Nonparoxysmal Atrial Fibrillation Patients Research Articles

Effectiveness of Maze IV procedure versus thoracoscopic ablation for atrial fibrillation: a propensity score-matched analysis.

Thoracoscopic ablation (TA) has emerged as a promising treatment for atrial fibrillation (AF), with the Cox-Maze IV Procedure (CMP-IV) as the current gold-standard intervention. This study aims to evaluate and compare the outcomes of TA and CMP-IV in treating AF. Patients with AF underwent either CMP-IV or TA through a left-side chest approach. The CMP-IV entailed bi-atrium ablation, whereas the TA involved creating three circular plus three linear ablations in the left atrium. We analyzed baseline characteristics, perioperative outcomes and recurrence rates using propensity score matching (PSM) at a 1:1 ratio, to ensure comparability between the two treatment groups. A total of 459 patients underwent either CMP-IV (n=93) or TA via left chest (n=366) and 174 patients were deemed eligible for 1:1 PSM. The TA group experienced significantly shorter intensive care unit (ICU) and hospital stays. The mean follow-up period was 31.5±22.1 months. Pre- and post-matching analysis showed that CMP-IV had a higher rate of freedom from recurrence compared to TA, particularly in non-paroxysmal AF patients. Multivariable Cox regression analysis revealed that CMP-IV was associated with a reduced risk of recurrence, while an increased left atrial size emerged as an independent predictor of postoperative recurrence, regardless of the use of CMP-IV or TA. Our study suggests that while the therapeutic efficacy of TA for "lone" AF may fall short of the classic CMP-IV, its less invasive nature results in significantly shorter ICU and hospital stays. To enhance patient outcomes following TA, it is essential to improve the quality of ablation, refine the ablation route, and focus on careful patient selection.

Pulsed-Field Ablation Does Not Worsen Baseline Pulmonary Hypertension Following Prior Radiofrequency Ablations

BackgroundStudies have reported development of pulmonary hypertension (PH) secondary to reduced LA compliance following AF ablation. ObjectivesThis study aimed to compare the risk of worsening of baseline PH between non-paroxysmal AF patients undergoing pulsed-field ablation (PFA) and standard radiofrequency ablation (RFA). MethodsThis multicenter study included 28 nonparoxysmal AF patients with PH undergoing a PFA-based ablation procedure after >1 failed RFA. A cohort of 28 AF patients with PH, scheduled for repeat RFA, 1:1 propensity-score matched using a multivariable logistic model, were used as the comparator group. Right heart catheterization and echocardiography were performed before and after the procedure to assess the pulmonary artery pressure (PAP). PH was defined as resting mean PAP of >20 mm Hg. ResultsThe baseline characteristics of the PFA and propensity-matched RFA groups were comparable. The mean PAP assessments at baseline, follow-up, and change from baseline were analyzed. The groups had comparable baseline mean pulmonary artery pressures (mPAP) (P = 0.177). After adjustment for baseline mPAP in an analysis of covariance model, the least-squares means change at 3 months after ablation was −1.71 ± 1.03 mm Hg and 19.67 ± 1.03 mm Hg in PFA and RFA, respectively (P <0.001). ConclusionsIn this propensity-matched population, no worsening of mPAP was detected following pulsed-field ablation in patients with pre-existing PH undergoing a repeat procedure for recurrence.

Mid-term changes in cognitive functions in patients with atrial fibrillation: a longitudinal analysis of the Swiss-AF cohort.

Longitudinal association studies of atrial fibrillation (AF) and cognitive functions have shown an unclear role of AF-type and often differ in methodological aspects. We therefore aim to investigate longitudinal changes in cognitive functions in association with AF-type (non-paroxysmal vs. paroxysmal) and comorbidities in the Swiss-AF cohort. Seven cognitive measures were administered up to five times between 2014 and 2022. Age-education standardized scores were calculated and association between longitudinal change in scores and baseline AF-type investigated using linear mixed-effects models. Associations between AF-type and time to cognitive drop, an observed score of at least one standard deviation below individual's age-education standardized cognitive scores at baseline, were studied using Cox proportional hazard models of each cognitive test, censoring patients at their last measurement. Models were adjusted for baseline covariates. 2,415 AF patients (mean age 73.2 years; 1,080 paroxysmal, 1,335 non-paroxysmal AF) participated in this Swiss multicenter prospective cohort study. Mean cognitive scores increased longitudinally (median follow-up 3.97 years). Non-paroxysmal AF patients showed smaller longitudinal increases in Digit Symbol Substitution Test (DSST), Cognitive Construct Score (CoCo)and Trail Making Test part B (TMT-B) scores vs. paroxysmal AF patients. Diabetes, history of stroke/TIA and depression were associated with worse performance on all cognitive tests. No differences in time to cognitive drop were observed between AF-types in any cognitive test. This study indicated preserved cognitive functioning in AF patients, best explained by practice effects. Smaller practice effects were found in non-paroxysmal AF patients in the DSST, TMT-B and the CoCo and could indicate a marker of subtle cognitive decline. As diabetes, history of stroke/TIA and depression-but not AF-type-were associated with cognitive drop, more attention should be given to risk factors and underlying mechanisms of AF.

Increasing comorbidity burden of patients undergoing catheter ablation for atrial fibrillation in the past 10 years: An analysis of more than 8000 left-atrial ablation procedures

Abstract Funding Acknowledgements Type of funding sources: None. Background Catheter ablation is the most effective rhythm control treatment for atrial fibrillation (AF). While it was indicated as a symptomatic treatment in the past years, prognostic benefits of early rhythm control (ERC) were recently demonstrated and catheter ablation advances more and more into this indication. Restrictions in patient selection for catheter ablation seem to melt. Only few data on comorbidity burden in patients undergoing AF ablation is available. Purpose To determine prevalence of common cardiovascular and related comorbidities in patients undergoing left-atrial (LA) procedures between 2010 and 2021 at a large tertiary-care ablation center.. Method Eligible cases with LA procedures were identified through analysis of coded OPS data between 2010 and 2021. Analysis included patients with atrial fibrillation undergoing an ablation procedure including a transseptal puncture and mapping in the left atrium, not for other supraventricular tachycardias. Analysis accounted for different versions of the ICD-10-GM and OPS-ICHI catalogues. Comorbidities were defined as derived variables on a case-wise analysis from documented ICD-10 and OPS codes. CHA2DS2-VASc-score was calculated from these derived variables and demographic parameters. Procedures were clustered by intervention year in one of following ranges 2010-2012, 2013-2015, 2016-2018 and 2019-2021. Results 8396 left atrial procedures in 6184 individual patients (35% female, 63.6±11.0 years old at index procedure) were identified. Median CHA2DS2-VASc was 2 (IQR 1;3) in the overall cohort. Mean age increased constantly from 60.3±11.4 years in 2011 to 64.5±11.1 years in 2021. Median CHA2DS2-VASc-score remained constant at 2 points. While the share of non-paroxysmal AF patients was 52% between 2010 and 2012, it increased to 59% in 2016-2018 and decreased again to 55% in 2019-2021. The relative number of cases in which patients suffered from diabetes mellitus, chronic kidney disease, chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), pulmonary hypertension, coronary artery disease and prior myocardial infarction increased constantly between 2010-2012. While the share of patients with heart failure was highest between 2013 and 2015 (1368/2117 cases, 65%), it decreased to 833/2318 cases (36%) in 2019-2021. the absolute number of procedures nearly doubled from 2010-2012 to 2013-2015, it increased by only 36% from range 2013-2015 to 2016-2018. The number of procedures decreased again from 2016-2018 to 2019-2021 by 19%, likely due to COVID19-pandemic restrictions. Conclusion Over the last decade, the age and number of comorbidities increased in patients undergoing AF ablation procedures. These results put emphasis on offering safe procedures and perform adequate pre-procedural assessment of comorbidity burden.

PO-02-001 MODIFIED BOX ABLATION WITH OR WITHOUT DRIVERS ABLATION FOR CHINESE PATIENTS WITH NON-PAROXYSMAL ATRIAL FIBRILLATION: A RETROSPECTIVE REAL-WORLD STUDY

The use of circumferential pulmonary vein electrical isolation (CPVI) combined with modified posterior wall box isolation (m-BOX) has been proved an improvement in the long-term success of chronic atrial fibrillation (AF) patients’ treatment. More evidence shows that electrical drivers are associated with the maintenance of persistent AF (PsAF). To explore the long-term effectiveness of m-BOX or m-BOX with driver-guided ablation for non-paroxysmal AF using high-density mapping (HOT). Data were obtained from electronic medical records between January 1,2018 and May 31, 2022 from Xiangya Hospital Central South University, Changsha, China. Patients aged ≥18 years, diagnosed as PsAF or long-standing PsAF and underwent either m-BOX or HOT index ablation after CPVI, were included. Patients were expected to follow up ≥12 months post index procedure. Recurrence was defined as AF, or atrial tachycardia, or flutter lasting ≥30 seconds after 3-month blanking period, which came first. The Cox proportional model adjusting for propensity score (including age, gender, AF type, baseline left ventricular ejection fraction, left atrial diameter, and medical history) was used for 2-group comparison. The proportion of patients with event, adjusted hazard ratio (HR) [95% CI], and stratified log-rank P were presented. A total of 148 and 113 patients were identified in the HOT and m-BOX groups, with mean (SD) ages 61.7 (10.1) and 60.8 (8.9) years, male sex 64.2% and 67.3%, and long-standing PsAF diagnosis in 54.1% and 41.6% of population, respectively. The 12-month recurrence rate was lower in the HOT group than in m-BOX group (21.8% vs. 34.8%, adjusted HR [95% CI]:0.49 [0.30,0.80]; P=0.005). In the HOT group, the recurrence rate of patients who restored sinus rhythm (SR) by ablation was numerically lower than those who did not (16.7% vs. 26.7%, adjusted HR [95% CI]:0.60 [0.28,1.28]; P=0.37). Regardless of the ablation strategy, the recurrence rate was lower when SR was restored by ablation (16.2% vs. 34.4%, adjusted HR [95% CI]:0.43 [0.24,0.76]; P=0.01). Restoration of SR in non-paroxysmal AF patients is associated with lower recurrence rates at 12 months. In patients who do not achieve SR after CPVI and m-BOX, HOT ablation may lead to improved long term clinical outcomes. Future’s prospective study is needed for a more comprehensive view of the comparison results.

ABO Blood Groups as a Disease Marker to Predict Atrial Fibrillation Recurrence after Catheter Ablation

Chronic inflammation harbors a vulnerable substrate for atrial fibrillation (AF) recurrence after catheter ablation. However, whether the ABO blood types are associated with AF recurrence after catheter ablation is unknown. A total of 2106 AF patients (1552 men, 554 women) who underwent catheter ablation were enrolled retrospectively. The patients were separated into two groups according to the ABO blood types, the O-type (n = 910, 43.21%) and the non-O-type groups (A, B, or AB type) (n = 1196, 56.79%). The clinical characteristics, AF recurrence, and risk predictors were investigated. The non-O type blood group had a higher incidence of diabetes mellitus (11.90 vs. 9.03%, p = 0.035), larger left atrial diameters (39.43 ± 6.74 vs. 38.20 ± 6.47, p = 0.007), and decreased left ventricular ejection fractions (56.01 ± 7.33 vs. 58.65 ± 6.34, p = 0.044) than the O-type blood group. In the non-paroxysmal AF (non-PAF) patients, the non-O-type blood groups have significantly higher incidences of very late recurrence (67.46 vs. 32.54%, p = 0.045) than those in the O-type blood group. The multivariate analysis revealed the non-O blood group (odd ratio 1.40, p = 0.022) and amiodarone (odd ratio 1.44, p = 0.013) were independent predictors for very late recurrence in the non-PAF patients after catheter ablation, which could be applied as a useful disease marker. This work highlighted the potential link between the ABO blood types and inflammatory activities that contribute to the pathogenic development of AF. The presence of surface antigens on cardiomyocytes or blood cells in patients with different ABO blood types will have an impactful role in risk stratification for AF prognosis after catheter ablation. Further prospective studies are warranted to prove the translational benefits of the ABO blood types for the patients receiving catheter ablation.

Abstract 12117: Machine Learning to Probe Variability in Patient Outcomes After Atrial Fibrillation Ablation - The Stanford AF Registry (start)

Introduction: A major challenge in improving atrial fibrillation (AF) ablation is the variability in outcome between patients, which is not captured by traditional biostatistics. Hypothesis: We hypothesized that machine learning (ML) can be used to probe phenotypes of variable response to AF ablation. Methods: We studied 632 patients with drug-refractory AF, enrolled prospectively for a uniform strategy of PVI plus map-guided AF ablation at Stanford Health. We applied unsupervised ML to 64 variables to identify features associated with freedom from AF or atrial tachycardia (AT) at 3 years. Results: Patients (N=632) were 65±10 years, 28.2% female, BMI 30.2±6 kg/m2, 59.7% with non-paroxysmal AF, and 70.0% at de novo ablation. At 1-year, freedom from AF and AF/AT were 77.5% (95% CI interval: 74.2%, 80.9%) and 70.1% at 1 year (66.5%, 73.8%). At 3 years, they were 55.5% (51.2%, 60.1%) and 48.6% (44.3%-53.3%) respectively, regardless of antiarrhythmic drugs (P=0.23). Unsupervised ML revealed 3 phenotypic clusters that crossed conventional AF labels (Fig1). An Early AF cluster had best outcomes (1Y/3Y: 79.6 /53.5%); a Non-remodeled AF cluster (69.8/52.0%) had most comorbidities, a substantial number of non-paroxysmal AF patients, yet better outcomes than a cluster characterized by atrial or ventricular Remodeling (66.4/42.3%) (p=0.028) (Table 1). Conclusions: In a large prospective AF registry, ML revealed clusters for outcomes, spanning conventional clinical labels and highlighting that patients with comorbidities may have good outcomes if they lack structural remodeling, and that electrical and structural remodeling may follow independent courses between patients.

Paroxysmal and Non-Paroxysmal Atrial Fibrillation in Middle Eastern Patients: Clinical Features and the Use of Medications. Analysis of the Jordan Atrial Fibrillation (JoFib) Study.

(1) Background: Atrial fibrillation (AF) is the most common arrhythmia causing an increased risk of mortality and morbidity. It is classified into paroxysmal and non-paroxysmal AF depending on the duration and frequency of the episodes. (2) Aims: Our goal was to investigate and compare the clinical profiles, risk of co-morbidities, the use of oral anticoagulation, and outcomes of patients with paroxysmal and non-paroxysmal AF in inpatient and outpatient settings. (3) Methods: Data were extracted from 28 different hospitals and centers in Jordan with a total of 2160 patients enrolled in the study using an observational non-interventional study model. The clinical features and the use of oral anticoagulants were compared in patients with paroxysmal and non-paroxysmal AF. (4) Results: Paroxysmal AF was documented in 35.6% (769) of the patients and non-paroxysmal types in 63.9% (1380); in addition, the type of AF was unknown in 11 (0.5%) patients. Our results showed that non-paroxysmal AF patients tend to be older with more co-morbidities and higher CHA2DS2-VASC and HAS-BLED scores. They also have higher rates of hypertension and diabetes. Anticoagulant, antiarrhythmic, and diuretic agents, overall, were used more in non-paroxysmal AF than paroxysmal AF. Hospital admissions were also more frequent in non-paroxysmal AF due to various factors, some of which are heart failure, bleeding risk, and COPD. (5) Conclusions: Non-paroxysmal AF is more common among Jordanian AF patients. The prevalence of comorbidities and the use of different types of therapies, especially anticoagulants, were higher in these patients.

Predictors of recurrence of atrial tachyarrhythmias after pulmonary vein isolation by functional and structural mapping of nonparoxysmal atrial fibrillation.

BackgroundThis study aimed to evaluate the predictors of recurrence of atrial tachyarrhythmias by structural and functional mapping: voltage, dominant frequency (DF), and rotor mapping after a pulmonary vein isolation (PVI) in nonparoxysmal atrial fibrillation (AF) patients.MethodsA total of 66 nonparoxysmal AF patients were prospectively investigated. After the PVI, an online real‐time phase mapping system was used to detect the location of rotors with critical nonpassively activated ratios (%NPs) of ≧50% in each left atrial (LA) segment, and high‐DFs of ≧7 Hz were simultaneously mapped. After restoring sinus rhythm, low‐voltage areas (LVAs < 0.5 mV) were mapped using the Advisor HD grid catheter (HDG).ResultsSixty‐four of 66 (97%) AF patients had minimum to mild LVAs regardless of an enlarged LAD and LA volume (45 ± 6.0 mm and 141 ± 29 ml). There were no significant differences in the max and mean DF values and %NPs between the patients with and without recurrent atrial tachyarrhythmias. However, there was a significant difference in the LVA/LA surface area between the patients with and without recurrent atrial tachyarrhythmias (p = .004). Atrial tachyarrhythmia freedom was significantly greater in those with LVAs of ≤3.3% than in those >3.3% after one procedure over 11.6 ± 0.8 months of follow‐up (77.1% vs. 33.3%, p < .001). In a multivariate analysis, the LVA/LA surface area after the PVI (HR 1.079; CI, 1.025–1.135, p = .003) was an independent predictor of AF recurrence.ConclusionsThe predictor of atrial tachyarrhythmia recurrence after the PVI was LVAs rather than DFs and rotors in nonparoxysmal AF patients.

Abstract 11167: Prevalent Locations of Left Atrial Scar in Patients with Non-Paroxysmal Atrial Fibrillation: A Single-Center Experience

Introduction: Left atrial (LA) scar, identified by bipolar voltage mapping, is a frequent finding in patients with non-paroxysmal atrial fibrillation (NPAF). We evaluated the most common sites of scar formation in the LA in a series of NPAF patients. Methods: Consecutive NPAF patients undergoing their first catheter ablation at our center were included in this analysis. Voltage mapping was performed in sinus rhythm (SR) using a 3D electro-anatomic mapping system and a 10-pole circular mapping catheter. The LA was divided into following regions: septum, posterior wall, lateral wall, anterior wall and roof. The threshold for low voltage was &lt;0.5 mV (with a color range setting 0.2-0.5 mV). Results: A total of 359 NPAF (224, 62.4% persistent AF) patients undergoing their first ablation procedure with voltage mapping performed in SR were included in this study. Mean number of points taken to map the scar was 281.2±96.3. Low voltage area was detected in 209/359 (58%) cases; 108 (48.62%) persistent AF, 101(74.8%) long-standing persistent AF, p&lt;0.001). The scarring was observed to be located in the anterior septum in 98 (46.9%) and posterior wall of the LA in 136 (65%) patients (FIGURE) Conclusion: In the NPAF population, LA scar was detected in significantly less number of persistent AF patients. Scars were mostly located in the posterior wall of left atrium followed by the antero-septum region. Characterization of the LA scars would be helpful in optimizing the ablation targets.

Comparison of the predictive value of ten risk scores for outcomes of atrial fibrillation patients undergoing radiofrequency pulmonary vein isolation

BackgroundA significant number of patients experience recurrent atrial fibrillation (AF) after ablation. Various risk scores have been described that may predict outcomes after AF ablation. In this study, we aimed to compare ten previously described risk scores with regard to their predictive value for post-ablation AF recurrence and procedural complications. MethodsA total of 482 AF patients (63% paroxysmal AF, 66% male, mean age 62 ± 9 years) undergoing initial radiofrequency pulmonary vein isolation (PVI) were included in the present analysis. Prior to ablation, all patients underwent both transthoracic echocardiography (TTE) and either cardiac CT imaging or CMR imaging. The following risk scores were calculated for each patient: APPLE, ATLAS, BASE-AF2, CAAP-AF, CHADS2, CHA2DS2-VASc, DR-FLASH, HATCH, LAGO and MB-LATER. ResultsMedian follow-up was 16 (12–31) months. AF recurrence after a 90-day blanking period was observed in 199 patients (41%), occurring after a median of 183 (124–360) days. AF recurrence was less frequent in paroxysmal AF patients compared to non-paroxysmal AF patients (34% vs. 54%, p < 0.001). Overall periprocedural complication rate was 6%. All scores, except the HATCH score, demonstrated statistically significant but poor predictive value for recurrent AF after ablation (area under curve [AUC] 0.553–0.669). CHA2DS2-VASc and CAAP-AF were the only risk scores with predictive value for procedural complications (AUC 0.616, p = 0.043; AUC 0.615, p = 0.044; respectively). ConclusionsCurrently available risk scores perform poorly in predicting outcomes after AF ablation. These data suggest that the utility of these scores for clinical decision-making is limited.

Circulating S100A4 as a prognostic biomarker for patients with nonparoxysmal atrial fibrillation after catheter ablation.

BackgroundAtrial fibrosis is involved in non-paroxysmal atrial fibrillation (NPAF) and is mainly mediated by the calcium-binding protein S100A4. This study aimed to verify the role of circulating S100A4 in the diagnosis of atrial fibrosis and the prognosis of NPAF.MethodsConsecutive NPAF patients undergoing catheter ablation were selected. Patients with low voltage amplitudes (<0.40 mV) in the left atrium (LA), defined as low voltage zones (LVZs), were grouped in the scar group by electroanatomic mapping (EAM). Circulating S100A4 was detected by a human enzyme-linked immunosorbent assay (ELISA). The role of S100A4 in atrial fibrosis was further evaluated by Masson’s trichrome staining and immunochemistry (IHC) in NPAF (atrial pacing) and control dogs. The prognostic value of the circulating S100A4 was evaluated by Cox regression analyses, the Kaplan-Meier (KM) method, and receiver operating characteristic (ROC) curves.ResultsWe enrolled a total of 101 NPAF patients (age 60±8 years) who underwent EAM, including 53 patients with scars and 48 patients without scars at 1-year follow-up. The scar group showed a higher serum level of S100A4 (3.4±1.7 vs. 2.5±1.4 ng/mL, P<0.001) than the non-scar group. In the canine model, scar size matched the larger location of interstitial fibrosis in the NPAF group determined by Masson’s trichrome staining. The expression of α-SMA and S100A4 was elevated in the NPAF group as determined by IHC compared to the control group (P<0.001). The clinical recurrence rate was markedly elevated in the scar group (27.1% vs. 8.9%, P<0.001), and the area under the ROC curve was high (0.865, 95% CI: 0.750–0.981) in predicting clinical recurrence of NPAF with the circulating S100A4 model.ConclusionsCirculating S100A4 plays a role in atrial fibrosis in NPAF patients following ablation. The level of serum S100A4 can predict the clinical recurrence of NPAF.

An impact of superior vena cava isolation in non-paroxysmal atrial fibrillation patients with low voltage areas.

BackgroundThis study aimed to investigate the correlation between left atrial low‐voltage areas (LVAs) and an arrhythmogenic superior vena cava (SVC) and the impact on the efficacy of an empiric SVC isolation (SVCI) along with a pulmonary vein isolation (PVI) of non‐paroxysmal atrial fibrillation (non‐PAF) with or without LVAs.MethodsWe retrospectively enrolled 153 consecutive patients with non‐PAF who underwent a PVI alone (n = 51) or empiric PVI plus an SVCI (n = 102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (<0.5 mV). An arrhythmogenic SVC was defined as firing from the SVC and an SVC associated with the maintenance of AF‐like rapid SVC activity.ResultsAn arrhythmogenic SVC and LVAs were identified in 28% and 65% of patients with a PVI alone and 36% and 73% of patients with a PVI plus SVCI, respectively (P = .275 and P = .353). In the multivariate analysis a female gender, higher pulmonary artery systolic pressure (PAPs), and arrhythmogenic SVC were associated with the presence of LVAs. In the PVI plus SVCI strategy, there was no significant difference in the atrial tachyarrhythmia/AF‐free survival between the patients with and without LVAs after initial and multiple sessions (50% vs. 61%; P = .386, 73% vs. 79%; P = .530), however, differences were observed in the PVI alone group (27% vs. 61%; P = .018, 49% vs. 78%; P = .046).ConclusionsThe presence of LVAs was associated with an arrhythmogenic SVC. An SVCI may have the potential to compensate for an impaired outcome after a PVI in non‐PAF patients with LVAs.

Additional complex fractionated atrial electrogram ablation does not improve the outcomes of non-paroxysmal atrial fibrillation: A systematic review and meta-analysis of randomized controlled trials

BackgroundNon-paroxysmal atrial fibrillation (AF) has a complex pathophysiological process. The standard catheter ablation approach is pulmonary vein isolation (PVI). The additional value of complex fractionated electrogram (CFAE) ablation is still unclear. We aimed to investigate the additional value of CFAE ablation for non-paroxysmal AF. MethodsWe performed a systematic review and meta-analysis of randomized controlled studies up to May 2020. Articles comparing pulmonary vein isolation (PVI) plus CFAE ablation and PVI alone for AF were obtained from the electronic scientific databases. The pooled mean difference (MD) and pooled risk ratio (RR) were assessed. ResultsA total of 8 randomized controlled trials (RCTs) including 1034 patients were involved. Following a single catheter ablation procedure, the presence of any atrial tachyarrhythmia (ATA) with or without the use of antiarrhythmic drugs (AADs) between both groups were not significantly different (RR = 1.1; 95% confidence interval [CI] = 0.97–1.24; p = 0.13). Similar results were also obtained for the presence of any ATA without the use of AADs (RR = 1.08; 95% CI = 0.96–1.22; p = 0.2). The additional CFAE ablation took longer procedure times (MD = 46.95 min; 95% CI = 38.27–55.63; p = < 0.01) and fluoroscopy times (MD = 11.69 min; 95% CI = 8.54–14.83; p = < 0.01). ConclusionAdditional CFAE ablation failed to improve the outcomes of non-paroxysmal AF patients. It also requires a longer duration of procedure times and fluoroscopy times.

The outcome of ablation for non-paroxysmal atrial fibrillation targeting spatiotemporal electrogram dispersion compared with ganglionated plexi ablation

Abstract Background Although catheter ablation targeting ganglionated plexi (GP) playing an important role in formation of triggers and substrates of atrial fibrillation (AF) has been reported as one of the effective ablation strategies in non-paroxysmal AF (non-PAF) patients, its effectiveness varies among the study groups. More recently, ablation targeting spatiotemporal electrogram dispersion (STED) areas, assumed to contain AF drivers in forms of rotational activation is proposed. However, the optimal ablation strategy for non-PAF is still controversial since the exact mechanisms of non-PAF are not well understood. Purpose To investigate the effectiveness of GP ablation for autonomic modification and STED ablation for modulation of AF drivers. Methods Consecutive 149 non-PAF patients who underwent STED ablation in our center were enrolled. We detected STED areas within the whole left and right atrium during AF using PentaRay®, and ablated them. If AF was terminated during STED ablation, we finished the procedure without burning the remaining STED areas. If not, electrical cardioversion was applied. The outcome was compared with that in consecutive 156 non-PAF patients undergoing GP ablation previously in our center. Results (1) The clinical characteristics were comparable between two groups (see Table). (2) A Kaplan-Meier curve showed that there was no significant difference between the freedom rates from non-PAF/non-paroxysmal atrial tachycardia (non-PAT) after single procedure in STED group and GP group (Figure, left). (3) However, the freedom rates from non-PAT in STED group was significantly lower than that GP group (Figure, right). Conclusions The recurrence type of atrial arrhythmia after ablation was remarkably different between ablation of STED and GP. STED ablation might eliminate fibrillatory conduction and control AF driver in patients with non-PAF. Freedom from atrial arrhythmia Funding Acknowledgement Type of funding source: None

The impact of an empiric superior vena cava isolation added to pulmonary vein isolation for non-paroxysmal atrial fibrillation associated with left atrial low voltage areas

Abstract Introduction Left atrial low-voltage areas (LVAs) are associated with recurrence after radiofrequency catheter ablation of atrial fibrillation (AF). However, the impact of LVAs on recurrence after an empiric pulmonary vein isolation (PVI) plus superior vena cava isolation (SVCI) strategy for non-Paroxysmal AF (PAF) patients remains unclear. Purpose We evaluated the impact of LVAs on the recurrence of atrial tachyarrhythmias (ATs)/AF in patients who underwent an empiric SVCI added to the PVI for non-PAF. Methods We enrolled 153 consecutive patients with non-PAF who underwent a PVI alone (PVI group; n=51) or empiric PVI plus SVCI (PVI+SVCI group; n=102). Left atrial voltage maps were constructed during sinus rhythm to identify the LVAs (&amp;lt;0.5 mV). No patients underwent a substrate modification of the LVAs. We divided the patients into two groups based on the LVAs (with or without an LVA &amp;gt;5% of the left atrial surface area) and investigated the ATs/AF free survival rate after the initial and multiple procedures. Results LVAs were identified in 65% and 73% of the PVI and PVI + SVCI groups, respectively (P=0.319). In the PVI group, the 18-month ATs/AF-free survival was 61% of the patients without LVAs and 27% of patients with LVAs after the initial session (P=0.018) (Figure 1-A). Seventy-two percent of the patients without LVAs and 46% of those with LVAs were free from ATs/AF after multiple sessions (P=0.083) (Figure 1-B). In the PVI+SVCI group, 50% of the patients with LVAs and 61% of those without LVAs had no recurrence after the initial session (P=0.374) (Figure 2-A). Moreover, there was no significant difference in the 18-month ATs/AF-free survival between the patients with and without LVAs after multiple sessions (73% vs. 79%; P=0.520) (Figure 2-B). Conclusion A PVI alone strategy for non-PAF patients with LVAs had limited efficacy for the outcomes, even with multiple procedures. However, an SVCI may have the potential to compensate for an impaired outcome in patients with LVAs. Funding Acknowledgement Type of funding source: None

Epicardial adipose tissue affects the efficacy of left atrial posterior wall isolation for persistent atrial fibrillation.

BackgroundEpicardial adipose tissue (EAT) contributes to atrial fibrillation (AF). However, its impact on the efficacy of left atrial posterior wall isolation (LAPWI) is unclear.MethodsForty‐four nonparoxysmal AF patients underwent LAPWI after pulmonary vein isolation. EAT overlap on LAPWI was assessed by fusing computed tomography images with electro‐anatomical mapping.ResultsDuring the 21 ± 7 months of follow‐up, AF recurred in 10 patients (23%). The total and left atrial EAT volumes were 113 ± 36 and 33 ± 12 cm3, respectively. No differences were found between the AF‐free and AF‐recurrent groups regarding EAT volume. The EAT overlaps on LAPWI lines and LAPWI area were 1.2 ± 1.0 and 0.5 ± 0.9 cm2 respectively. Although no difference was found between groups regarding the EAT overlap on LAPWI area, the AF‐free group had a significantly larger EAT overlap on LAPWI lines (1.4 ± 1.0 vs 0.6 ± 0.6 cm2, P = .014). Multivariate analysis identified EAT overlap on LAPWI lines as an independent predictor of AF recurrence (hazard ratio: 0.399, 95% confidence interval: 0.178‐0.891, P = .025). Kaplan‐Meier analysis revealed that, during follow‐up, 92% of the large EAT overlap group (≥1.0 cm2) and 58% of the small EAT overlap group (<1.0 cm2) remained AF‐free (P = .008).ConclusionsEAT overlap on LAPWI lines is related to a high AF freedom rate. Direct radiofrequency application to EAT overlap may be necessary to suppress AF.

Clinical efficacy of "ICE-FIRE" ablation for non-paroxysmal atrial fibrillation.

Catheter ablation is less successful for non-paroxysmal atrial fibrillation (NPAF) according to numerous follow-up studies. The choice of ablation strategy for patients with NPAF remains controversial. The objective of the study was to explore the clinical efficacy of the "ICE-FIRE" ablation. Ninety NPAF patients were enrolled. Patients were randomly divided into RF (treated with circumferential pulmonary vein isolation (CPVI) and additional substrate modification by radiofrequency ablation) group and I-F (treated with CPVI by cryoablation and additional substrate modification by radiofrequency ablation) group. After CPVI and cardioversion to sinus rhythm, high-density mapping was performed. Eight-one of 90 participants restored to sinus rhythm. Seventy-four of 81 NPAF patients showed low-voltage zone. Substrates with low-voltage zone were targeted for further modification. Participants were followed at baseline, 3, 6, 9, and 12months after the initial ablation. The I-F group shared more X-ray exposure (I-F, 264.4 ± 97.4mGy; RF, 224.9 ± 62.0mGy; P = 0.039) and less duration of the procedure (I-F, 150.3 ± 27.5min; RF, 174.2 ± 38.5min; P = 0.003) compared to RF group. The freedom from atrial arrhythmia recurrence at 12months post-ablation was similar between the RF and I-F groups (RF, 57.1%; I-F, 71.8%; P = 0.197). However, I-F group experienced lower rehospitalization rate of AF recurrence (RF, 42.9%; I-F, 20.5%; P = 0.038). In NPAF patients requiring substrate mapping and modification, the "ICE-FIRE" ablation demonstrated non-inferior clinical efficacy and lower rehospitalization rate of AF recurrence when compared with pure radiofrequency ablation strategy.

Additional cavotricuspid isthmus block ablation may not improve the outcome of atrial fibrillation ablation.

Pulmonary vein isolation (PVI) is an effective procedure for atrial fibrillation (AF). The role of additional cavotricuspid isthmus (CTI) block ablation remains controversial in AF patients without atrial flutter (AFL). Therefore, this study aimed to explore the clinical outcome of additional CTI block ablation in patients without AFL. Between January 2013 and December 2017, a total of 139 patients who did not have documented AFL and who underwent catheter ablation for AF were recruited. Fifty-seven patients were classified in additional CTI block ablation group and 82 patients were classified in without CTI group. The incidence of early-onset and late-onset atrial arrhythmia recurrence was compared between the two groups. The additional CTI group had a higher prevalence of persistent or long-standing AF and larger left atrial volume. The additional CTI group had a higher incidence of late-onset atrial arrhythmia recurrence (38.6%vs 12.2%; P<.001). When compared to without CTI group, additional CTI therapy did not have a better outcome in terms of freedom of atrial arrhythmia in subgroup analysis. The incidence of early-onset and late-onset atrial arrhythmia recurrence did not differ between additional CTI group and without CTI group in paroxysmal AF patients and nonparoxysmal AF patients after propensity scoring matching. CTI block ablation in addition to PVI for AF patients without a history of AFL or inducible AFL during ablation may not improve the clinical outcome of AF ablation in the patients with larger LA volume, nonparoxysmal AF, or post-PVI inducible AF.

Non-paroxysmal atrial fibrillation mapping: characterization of the electrophysiological substrate using a novel integrated mapping technique.

Clinical outcomes after radiofrequency catheter ablation (RFCA) remain suboptimal in the treatment of non-paroxysmal atrial fibrillation (AF). Electrophysiological mapping may improve understanding of the underlying mechanisms. To describe the arrhythmia substrate in patients with persistent (Pers) and long-standing persistent (LSPers) AF, undergoing RFCA, using an integrated mechanism mapping technique. Patients underwent high-density electroanatomical mapping before and after catheter ablation. Integrated maps characterized electrogram (EGM) cycle length (CL) in regions with repetitive-regular (RR) activations, stable wavefront propagation, fragmentation, and peak-to-peak bipolar voltage. Among 83 patients (72% male, 60 ± 11 years old), RR activations were identified in 376 regions (mean CL 180 ± 31 ms). PersAF patients (n = 43) showed more RR sites per patient (5.3 ± 2.4 vs. 3.7 ± 2.1, P = 0.002) with faster CL (166 ± 29 vs. 190 ± 29 ms; P < 0.001) and smaller surface area of fragmented EGMs (15 ± 14% vs. 27 ± 17%, P < 0.001) compared with LSPersAF. The post-ablation map in 50 patients remaining in AF, documented reduction of the RR activities per patient (1.5 ± 0.7 vs. 3.7 ± 1.4, P < 0.001) and area of fragmentation (22 ± 17% vs. 8 ± 9%, P < 0.001). Atrial fibrillation termination during ablation occurred at RR sites (0.48 ± 0.24 mV; 170.5 ± 20.2 ms CL) in 31/33 patients (94%). At the latest follow-up, arrhythmia freedom was higher among patients receiving ablation >75% of RR sites (Q4 82.6%, Q3 63.1%, Q2 35.1%, and Q1 0%; P < 0.001). The integrated mapping technique allowed characterization of multiple arrhythmic substrates in non-paroxysmal AF patients. This technique might serve as tool for a substrate-targeted ablation approach.