Long-standing Persistent Atrial Fibrillation Research Articles

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.

The effects of radiofrequency catheter ablation for atrial fibrillation on right ventricular function

Abstract Background The effects of radiofrequency catheter ablation (RFCA) for atrial fibrillation (AF) on right ventricular (RV) function are not well known. Methods Patients who underwent RFCA for AF and underwent pre- and post-procedural echocardiography were enrolled. Fractional area change (FAC), RV free-wall longitudinal strain (RVFWSL), and RV 4-chamber strain (RV4CSL) were measured. Changes in FAC, RVFWSL, and RV4CSL before and after RFCA were compared among paroxysmal (PAF), persistent (PeAF), and long-standing persistent AF (LSPeAF) groups. Results A total of 164 participants (74 PAF, 47 PeAF, and 43 LSPeAF; age, 60.8±9.8 years; men, 74.4%) was enrolled. The patients with PeAF and LSPeAF had worse RV4CSL (p<0.001) and RVFWSL (p<0.001) than those with PAF and reference values. Improvements in RVFWSL and RV4CSL after RFCA were significant in the PeAF group compared with the PAF and LSPeAF groups (ΔRV4CSL, 8.4% [5.1–11.6] in PeAF vs. 1.0% [-1.0–4.1] in PAF, 1.9% [-0.2–4.4] in LSPeAF, p<0.001; ΔRVFWSL, 9.0% [6.9–11.5] in PeAF vs. 0.9% [-1.4–4.9] in PAF, 1.0% [-1.0–3.6] in LSPeAF, p<0.001). Conclusions RV function is impaired in patients with PeAF and LSPeAF than in those with PAF. RV function is more improved after RFCA in patients with PeAF than in those with PAF or LSPeAF.Changes of echocardiographic parameters

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 <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

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 (>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<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<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 procedural safety of the pentaspline pulsed field ablation catheter for atrial lesions beyond pulmonary vein isolation

Abstract Background The pentaspline multi-electrode pulsed-field ablation (PFA) catheter is widely used for the ablation of atrial fibrillation (AF). Given the favorable safety profile of PFA, lesions beyond pulmonary vein isolation (PVI) are increasingly performed. Purpose We aimed to assess the feasibility and safety of PFA beyond PVI with the pentaspline PFA catheter. Methods We retrospectively studied all patients who underwent PFA for atrial arrhythmias in our center between January and October 2023. Procedural characteristics and complications were compared between patients undergoing only PVI (PVI-only group) and those receiving extra-venous applications (extra-PVI group). Results We analysed 202 PFA cases. Indications for ablation included paroxysmal AF (34.7%), persistent AF (57.4%), long-standing persistent AF (5.9%) and atypical atrial flutter (2%). Redo procedures accounted for 18.8% of the total cases. PFA beyond PVI was performed in 142 (70.3%) patients. Patients in the extra-PVI group had a higher incidence of persistent AF (76.8% vs 11.7%, p<0.001), a higher BMI (29±5 vs 26±5 kg/m2, p=0.001) and a more dilated left atrium (LAVI: 73±24 vs 52±20 ml/m2, p<0.001, Table 1). PFA in this group consisted of PVI (98.6%), posterior wall isolation (PWI) (93%), mitral isthmus (MI) ablation (56.3%), a roof line (2.1%), ablation of dispersion electrograms (10.6%) and cavotricuspid isthmus (CTI) ablation (0.7%). In 22 (15.5%) patients, additional CTI ablation with radiofrequency (RF) was performed, while alcohol ablation of the vein of Marshall and RF ablation in the coronary sinus were required in 9 (6.3%) and 2 (1.4%) patients, respectively, to achieve MI block. Compared to the PVI-only group, PFA beyond PVI required a mean of 43 additional applications, a longer procedural (84±29 vs 65±22 min, p<0.001) and fluoroscopy time (25±10 vs 18±6 min, p<0.001) and had a higher fluoroscopy dose (24±35 vs 16.4±28.5 Gy.cm2, p=0.001). A three-dimensional electroanatomic map was used in 12% of cases. Acute success rates were 99% for PVI and PWI, 89% for MI ablation and 100% for roof lines and CTI ablation. Overall complication rates were similar in both groups (16.2% vs 13.3%, p=0.68, Table 2). One cardiac tamponade was observed in the extra-PVI group (0.7%) compared to 4 in the PVI-only group (6.7%, p=0.03). Among the latter, 2 incidents occurred during PVI in patients with long-standing persistent AF, precluding further extra-venous ablation. A small pericardial effusion (without hemodynamic compromise) and/or pericarditis were seen in 9.2% of patients in the extra-PVI group compared to 6.7% in the PVI-only group (p=0.78). No deaths occurred in either group. Conclusions Ablation beyond PVI with the pentaspline PFA catheter is feasible with high success rates and no apparent increase in procedural complications. However, it increases procedural duration and fluoroscopy. Notably, the majority of cardiac tamponades in this cohort occurred during PVI.

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.

Multielectrode catheter-based pulsed field ablation of persistent and long-standing persistent atrial fibrillation

Abstract Background Rhythm control of non-paroxysmal atrial fibrillation (AF) is significantly more challenging, as a result of arrhythmia perpetuation promoting atrial substrate changes and AF maintenance. Purpose We describe a tailored ablation strategy targeting multiple left atrial (LA) sites via the multielectrode FarawaveTM pulsed field ablation (PFA) catheter in patients with persistent AF sustained beyond 6 months (PerAF>6m) and long-standing persistent AF (LSPAF). Methods The ablation protocol included the following stages: pulmonary vein antral and posterior wall isolation plus anterior roof line ablation (Stage 1); electrogram-guided substrate ablation (Stage 2); atrial tachyarrhythmia (AT) regionalization and ablation (Stage 3). Results Seventy-two [age:68±10y, 61.1%males; AF history: 25 (18-45) months] patients with PerAF>6m (52.8%) and LSPAF (47.2%) underwent their first PFA via the FarapulseTM system. LA substrate ablation (Stage 1 and 2) led to AF termination in 95.8% of patients. AF termination occurred while ablating the mitral edge of the postero-lateral ridge (40.3%), the inferior left atrium above the proximal coronary sinus (27.4%), the interatrial septum (22.6%), the superior aspect of the postero-lateral ridge (6.5%), the base of the appendage (3.2%). AF organized into a left-sided atrial flutter (AFlu) in 46 (74.2%) patients. The FarawaveTM catheter was used to identify LA sites showing diastolic, low-voltage electrograms and entrainment from its splines was performed to confirm the pacing site was inside the AFlu circuit (Figure 1). Left AFlu termination was achieved in all cases via PFA delivery. Total procedural and LA dwell times were 112±25min and 59±22 min, respectively. Major complications occurred in 2 (2.8%) patients with pre-existing left ventricular systolic dysfunction (EF<35%) who required inotropic therapy due to acute heart failure. Hemodynamics normalized within 24h and both patients were discharged after 2 and 3 additional hospital days. Transient ST-segment elevation was documented in 4 patients after peri-mitral PFA; timely nitrate administration led to ECG normalization within 10 minutes. Single-procedure success rate was 81.8% after 13.3±1.9 months of follow-up; AF-free survival was 93.1% (Figure 2). A subgroup of 36 patients completed a follow-up transthoracic echocardiography study to assess left atrial mechanical contraction changes after ablation. Median A-wave velocity was 30 (IQR: 20-35) cm/s post-ablation and 50 (IQR: 41-70) cm/s after a mean of 7.3±1.8 months post-ablation. Conclusions In our cohort, PFA-based AF substrate ablation led to AF termination in 95.8% of cases. Very favorable clinical outcomes were observed at one year of follow-up.Entrainment from the PFA Catheter.Kaplan-Meier Analysis.

One-year freedom from arrhythmia following radiofrequency ablation using proactive oesophageal cooling

Abstract Background Proactive esophageal cooling is increasingly being utilized, and is now FDA cleared, to reduce the likelihood of ablation-related esophageal injury resulting from radiofrequency (RF) cardiac ablation of atrial fibrillation (AF). One-year follow-up from the largest randomized controlled study, the IMPACT trial, showed a trend towards improvement in long-term efficacy versus luminal esophageal temperature (LET) monitoring. With larger data sets now available for analysis, we sought to determine 1-year freedom from atrial arrhythmia associated with the use of proactive esophageal cooling. Methods Data from 2 trials comparing freedom from atrial arrhythmia after RF ablation using proactive esophageal cooling to LET monitoring were combined. Data were analyzed using a stratified Cox proportional hazards model to compare arrhythmia recurrence rates, with R statistical analysis software. Results Data from 631 patients across two studies comparing arrhythmia outcomes for proactive oesophageal cooling versus LET monitoring were analysed. Mean patient age was 66.4±9.8 years, and 37.4% were female. Arrhythmias were 56.3% paroxysmal AF and 43.7% persistent or long-standing persistent AF. Freedom from atrial arrhythmia at one year was 77.2% for patients receiving proactive oesophageal cooling and 64.4% for patients receiving LET monitoring (Figure 1), with a hazard ratio for cooling of 0.65 (95% CI 0.43 to 0.99, P = 0.044). Conclusions Proactive oesophageal cooling was associated with significantly greater freedom from atrial arrhythmia at one year when compared to LET monitoring during RF ablation.

Ten-year follow-up results of patients with persistent atrial fibrillation treated by combined pulmonary vein isolation and complex fractionated atrial electrocardiogram ablation

Abstract Background For persistent atrial fibrillation (AF), pulmonary vein isolation (PVI) alone is associated with lower success rate compared to paroxysmal AF and additional strategies are needed. Ablation targeting on complex fractionated atrial electrograms (CFAE) is an alternative method. Although clinical benefits of the strategy combined PVI and CFAE ablation have not been shown by large trials, clinical situations and consequences of this approach have not been clearly demonstrated during very long term follow-up. Purpose This study aimed to retrospectively investigate clinical outcomes of patients with persistent AF treated by the approach combined PVI and CFAE ablation during a follow-up period of 10 years. Methods 73 patients (59.4±8.1 years, 64 male, AF history 5.5 years) with persistent (23, 31.5%) and long-standing persistent AF (50, 68.5%) who underwent combined PVI and CFAE ablation in the first procedure were included. Structural heart disease was found in 9 patients, and a history of ablation for typical atrial flutter (AFL) in 4. A complete CFAE mapping in the left atrium and coronary sinus was performed with a 3-D mapping system (EnSite NavX). All CFAEs defined as electrograms with continuous activities or mean cycle length detected by the system <80 ms were eliminated. All patients were controlled regularly during the first year with 12-lead ECG and Holter monitoring and followed by annual control. The electronic health records for all patients were extensively investigated and the patients were interviewed in 2020-2022. Any documented atrial tachyarrhythmia (ATA) after 3-month blanking period was regarded as recurrence. Results Mean 2.2±1.2 (1-5) ablation procedures were performed in each patient. After index ablation, 18 (24.7%) were free of ATAs during 10-year follow-up. 26 (35.6%) had recurrence of only AF, 6 (8.2%) of only AFL and 23 (31.5%) had both AF and AFL. The proportion of AFL was 39.7% with 6 typical AFL. After multiple ablation procedures, 33 (45.2%) patients were free of ATA during the follow-up. 23 (31.5%) had recurrence of only AF, 5 (6.8%) of only AFL and 12 (16.4%) of both AF and AFL. The proportion of AFL was 23.2% with no typical AFL. At 1-year follow-up, freedom of ATAs in persistent AF was higher than that in long-standing AF (65.2 vs. 40.0%, p=0.033) and no significant difference was found after 2 years (47.8 vs. 34.0%, p=0.129) until 10 years (30.4 vs. 22.0%, p=0.167, Figure 1). No difference was observed between these subgroups after multiple procedures at 10-year follow-up (47.8 vs. 44.0%, p=0.708, Figure 2). Conclusions PVI plus CAFE ablation in patients with persistent AF led to a high recurrence of ATA after index ablation. Difference of ATA-freedom between persistent and long-standing persistent AF groups was found only 1 year after the index procedure, but not during further follow-up. Incidence of post-ablation AFL was particularly high, even after multiple ablation procedures.Figure 1Figure 2

Incidence, types, and predictors of AF recurrence after AF ablation with pulsed field ablation. A single-centre experience

Abstract Background Pulsed field ablation (PFA) is an emerging method for the ablation of atrial fibrillation (AF). As there are few data on incidence, types, and predictors of AF recurrence after PFA for AF ablation, we are continuously analysing our cohort. Methods We report our outcome data after PVI with PFA. Each procedure was performed under deep sedation with propofol and fentanyl. Before transeptal puncture, unfractionated heparin was administered to maintain an ACT level >300sec throughout the procedure. Isolation of pulmonary veins was started after administration of 1mg of atropine with 8 applications per vein (4 in basket, 4 in flower configuration). In recent months we have routinely performed 2 additional ablations in flower configuration with an anterior twist at both right pulmonary veins. All veins were checked for entrance- and exitblock to confirm isolation in sinus rhythm. An additional ablation was performed if necessary. Results In total, 231 patients were analysed. Mean age was 62±10 years, 38% were female. Mean CHADS-VASc score was 2±1. 61% had paroxysmal AF (PAF), 36% persistent AF, and 3% patients had long-standing persistent AF. In 85% (n=197) first-pass isolation of all veins was possible. Primary PV isolation was achieved in all patients at the end of the procedure. In addition to PVI, the cavo-tricuspid isthmus (CTI) was blocked in 6% (using radiofrequency ablation in case of previously or during the procedure documented typical flutter) and the posterior wall was isolated in another 6% during the first procedure. Mean procedure time was 60±20 minutes (24-175 minutes), mean X-ray time 19±9 minutes. In 231 procedures, only two catheter-associated complications were documented. 38 patients (16%) had arrhythmia recurrence after a blanking period of 3 months and a mean follow-up of 273±177 days. Mean time to recurrence was 171±84 days. Women were more likely to have recurrences [OR 2.042 (CI 95% 1.012-4.121), p<0,05]. Patients who had undergone any type of cardiac surgery prior to ablation were also significantly more likely to have recurrence [OR 0.517 (CI 95% 0.116-0.212); p<0.001]. Patients with no other comorbidities were more likely to remain free from arrhythmias [OR 0.792 (95% CI 0.736-0.853); p<0,01]. The type of AF did not make a significant difference according to the risk of recurrence in this cohort. To date, we have performed 18 re-do procedures in patients after PVI with PFA. The recurrent arrhythmia was AF in 39% (n=7), atypical AT in 50% (roof-dependent: 28%, n=5; mitral isthmus dependent: 22%, n=4), and CTI-dependent flutter in 39% (n=7). All but one patient had PV reconnections, and all were successfully reablated. Conclusion PFA success rate is similar to that of thermal techniques. Procedure time is shorter in experienced operators and the complication rate is low in our cohort. Results from RCTs are needed to further evaluate this new method compared to other ablation techniques.

Multicenter retrospective evaluation of a patient-tailored electrogram-based ablation strategy using an artificial intelligence software in repeat atrial fibrillation ablation procedures

Abstract Background While pulmonary vein isolation (PVI) is the gold standard approach of treatment of atrial fibrillation (AF), the optimal strategy in case of AF recurrences for redo patients is not well established. Several studies described the usefulness of ablating in atrial regions exhibiting abnormal electrograms, i.e. spatio-temporal dispersion, during AF and an artificial intelligence (AI) electrograms (EGMs)-based software solution has been developed and validated to obtain real-time adjudications of multipolar electrograms in de novo patients. Purpose This study sought to evaluate the novel AI-EGMs-based software approach for redo-AF ablation procedures. Methods This study was a retrospective, multicentric, nonrandomized study. Patients with recurrent symptomatic AF were enrolled in 7 European centers. Redo ablation procedures were performed using the AI software and acute and long-term outcomes after ablation were evaluated. Results A total of 117 patients with refractory symptomatic AF admitted for redo procedure were included with 30% paroxysmal, 42% short-standing persistent and 28% long-standing persistent AF at the time of the redo procedure. During the index procedures, a previous PVI ablation was performed in all patients while additional ablation such as lines and EGM-based ablation was performed in 64 patients (55%). Out of 117 patients, 30 (26%) presented with structural heart disease, 61 (52%) with hypertension, 31 (26%) with a BMI >30, 16 (14%) a sleep apnea syndrome and 24 (20%) had an antiarrhythmic treatment at the time of the procedure. The average AF history was 6.54 ± 4.15 years with an average sustained duration equal to 25 ± 62 months. AI-EGMs-based AF ablation was performed in all patients and easily integrated in the physicians’ workflow during redo procedures. AF termination, i.e. AF regularization or sinus rhythm conversion, occurred in 82/117 patients (71%) with sinus rhythm conversion by ablation in 79/117 patients (68%). After a mean follow-up of 11 ± 5 months, 81% of patients were free from documented AF, with or without antiarrhythmic drugs (AADs) after one redo procedure and 60% of patients were free from any documented atrial arrhythmia, with or without AADs, after one redo procedure per patient. Furthermore, we observed that 77%, 84% and 82% of patients were free from documented AF with or without AADs in paroxysmal, short-standing and long-standing persistent AF patients respectively, and that 71%, 59% and 49% of patients were free from any documented atrial arrhythmia with or without AADs in paroxysmal, short-standing and long-standing persistent AF patients respectively. Conclusions This retrospective study reports that patient-tailored spatiotemporal dispersion ablation is a relevant and standardized approach for repeat AF ablation. This was obtained with an AI-EGMs-based software solution, which may be added to the operative workflow of redo AF procedures.

Pulsed field ablation versus very high-power short-duration radiofrequency ablation in persistent atrial fibrillation: a single-centre experience

Abstract Background Pulsed Field ablation (PFA) has recently emerged as a treatment strategy for patients with atrial fibrillation (AF) and early studies showed promising procedural data and durable pulmonary vein isolation (PVI). However, Very High-Power Short-Duration ablation (VHPSD) has previously reported good efficiency and mid-term outcomes, and only a few works compared these two procedures, especially in patients with persistent AF. Objective Our aim is to compare these different modalities of transcatheter ablation in patients with persistent AF, focusing mainly on some procedural aspects, safety and efficacy. Methods We performed a retrospective observational study enrolling all consecutive patients with persistent AF from September 2021 to May 2023 undergoing transcatheter ablation with PFA or VHPSD. In the first group, PVI was achieved by 2kV pulses with eight applications to each vein using both catheter configurations, while isolation of the posterior wall of the left atrium was achieved by applications through the only "flower" configuration; additional lesions were then added at the operator's discretion. In the second group, PVI was achieved by delivering 90W radiofrequency pulses for 4 seconds in the posterior portions of the left atrium and 50W pulses in the anterior region of the pulmonary veins; additional lesions were occasionally applied. All patients received general anaesthesia or deep sedation with fentanyl and dexmedetomidine. Results A total of 79 patients were included, n = 24 (30%) in the PFA group and N = 55 (70%) in the VHPSD one: early persistent AF (n= 2 [8,3%]; N = 7 [12,7%]), persistent AF (n= 17 [70,8%]; N = 36 [65,5%]), long-standing persistent AF (n= 5 [20,8%]; N = 12 [21,8%]). The two populations showed similar clinical features: CHA2DS2-VASc (median value 3 [0-6] in PFA vs 2 [0-6] in VHPSD, p = 0,10), indexed left atrial volume (mean value 42,6 ml/m² in PFA vs 42,4 ml/m² in VHPSD, p = 0,07) and EF (mean value 55,4% in PFA vs 54,8% in VHPSD, p = 0,33). PVI was successfully achieved in all patients. Nevertheless, the PFA group was associated with shorter procedural duration (92,1 ± 36,9 vs 134,2 ± 36,1 minutes, p = 0,00001) but longer fluoroscopy time (25,5 ± 9,3 vs 17,4 ± 11,5 minutes, p = 0,001); it also showed a lower rate of minor complications (n = 1 [4,2%] vs N = 3 [5,5%], p = 0,057), even though serious complications were not observed in either group. After a median follow-up of 14 (9-26) months, n = 19 [79.2%] in the PFA and N = 43 [78.2%] in the VHPSD population were free of any atrial arrhythmia (p = 0,92). Conclusion PFA allows faster procedures, representing a major advantage for the operator and the patient, who is at lower risk of peri-procedural complications. On the other hand, VHPSD correlates with shorter fluoroscopy times, reducing exposure to ionizing radiation. Finally, the two procedures show similar mid-term efficacy in terms of recurrence-free time.

A multicenter evaluation of repeat ablation for atrial fibrillation in patients with isolated pulmonary veins: a Netherlands Heart Registration study

Abstract Background Of the 25-50% atrial fibrillation (AF) ablation patients who undergo repeat ablation, approximately 15-30% have all pulmonary veins (PVs) isolated at the repeat procedure. Currently, there is limited evidence and a lack of consensus on the appropriate treatment strategy for patients with isolated PVs. Purpose Our aim was to characterize and compare the effectiveness of repeat AF ablation strategies to reduce AF recurrences in patients with isolated PVs using a real-world multicenter registry. Methods All AF patients referred for repeat AF ablation with all PVs isolated at 8 hospitals in the Netherlands were included (Netherlands Heart Registration; 2016-2019). Medical record reviews were conducted for all patients referred for repeat AF ablation to determine study eligibility, the presence of PV reconnection, ablation strategy used, and the outcome of AF recurrence. Patients referred for repeat AF ablation, with PVI only conducted during previous ablations, and all PVs isolated were eligible. Effectiveness of repeat AF ablation strategies were assessed with multivariable Cox models comparing individual ablation strategies, number of ablation strategies performed, and presence of persistent AF. Results Of 2,311 repeat AF ablations performed, 274 (11.9%) were eligible and had all PVs isolated (Figure 1). Patients with isolated PVs were a median age of 66 (IQR 58-70) years, 44.2% were women, 45.6% had persistent or long-standing persistent AF, and the median CHA2DS2-Vasc score was 2 (IQR 1-3). Ablation was not performed in 33 (12.0%) patients with isolated PVs (Figure 2a). A single ablation strategy was performed most often (41.2%; Figure 2a). Posterior box ablation was the most frequent (58.4%) ablation strategy performed, followed by antralization of the PVs (26.3%). Over a median follow-up of 2.0 (1.0-3.3) years, 147 (59.8%) patients with isolated PVs had an AF recurrence >3 months after repeat ablation and 30 (12.7%) patients had another repeat AF ablation within 1 year of repeat procedure. After multivariable adjustment, no difference in AF recurrences was detected between ablation strategies [p>0.05 for all; Figure 2b]. Further, there was no difference detected in AF recurrences for the number of ablation strategies performed (Figure 2c), the individual ablation strategy conducted, and persistent AF (p>0.05 for all). Among patients with isolated PVs, patients with larger left atrial size had a higher risk of AF recurrences [adjusted HR 1.03 (95% CI 1.01-1.05)]. Conclusion Among the 2,311 repeat AF ablations performed, 11.9% had all PVs isolated. Despite multiple ablation strategies performed for isolated PVs, 59.8% of patients had an AF recurrence over follow-up and no difference in the incidence of AF recurrences was detected between repeat ablation strategies. Further evidence is warranted to determine an effective treatment strategy to reduce AF recurrences in AF patients with isolated PVs.

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

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

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 >50%) or diminished baseline LVEF (LVEF <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 <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)

Left atrial appendage clipping during hybrid atrial fibrillation ablation: a very long-term, single-center experience

Abstract Background/introduction Epicardial left atrial appendage (LAA) clipping is an effective strategy for stroke prophylaxis in high thromboembolic (TE) and bleeding risk patients with atrial fibrillation (AF). In addition to LAA exclusion from systemic circulation, clipping promotes concomitant appendage isolation, which might have positive impacts on arrhythmia control. Purpose The aim of this study was to report safety, success rate, and the long-term clinical outcomes of LAA clipping in a large cohort of AF patients undergoing concomitant hybrid ablation. Methods Consecutive patients undergoing hybrid AF ablation between 2013 and 2023 were enrolled. Hybrid ablation was performed in a one-step procedure consisting of thoracoscopic epicardial radiofrequency (RF) ablation followed by endocardial mapping and ablation, if needed. Ablation lesion set included pulmonary vein (PV) and posterior wall (PW) isolation, as well as RF applications to the LAA/posterolateral ridge. LAA clipping was performed via Atriclip exclusion system (Atricure, Inc., The Nederlands) after epicardial ablation. Additional endocardial lesions were performed in case of incomplete epicardial ablation or at physician’s discretion. Results A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF, respectively. Mean CHA2DS2-VASC and HAS-BLED were 3.1±1.1 and 2.3+-0.5. Five patients (3.8 %) had absolute contraindication to long-term oral anticoagulation, 3 (2.3%) had previous life-threatening bleeding events, 17 (13.1%) had a previous TE event. The final clip size was 35mm in 90.7% cases. Acute success was achieved in 97.7%; failure was due to LAA size (n=1), proximity to phrenic nerve (n=1), or bypass graft (n=1). One patient had incomplete occlusion due to a large secondary lobe, which required a second clip. No periprocedural complications related to clipping were documented. At a mean follow-up of 51±35 months, one (0.8%) patient had a stroke and 3 (2.3%) a transient ischemic attack (4 events per 552 patient/years; 0.7%). One patient had a microreentrant tachycardia mapped from the area near the LAA clipping. Conclusion In a large cohort undergoing hybrid AF ablation, epicardial LAA clipping was safe and highly successful. Acute failure was rare and due to LAA morphology or proximity to phrenic nerve and bypass graft. Thromboembolic event rate was very low.

Acute and long-term lesion durability and reconnection patterns following hybrid atrial fibrillation ablation

Abstract Background/introduction Hybrid ablation (AF) is a well-established rhythm control strategy in non-paroxysmal AF patients and can be performed as a staged or one-step epicardial-endocardial approach. Data on need for endocardial touch-up acutely after epicardial ablation are limited, as well as long-term reconnection patterns in patients undergoing redo procedures. Purpose to evaluate the lesion transmurality detected via endocardial mapping acutely after epicardial radiofrequency (RF) ablation, as well as anatomical and clinical predictors of residual endocardial gaps in a large cohort of patients undergoing hybrid AF ablation. Furthermore, long-term lesion durability will be assessed in patients undergoing repeat endocardial ablation. Methods Hybrid procedures were performed in a one-step fashion (endocardial mapping +/- ablation immediately following left thoracoscopy epicardial ablation). Epicardial pulmonary vein (PV) isolation was achieved via a bipolar RF clamp; further epicardial linear ablation was performed with a RF bipolar linear device. Additional lesions were performed according to physician’s preference on a patient basis. At the end of the procedure, the left atrial appendage (LAA) was clipped. Results A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF. All patients received epicardial PV and posterior wall (PW) isolation plus additional RF applications to the LAA/posterolateral ridge. Other targets included the right inferior ganglionted plexus in 36.2% (n=47) and anterior mitral line (AML) in 3.8% (n=5). In 13.1% (n=17) epicardial lesions could not be completed due to difficult anatomy. At the end of the procedure, an attempt to clip the LAA was done in all patients, resulting in 97.7% success (3 LAA clip failures due to anatomical reasons). Acute endocardial mapping revealed a PV reconnection rate of 4.6% (n=24), left superior and right superior PVs being the veins most commonly reconnected (6.15% and 5.38%, respectively). PW and AML reconnections were documented in 8.5 % and 60% (3 out of 5 patients). Multivariate analysis showed left atrial (LA) volume and male gender as predictors for acute endocardial gaps after complete epicardial lesions. A redo procedure after first recurrence was performed in 24.6% (n=32), showing lesion durability of 100% for left PVs, 90.6% for right superior and 93.7% for right inferior PVs. PW remained isolated in 78.1% of patients. Age was a predictive factor for chronic gaps after recurrence. At a mean follow-up of 51±35 months, arrhythmia-free survival after multiple procedures was 68.5%. Conclusion In a large cohort of AF patients undergoing hybrid ablation,acute and chronic lesion durability was hight.LA volume and male gender were predictors of acute reconnection after epicardial ablation.

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 >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<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 >1 AAD at twelve months follow up (p<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

Pulsed field ablation for complex resistant atrial tachycardia recurring after radiofrequency ablation of persistent atrial fibrillation

Abstract Background There is a limited knowledge on immediate and long-term efficacy of pulsed field ablation (PFA) for residual atrial tachycardia (AT) recurring after persistent atrial fibrillation ablation (AF). Purpose To present immediate and medium-term outcome of PFA (Farapulse) for complex AT recurring after ≥1 radiofrequency ablation (RFA) of primary (longstanding) persistent AF. Methods In 5/2022-10/2023, 81 patients (64±8 years, 19 females) underwent PFA for complex AT in 83 PFA procedures after prior RFA procedure(s); in first (n=21), second (n=33), third (n=23), fourth (n=5), or fifth (n=1) repeat ablation procedure, respectively. Mapping/ablation strategy was directed by the CS activation/entrainment to: 1) no 3D mapping and direct PFA in left atrium (n=67); 2) PFA directly after 3D LA mapping (n=9); 3) PFA following RFA after 3D LA mapping (n=7). AT sources were classified as macroreentry (MRAT) (perimitral, roof-dependent, typical flutter) or localized (LOCAT) in case of smaller reentry or ectopic origin. Results At the procedure onset, persistent AT was present in 58 patients, in the remaining cases AT (n=21) or AF (n=4) were induced. AF eventually occurred at some time of procedure in another 10 patients and was terminated by ablation at LA ridge/CS/LOM region 8x, LA posterior wall 3x, LUPV 1x, RUPV 1x, and RA low lateral wall 1x. Only MRAT, only LOCAT, or both AT types were found at 34 (41%), 35 (42%), and 14 (17%) procedures, respectively. A total of 125 ATs was identified (1, 2, and 3 ATs in 52, 20, and 11 patients). MRAT (n=60) included 32 perimitral ATs, 20 roof-dependent ATs, and 8 typical flutters. LOCAT (n=65) included RUPV source (n=1), LA extraPV sources (n=59), and RA sources (n=5). SR was restored with a 5±7 PFA applications at the site of AF source, total of PFA deliveries was 71±27, and procedure and fluoroscopy times were and 89±37 and 9±5 minutes, respectively. In the 7 patients with initial ineffective 6, 6, 11, 5, 18, 10, and 2 minutes of RFA, the AT was converted into SR by subsequent 1, 4, 1, 13, 4, 24, and 20 PFA applications. All ATs were terminated and noninducibility was achieved in 82 (99%) and 74 (89%) procedures, respectively. In 52 patients with >3 month follow-up, 46 (88%) patients remain in stable SR (41 / 79%) off AAD); 3 and 3 patients have paroxysmal or persistent AT. Conclusion PFA with catheter Farapulse can affect complex/epicardial AT sources resistant to RFA in prior or present ablation procedure; however, there is a certain discrepancy between high efficacy in AT terminating and medium-term clinical outcome.

Different predictors of AF recurrence after pulmonary vein isolation with cryoballoon and radiofrequency ablation: insights from clinical and electroanatomical mapping data of the NO-PERSAF study

Abstract Background Pulmonary vein isolation (PVI) with cryobaloon ablation (CBA) and radiofrequency ablation (RFA) lead to a similar outcome of freedom from atrial tachyarrhythmia (ATA) during follow-up as showed by the NO-PERSAF study. Analyses of ATA recurrence for these two techniques based on data of electroanatomical mapping (EAM) are scarce from randomized clinical trials. Purpose This study aimed to evaluate and compare clinical outcomes and EAM data recorded in the left atrium (LA) during CBA and RFA procedures in patients with persistent atrial fibrillation (AF). Methods For the NO-PERSAF study, 101 patients (mean 63.2±8.6 years, 80 male, 21 female) with persistent AF (77 persistent AF, 24 long-standing persistent AF) referred to PVI were randomized (1:1) to CBA or RFA and followed for 12 months. A prolonged 3-year follow-up was carried out. EAM was performed by a circular mapping catheter with a 3-dimensional mapping system in all patients. EAM data were recorded and analyzed off-line. The areas of the LA, posterior wall, low-voltage (<0.5mV) and complex fractionated electrogram (cycle length <120 ms) were measured and corrected by body surface area (BSA). EAM data from 90 patients were qualified for further analysis and the others (5 in CBA and 6 in RFA) excluded because of disqualification or technical failure of recording. Correlation between clinical results of 3-year follow-up and the EAM data were analyzed using univariate cox regression. Results After 3-year follow-up, freedom from ATA was achieved in 51 (50.5%) of the 101 patients, 28 (54.9%) out of 51 patients in the CBA group and 23 (46.0%) out of 50 patients in the RFA group and no difference was found (p=0.327). RFA compared with CBA resulted in larger ablation lesions in the LA (23.9% vs. 21.3%; p=0.037) and particularly in the posterior wall (44.2% vs 31.8%; p<0.001). Compared between the patients with and without recurrence, there was no difference with respect to age, gender, AF history, body mass index, heart disease and CHA2DS2-vasc score. For EAM data, the area of the LA and low voltage were significantly higher in ATA recurrent patients in CBA group, but not in RFA group (Table 1). Univariate cox regression analyses suggested that 3-year follow-up outcomes were associated with the size of the LA and the amount of low voltage corrected by BSA. The criteria of the LA area >55 cm2/m2 or low voltage area <19 cm2/m2 could predict ATA recurrence after CBA, but not after RFA procedure (Figure 1). Conclusions The size of the LA and the amount of low voltage corrected by BSA was associated with the outcomes of PVI during follow-up and could be employed as predictors of ATA recurrence for CBA, but not for RFA procedure.Table 1Figure 1K-M curves after CBA and RFA