Left Atrial Linear Ablation Research Articles

Risk assessment of esophageal ulceration following left atrial radiofrequency linear ablation.

Esophageal safety following radiofrequency (RF) left atrial (LA) linear ablation has not been established. To determine the esophageal safety profile of LA linear RF lesions, we performed systematic esophagogastroduodenoscopy in all patients with intraesophageal temperature rise (ITR) ≥ 38.5°C. Between December 2021 and July 2023, a total of 200 consecutive patients with atrial tachyarrhythmia (ATA) underwent linear ablation with posterior dome (roof or floor) or posterior mitral isthmus line transection. Patients with ITR ≥ 38.5°C were scheduled for esophageal endoscopy ~3 weeks after ablation. Patient and ATA characteristics, procedural parameters, endoscopy findings and ablation lesion data were collected and analyzed. One hundred thirty-threeout of 200 (67%) patients showed ITR ≥ 38.5°C during LA linear ablation. ITR (with maximal temperature of 45.7°C) was more frequently observed during floor line ablation (82% of cases). ITR was less observed during roof line ablation (34%) and posterior mitral isthmus ablation (4%). Endoscopy, performed in 115 patients after 24 ± 10 days, showed esophageal ulceration in four patients (two patientsKansas City classification [KCC] 2a and two patients KCC 2b). No patient showed esophageal perforation or fistula. Temperature rise during LA linear ablation is frequent and ulceration risk exists, particularly when floor line is performed. Safety measures are needed to avoid potential severe complications like esophageal perforation and fistula.

Catheter Ablation of Paroxysmal and Persistent Atrial Fibrillation in Patients with Secondary Atrial Septal Defect. Evaluation of the Results and Impact on the Quality of Life

Introduction. The presence of atrial fibrillation (AF) in patients with secondary atrial septal defect (ASD) has significant impact on their quality of life (QoL) and reduces life expectancy. Current guidelines recommend catheter ablation (CA) for patients with AF in case of medical treatment failure, however, its use in patients with AF and ASD is still poorly studied.
 The aim. To study the efficacy and safety of CA and its impact on the QoL in patients with AF and secondary ASD.
 Materials and methods. In 2003-2023, 1408 patients with secondary ASD were treated at the National Amosov Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine. Of these, 54 patients who had AF and underwent the CA procedure were included in group 1 of our study. There were 36 (66.7%) men and 18 (33.3%) women aged 24-76 years (mean age 61.4 ± 9.8 years). Four (9.3%) patients had persistent AF and 50 (90.7%) patients had paroxysmal AF. Fifty-six patients with paroxysmal or persistent AF and with the comparable age, duration of symptoms and associated pathology but without ASD were examined as group 2. The type and results of surgical interventions were analyzed according to surgical reports. The results of the treatment and QoL were assessed using the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire during the follow-up period 1, 2 and 3 months after the procedure.
 Results. Pulmonary vein isolation was performed in all 54 (100%) patients of the group 1, as well as cavotricuspid isthmus ablation in 26 (48.2%) cases, cavotricuspid isthmus ablation and left atrial linear ablation in 2 (3.6%) cases. Type, length and complication of the procedure were comparable to those in the group 2. Fourty-four (81.5%) patients with ASD were free from AF 3 months after procedure, and their results did not differ from those obtained in the group 2 (p > 0.05). Average QoL indicators according to AFEQT significantly improved in both groups of patients who underwent CA. The differences in post-treatment QoL between patients of both groups were insignificant (p > 0.05).
 Conclusions. CA was found to be safe and beneficial in patients with AF and secondary ASD. The rate of procedural complications and cure rate in patients with AF and secondary ASD (81.5%) were compatible to those in patients without ASD (80.5%). AF has negative effect on the main indicators of the patient’s life. In patients with secondary AF with ASD who underwent CA, a significant improvement in AF symptoms and QoL according to the AFEQT questionnaire (total score 56.1 ± 2.7 before the procedure vs. 78.7 ± 4.0 at follow-up) was noted.

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.

Spontaneous left-sided atypical flutter: revising the mechanisms in patients not submitted to prior linear ablation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction The decrease in the use of linear ablation for atrial fibrillation treatment has reduced the frequency of iatrogenic feft-sided atypical flutters (AFl). However, AFl are becoming increasingly frequent, associated with population age and risk factors for atrial scar. Revising the mechanisms of non-iatrogenic AFl may lead to a better procedure workflow. Purpose To describe the mechanisms of non-iatrogenic AFl. Methods Retrospective single-center study of AFl patients (pts) submitted high-density mapping from 2018 to 2022. Patients submitted to any prior left atrial linear ablation were excluded. Map collection was performed just visualizing the voltage map and a comprehensive workflow was applied for activation map interpretation, starting by facing the mitral annulus and following the sequence of colors to systematically identify all potential circuits, their common-isthmuses, and eventual slow-conduction sites. Entrainment maneuvers were performed to confirm the circuit interpretation if sinus rhythm was not restored with the completion of the planned ablation set. Results A total of 59 pts were included (male: 56% male; 67 ± 13 years), 28 previously submitted to atrial fibrillation ablation, restricted to pulmonary vein (PV) isolation. About 88% presented a macro-reentrant mechanism, either restricted to the left atrium (N=50) or biatrial (N=2) and involving 2 or 3 loops in 61% - Figure 1. Perimitral loop was the most frequent reentrant circuit, representing 60% of macro-reentrant arrhythmias (N=30) and exhibiting an evident out-of-proportion predominance of counterclockwise rotations (73% versus 27%). Among perimitral flutters with at least one additional loop, a balanced distribution was recognized of rotations around the left and right PVs (10 versus 10). As a result of the existence of additional loops producing common-isthmuses locations in various atrial regions, the classical inferior mitral isthmus line (from the mitral annulus to the left inferior PV) would only terminate as much as 53% of the perimitral AFl. The mechanism-tailored ablation strategy, particularly targeting the AFl common-isthmuses, resulted in restoration of sinus rhythm in 96.6% of pts (N=57). Conclusions In pts not previously submitted to linear ablations, AFl are predominantly caused by macro-reentrant circuits involving a perimitral rotation but not necessarily possible to treat with a conventional mitral isthmus line. With current high-density mapping tools, a comprehensive analysis of the substrate and activation maps and a mechanism-tailored ablation strategy results in an unprecedently high acute success rate.

An evaluation of the clinical efficacy of the application of 28mm cryoballoon for linear ablation of left atrial apex combined with enlarged pulmonary vein vestibule ablation for persistent atrial fibrillation

Objectiveto retrospectively investigate the efficacy and safety of the application of 28 mm cryoballoon for pulmonary vein electrical isolation (PVI) combined with top left atrial linear ablation and pulmonary vein vestibular expansion ablation for persistent atrial fibrillation. MethodsFrom July 2016 to December 2020, 413 patients diagnosed with persistent atrial fibrillation were evaluated, including 230 (55.7%) in the PVI group (PVI only) and 183 (44.3%) in the PVIPLUS group (PVI plus ablation of the left atrial apex and pulmonary vein vestibule). The safety and efficacy of the two groups were retrospectively analyzed. ResultsThe AF/AT/AFL-free survival rates at 6, 12, 18, 24 and 30 months after procedure was 86.6%, 72.6%, 70.0%, 61.1% and 56.3% in the PVI group and 94.5%, 87.0%, 84.1%, 75.0% and 67.9% in the PVIPLUS group, respectively. At 30 months after procedure, the AF/AT/AFL-free survival rate was significantly higher in the PVIPLUS group than in the PVI group (P = 0.036; HR:0.63; 95% CI:0.42 to 0.95). ConclusionThe application of 28-mm cryoballoon for pulmonary vein electrical isolation combined with linear ablation of the left atrial apex and expanded ablation of the pulmonary vein vestibule improves the outcome of persistent atrial fibrillation.

Catheter ablation for atrial fibrillation in adult congenital heart disease: an international registry study

Abstract Background Life expectancies for patients with congenital heart disease (CHD) have dramatically increased in recent years, accompanied by a rise in atrial fibrillation (AF) prevalence. Data on AF ablation strategy and outcomes are limited in CHD. Purpose We aimed to investigate the characteristics of CHD patients presenting for AF ablation and their outcomes. Methods A multicenter, retrospective analysis was performed of CHD patients undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using the 2014 PACES/HRS guidelines. Clinical data were collected including ablation strategy and follow up. One-year procedural success was defined as freedom from AF in the absence of antiarrhythmic drugs (AADs, complete) or including previously failed AADs (partial). Results Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±0.9 years. CHD complexity categories included 147 (61.3%) simple, 69 (28.8%) intermediate and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had AF despite at least one AAD. 46 patients (22.1%) had a reduced systemic ventricular ejection fraction <50%, and the mean left atrial diameter was 44.1±0.7 mm. PV isolation (PVI) was performed in 227 patients (94.6%); additional ablation strategies included left atrial linear ablations (25.4%), CFAE (19.2%), and cavotricuspid isthmus ablation (40.8). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications. Conclusion AF ablation in this complex population was safe and resulted in AF control in the majority of patients. Future work should address the most appropriate ablation targets in the challenging population. Funding Acknowledgement Type of funding sources: None.

Catheter Ablation for Atrial Fibrillation in Adult Congenital Heart Disease: An International Multicenter Registry Study.

Data on atrial fibrillation (AF) ablation and outcomes are limited in patients with congenital heart disease (CHD). We aimed to investigate the characteristics of patients with CHD presenting for AF ablation and their outcomes. A multicenter, retrospective analysis was performed of patients with CHD undergoing AF ablation between 2004 and 2020 at 13 participating centers. The severity of CHD was classified using 2014 Pediatric and Congenital Electrophysiology Society/Heart Rhythm Society guidelines. Clinical data were collected. One-year complete procedural success was defined as freedom from atrial tachycardia or AF in the absence of antiarrhythmic drugs or including previously failed antiarrhythmic drugs (partial success). Of 240 patients, 127 (53.4%) had persistent AF, 62.5% were male, and mean age was 55.2±13.3 years. CHD complexity categories included 147 (61.3%) simple, 68 (28.3%) intermediate, and 25 (10.4%) severe. The most common CHD type was atrial septal defect (n=78). More complex CHD conditions included transposition of the great arteries (n=14), anomalous pulmonary veins (n=13), tetralogy of Fallot (n=8), cor triatriatum (n=7), single ventricle physiology (n=2), among others. The majority (71.3%) of patients had trialed at least one antiarrhythmic drug. Forty-six patients (22.1%) had reduced systemic ventricular ejection fraction <50%, and mean left atrial diameter was 44.1±8.2 mm. Pulmonary vein isolation was performed in 227 patients (94.6%); additional ablation included left atrial linear ablations (40%), complex fractionated atrial electrogram (19.2%), and cavotricuspid isthmus ablation (40.8%). One-year complete and partial success rates were 45.0% and 20.5%, respectively, with no significant difference in the rate of complete success between complexity groups. Overall, 38 patients (15.8%) required more than one ablation procedure. There were 3 (1.3%) major and 13 (5.4%) minor procedural complications. AF ablation in CHD was safe and resulted in AF control in a majority of patients, regardless of complexity. Future work should address the most appropriate ablation targets in this challenging population.

Contact force-controlled high power short duration radiofrequency ablation enables efficient creation of roof line and anterior mitral line in course of low voltage areas

Abstract Funding Acknowledgements Type of funding sources: None. Background Linear ablation lines in the left atrium are questionable for treatment of atrial fibrillation (AF). In particular they are challenging, performed with limited success rate and are arrhythmogenic due to recurrence of conduction. Contact force (CF)-controlled high power short duration (HPSD) radiofrequency ablation (RFA) in areas of fibrosis may overcome these limitations. Purpose We investigated the efficiency of contact force (CF)-controlled high power short duration (HPSD) radiofrequency ablation (RFA) for creation of linear lines in case of fibrotic areas in the anterior left atrium. Methods In 530 consecutive patients (pts), age 65±9 years, paroxysmal AF in 45%, persistent AF in 55%, AF-re-ablation in 32% of pts, undergoing HPSD CF-controlled RF ablation of AF. Besides from pulmonary vein isolation (PVI) additional left atrial linear ablation in the anterior left atrium was performed in 28% of patients exclusively in case of low voltage areas in the course of the line or in case of re-ablation of prior performed lines. Fibrosis was defined by areas of less than 0.5mV signals in high density 3D microelectrode mapping. More than 5% low voltage was present in 46% of pts and more than 20% low voltage in 27% of pts. HPSD RF ablation was performed using a power of 50 Watt, duration 5-15s, with CF-controlled catheters, seeking for CF of 10-30g, and an interlesion distance of 6mm. Results A anterior roof line between both upper pulmonary veins was performed in 25% of pts (n=133), and an anterior mitral line in 17% of pts (n=88). The anterior mitral line connected the superior mitral anulus with left upper, right upper PV or anywhere this the roof line depending on the distribution of low voltage areas. Overall success rate of bidirectional conduction block at the roof line was 92% and at the mitral line 94%. After remapping of gaps and re-ablation with conventional 35-40 Watt RF application of unlimited duration, success rate at the roof line improved to 98% and at the mitral line to 97%. No serious complications were associated with creation of these lines, especially, no pericardial tamponade occurred. Limited follow up will presented at the time of presentation. Conclusions CF-controlled creation of ablation lines in the anterior left atrium (roof line and anterior mitral line) by HPSD RF ablation is very efficient and safe in case of areas of low voltage in the course of the linear ablation. In rare cases additional conventional RF application of unlimited duration becomes necessary to complete the lines supported by identification of gaps by high density 3D microelectrode mapping. This approach has the potential to improve efficacy of AF ablation in patients with atrial fibrosis. The hypothesis have to be proven by a prospective controlled study in the near future.

Vein of Marshall Ethanol Infusion as First Step for Mitral Isthmus Linear Ablation.

In this study, the authors sought to investigate the added value of vein of Marshall ethanol infusion (VOMEt) as first step in facilitating radiofrequency (RF)-guided mitral isthmus (MI) block. Achieving MI block with the use of RF ablation is challenging. Seventy patients planned for MI ablation were randomized 1:1 to VOMEt as a first step preceding RF (endocardial and epicardial, VOMFIRST group) vs RF ablation as a first step preceding VOMEt (RFFIRST group). The study end point was incidence of MI block after RF ablation and after the 2 steps. In VOMFIRST, VOMEt was successful in 30/35 patients (86%) resulting in a low-voltage area of 12 ± 7.4cm2 and MI block in 2/35 patients (6%). VOMFIRST, compared with RFFIRST, was associated with higher incidence of MI block after endocardial (46% vs 11%; P< 0.001) and epicardial ablation (94% vs 43%; P< 0.001), with fewer endocardial applications (4 vs 11 vs 4; P< 0.001) and similar epicardial applications (7 vs 8; P = 0.68). Incidence of MI block after the 2 steps was 94% vs 63% (P = 0.001) in VOMFIRST vs RFFIRST, respectively. Additional touch-up RF ablation in both groups resulted in final MI block in all but 1 patient (99%). VOMEt as a first step in RF-guided MI line ablation significantly reduced the number of RF applications needed to achieve MI block, even if the sequence of the ablation steps did not affect the final incidence of block. (Evaluation of Vein of Marshall Ethanol Infusion During Left Atrial Linear Ablation in Patients With Persistent Atrial Fibrillation [MARSHALINE]; NCT04124328).

Optimal Ablation Settings Predicting Durable Scar Detected Using LGE-MRI after Modified Left Atrial Anterior Line Ablation.

(1) Background: The modified anterior line (MAL) has been described as an alternative to the mitral isthmus line. Despite better ablation results, achieving a bidirectional line block can be challenging. We aimed to investigate the ablation parameters that determine a persistent scar on late-gadolinium enhancement magnet resonance imaging (LGE-MRI) as a surrogate parameter for successful ablation 3 months after MAL ablation. (2) Methods: Twenty-four consecutive patients who underwent a MAL ablation have been included. The indication for MAL was perimitral flutter (n = 5) or substrate ablation in the diffuse anterior left atrial (LA) low-voltage area in persistent atrial fibrillation (AF) (n = 19). The MAL was divided into three segments: segment 1 (S1) from mitral annulus to height of lower region of left atrial appendage (LAA) antrum; segment 2 (S2) height of lower region of LAA antrum to end of upper LAA antrum; segment 3 (S3) from end of upper LAA antrum to left superior pulmonary vein. Ablation was performed using a contact force irrigated catheter with a power of 40 Watt and guided by automated lesion tagging and the Ablation Index (AI). The AI target was left to the operator’s choice. An inter-lesion distance of ≤6 mm was recommended. The bidirectional block was systematically evaluated using stimulation maneuvers at the end of procedure. All patients underwent LGE-MRI imaging at 3 months, regardless of symptoms, to identify myocardial lesions (scars). (3) Results: Bidirectional MAL block was achieved in all patients. LGE-MRI imaging revealed scarring in 45 of 72 (63%) segments. In all three segments of MAL, ablation time and AI were significantly higher in scarred areas compared with non-scar areas. The mean AI value to detect a durable scar was 514.2 in S1, 486.7 in S2 and 485.9 in S3. The mean ablation time to detect a scar was 20.4 s in S1, 22.1 s in S2 and 20.2 s in S3. Mean contact force and impedance drop were not significantly different between scar and non-scar areas. (4) Conclusions: Targeting optimal AI values is crucial to determine persistent left atrial scars on an LGE-MRI scan 3 months after ablation. AI guided linear left atrial ablation seems to be effective in producing durable lesions.

Clinical Outcomes of low-voltage area-guided left atrial linear ablation for non-paroxysmal atrial fibrillation patients

BackgroundThe therapeutic effect of low-voltage area (LVA)-guided left atrial (LA) linear ablation for non-paroxysmal atrial fibrillation (non-PAF) is uncertain. We aimed to investigate the efficacy of LA linear ablation based on the preexisting LVA and its effects on LA reverse remodeling in non-PAF patients.MethodsWe retrospectively evaluated 145 consecutive patients who underwent radiofrequency catheter ablation for drug-refractory non-PAF. CARTO-guided bipolar voltage mapping was performed in atrial fibrillation (AF). LVA was defined as sites with voltage ≤ 0.5 mV. If circumferential pulmonary vein isolation couldn’t convert AF into sinus rhythm, additional LA linear ablation was performed preferentially at sites within LVA.ResultsAfter a mean follow-up duration of 48 ± 33 months, 29 of 145 patients had drugs-refractory AF/LA tachycardia recurrence. Low LA emptying fraction, large LA size and high extent of LVA were associated with AF recurrence. There were 136 patients undergoing LA linear ablation. The rate of linear block at the mitral isthmus was significantly higher via LVA-guided than non-LVA-guided linear ablation. Patients undergoing LVA-guided linear ablation had larger LA size and higher extent of LVA, but the long-term AF/LA tachycardia-free survival rate was higher than the non-LVA-guided group. The LA reverse remodeling effects by resuming sinus rhythm were noted even in patients with a diseased left atrium undergoing extensive LA linear ablation.ConclusionsLVA-guided linear ablation through targeting the arrhythmogenic LVA and reducing LA mass provides a better clinical outcome than non-LVA guided linear ablation, and outweighs the harmful effects of iatrogenic scaring in non-PAF patients.

Sex Differences in Ablation Strategy, Lesion Sets, and Complications of Catheter Ablation for Atrial Fibrillation: An Analysis From the GWTG-AFIB Registry

When presenting for atrial fibrillation (AF) ablation, women, compared with men, tend to have more nonpulmonary vein triggers and advanced atrial disease. Whether this informs differences in AF ablation strategy is not well described. We aimed to characterize ablation strategy and complications by sex, using the Get With The Guidelines-AF registry. From the Get With The Guidelines-AF registry ablation feature, we included patients who underwent initial AF ablation procedure between January 7, 2016, and December 27, 2019. Patients were stratified based on AF type (paroxysmal versus nonparoxysmal) and sex. We compared patient demographics, ablation strategy, and complications by sex. Among 5356 patients from 31 sites who underwent AF ablation, 1969 were women (36.8%). Women, compared with men, were older (66.8±9.6 versus 63.4±10.6, P<0.0001) and were more likely to have paroxysmal AF (59.4% versus 49.5%, P<0.0001). In women with nonparoxysmal AF, left atrial linear ablation was more frequent (roof line: 53.9% versus 45.3%, P=0.0002; inferior mitral isthmus line: 10.2% versus 7.0%, P=0.01; floor line: 46.1% versus 40.6%, P=0.02) than in men. In multivariable analysis, the association between patient sex and complications from ablation was not statistically significant. In this US wide AF ablation quality improvement registry, women with nonparoxysmal AF were more likely to receive adjunctive lesion sets compared with men. These findings suggest that patient sex may inform ablation strategy in ways that may not be strongly supported by evidence and emphasize the need to clarify optimal ablation strategies by sex.

P wave duration ≥150 ms predicts poor left atrial function and ablation outcomes in non-paroxysmal atrial fibrillation

BackgroundIt remains unknown whether P wave duration (PWD) ≥ 150 ms measured after extensive radiofrequency catheter ablation (RFCA) can identify non-paroxysmal atrial fibrillation (non-PAF) patients at increased risk of atrial tachyarrhythmia recurrence. We investigated the predicting power of PWD and its association with left atrial (LA) reverse remodeling in patients with non-PAF undergoing pulmonary vein isolation with LA linear ablation. MethodsWe retrospectively evaluated 136 patients who underwent RFCA for drug-refractory non-PAF. Electroanatomic mapping was acquired during AF. Low-voltage area (LVA) was defined as an area with bipolar voltage ≤0.5 mV. Electrocardiography and echocardiography were performed during sinus rhythm 1 day and 3 months after RFCA. PWD was measured using amplified 12‑lead electrocardiography. Prolonged PWD was defined as maximum PWD ≥ 150 ms. ResultsOver a mean follow-up duration of 48 ± 35 months, 28 patients experienced atrial tachyarrhythmia recurrence. PWD was positively correlated with LVA (r = 0.527, p < 0.001) and inversely correlated with LA emptying fraction (r = −0.399, p < 0.001). PWD was shortened and LA emptying fraction (LAEF) was increased in patients without atrial tachyarrhythmia recurrence during follow-up. Atrial tachyarrhythmia-free survival was significantly more likely in patients without a prolonged PWD (83.5% vs 60.7%, p = 0.002). Multivariate analysis showed that LAEF and PWD were independent predictors of atrial tachyarrhythmia recurrence. ConclusionsPWD ≥ 150 ms measured after RFCA can identify patients with non-PAF at increased risk of atrial tachyarrhythmia recurrence. PWD is correlated with LVA and LAEF and reflects LA reverse remodeling.

Repeat procedures for recurrent persistent atrial fibrillation: A propensity-matched score comparison between left atrial linear ablation with radiofrequency and posterior wall isolation with the cryoballoon.

AimsTo evaluate the clinical outcome in patients undergoing repeat procedures for recurrent persistent atrial fibrillation following an index cryoballoon (CB‐A) pulmonary vein isolation ablation on a mid‐term follow‐up of 12 months.MethodsIn this propensity score‐matched comparison, 50 patients undergoing left atrial posterior wall isolation (LAPWI) with the CB‐A were matched to 50 patients treated with additional linear ablation using radiofrequency catheter ablation (RFCA).ResultsMeantime to repeat the procedure was 9.74 ± 4.36 months. At 12 months follow‐up freedom from atrial tachyarrhythmias (ATas) was achieved in 82% of patients in the LAPWI group and in 62% of patients in the linear ablation group (P = .03). Regression analysis demonstrated that relapses during the blanking period and LA dimensions were independent predictors of ATas recurrences following the repeat procedure.ConclusionLAPWI using CB‐A is associated with a significantly higher freedom from atrial arrhythmias when compared with the RFCA mediated left atrial linear lesions on a mid‐term follow‐up of 12 months in patients with persAF undergoing a redo procedure.

B-PO05-093 VALIDATION OF A NEW ABLATION INDEX PROTOCOL FOR LEFT ATRIAL LINEAR ABLATION

Standardized contiguous and optimized radiofrequency ablation encircling ipsilateral pulmonary veins (PV) with high incidence of first-pass isolation has been established with the CLOSE protocol. In this study, we evaluated the acute outcome of a specific ablation index protocol for left atrial (LA) linear ablation. This prospective study comprised 81 patients (age: 67±14 y, male: 52 %) undergoing de-novo ablation for persistent atrial fibrillation (AF) or patients requiring substrate ablation beyond PV isolation. We hypothesized that point-by-point ablation with an ablation index of 600 for the anterior line and 500 for the roof line and an interlesion distance <6mm will result in a high rate of first-pass block. Touch-up ablation was performed in case of incomplete line block. Line integrity was evaluated with a high-density mapping catheter (Pentaray) and the coherent activation mapping tool (CARTO3 V7) during LAA pacing and differential pacing maneuver. First-pass block of the roof line was achieved in 70 (92 %) patients, while another 5 (7 %) patients required additional touch-up ablation to complete the line, resulting in a total of 75 (99 %) blocked roof lines. A first-pass anterior line block was observed in 47 (69 %) patients. An additional 17 (25 %) patients required touch-up ablation for block achievement, resulting in a total of 64 (94 %) blocked anterior lines. For the anterior line, the Bachmann bundle insertion was identified as the predominant location of gaps. The mean ablation index of roof line ablation was 512±14 and 610±13 in anterior line ablation. The mean overall procedure and fluoroscopy time was 136±30 min and 7.2±3.8 min, respectively. The mean RF ablation time for roof line was 8±5.4 min and for anterior line 14±5.9 min. Baseline rhythm was AF in 46 patients, which terminated by linear ablation in 19 (41%) patients. This new standardized Ablation Index protocol accomplishes first-pass block of left atrial linear lesions in the vast majority of patients. Furthermore, with additional touch-up ablation at gap sites, line block was achieved in almost all patients.

Long-term outcomes of empirical extra-pulmonary vein linear ablation in patients with persistent atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by grants [HI18C0070] and [HI19C0114] from the Korea Health 21 R&amp;D Project, Ministry of Health and Welfare, and a grant [NRF-2020R1A2B01001695] from the Basic Science Research Program run by the National Research Foundation of Korea (NRF). Background Although extra-pulmonary vein (PV) left atrial (LA) linear ablation has been performed during catheter ablation (CA) of persistent atrial fibrillation (PeAF), the long-term efficacy and safety of this procedure have not yet been verified. Purpose We investigated whether an anterior line (AL) and posterior box ablation (POBA) in addition to circumferential PV isolation (CPVI) improves the rhythm without worsening the LA function in PeAF patients. Methods We retrospectively compared the additional AL + POBA and CPVI alone groups in 604 patients with PeAF who underwent regular rhythm follow-ups (16.9%; males 79.3%, 58.5 ± 10.7 years of age) after propensity score matching. The primary endpoint was AF recurrence after single procedures and secondary endpoints were the cardioversion rate, response to anti arrhythmic drugs, LA changes, and re-conduction rates of the de-novo ablation lesion set. Results After a mean follow-up of 45.2 ± 33.6 months, the clinical recurrence rate did not significantly differ between the two groups (log-rank p = 0.554) despite longer procedure times in the AL + POBA group (p &amp;lt; 0.001). Atrial tachycardia recurrences (p = 0.001) and the cardioversion rates after ablation (p &amp;lt; 0.001) were higher in the AL + POBA group than CPVI group. AL + POBA was associated with better rhythm outcomes in patients with large anterior LA volume indices (p for interaction 0.037) and low mean LAA(left atrial appendage) voltages (p for interaction 0.019). In repeat procedures, the LA pulse pressure elevation was significant after the AL + POBA. Conclusion In patients with PeAF, an AL + POBA in addition to the CPVI did not improve the rhythm outcomes nor influence the long-term safety, and lead to more extended procedures. Procedure outcomes OverallAL + POBACPVIp-value(n = 604)(n = 302)(n = 302)Procedure time, min190.8 ± 62.6226.9 ± 49.4154.6 ± 52.8&amp;lt;0.001Ablation time, sec5079 ± 19566420 ± 13723738± 1475&amp;lt;0.001Overall complications24 (4.0)13 (4.3)11 (3.6)0.835Early recurrence, n (%)277 (45.9)129 (42.7)148 (49.0)0.142Recurrence type AT, n (% in early recur)77 (27.8)51 (39.5)26 (17.6)&amp;lt;0.001Clinical recurrence within 1-year, n(%)116 (19.2)52 (17.2)65 (21.5)0.256Recurrence type AT, n (% in clinical recur)60 (23.1)46 (30.7)14 (12.7)0.001Cardioversion, n (% in total recur/ % overall)105 (40.4/17.4)74 (49.3/24.5)31 (28.1/10.3)&amp;lt;0.001POBA, posterior box ablation; AL, anterior line; CPVI, circumferential pulmonary vein isolation; AT, atrial tachycardia;Abstract Figure. Long term ablation outcome

Long-Standing Persistent Atrial Fibrillation Ablation: How Do You Perform? Left and Right Atrial Linear Ablation in Addition to Pulmonary Vein Isolation

Catheter ablation of long-standing persistent atrial fibrillation is not yet clearly defined with respect to endpoints, and different ablative strategies are offered to patients. Presented here is an approach aiming at biatrial debulking in the form of extensive linear ablation, specifically targeting areas of low-voltage complex fractionated electrograms, in addition to pulmonary vein isolation. Its main advantage is that it is not dependent on operator/system variability, since the strategy of isolating the pulmonary veins, superior vena cava and left atrial posterior wall together with achievement of bidirectional block during linear ablation provides objective endpoints that can consistently be reproduced.

Clinical investigation of the durability of the lesions created by left atrial linear ablation with a cryoballoon.

Pulmonary vein isolation (PVI) and linear ablation with a roof line and bottom line on the left atrial (LA) posterior wall (LAPW) can be achieved with a cryoballoon (CB). This study sought to investigate the long-term durability of these linear lesions. Among 290 persistent patients with atrial fibrillation (AF) who had undergone linear ablation with a CB on the roof and bottom line of the LAPW in addition to the PVI, we analyzed those patients who underwent a re-do AF ablation. Arrhythmia recurrence was confirmed in 70 (24%) out of 290 patients, and 47 (16%) patients underwent re-do sessions. At the beginning of the re-do ablation, we examined the reconnection sites of the linear lesions on the LAPW and PVI. Maintenance of the conduction block on the LAPW roof and bottom lines was observed in 35 out of 47 patients (74.5%), and 16 out of 35 patients (45.7%), respectively. The length of the roof line was significantly shorter in patients with preservation of the conduction block on the LAPW roof than in those without (36.2 ± 6.5 mm vs 41.6 ± 4.7 mm, P = .02). Durable lesions could be obtained after linear ablation with the CB for the LAPW roof line, especially in those with a relatively short LAPW roof line. However, patients requiring touch-up ablation with radiofrequency were included, and that was associated with a potential financial implication.

Segmental Versus Circumferential Ablation of Pulmonary Veins in Patients with Paroxysmal Atrial Fibrillation

INTRODUCTION: Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation techniques for the treatment of paroxysmal atrial fibrillation (PAF), with significantly improved efficacy compared to antiarrhythmic drugs as shown in CABANA trial. However, the question arises in which PAF patients whether the procedure can be limited to PVs only showing potentials (segmental), or it is really necessary to isolate all PV (circumferential). Even though success rates for circumferential PV ablation (CPVA) have been reported to be higher (up to 90%), than segmental PV ablation, most CPVA procedures previously reported included left atrial linear ablation, additional ablation lesions or lines connecting the mitral valve to the posterior PVs or along the roof of the left atrium which made bias to these studies.&#x0D; AIM: Thus, we initiated this randomized controlled study to evaluate the efficacy of CPVA versus SPVI in subjects undergoing ablation of PAF.&#x0D; METHODS: Our study included 31 consecutive patients who underwent their first radiofrequency ablation for PAF between March 2015 and March 2017. Patients were randomized for circumferential or segmental ablation on the day of the procedure. We had two groups, circumferential (17 patients) and segmental group (14 patients).&#x0D; RESULTS: There was no difference between two groups on our primary endpoint, the recurrence, which was 2 out of 14 patients (14.3%) in the segmental ablation group, compared to 3 out of 17 patients (17.6%) who were circumferential ablated. This difference is statistically insignificant (p = 1). For other endpoints, there was also no statistically significant difference between circumferential and segmental regarding fluoroscopy time, 53.47 ± 8.7 min versus 54.93 ± 15.02 min, p = 0.738, procedure time, 184.18 ±19.28 min versus 191.43 ± 20 min p = 0.315, and even for radio frequency time which was lower in segmental group but did not differ statistically, 35.71 ± 5.73 min versus 34.79 ± 5.29, min p = 0.649.&#x0D; CONCLUSION: The previous studies showed the superiority of circumferential PVI on segmental strategy regarding effectiveness, but in those studies, linear ablations were added to circumferential strategy and done in cases of persistent and PAF. In our randomized study, we compared between two methods in cases of PAF, which showed that segmental ablation is not inferior to circumferential ablation of PVI.

Ablation strategies for different types of atrial fibrillation in Europe: results of the ESC-EORP EHRA Atrial Fibrillation Ablation Long-Term registry.

The ESC EORP EHRA Atrial Fibrillation (AF) Ablation Long-Term registry was designed to assess management and outcomes of AF catheter ablation procedures in Europe. To investigate the current ablation approaches and their outcomes for patients with paroxymal AF (PAF) and non-PAF in Europe. Data from index ablations were collected in 27 European countries at 104 centres in a prospective fashion. Pre-procedural, procedural, and 1-year follow-up data were captured on a web-based electronic case record form. Data on the ablation procedure were available for 3446 patients. Of these, 2513 patients and 933 patients underwent pulmonary vein isolation (PVI) or PVI plus (PVIplus) additional ablation, respectively. The ablation strategy was limited to PVI in 81% and 56% of patients in the PAF and non-PAF group, respectively (P < 0.001). In the non-PAF group, left atrial linear ablation and ablation of complex fragmented atrial electrograms were more commonly performed. Arrhythmias recurrence after PVI was 29% and 39% in the PAF and non-PAF group, respectively (P < 0.001) and 42% after PVIplus in both groups. Atrial fibrillation related hospital admissions were more common in the PVIplus group (20% vs. 14%). A very low procedural complication rate was observed. No relevant differences were observed with regard to repeat ablation (PVI 9% and PVIplus 11%). In patients with PAF and non-PAF, the ablation strategies of PVI and PVIplus led to similar arrhythmia-free survival rates after 1 year. A considerable hospital readmission rate was noted.