Left Ablation Research Articles

Cryoballoon-Assisted Pulmonary Vein Isolation and Left Atrial Roof Ablation Using a Simplified Sedation Strategy without Esophageal Temperature Monitoring: No Notable Thermal Esophageal Lesions and Low Arrhythmia Recurrence Rates after 2 Years.

Atrial fibrillation (AF) ablation is increasingly effective for managing heart rhythm but poses risks like esophageal fistulas. Minimizing esophageal thermal lesions while simplifying procedures is crucial. This prospective study involved 100 consecutive AF patients undergoing cryoballoon ablation with simplified sedation, without esophageal temperature monitoring. Patients with paroxysmal AF (Group A) received pulmonary vein isolation only, while those with persistent AF (Group B) also had left atrial roof ablation. Gastroesophageal endoscopy was performed post-procedure to detect lesions, and cardiological follow-ups were conducted at 3, 12, and 24 months. The cohort included 69% men, with a median age of 65.5 years. Post-ablation endoscopy was performed in 92 patients; esophageal lesions were found in 1.1% of Group A and none of Group B. GERD was diagnosed in 14% of patients, evenly distributed between groups and not linked to lesion occurrence. Gastric hypomotility was observed in 16% of patients, with no significant difference between groups. At 24 months, arrhythmia-free survival was 88% in Group A and 74% in Group B. Cryoballoon-assisted pulmonary vein isolation, with or without additional left atrial roof ablation and without esophageal temperature monitoring during a simplified sedation strategy, shows low risk of esophageal thermal injury and effective ablation outcomes.

In Silico TRials guide optimal stratification of ATrIal FIbrillation patients to Catheter Ablation and pharmacological medicaTION: the i-STRATIFICATION study.

Patients with persistent atrial fibrillation (AF) experience 50% recurrence despite pulmonary vein isolation (PVI), and no consensus is established for secondary treatments. The aim of our i-STRATIFICATION study is to provide evidence for stratifying patients with AF recurrence after PVI to optimal pharmacological and ablation therapies, through in silico trials. A cohort of 800 virtual patients, with variability in atrial anatomy, electrophysiology, and tissue structure (low-voltage areas, LVAs), was developed and validated against clinical data from ionic currents to electrocardiogram. Virtual patients presenting AF post-PVI underwent 12 secondary treatments. Sustained AF developed in 522 virtual patients after PVI. Second ablation procedures involving left atrial ablation alone showed 55% efficacy, only succeeding in the small right atria (<60 mL). When additional cavo-tricuspid isthmus ablation was considered, Marshall-PLAN sufficed (66% efficacy) for the small left atria (<90 mL). For the bigger left atria, a more aggressive ablation approach was required, such as anterior mitral line (75% efficacy) or posterior wall isolation plus mitral isthmus ablation (77% efficacy). Virtual patients with LVAs greatly benefited from LVA ablation in the left and right atria (100% efficacy). Conversely, in the absence of LVAs, synergistic ablation and pharmacotherapy could terminate AF. In the absence of ablation, the patient's ionic current substrate modulated the response to antiarrhythmic drugs, being the inward currents critical for optimal stratification to amiodarone or vernakalant. In silico trials identify optimal strategies for AF treatment based on virtual patient characteristics, evidencing the power of human modelling and simulation as a clinical assisting tool.

Safety and effectiveness of additional left atrial posterior wall ablation using pulsed field ablation for persistent and long-standing persistent atrial fibrillation patients.

The unique safety profile of pulsed field ablation (PFA) has made pulmonary vein isolation (PVI) + left atrial posterior wall (LAPW) ablation promising for treating persistent atrial fibrillation (PerAF). The goal of this study was to assess long-term freedom from atrial fibrillation, atrial flutter, and atrial tachycardia (AF/AFL/AT), as well as the safety and feasibility of LAPW PFA using multipolar, pentaspline Farawave catheter. Retrospective observational study at a single institution. Data for 94 patients were collected from a prespecified intraprocedural registry. The long-term AF/AFL/AT recurrence assessment was based on an analysis of medical history; 24-h Holter ECGs at 3, 6, and 12 months postablation; and 12-lead ECGs recorded during symptomatic episodes or visits. Half of the patients had ls-PerAF, and half had a history of catheter ablation-mostly RF PVI. The acute ablation success rate was 100%, and the primary safety outcome was observed in 2 patients. Fifty patients experienced AF/AFL/AT recurrence (54.3%). An increase in LAPW low-voltage areas and AF classification were associated with arrhythmia recurrence. After a median follow-up of 13 months, the Kaplan‒Meier estimated median time free of AF/AFL/AT after a single procedure was 14.7 months. PFA PVI + PWA had the best outcome in perAF patients without extensive LA fibrosis. AF recurrence was paroxysmal in significant part of the cohort. The addition of PWA to PVI using multipolar PFA was safe and did not significantly influence the transpired ablation time.

Left atrial low-voltage area is associated with poor rhythm outcome and poor efficacy of left atrial additional ablation in patients with long-standing persistent atrial fibrillation ablation

Abstract Background Although left atrial additional ablation other than pulmonary vein (PV) isolation is often performed in order to modify arrhythmogenic substrate, rhythm outcome in patients with long-standing persistent atrial fibrillation (LS-PerAF) is still challenging. Left atrial low-voltage areas (LVAs) is correlated with degeneration of atrial myocardium, and atrial fibrillation (AF) recurrence following catheter ablation. However, in patients with LS-PerAF, the association between the prevalence of LVAs and rhythm outcome has not been clarified. We hypothesized that AF recurrence after AF ablation more frequently occurred in patients with LVAs than in those without, and that the prevalence of LVAs was associated with the efficacy of left atrial additional ablation. Purpose The purpose of this study was to investigate the association between the prevalence of LVAs and rhythm outcome or efficacy of left atrial additional ablation in patients with LS-PerAF ablation. Methods In total, 123 (age, 66 ± 9 years; female, 28 [23%]) consecutive patients who underwent initial ablation for LS-PerAF were included. Left atrial additional ablation was defined as an ablation for left atrium other than PV isolation and ablation for non-PV foci. The definition of LVAs was sites with a bipolar voltage of &amp;lt;0.5 mV covering ≥5 cm² of left atrium. Rhythm outcome after the catheter ablation was followed for 24 months. Results LVAs was found in 31 (25%) patients, and left atrial additional ablation was performed for 31 (25%) patients. Freedom from AF recurrence was significantly lower in patients with LVAs than in those without (Figure 1A). In contrast, freedom from AF recurrence was similar between patients with left atrial additional ablation and those without (Figure 1B). In patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without (Figure 2A). On the contrary, in patients with LVAs, freedom from AF recurrence during was similar between patients with left atrial additional ablation and those without (Figure 2B). Conclusions In patients undergoing LS-PerAF ablation, AF recurrence more frequently occurred in patients with LVAs than in those without. Only in patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without.Figure 1Figure 2

Findings at repeat ablation after complex left atrial pulsed field ablation for longstanding persistent atrial fibrillation

Abstract Background There is a limited knowledge on atrial arrhythmias recurring after complex left atrial (LA) pulsed field ablation (PFA) for longstanding persistent atrial fibrillation (LSPAF). Purpose To present recurrent atrial arrhythmias and their sources found at repeat ablation following PFA for LSPAF. Methods and results Of 214 patients with LSPAF (age 65±8, 53 females, continuous AF for 30±27 months) with complex LA PFA (Farapulse) in 10/2021-10/2023, 19 patients (64±8 years, 5 females) underwent repeat ablation for recurrent AF or arial tachycardia (AT) in 20 procedures. First PFA procedure included pulmonary vein isolation (PVI), roof/posterior wall, and mitral isthmus/coronary sinus/Ligament of Marshal region (LOM) ablation. At repeat ablation, 3D activation and entrainment mapping and ablation identified the AF/AT sources; ATs sources were classified as macroreentry (MRAT) (perimitral, roof-dependent, typical flutter) or localized (LOCAT) in case of smaller reentry or ectopic origin. Results The clinical recurrent arrhythmias included paroxysmal AF (n=1), persistent AF (n=2), paroxysmal AT (n=1) or persistent AT (n=16). At the onset of repeat ablation, persistent AF/AT was present (n=15) or had to be induced (n=5). AF was finally present during the procedure in 8 patients, and was terminated by ablation directly into SR (n=3) or into intermediate AT (n=3) (conversion sites included LA ridge/LOM region 2x, RA septum 1x, RA low lateral 2x, CTI 1x), or required DCC (n=2). Primary recurrent or from AF converted AT was present in 15 patients; only MRAT in 6 patients, only LOCAT in 3 patients, and both AT types in 6 (patients). Of MRAT (N. ATs = 16), there were 12 perimitral ATs, 0 roof-dependent AT, and 2 typical flutters. Of LOCATs, sources were located at LA anterior wall 4x, LA septum 2x, LA roof 1x, LA ridge/LOM 1x, persistent left vena cava 1x, and RA – para SA node 1x. Recurrent AF/AT sources were targeted by radiofrequency or PFA in 16 and 4 cases, respectively, all spontaneous and induced AF/AT were finally terminated into SR in 16 cases, subsequent noninducibility by atrial pacing up to 300 bpn was achieved in 13 cases, and recurrent AF/AT occurred in 3 patients. Conclusion At repeat ablation PFA (Farapulse) for LSPAF, recurrent AT dominated over AF, MRAT slightly prevailed over LOCAT, mostly constituted by perimitral AT, while roof-dependent AT recurrence was reduced to zero. A majority of AF/AT sources were located outside prior PFA lesions at the LA anterior wall, septum and the right atrium.

Atrial fibrillation burden, symptoms and medication use after left bundle branch area pacing combined with AV-node ablation in patients with symptomatic atrial fibrillation

Abstract Background AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP). Purpose To investigate the AF burden, AF related symptoms and anti-arrhythmic drug (AAD) use after AV-node ablation combined with LBBAP. Methods Consecutive patients with symptomatic AF, intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation, were included. At baseline, AF related symptoms classified according to the EHRA classification and AAD use were scored. After DDD-pacemaker implantation with an LBBAP lead and subsequent AV-node ablation device detected AF burden was assessed six weeks, six months and twelve months later. AF burden at six weeks after AV-node ablation was considered the baseline measurement for AF burden. AF related symptoms and AAD use were collected at twelve months follow-up. Results Twenty-four patients (67% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Eighteen patients had persistent (75%) and three long-standing persistent (12.5%) AF with enlarged left atria (left-atrial volume index (LAVI) 52 ± 18ml/m2) and EHRA class IIb or higher in twenty (69%) patients. Twenty-three patients (96%) used at least one AAD with fifteen patients (63%) using &amp;gt;1 AAD at baseline, fig. 1. AF burden did not change at six months (-1.3 [-17, 15] %, p=0.87) and twelve months (-2.9 [-40,35] %, p=0.86) follow-up relative to six weeks follow-up, fig 2A. AF symptoms were significantly reduced with most patients in EHRA class I (6, 25%) or class IIa (17, 71%; p&amp;lt;0.001) at twelve months follow-up, fig 2B. There was a significant reduction in AAD use with fourteen patients (58%) using no AAD at twelve months follow-up and no patients using &amp;gt;1 AAD at twelve months follow up (p&amp;lt;0.001), fig 2C. Conclusion AV node ablation followed by permanent LBBAP did not reduce AF burden in an AF population with advanced disease. However, a significant reduction in AF symptoms and medication use was demonstrated with this therapy. Figure 2. AF burden (panel A), symptoms (panel B) and AAD use (panel C) at baseline and twelve months after ‘pace-and-ablate’ therapy. AF = atrial fibrillation; EHRA = EHRA = European Heart Rhythm Association symptom classification for AF; AAD = anti-arrhythmic drug. *relative to AF burden at six weeks follow-up.Baseline characteristicsBaseline and follow-up measurements

Procedural safety and outcome of additional left atrial posterior wall ablation using pulse field ablation for atrial fibrillation

Abstract Introduction Pulsed field ablation (PFA) has recently been shown to be comparable to radiofrequency ablation and cryoablation in terms of acute safety and outcome for pulmonary vein isolation (PVI) for atrial fibrillation (AF). Efficacy and safety of additional left atrial posterior wall ablation (LAPWA) is unknown. We hereby report safety profile and short-term success at 6 months. Methods Consecutive patients with paroxysmal or persistent atrial fibrillation who underwent PFA were included. Procedures were performed under conscious sedation or general anaesthesia, with or without intracardiac echocardiography/ pre- or post-ablation electroanatomic mapping at the operators’ discretion. Safety endpoints included all-cause death within 30 days, cardiac tamponade, stroke/ TIA, MI, diaphragmatic paralysis, AE fistula. Primary efficacy endpoint was arrhythmia recurrence after 90 days blanking period at 6 months. LAPWA was performed using 2.0 kV biphasic waveforms, 2 deliveries for each application site. The lesion set depended on the patient’s AF ablation history, LA size, and anatomy. After LA mapping post PVI (index or re-do), 2 anchor lesions per vein extending to the LAPW were deployed. A lesion set was then performed between the anchor lesions on the LAPW (upper and lower row) with the catheter in a flower configuration and the intention of 50% overlap for the neighbouring application sites at 3D EAM. Results Seventy-two (76% males) patients underwent PFA for AF, 55 (76.4%) were paroxysmal and 4 (5.6%) were redo cases. 19 (72%) underwent additional LAPWA. LAPWA was more likely performed in patients with persistent AF (57.9% vs 11.3%, p&amp;lt;0.001), require GA (p=0.043), with 100% EAM use (p=0.026). While total PFA applications was expectedly higher in the LAPWA group (65.7 ± 12.4 vs 42.9 ± 9.0, p&amp;lt;0.001), there were no significant differences in PFA dwell time in LA (44.2 ± 14.8 vs 42.3 ± 15.5min, p=0.628), procedural time (121.3 ± 43.8 vs 119.2 ± 49.4min, p=0.866) and fluoroscopic dose, AK (130 ± 107 vs 139 ± 102mGy, p=0.748). Average number of applications required for LAPW was 18 applications. LAPW isolation was acutely successful in all 19 patients on EAM. There were 6 inpatient complications of which all happened in the non-LAPWA group and unrelated to PFA. Arrhythmia recurrence was comparable at 6 months (11.1% vs 8.9%, p=1.00). Conclusion Additional LAPWA on top of PVI using PFA is safe with excellent acute isolation of posterior wall and does not increase procedural nor fluoroscopic duration. Short term outcome appears comparable and LAPWA may be useful especially in patients with persistent AF who may not be able to tolerate long procedures but will benefit from durable rhythm control.

Echocardiographic follow-up after AV node ablation combined with left bundle branch area pacing for patients with symptomatic atrial fibrillation

Abstract Background AV node ablation combined with permanent pacing is an established therapy for rate control in patients with symptomatic atrial fibrillation (AF) refractory or intolerant to pharmacological rate or rhythm control and not eligible for rhythm control by left atrial catheter ablation. The threshold for performing this so-called "pace-and-ablate" strategy has decreased since the introduction of conduction system pacing, and especially left bundle branch area pacing (LBBAP). Purpose To investigate the change of the left-ventricular (LV) ejection fraction (EF) and left-atrial volume index (LAVI) in patients with symptomatic AF, twelve months after LBBAP and AV-node ablation. Methods Consecutive patients with symptomatic AF intolerant or refractory to pharmacological rate and symptom control and deemed not eligible for left atrial catheter ablation were included. At baseline, the EHRA score was noted and the LVEF and LAVI were measured echocardiographically. Patients were subdivided in a normal baseline LV ejection fraction (LVEF &amp;gt;50%) or diminished baseline LVEF (LVEF &amp;lt;50%) group. After LBBAP, patients underwent AV node ablation in the same procedure or four weeks later. After twelve months, the LVEF and LAVI were reassessed in the entire cohort and the two subgroups. Results Twenty-two patients (68% female, mean age 79±4 years) scheduled for pace-and-ablate therapy were prospectively included. Three (14%) had paroxysmal, sixteen patients (72%) had persistent AF and three patients (14%) long-standing persistent AF. An EHRA class IIb or higher was found in eighteen patients (82%). At baseline, the mean LVEF was 51 ± 7%, the mean LVEDD 47 ± 6 mm and LAVI 54 ± 18 ml/m2. Twelve patients (55%) had a preserved LVEF, whereas ten patients (45%) had an LVEF &amp;lt;50%, fig. 1. After twelve months, the overall ejection fraction increased to 54 ± 5% (p=0.016), fig. 2A. This was mostly attributed to the increase in LVEF to 51 ± 5% in the subgroup with a reduced baseline LVEF (p=0.009 compared to baseline 44 ± 5%), fig. 2A. The LVEF was unaffected in the other group (57 ± 3% vs. 57 ± 4%, p=0.63), fig. 2A. The LAVI was not significantly reduced in the overall cohort or the subgroups (54 ± 18 ml/m2 to 51 ± 19 ml/m2, p=0.16), fig 2B. Conclusion AV node ablation combined with LBBAP results in a significant improvement in LVEF at twelve months follow-up. This is mainly driven by an improvement in LVEF in those patients with a diminished LVEF at baseline. The data suggests that the therapy can reverse a tachycardiomyopathy without inducing a pacing-induced cardiomyopathy. No significant reduction in LAVI was found.Baseline characteristicsChanges in LVEF (A) and LAVI (B)

Predictive value of guideline-referred risk scores in estimating left atrial low voltage areas and recurrence of atrial fibrillation in repeat ablation procedures

Abstract Background Despite advances in mapping and ablation techniques, atrial fibrillation (AF) recurrence remains a challenge after pulmonary vein isolation. Low voltage areas (LVA) in the left atrium are associated with higher recurrence rates after left atrial ablation. Risk scores for evaluating post-ablation recurrences are not well established, although a better patient selection for repeat procedures would be of great help in clinical practice. Purpose Risk scores for prediction of AF recurrence have not been tested in a cohort of repeat ablations. Methods This single-center study includes consecutive patients from the prospective Bernau ablation registry undergoing ultra-high-density (UHD) mapping and repeat ablation for AF/AT recurrence between 2016 and 2020. The potential of seven guideline mentioned risk scores (APPLE, DR-FLASH, MB-LATER, ATLAS, CAAP-AF, BASE-AF 2, ALARMEc) to predict (1) AF/AT recurrence beyond a three-months blanking period after repeat left atrial ablation (Re-PVI ± further LA ablation) and (2) the percentage of left atrial LVA in UHD mapping was investigated. LVA were defined as sites with a bipolar peak-to-peak voltage of &amp;lt;0.5 mV with an extent of &amp;gt;1cm². Optimal cutoff for sensitivity and specificity for LVA and AF/AT recurrence as endpoint was chosen using C statistics with receiver-operator characteristics (ROC). Further ROCs were performed to illustrate the predictive ability of the scores. Pearson correlation was used to test associations between variables. Results 160 patients (mean age 67.9 ± 9.1 years, 60.6% persistent AF, mean AF duration 4.6 ± 3.8 years) with complete left atrial UHD mappings (mean EGMs 9754 ± 5808) were included. Overall recurrence rate over a mean follow-up time of 16 ± 11 months was 55.6%. The predictive value of the investigated risk scores on AF/AT recurrence in our cohort was low (Table 1), with the highest power for CAAP-AF (p = 0.015, AUC = 0.615) and DR-FLASH score (p = 0.040, AUC = 0.594), Figure 1. With respect to left atrial LVA we found a better predictive power for the CAAP-AF (p &amp;lt; 0.001, AUC 0.702), APPLE (p &amp;lt; 0.001, AUC 0.687), DR-FLASH (p &amp;lt; 0.001, AUC 0.688), ATLAS (p = 0.005, AUC 0.634) and ALARMEc (p = 0.007, AUC 0.608) score to predict low voltage based on a calculated cut-off of 22% of total left atrial surface (Figure 1). Conclusion The predictive value of guideline-referred risk scores in estimating AF/AT recurrence after repeat ablation is low and does not seem to be of relevant help in patient selection for further interventional treatment. Some scores demonstrate a fairly good prediction for the amount of left atrial LVA and therefore might help in choosing the right mapping and ablation regime beforehand.

Radiofrequency balloon ablation: 1-year outcomes of the AURORA registry

Abstract Background and Objectives A novel irrigated radiofrequency balloon (RFB) for pulmonary vein isolation (PVI) integrated into 3D mapping system was recently launched. Methods Patients ablated for paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (persAF) at two German high-volume electrophysiology centers were included into the prospective AURORA registry. All patients underwent clinical follow-up (FU) at 90, 180 and 360 days following ablation including 24h Holter ECGs. Results A total of 101 patients were enrolled (50 from centre A, 51 from centre B) and 86 patients (48% male, 65 ± 11 years, 55% PAF, 59 ± 7% left ventricular ejection fraction (LVEF)) completed the follow-up. Mean ablation and procedure times were 26 ± 13 min and 71 ± 20 min, respectively. Dose area product was 1501 ± 1634 mGycm2. Acute PVI was achieved in 100%. Atrial fibrillation (AF) free survival after a mean FU of 361 (219-375) days was 78.4% for PAF and 75.4% for persAF. (p= 0.828). A multiple regression analysis did not reveal any clinical or procedural predictors of AF recurrence among sex, age, BMI, left atrial diameter, LVEF, ablation time, procedure time and single shot PVI. However, early recurrence of atrial tachyarrhythmia (ERAT) was an independent predictor for AF recurrence at 1-year (Hazard Ratio [HR]: 3.198; 95% confidence interval [95% CI]: 1.036 - 10.32, p value = 0.0433). Primary adverse events occurred in 3.5% of patients (1 postprocedural pharyngeal bleeding, 1 myocardial infarction, 1 non-cardiovascular death); no pericardial effusion, stroke or phrenic nerve paralysis were observed. Conclusions RFB-based PVI is clinically effective and safe. ERAT at the first follow-up visit is an independent predictor of late AF recurrence.

Two-year safety and effectiveness of hybrid ablation versus catheter ablation in patients with non-paroxysmal AF: mid-term results of the CEASE-AF trial

Abstract Background Hybrid Ablation for atrial fibrillation (AF) combines epicardial and endocardial ablation through a Heart Team approach to target durable, transmural isolation of the pulmonary veins (PV) and left atrial posterior wall (LAPW). While the primary efficacy endpoint at 12 months was met with a significant benefit increase for hybrid ablation, we now report the midterm durability of those results. Purpose To evaluate 24-months safety and effectiveness of Hybrid Ablation with left atrial appendage exclusion (LAAE) versus Catheter Ablation in patients with persistent AF/enlarged left atrium and longstanding persistent AF (LSPAF). Methods CEASE-AF is a prospective, multi-center, 2:1 randomized controlled trial. Eligible patients were 18-75 years of age, had symptomatic, drug-refractory persistent AF and enlarged left atrium (&amp;gt;4 cm) or LSPAF, and were undergoing a first ablation. Hybrid Ablation consisted of two stages: thoracoscopic epicardial radiofrequency (RF) ablation for PV and LAPW isolation and epicardial LAAE followed by endocardial ablation 91-180 days later. Catheter Ablation consisted of minimum PV isolation by endocardial RF ablation, and repeat ablation was allowed between 91-180 days. In both arms, additional lesions were permitted according to institutional practices. Effectiveness was freedom from AF/atrial flutter (AFL)/atrial tachycardia (AT) off anti-arrhythmic drugs (AAD) (except AADs not exceeding doses which previously failed) and was assessed through 48-h Holter monitoring reviewed by an independent core laboratory blinded to the study. Safety was major adverse events throughout the study, adjudicated by an independent Clinical Events Committee. Results There were 102 Hybrid Ablation and 52 Catheter Ablation patients; 26% were female, mean age was 60.7±7.9 years, mean LAD was 4.7±0.4 cm, and 19% had LSPAF with no differences between arms. The 12- and 24-month results are shown for comparison (Table). Through 24-months, effectiveness was 66.3% (63/95) in the Hybrid Arm and 33.3% (17/51) in the Catheter Arm (absolute difference 33.0% [95% CI 14.3%, 48.3%; p&amp;lt;0.001]). Major adverse event rates through 24-months were statistically similar at 10.8% (11/102) in the Hybrid Arm and 9.6% (5/52) in the Catheter Arm (p=1.0). Through 24-months, repeat ablations were performed in 7.4% (7/95) of the Hybrid Arm versus 37.3% (19/51) of the Catheter Arm (p&amp;lt;0.001), and cardioversions were performed in 14.7% (14/95) of the Hybrid Arm versus 29.4% (15/51) of the Catheter Arm (p=0.034) Conclusions: CEASE-AF demonstrated that superior effectiveness of Hybrid Ablation including LAAE versus Catheter Ablation was durable through 24-month follow-up, with 33% absolute improvement in freedom from AF/AFL/AT. Safety rates continued to be similar between arms. Three-year follow-up is ongoing.

Feasibility and safety of left atrial roof ablation with the third-generation visually guided laser balloon

Abstract Background The roof area ablation beyond pulmonary vein (PV) isolation (PVI) using a cryoballoon has been widely performed for patients with atrial fibrillation (AF). However, the feasibility of roof area ablation using a visually guided laser balloon (VGLB) remains to be elucidated. Purpose This study aims to investigate the feasibility and safety of additional roofline creation by VGLB ablation alone in patients with AF. Methods A total of 30 patients with AF (paroxysmal AF=15, persistent AF=15) who underwent VGLB ablation from March 2023 to August 2023 were analyzed retrospectively. VGLB ablation was performed using a third-generation VGLB. After initial circular ablation, VGLB was inflated to a larger size to extend and fuse the isolation area at the roof portion during the superior PVs occlusion. The complete conduction block of the left atrial (LA) roof was assessed by the differential pacing methods and the high-resolution mapping system at the end of the procedure. Results Acute success in complete roofline creation was achieved in 70% of patients. The PVI time was 21.6±5.5 minutes, and additional roof ablation time was 8.7±3.5 minutes, respectively. The anatomical LA roof length was significantly shorter in patients with successful roofline generation than without (30.4±7.2mm vs. 42.9±4.0mm, P&amp;lt;0.001). A cut-off value of 40.2mm for the LA roof length calculated by a receiver operating characteristic curve predicted a successful construction of the LA roofline with the highest sensitivity of 94.7%, specificity of 83.3%, and the area under the curve was 0.94 (95% confidence interval, 0.35-0.99). No complications occurred during laser energy titration at the roof area. Conclusion The roofline creation using a third-generation VGLB is possible with acceptable safety concerns. The length of the LA roof≤40.2mm was a predictor of the successful LA roofline generation.Fluoroscopic and endoscopic imageVoltage map after ablation

Direct epicardial validation of posterior wall isolation in persistent atrial fibrillation: pulsed field versus radiofrequency ablation

Abstract Background Lesion transmurality is an important determinant of durable effectiveness of catheter ablation (CA) for atrial fibrillation (AF). The impact of different energy sources on the achievement of transmural left atrial (LA) ablation has not been explored so far. Purpose We sought to compare the transmurality associated with pulsed field ablation (PFA) and radiofrequency (RF) ablation of LA posterior wall (PW) among patients with persistent AF. Methods Eight patients (mean age, 70±7 years; 88% male) undergoing CA for persistent AF with PW ablation and adjunctive high-density epicardial mapping were included in a multicenter international registry. In four patients, PW ablation was performed using PFA, while in the remaining four, RF energy was used with high/very-high-power short-duration settings. The primary study outcome was transmural PW isolation (PWI) with endocardial-only ablation. Results A trend towards shorter times required to complete endocardial PW ablation was observed with PFA compared to RF (9±1 vs 11±2min, p=0.065). At endocardial mapping, apparent PWI was observed in all cases. However, transmural PWI after endocardial-only ablation was demonstrated in each patient in the PFA group, but only in one RF case, in whom 50 Watt/≥10 sec settings were used (100% vs 25%, p=0.143). Interestingly, in three patients in the RF group, endocardial ablation resulted in conversion of AF into atypical flutter, which could be successfully terminated by epicardial ablation. Conclusions We observed a trend towards greater transmurality with PFA compared to high/very-high power RF ablation in the region of septopulmonary bundle. This observation may have potential implications on clinical outcomes after endocardial AF CA.

Pacemaker dependency after Cox Maze procedure concomitant with cardiac surgery, The road between Scylla and Charybdis

Abstract Background The Cox Maze (CM) procedure is a well-established treatment for atrial fibrillation. However, recent trials report alarming rates of pacemaker implantation (PMI) during hospitalization after CM. As PMI, generator replacement and Lead management are sometimes accompanied by complications, such as infection or bleeding and represent a burden for patients and healthcare systems. We thought to investigate the rates of pacemaker dependency 6 months after pacemaker implantation regarding the applied energy source and the performed lesion set, to determine whether PPM implantation timing and specific conduction disturbances as indications are associated with late pacemaker dependency. Methods We performed a retrospective review of 3695 patients underwent elective cardiac surgery in our institution between the years 2005 and 2022. Patients who use of devices for rhythm control, resynchronisation therapy, implantablecardioverter defibrillator (ICD) or both were excluded from the present study. A total of 283 patients met the inclusion criteria; Various energy sources, including cryoablation (n= 123) and radiofrequency (n= 160) were used. Left atrial (n= 228) and biatrial (n= 55) ablation was performed The distribution of the preoperative and perioperative variables was similar. Results There was no statistical difference in the incidence pacemaker dependency regarding the applied energy source whether radiofrequencyablation or cryoablation (25% vs. 30%; p = 0.2 respectively). On the other hand, biatrial ablation led to a significant pacemaker dependency rate compared with isolated left-sided ablation (78,2% vs 14.9%; P = .001 respectively), moreover Sinus node dysfunction as indication for PPM implantation was predictive of being not PPM dependent (OR 6.59; 95% CI, 1.67-26.06; P = .007). Conclusion Concomitant CM procedure showed a pacemaker implantation rate of 7,4%. Univariate and multivariate analysis showed biatrial lesion set as the only statistically significant predictor for pacemaker dependency after CM procedure. Further large-scale randomized controlled studies are needed to elucidate the Impact of the CM on the late pacemaker dependency.

Left atrial strain measurement in patients with heart failure and atrial fibrillation compared to a control group

Abstract Background Left atrial (LA)-strain measurement is a non-invasive and widely available echocardiographic method to detect atrial cardiomyopathy as a process of structural and functional remodeling. The aim of this study is to measure LA-strain in patients with heart failure (HF) and atrial fibrillation (AF), compared to patients without structural heart disease and to evaluate whether or not LA-Strain could be part of a multi-modality assessment that influences therapy strategies and prognosis in patients suffering AF. Methods This study includes 18 patients with HF in sinus rhythm who underwent CRT implantation (HF group), 25 patients with persistent AF and preserved ejection fraction (EF) who underwent left atrial catheter ablation (AF group) and 22 patients without structural heart disease or AF who underwent electrophysiological study (control group). All subjects received measurement of reservoir (LASr), conduit (LAScd) and contraction (LASct) LA strain imaging using two-dimensional speckle tracking echocardiography (2D-STE). Results Patient characteristics in the HF-group showed mean age 68y (SD 10,6), mean EF 29% (SD 6,8), 66% male compared to the AF-group with mean age 66y (SD 8.0), mean EF 60% (SD 5.1), 68% male. The control-group showed mean age 55y (SD 13.8), mean EF 60% (SD 5.4), 55% male. For LASr we found normal values in the control groups and reduced values in the HF und AF group (HF: mean 20% [9 – 45%], AF: mean 24% [7 – 52%], control: mean 42% [30 – 67%]). In LASr, LAScd and LASct there was a statistically significant difference between the HF and the control group (p &amp;lt; 0.001) as well as the AF and control group (p &amp;lt; 0.001), whereas there was no difference between AF and HF group (p = 0.444). Discussion Patients with persistent AF show similar LA-strain compared to patients with HF and patients without structural heart disease present significant better LA strains. The findings of this study suggest, that LA strain analysis might contribute to comprehensive assessment of patients with AF especially as a simple imaging method. A limitation of our results could be the significant younger age of our control group (p = 0.004) as fibrotic remodeling increases in advanced age. It remains to be analyzed whether early AF treatment could prevent further fibrotic remodeling and whether measuring LA strain could provide further information for risk stratification and the definition of therapeutic intervention strategies.

Comparison of pulsed field and radiofrequency ablation for non-paroxysmal atrial fibrillation: a propensity score-matched analysis

Abstract Background Ablation of non-paroxysmal atrial fibrillation (AF) is challenging and often requires left atrial substrate ablation. While the pentaspline, multi-electrode pulsed-field ablation (PFA) catheter is approved for pulmonary vein isolation (PVI), its role in procedures involving substrate ablation for nonparoxysmal forms of AF remains unknown. Purpose We conducted a retrospective study to assess the safety and long-term outcomes of PFA for non-paroxysmal AF. Methods Procedural and follow-up data were retrospectively collected for all patients undergoing a first-time ablation for non-paroxysmal AF across two centers, between November 2021 and December 2022. Patients undergoing PFA consisting of PVI, isolation of the posterior wall (PWI) and ablation of the mitral isthmus (MI) with the pentaspline multi-electrode PFA catheter, were compared with patients undergoing radiofrequency ablation (RFA) involving PVI, a roof line or PWI, alcohol ablation of the vein of Marshal (VOM) and MI ablation. Patients were matched using propensity scores to minimize potential confounders. The primary endpoint was arrhythmia (AF/atrial flutter/atrial tachycardia) recurrence after a 90-day blanking period. Results The baseline characteristics of the 116 matched patients are detailed in Table 1. PVI was successful in all patients. In the PFA group, PWI was additionally performed in all patients and MI ablation in 83% of cases, resulting in acute success rates of 97% and 96%, respectively. In the RFA group lesions beyond PVI included: a roof line (90%), PWI (10%), VOM alcohol ablation (93%) and MI ablation with ablation in the coronary sinus (CS) if needed (97%). Procedural block across the roof and the MI was achieved in 96% and 95%, respectively and complete PWI in 83% of cases. The PFA group had a shorter total procedure (84.2±22.3 vs 117.3±24.8 min, p&amp;lt;0.001) but a longer fluoroscopy time (23.1±7.2 vs 16.8±6.3 min, p&amp;lt;0.001). The difference in radiation dose, however, was not statistically significant (57.7±74.1 Gy.cm2 in the PFA vs 49.8±53.6 Gy.cm2 in the RFA group, p=0.24). The overall periprocedural complication rates were similar in both groups (8.6% PFA vs 12.1% RFA, p=0.76), with no cardiac tamponades or deaths. Group-specific complications included 1 coronary spasm in the PFA group and 1 CS dissection in the RFA group. During a median follow-up of 447 days (IQR: 364-552), 1 stroke occurred in each group and 1 sudden cardiac death in the RFA group, 13 months post-procedure. Both groups had similar rates of recurrences (32.8% PFA vs 25.9% RFA, p=0.54). Arrhythmia-free survival probability at 16 months was estimated at 67.2% for PFA and 77.6% for RFA by Kaplan-Meier analysis (p=0.16, Figure 1). Conclusions In this propensity-matched cohort of patients with non-paroxysmal AF, PFA and RFA demonstrated similar complication rates and arrhythmia-free survival at follow-up. The procedure duration, however, was significantly shorter with PFA.Figure 1

Efficacy of laser balloon left atrial roof ablation for patients with atrial fibrillation

Abstract Background The roof area ablation beyond pulmonary vein (PV) isolation (PVI) using a cryoballoon has been described as an effective therapy for patients with atrial fibrillation (AF). However, the effect of roof area ablation performed with a visually guided laser balloon (VGLB) remains to be elucidated. Purpose This study aims to investigate the efficacy of roof area ablation using VGLB. Methods A total of 325 patients with AF (paroxysmal AF=199, persistent AF=126) who underwent VGLB ablation from July 2018 to May 2022 were analyzed retrospectively. After initial circular isolation, VGLB was inflated to a larger size on both sides of superior PVs, and the isolation areas were extended to the roof portion. At the end of the procedure, left atrial (LA) voltage mapping was obtained to assess the LA roof scar area, and differential pacing was performed to confirm the complete conduction block. Our study population was divided into the PVI group (LB-PVI, n=228) and the roof line block beyond PVI group (LB-Roof, n=97). The efficacy endpoint was defined as freedom from atrial tachyarrhythmia (ATa) between months 3 and 12. Results One-year clinical follow-up could be obtained in 170 patients with LB-PVI and 81 patients with LB-Roof. The Kaplan-Meier survival curves are shown in Figure. At the end of the 12 months of follow-up, freedom from ATa was 80.8% in patients with LB-PVI and 91.2% in LB-Roof. The ATa freedom rate was significantly higher in the LB-Roof than in the LB-PVI (P=0.03). Conclusion The roof area ablation using VGLB was proved to be effective for patients with AF.The Kaplan-Meier survival curves

Long-term success and predictors of atrial arrhythmia recurrence following left atrial flutter ablation

Abstract Background In recent years, success rate of left atrial flutter (LAFL) ablation has witnessed improvement, attributed to enhanced comprehension of the arrhythmia mechanism and technological advancements. However, the recurrence rate and specific types of atrial arrhythmias, along with their potential predictors, remain inadequately understood. Purpose The aim of this study is to assess the factors influencing the efficacy, safety, and long-term success of radiofrequency (RF) ablation for LAFL. Methods Patients with sustained LAFL undergoing RF ablation were included in the study. LAFL mapping employed a combination of activation, voltage, and entrainment with 3D electroanatomical mapping. RF ablation targeted a protected isthmus of slow conduction, and if not localized, it involved creating lines of conduction block transecting the reentrant circuit or empirically created lines. Ablation success was defined as clean arrhythmia termination during RF application and no LAFL induction with pacing maneuvers. Follow-up included outpatient visits at 6 and 12 months. Ablation success at follow-up was defined as the absence of arrhythmia recurrence (≥30s) at regular outpatient or emergency department visits. Clinical and electrophysiological characteristics were analyzed and correlated with ablation success, complications, and freedom from arrhythmia recurrences at follow-up. Results The study included 104 consecutive patients undergoing LAFL ablation (67.5 ± 11.3 years, 67% male). Clinical characteristics comprised 12 with HFrEF, 44 with structural heart disease, 25 with valvular heart disease, 43 with previous pulmonary vein isolation (PVI) ablation, and 39 with significant left atrium enlargement. Simultaneous cavotricuspid isthmus ablation (CTI) was performed in 46 patients. LAFL cycle length was 293±68 ms, with more than one LAFL mechanism (2.0±0.8 mechanisms) demonstrated in 76 patients (73%). The most common LAFL mechanism was perimetral reentry (37%). LAFL was successfully ablated 83% of cases, with 7 patients experiencing complications (4 tamponades and 3 sinus node dysfunctions following LAFL termination). At a median follow-up of 28 months, 35 patients (34%) had AFL recurrence, and 15 of them required a second ablation procedure. No factor was associated with LAFL recurrence, except for a short LAFL cycle length (P=0.04) at the ablation procedure. Demonstration of more than one LAFL mechanism (P=0.48) or LAFL termination by focal or linear RF application (P=0.99) were not associated with AFL recurrences at follow-up. Conclusions Despite the relatively high efficacy of LAFL ablation, the rate of atrial arrhythmia recurrences at follow-up after a single procedure remains elevated, predominantly in the form of AFL rather than AF. Short LAFL cycle length at the index procedure appears to be a significant predictor of these recurrences. Arrythmia cycle length proved to be predictive factor of LAFL ablation success rate.Peri-veinal left AFL, LAT map, CranialPeri-veinal left AFL, LAT map, PA

Differential and synergistic effects of left and right atrial ablation of paraseptal ganglionated plexuses in a cohort of consecutive patients undergoing cardioneuroablation

Abstract Background Cardioneuroablation (CNA) treats reflex syncope by ablating the main epicardial ganglionated plexuses (GPs) conveying vagal outputs to the sino-atrial (SA) and atrio-ventricular (AV) nodes. The two main GPs, superior paraseptal (SPSGP) and inferior paraseptal (IPSGP), regulate vagal tone to SA and AV nodes, respectively. Both GPs can be targeted with radiofrequency energy (RF) from the right (RA) and left atrium (LA). It is unclear if bi-atrial ablation yields more effective GP ablation or if the ablation sequence affects GP response. Purpose We aimed to assess the added efficacy of ablating the SPSGP and IPSGP in the LA after initial RA ablation, and vice versa, in a separate group of patients. Methods In a consecutive patient population undergoing CNA we evaluated the acute efficacy of RF delivery on the SPSGP and the IPSGP. The population was divided into two consecutive groups: one receiving RF initially in the RA and then in the LA (group 1), and the other in the reverse order (group 2). The acute effect of RF applications was measured as percentage increase in heart rate (HR) for the SPSGP and as reduction of PR interval for the IPSGP. Results Sixty-one patients (50±15 years; 61% males) underwent CNA. Of these, 17 underwent ablation of the SPSGP and IPSGP starting from the RA and completing the procedure in the LA (group 1), while in 44 patients, the procedure was performed in the opposite order (group 2). In group 1, RF delivery on the SPSGP from the RA prompted an increase in HR (54.1±11.1 vs 60.6±14.7 bpm; p=0.03; median HR increment 3.8%, IQR 0-38.3) that was further enhanced after LA ablation (from 57.5±11.9 to 64.5±13.5 bpm; p&amp;lt;0.001; median HR increment: 8.0%, IQR: 2.0-13.5). In group 1, RA ablation of the IPSGP reduced PR interval in a single patient (from 224 to 184 ms), without further shortening after LA ablation. Final CNA success was 82% in group 1. In group 2, RF delivery on the SPSGP from the LA induced a marked increase in HR (58.4±13.1 vs 76.8±16.1 bpm; p&amp;lt;0.001; median HR increase 30.0%, IQR 14.0-43.0). In the same patients, additional ablation from the RA prompted further but lower incremental effect (from 70.0±17.3 to 76.9±17.9 bpm; p&amp;lt;0.001; median HR increment 8.3%, IQR: 0-16.4). In group 2, 4 (9%) patients had PR shortening after LA ablation of the IPSGP (241±93 vs 172±14 ms; p value). Of these, a single patient had further PR reduction after IPSGP RA ablation (from 189 to 161 bpm). Final CNA success was 93% in group 2. Symptoms-free survival was 88% at 16±5 months in group 1 and 89% at 19±7 months in group 2 (p= ns). Conclusions Bi-atrial ablation of the SPSGP and IPSGP provides incremental acute efficacy compared to ablation from either the RA or the LA alone. LA ablation of the main GPs seems an essential component of CNA. The physiological significance of these findings requires further investigationGanglionated Plexuses Segmentation

Prevalence of diabetes mellitus diminished the efficacy of additional ablation following pulmonary vein isolation: a sub-analysis of the EARNEST-PVI trial

Abstract Introduction Diabetes mellitus (DM) is a well-known cause of atrial remodeling in patients with atrial fibrillation (AF). Although additional left atrial ablation following pulmonary vein isolation (PVI) is a strategy to modify AF substrate, its efficacy has not been well elucidated in patients with DM. We hypothesized that the efficacy of additional ablation was different in patients with DM and in those without. Purpose The purpose of this study was to investigate the efficacy of additional ablation following PVI in patients with or without DM. Methods The EARNEST-PVI was a multicenter, prospective, randomized controlled trial. In this sub-analysis, 493 consecutive patients of persistent AF (age, 65 ± 9 years; female, 120 [24%] patients) who underwent the initial radiofrequency catheter ablation were analyzed. Patients were randomized to be treated with PVI only (PVI-alone) or PVI plus linear and/or complex fractionated atrial electrogram ablation (PVI-plus). Primary outcome measure was defined as AF recurrence during the 12 months follow-up periods. Results In total, 84 (17%) patients had DM. Primary outcome occurred in 120 (24%) patients. In patients without DM, freedom from AF recurrence was significantly higher in PVI-plus group than in PVI-alone group (80.0% versus 71.1%, p=0.03) (Figure 1A). Conversely, in patients with DM, freedom from AF recurrence was similar between PVI-plus group and PVI-alone group (75.4% versus 72.9%, p=0.70) (Figure 1B). Conclusion Additional ablation following PVI reduced AF recurrence after radiofrequency catheter ablation only in patients without DM.Figure 1