from 1/1/2016 - 6/30/2021, comparing those with ILR to those with CEM (>48 hours to 30 days) or Holter (≤48 hours). Eligibility criteria included: ischemic stroke during 6 month baseline; continuous enrollment with medical and pharmacy coverage; no evidence of pacemaker, implantable cardioverter-defibrillator, AF, left atrial appendage ablation, or oral anticoagulants. The primary outcome was 12-month all-cause mortality, secondary outcomes included new diagnosis of AF + initiation of anticoagulants, hemorrhagic stroke, and total and device-related costs. Final analyses were adjusted for CHA 2 DS 2 -VASc score. Results: Among 48,801 individuals, 18.9% received ILR, 59.5% CEM, and 21.6% Holter. Groups had similar demographics and comorbidities (Table). Compared to those with CEM, the ILR group had higher odds of a new diagnosis of AF plus initiation of anticoagulants (OR 2.27; (95% CI 2.09, 2.48)), and hemorrhagic stroke (OR of 1.60 (95% CI 1.34, 1.93)). There was no difference in mortality. Unadjusted direct medical cost of monitoring was substantially higher in the ILR group ($13,975) compared to CEM ($449) and Holter ($149). Conclusions: Although the use of ILRs was associated with increased detection and treatment for AF, there was no impact on all-cause mortality. ILR was associated with increased hemorrhagic stroke and higher costs.

Abstract 12216: A Novel Designed Atrial Postero-Septum Linear Ablation Method (Icho Line) for Non-Pulmonary Vein Triggers of Atrial Fibrillation (AF)

Introduction: Therapeutic strategy for non-pulmonary vein (PV) triggers of atrial fibrillation (AF) has not been well established although they are the major cause of AF recurrence after PV isolation. The atrial postero-septum or right atrial crista terminalis (CT) are the common non-pulmonary vein (PV) trigger sites of atrial fibrillation (AF). For them, a focal ablation is often insufficient due to a regional arrhythmogenicity. We devised an original linear ablation method, named "Icho Line” covering the non-PV triggers from this area. Methods: Eight hundred and thirty-two AF ablation patients were retrospectively studied. An AF induction test was conducted after each PV isolation procedure. Non-PV triggers were detected in 104 patients (12.7%), among which Icho line ablation was performed in 39 patients (37.5%) with documented triggers of AF from postero-septum or CT. A linear ablation was designed horizontally from the anterior right PV isolation line to fossa ovalis in the left atrium. In the right atrium, the opposite side of the left atrial ablation was continuously ablated toward the CT like the shape of a ginkgo leaf (Figure). Results: Atrial tachyarrhythmia recurrence free rate in the Icho line group and other non-PV ablation patients were 61.8% and 45.4%, respectively (P=0.54, Figure). Recurrence with atrial tachycardia was very rare in the Icho line group. Conclusions: A novel designed Icho line is a feasible and effective ablation strategy covering non-PV triggers from the atrial septum and CT.

Abstract 17174: New Criteria for Block Across Anterior Mitral Line That Includes Bachmann’s Bundle in Patients With Scar Perimitral Flutter

Background: The recurrence rate of scar perimitral flutter (SMF) after anterior mitral line (AML) ablation remains high. Epicardial connections from high right atrium (HRA) to high lateral left atrium (HLA) including the Bachmann bundle (BB) plays a significant role in perimitral flutter recurrence. Hypothesis: We hypothesize that block across BB (BBB) during endocardial anterior line ablation reduces recurrence of atrial tachycardia (AT) and SMF. Methods: Patients undergoing left atrial ablation with SMF that were treated with AML were retrospectively enrolled. Pulmonary veins isolation and bidirectional AML block achieved in all patients. Baseline HRA-HLA, final HRA-HLA, and delta HRA-HLA intervals measured. Changes in HLA activation sequence determined. BBB identified when HRA-HLA interval increased with change in HLA activation sequence and confirmed with differential pacing. (Figure 1). The primary endpoint was recurrence of AT/SMF Results: We identified 101 patients, 51% comprised of women, with a mean age of 69. Patients who had AML without evidence of BBB were 48 compared to 53 patients who had AML with evidence of BBB. The mean baseline, final and delta HRA-LAA were 123 ± 42ms, 219 ± 45 ms and 96± 21 ms respectively in patients with BBB. After median follow up of 48 months, AT/SMF recurred in 43 % of patient without BBB vs 15 % in patient with BBB (p<0.008) (Figure 2). In patients with BBB, delta HRA-HLA >107ms discriminated between recurrence and no recurrence (p<0.023ms and 93% negative predictive value) Conclusion: During endocardial AML ablation for SMF, bidirectional block with evidence of BBB is associated with significant reduction in AT/SMF recurrence.

Abstract 15366: Quantification of Recent Reporting Rates of Atrioesophageal Fistula After Left Atrial Ablation for the Treatment of Atrial Fibrillation

Introduction: Atrio-esophageal fistulas (AEF) are a feared and fatal complication of left atrial ablation for the treatment of atrial fibrillation (AF). The recent POTTER-AF survey suggests that AEFs continue to occur despite best efforts to prevent them. A quantification of recent incidence rates and outcomes of AEF reported to the Manufacturer and User Facility Device Experience (MAUDE) database of the U.S. FDA may further elucidate trends in this complication. Research Question(s): What are the recent trends in reporting rates of AEF, and what are the outcomes? Purpose: To quantify the number of AEF reports as well as any reported outcomes of atrioesophageal fistulas and determine any trends over the last 4 years. Methods: We reviewed data from the Manufacturer and User Facility Device Experience (MAUDE) database for complications under the category of fistula that occurred over the last 4 years (2019 to 2022 inclusive). Reports were reviewed for any descriptions of outcome, and narratives were compared in an attempt to identify and exclude any duplicate reporting. Results: In total, three product codes resulted in 121 reported AEFs. Of these, 50 (41%) were listed as fatal. When provided, the time frame of death ranged from 12 days to several weeks after the index procedure. Product codes reporting AEFs included LPB (88 cases), OAE (22 cases), and OAD (11 cases), with codes representing cardiac ablation catheters and radiofrequency generators. Incidence by year showed a generally increasing trend (21 in 2019, 22 in 2020, 41 in 2021, and 37 in 2022, Figure 1). Conclusion: The annual rate of reported AEFs has not decreased over the last 4 years, and instead shows a generally increasing trend. Reported fatality rates remain high at 41%.

Abstract 11697: Combined-Energy Pulmonary Vein Isolation and Posterior Wall Isolation for Persistent Atrial Fibrillation: Results of a 3-year Follow-Up

Introduction: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation for paroxysmal atrial fibrillation (AF), but the optimal ablation strategy for persistent AF (PsAF) remains controversial. Hypothesis: The purpose of this study was to investigate whether combined-energy cryoballoon (CB) PVI and radiofrequency (RF) left atrial posterior wall isolation (LAPWI) at index ablation of PsAF yields higher success than PVI alone. Methods: Patients with persistent AF (n = 186) who underwent catheter ablation between 2016 and 2019 at a single large academic medical center were retrospectively reviewed. Patients with congenital heart disease or prior left atrial ablation or surgery were excluded. Combined-energy ablation (n=92) consisted of CB antral PVI followed by RF roof and floor lines to achieve LAPWI, along with isolation inside the box as needed. The control group had PVI only (n=94) with either CB (n=57) or RF (n=37). The primary endpoint was 12-, 24-, and 36-month freedom from any documented atrial tachyarrhythmia over 30 seconds after a 90-day blanking period following catheter ablation, compared by Kaplan-Meier analysis. Secondary endpoints included AF burden, procedural parameters, and complications. Results: The primary endpoint of 12-month freedom from any atrial tachyarrhythmia was higher for the combined-energy group vs the control group (79.1% vs 58.2%, p = 0.009). This improvement was sustained at 24 months (63.0% vs 45.8%) and at 36 months (60.3% vs 43.1%) and remained significant after adjustment for clinical covariates (adjusted HR 0.45, 95% confidence interval 0.22-0.95; p = 0.03). There was no significant difference in procedure time or complication rates, however fluoroscopy time was shorter with combined-energy ablation (p<.001). Conclusions: In this single center experience, combined-energy CB-PVI and RF-LAPWI was associated with reduced AF recurrence compared to PVI with a single energy source.

Comparison of clinical outcomes of Ibutilide-guided cardioversion and direct current synchronized cardioversion after radiofrequency ablation of persistent atrial fibrillation.

Ibutilide has already been used for cardioversion of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). The purpose of this study was to determine the effect of Ibutilide-guided cardioversion on clinical outcomes after individualized ablation of PsAF. From October 2020 to September 2021, consecutive patients with PsAF accepted for RFCA were prospectively enrolled. After individualized ablation including pulmonary vein isolation plus left atrial roof line ablation and personalized linear ablation based on left atrial low-voltage zones, patients were divided into the spontaneous conversion (SCV) group, direct current synchronized cardioversion (DCC) group and Ibutilide group according to different cardioversion types during ablation. The rates of freedom from atrial tachyarrhythmia (ATT) among the three groups were evaluated after follow-up. In this study, 110 patients were enrolled, including 12 patients with SCV, 50 patients receiving DCC and 48 patients receiving Ibutilide cardioversion after individualized ablation. Among the three groups, the SCV group had shorter AF duration {12 months [interquartile range (IQR) 12-16], P = 0.042} and smaller left atrial diameter (LAD) [35 mm (IQR: 33-42), P = 0.023]. A 12-month freedom from ATT rate was 83.3% in SCV group, 69.4% in DCC group, and 79.2% in Ibutilide group, respectively (Log-rank, P = 0.745). During the follow-up [17 months (IQR: 15-19)], the rate of freedom from ATT of SCV group (83.3%), and Ibutilide group (72.9%) were both higher than that of DCC group (53.1%, P = 0.042). Moreover, Kaplan-Meier analysis showed a significantly higher sinus rhythm (SR) maintenance in Ibutilide group than in DCC group (Log-rank, P = 0.041). After adjusting for risk factors of AF recurrence, the hazard ratio for AF recurrence of the DCC group with reference to the Ibutilide group was 4.10 [95% confidence interval (CI) (1.87-8.98), P < 0.001]. Furthermore, subgroup analysis showed that freedom from ATT rate in effective Ibutilide subgroup was significantly higher than noneffective Ibutilide subgroup (Log-rank, P < 0.001). For the treatment of the patients with PsAF, Ibutilide-guided cardioversion after individualized RFCA may be benefit for maintenance of SR compared to conventional DCC, especially for the patients who are effective for administration of Ibutilide.

Symptomatic periesophageal vagal nerve injury by different energy sources during atrial fibrillation ablation.

Symptomatic gastric hypomotility (SGH) is a rare but major complication of atrial fibrillation (AF) ablation, but data on this are scarce. We compared the clinical course of SGH occurring with different energy sources. This multicenter study retrospectively collected the characteristics and clinical outcomes of patients with SGH after AF ablation. The data of 93 patients (67.0 ± 11.2 years, 68 men, 52 paroxysmal AF) with SGH after AF ablation were collected from 23 cardiovascular centers. Left atrial (LA) ablation sets included pulmonary vein isolation (PVI) alone, a PVI plus a roof-line, and an LA posterior wall isolation in 42 (45.2%), 11 (11.8%), and 40 (43.0%) patients, respectively. LA ablation was performed by radiofrequency ablation, cryoballoon ablation, or both in 38 (40.8%), 38 (40.8%), and 17 (18.3%) patients, respectively. SGH diagnoses were confirmed at 2 (1-4) days post-procedure, and 28 (30.1%) patients required re-hospitalizations. Fasting was required in 81 (92.0%) patients for 4 (2.5-5) days; the total hospitalization duration was 11 [7-19.8] days. After conservative treatment, symptoms disappeared in 22.3% of patients at 1 month, 48.9% at 2 months, 57.6% at 3 months, 84.6% at 6 months, and 89.7% at 12 months, however, one patient required surgery after radiofrequency ablation. Symptoms persisted for >1-year post-procedure in 7 patients. The outcomes were similar regardless of the energy source and LA lesion set. The clinical course of SGH was similar regardless of the energy source. The diagnosis was often delayed, and most recovered within 6 months, yet could persist for over 1 year in 10%.

Detection of brain lesions after catheter ablation depends on imaging criteria: insights from AXAFA-AFNET 5 trial.

Left atrial catheter ablation is well established in patients with symptomatic atrial fibrillation (AF) but associated with risk of embolism to the brain. The present analysis aims to assess the impact of diffusion-weighted imaging (DWI) slice thickness on the rate of magnetic resonance imaging (MRI)-detected ischaemic brain lesions after ablation. AXAFA-AFNET 5 trial (NCT02227550) participants underwent MRI using high-resolution (hr) DWI (slice thickness: 2.5-3 mm) and standard DWI (slice thickness: 5-6 mm) within 3-48 h after ablation. In 321 patients with analysable brain MRI (mean age 64 years, 33% female, median CHA2DS2-VASc 2), hrDWI detected at least one acute brain lesion in 84 (26.2%) patients and standard DWI in 60 (18.7%; P < 0.01) patients. High-resolution diffusion-weighted imaging detected more lesions compared to standard DWI (165 vs. 104; P < 0.01). The degree of agreement for lesion confirmation using hrDWI vs. standard DWI was substantial (κ = 0769). Comparing the proportion of DWI-detected lesions, lesion distribution, and total lesion volume per patient, there was no difference in the cohort of participants undergoing MRI at 1.5 T (n = 52) vs. 3 T (n = 269). The pre-specified AXAFA-AFNET 5 sub-analysis revealed significantly increased rates of MRI-detected acute brain lesions using hrDWI instead of standard DWI in AF patients undergoing ablation. In comparison to DWI slice thickness, MRI field strength had a no significant impact in the trial. Comparing the varying rates of ablation-related MRI-detected brain lesions across previous studies has to consider these technical parameters. Future studies should use hrDWI, as feasibility was demonstrated in the multicentre AXAFA-AFNET 5 trial.

Efficacy of Vein of Marshall Ethanol Infusion Added to Left Atrial Anatomical Ablation for Treatment of Persistent Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy.

Radiofrequency catheter ablation (RFCA) has been shown to have low efficacy for the treatment of persistent atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). We conducted this study to evaluate the benefit of adjunctive vein of Marshall (VOM) ethanol infusion during RFCA for persistent AF (PsAF) in patients with non-obstructive HCM. This multicenter retrospective observational study included 102 consecutive non-obstructive HCM patients with PsAF who underwent RFCA plus VOM ethanol infusion (VOM-EI) (RFCA + VOM, n = 56) or RFCA alone (RFCA, n = 46) for the first time. The efficacy endpoint was survival without AF or atrial tachycardia (AT) after the blanking period. We completed the VOM-EI in 92.9% (52/56) patients. The left pulmonary vein antrum ablation time (RFCA + VOM: 19.9 6.1 min vs. RFCA: 27.2 9.3 min), mitral isthmus (MI) ablation time (RFCA + VOM: 16.9 3.7 min vs. RFCA: 28.4 7.8 min), and rate of coronary sinus (CS) vein ablation (RFCA + VOM: 57.69% vs. RFCA: 80.43%) were lower but the acute success rate of MI block (RFCA + VOM: 98.1% vs. RFCA: 84.8%) were higher in the RFCA + VOM group than those in the RFCA group (all p 0.05). After twelve months follow-up, 84.6% of patients (44/52) survived without AF/AT in the RFCA + VOM group, compared to 65.2% of patients (30/46) in the RFCA group (p = 0.03; odds ratio = 2.93, 95% CI: 1.18-7.79). VOM-EI combined with RFCA decreased the recurrence rate of AF/AT at 12 months in HCM patients with PsAF. VOM-EI simplified the ablation of the left pulmonary vein antrum and MI and increased the success rate of MI bidirectional block.

Comparison of pulmonary vein isolation using cryoballoon, high-power short-duration, and conventional radiofrequency ablation for atrial fibrillation: a propensity score-weighted study.

The comparative efficacy, saftey, and heart rate variability (HRV) parameters after pulmonary vein isolation using cryoballoon (Cryo-PVI), high-power short-duration (HPSD-PVI), and conventional radiofrequency ablation (conventional-PVI) for atrial fibrillation (AF) is unclear. In this propensity score-weighted, retrospective analysis of a single-center cohort, we analyzed 3,395 patients (26.2% female, 74.5% paroxysmal AF) who underwent AF catheter ablation without an empirical left atrial ablation. Procedural factors, recurrence rates, complication rates, and the post-procedural HRV parameters were compared across the Cryo-PVI (n = 625), HPSD-PVI (n = 748), and conventional-PVI (n = 2,022) groups. Despite the shortest procedural time in the Cryo-PVI group (74 min for Cryo-PVI vs. 104 min for HPSD-PVI vs. 153 min for conventional-PVI, p < 0.001), the major complication (p = 0.906) and clinical recurrence rates were similar across the three ablation groups (weighted log-rank, p = 0.824). However, the Cryo-PVI group was associated with a significantly lower risk of recurrent AF in patients with paroxysmal AF [weighted hazard ratio (WHR) 0.57, 95% confidence interval (CI) 0.37-0.86], whereas it was associated with a higher risk of recurrent AF in patients with persistent AF (WHR 1.41, 95% CI 1.06-1.89, p for interaction of <0.001) compared with the conventional-PVI group. In the subgroup analysis for the HRV, the Cryo-PVI group had the highest low-frequency-to-high-frequency ratio at 1-year post-procedure, whereas the HPSD-PVI group had the lowest low-frequency-to-high-frequency ratio at 1-year post-procedure (p < 0.001). The Cryo-PVI group had better rhythm outcomes in patients with paroxysmal AF but worse rhythm outcomes in patients with persistent AF and a higher long-term post-procedural sympathetic nervous activity and sympatho-vagal balance compared with the conventional-PVI group.

How to ablate the septo-pulmonary bundle: a case-based review of percutaneous ablation strategies to achieve roof line block.

Electrical conduction through cardiac muscle fibres separated from the main myocardial wall by layers of interposed adipose tissue are notoriously difficult to target by endocardial ablation alone. They are a recognised important cause for procedural failure due to the difficulties of delivering sufficient energy via the endocardial radiofrequency catheter to reach the outer epicardial layer without risking adverse events of the otherwise thin walled atria. Left atrial ablations for atrial fibrillation (AF) and tachycardia are commonly affected by the presence of several epicardial structures, with the septo-pulmonary bundle (SPB), Bachmann's bundle, and the ligament of Marshall all posing substantial challenges for endocardial procedures. Delivery of a transmural lesion set is essential for sustained pulmonary vein isolation and for conduction block across linear atrial lines which in turn has been described to translate into a reduced AF/atrial tachycardia recurrence rate. To overcome the limitations of endocardial-only approaches, surgical ablation techniques for epicardial or combined hybrid endo-epicardial ablations have been described to successfully target these connections. Yet, these techniques confer an increase in procedure complexity, duration, cost, and morbidity. Alternatively, coronary venous system ethanol ablation has been successfully employed by sub-selecting the vein of Marshall to facilitate mitral isthmus line block, although this approach is naturally limited to this area by the coronary venous anatomy. Increased awareness of the pathophysiological relevance of these epicardial structures and their intracardiac conduction patterns in the era of high-resolution 3D electro-anatomical mapping technology has allowed greater understanding of their contribution to the persistence of AF as well as failure to achieve transmural block by traditional ablation approaches. This might translate into novel catheter ablation strategies with procedural success rates comparable to surgical 'cut-and-sew' techniques. This review aims to give an overview of percutaneous catheter ablation strategies to target the SPB, an important cause of failed block across the roof line and isolation of the left atrial posterior wall and/or the pulmonary veins. Existing and investigational technologies will be discussed and an outlook of future approaches provided.

Pulsed-field ablation of pulmonary vein and left atrial posterior wall combined with left atrial appendage occlusion as single procedure.

Pulmonary vein isolation and left atrial posterior wall ablation using the Farapulse system, followed by left atrial appendage occlusion, have been achieved as single combined procedure to treat long-standing persistent atrial fibrillation in a patient at high hemorrhagic risk.

Three Ablation Techniques for Atrial Fibrillation during Concomitant Cardiac Surgery: A Systematic Review and Network Meta-Analysis.

Atrial fibrillation (AF) ablation is a frequent procedure used in concomitant cardiac surgery. However, uncertainty still exists concerning the optimal extent of lesion sets. Hence, the objective of this study was to assess the results of various ablation techniques, aiming to offer a reference for clinical decision making. This review is listed in the prospective register of systematic reviews (PROSPERO) under ID CRD42023412785. A comprehensive search was conducted across eight databases (Scopus, Google Scholar, EBSCOHost, PubMed, Medline, Wiley, ProQuest, and Embase) up to 18 April 2023. Studies were critically appraised using the Cochrane Risk of Bias 2.0 for randomized control trials (RCTs) and the Newcastle Ottawa Scale adapted by the Agency for Healthcare Research and Quality (AHRQ) for cohort studies. Forest plots of pooled effect estimates and surface under the cumulative ranking (SUCRA) were used for the analysis. Our analysis included 39 studies and a total of 7207 patients. Both bi-atrial ablation (BAA) and left atrial ablation (LAA) showed similar efficacy in restoring sinus rhythm (SR; BAA (77.9%) > LAA (76.2%) > pulmonary vein isolation (PVI; 66.5%); LAA: OR = 1.08 (CI 0.94-1.23); PVI: OR = 1.36 (CI 1.08-1.70)). However, BAA had higher pacemaker implantation (LAA: OR = 0.51 (CI 0.37-0.71); PVI: OR = 0.52 (CI 0.31-0.86)) and reoperation rates (LAA: OR = 0.71 (CI 0.28-1.45); PVI: OR = 0.31 (CI 0.1-0.64)). PVI had the lowest efficacy in restoring SR and a similar complication rate to LAA, but had the shortest procedure time (Cross-clamp (Xc): PVI (93.38) > LAA (37.36) > BAA (13.89)); Cardiopulmonary bypass (CPB): PVI (93.93) > LAA (56.04) > BAA (0.03)). We suggest that LAA is the best surgical technique for AF ablation due to its comparable effectiveness in restoring SR, its lower rate of pacemaker requirement, and its lower reoperation rate compared to BAA. Furthermore, LAA ranks as the second-fastest procedure after PVI, with a similar CPB time.

Safety of an esophageal deviator for atrial fibrillation catheter ablation.

Esophageal thermal injury is a complication of atrial fibrillation (AF) ablation, and it can be avoided by esophageal deviation during left atrial posterior wall radiofrequency catheter ablation. This study aimed to evaluate the safety of a nitinol-based mechanical esophageal displacement device (MEDD) and its performance. This preclinical safety study was conducted on 20 pigs, with 10 undergoing radiofrequency AF ablation using the MEDD and 10 serving as a control group under anticoagulation but without radiofrequency application. Esophageal traumatic injuries were classified from 0 to 4 and were grouped as absent (grade 0), minor (grade 1 or 2), moderate (grade 3), or major risk lesions (grade 4) by anatomopathological study. Grades 1 and 2 were considered acceptable. Fluoroscopy was used to measure displacement. Five (25%) pigs developed traumatic lesions, 4 with grade 1 and 1 with grade 2 (2-mm superficial ulcer). There was no difference in lesion occurrence between the radiofrequency and control groups (30% and 20%, respectively; P = .43). Under rightward displacement, the right edge moved 23.9 (interquartile range [IQR] 21.3-26.3) mm and the left edge moved 16.3 (IQR 13.8-18.4) mm (P < .001) from baseline. Under leftward displacement, the right edge moved 13.5 (IQR 10.9-15.3) mm and the left edge moved 16.5 (IQR 12.3-18.5) mm (P = .07). A perforation to the pharyngeal diverticulum occurred in 1 pig, related to an accidental extubation. In pigs, the MEDD demonstrated safety in relation to esophageal tissue, and successful deviation. Esophageal traumatic injuries were acceptable, but improper manipulation led to pharyngeal lesion.

État de l'activité de rythmologie interventionnelle en France et conséquences des réformes des seuils sur les autorisations d'activité

BackgroundInterventional rhythmology activity (electrophysiology and pacing) has progressed in France during the last decade. The objective of this article is to assess the distribution of this activity depending on the type of centre (public, university or non-university, private). As the French government issued a new regulation regarding rhythmology activity in 2022, the impact of this regulation on activity distribution has been evaluated. MethodologyAll French data activity can be evaluated after accessing to a national database called PMSI [Programme de Médicalisation des Systèmes d'Information]. Based on data collected in year 2021, the level of activity of the different centres, and the impact of the new criteria of the French regulation regarding rhythmology activity have been analysed. ResultsAbout 200,000 arrhythmias interventions have been done in France in 2021 in 382 centres. According to the new criteria of the French regulation, 66% responded to level A (diagnostic electrophysiology, single- and dual-chamber pacing), 68% for level B (A+ right atrial ablation, implantable automatic defibrillator, cardiac resynchronisation therapy) and 70% for level C (B + left atrial and ventricular ablation). 1/4 of the centres do not meet criteria for level A activity, and 1/5 of them for levels B and C ConclusionsThis work showed that immediat and systematic application of new threshold could be threatening for 1/4 of A center and 1/5 of B or C center. The priority will be to reinforce existing centres before allowing new centres to perform arrhythmias management activity in France.

Long-Term Impact of Additional Ablation After Pulmonary Vein Isolation: Results From EARNEST-PVI Trial.

Background An optimal strategy for left atrial ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not been determined. Methods and Results We conducted an extended follow-up of the multicenter randomized controlled EARNEST-PVI (Efficacy of Pulmonary Vein Isolation Alone in Patients With Persistent Atrial Fibrillation) trial, which compared 12-month rhythm outcomes in patients with persistent AF between patients randomized to a PVI-alone strategy (n=248) or PVI-plus strategy (n=248; PVI followed by left atrial additional ablation, including linear ablation or ablation targeting areas with complex fractionated electrograms). The present study extended the follow-up period to 3 years after enrollment. Outcomes were compared not only between randomly allocated groups but also between on-treatment groups categorized by actually created ablation lesions. Recurrence rate of AF or atrial tachycardia (AT) was lower in the randomly allocated to PVI-plus group than the PVI-alone group (29.0% versus 37.5%, P=0.036). On-treatment analysis revealed that patients with PVI+linear ablation (n=205) demonstrated a lower AF/AT recurrence rate than those with PVI only (26.3% versus 37.8%, P=0.007). In contrast, patients with PVI+complex fractionated electrograms ablation (n=37) had an AF/AT recurrence rate comparable to that of patients with PVI only (40.5% versus 37.8%, P=0.76). At second ablation in 126 patients with AF/AT recurrence, ATs excluding common atrial flutter were more frequent in patients with PVI+linear ablation than in those with PVI only (32.6% versus 5.7%, P<0.0001). Conclusions Left atrial ablation in addition to PVI was efficacious during 3-year follow-up. Linear ablation was superior to other ablation strategies but may increase iatrogenic ATs. Registration URL: http://www.umin.ac.jp/ctr/index-j.htm; Unique identifier: UMIN000019449.

Unipolar-voltage-based evaluation of left atrial tissue properties and ablation outcome in patients with atrial fibrillation.

The relationship between local unipolar voltage (UV) in the pulmonary vein (PV)-ostia and left atrial wall thickness (LAWT) and the utility of these parameters as indices of outcome after atrial fibrillation (AF) ablation remain unclear. Two-hundred seventy-two AF patients who underwent AF ablation were enrolled. Unipolar voltage of PV-ostia was measured using a CARTO system, and LAWT was measured using computed tomography. The primary endpoint was atrial tachyarrhythmia (ATA) recurrence including AF. The ATA recurrence was documented in 74 patients (ATA-Rec group). The UV and LAWT of the bilateral superior PV roof to posterior and around the right-inferior PV in the ATA-Rec group were significantly greater than in patients without ATA recurrence (ATA-Free group) (P < 0.001). The UV had a strong positive correlation with LAWT (R2 = 0.446, P < 0.001). The UV 2.7 mV and the corresponding LAWT 1.6 mm were determined as the cut-off values for ATA recurrence (P < 0.001, respectively). Multisite LA high UV (HUV, ≥4 areas of >2.7 mV) or multisite LA wall thickening (≥5 areas of >1.6 mm), defined as LA hypertrophy (LAH), was related to higher ATA recurrence. Among 92 LAH patients, 66 had HUV (LAH-HUV) and the remaining 26 had low UV (LAH-LUV), characterized by history of non-paroxysmal AF and heart failure, reduced LV ejection fraction, or enlarged LA. In addition, LAH-LUV showed the worst ablation outcome, followed by LAH-HUV and No LAH (log-rank P < 0.001). Combining UV and LAWT enables us to stratify recurrence risk and suggest a tailored ablation strategy according to LA tissue properties.