Recurrent Paroxysmal Atrial Fibrillation Research Articles

Coagulopathy and Extremely Elevated PT/INR after Dabigatran Etexilate Use in a Patient with End-Stage Renal Disease.

Introduction. Dabigatran is an oral direct thrombin inhibitor which has been approved for prophylaxis of stroke in patients with atrial fibrillation. The use of dabigatran etexilate increased rapidly due to many benefits. However, questions have been raised constantly regarding the safety of dabigatran etexilate. Case. A 58-year-old Caucasian male with a history of recurrent paroxysmal atrial fibrillation status after pacemaker and end-stage renal disease on hemodialysis came to the Emergency Department with the complaint of severe epistaxis. He had been started on dabigatran 150 mg twice a day about 4 months ago as an outpatient by his cardiologist. His prothrombin time (PT) was 63 seconds with international normalized ratio (INR) of 8.8 and his activated partial thromboplastin time (aPTT) was 105.7 seconds. Otherwise, all labs were unremarkable including the liver function test. Dabigatran was stopped immediately. His INR and aPTT trended downward, reaching normal levels 5 days after admission. Conclusion. Dabigatran is contraindicated in patients with severe kidney insufficiency as it is predominantly excreted via the kidney (~80%). Elderly patients over 75 and patients with chronic renal impairment should be carefully evaluated before starting dabigatran. Despite studies showing only mild increase in aPTT and PT/INR in patients receiving dabigatran, close monitoring may be reasonable in patients with renal insufficiency.

Cryoballoon Versus Radiofrequency for Pulmonary Vein Re‐Isolation After a Failed Initial Ablation Procedure in Patients with Paroxysmal Atrial Fibrillation

Catheter ablation of paroxysmal atrial fibrillation (PAF) is associated with an important risk of early and late recurrence, necessitating repeat ablation procedures. The aim of this prospective randomized patient-blind study was to compare the efficacy and safety of cryoballoon (Cryo) versus radiofrequency (RF) ablation of PAF after failed initial RF ablation procedure. Patients with a history of symptomatic PAF after a previous failed first RF ablation procedure were eligible for this study. Patients were randomized to Cryo or RF redo ablation. The primary endpoint of the study was recurrence of atrial tachyarrhythmia, including AF and left atrial flutter/tachycardia, after a second ablation procedure at 1 year of follow-up. All patients were implanted with a cardiac monitor (Reveal XT, Medtronic) to continuously track the cardiac rhythm. Patients with an AF burden (AF%) ≤ 0.5% were considered AF-free (Responders), while those with an AF% > 0.5% were classified as patients with AF recurrences (non-Responders). Eighty patients with AF recurrences after a first RF pulmonary vein isolation (PVI) were randomized to Cryo (N = 40) or to RF (N = 40). Electrical potentials were recorded in 77 mapped PVs (1.9 ± 0.8 per patient) in Cryo Group and 72 PVs (1.7 ± 0.8 per patient) in RF Group (P = 0.62), all of which were targeted. In Cryo group, 68 (88%) of the 77 PVs were re-isolated using only Cryo technique; the remaining 9 PVs were re-isolated using RF. In RF group, all 72 PVs were successfully re-isolated (P = 0.003 vs Cryo). By intention-to-treat, 23 (58%) RF patients were AF-free vs 17 (43%) Cryo patients on no antiarrhythmic drugs at 1 year (P = 0.06). Three patients had temporary phrenic nerve paralysis in the Cryo group; the RF group had no complications. Of the 29 patients who had only Cryo PVI without any RF ablation, 11 (38%) were AF-free vs 20 (59%) of the 34 patients who had RF only (P = 0.021). When patients require a redo pulmonary vein isolation ablation procedure for recurrent PAF, RF appears to be the preferred energy source relative to Cryo.

Recurrence of paroxysmal atrial fibrillation after cryoisolation of the pulmonary veins. Is a “redo” procedure using the cryoballoon useful?

Pulmonary vein (PV) isolation with the cryoballoon technique is an effective and safe method to treat patients with paroxysmal atrial fibrillation (AF). However, the optimal treatment strategy for patients with recurrences after this ablation is unclear. The aim of this single centre study was to evaluate the efficacy and safety of a "redo" procedure using the cryoballoon in this patient cohort. The secondary study objectives were to determine the rate of reconduction for individual PVs of the patients undergoing "redo" ablation and potential predictors of persistent PV isolation (PVI). Between April 2006 and September 2009, all patients with paroxysmal AF recurrences after cryoballoon ablation a "redo" ablation with the cryoballoon was offered. PV conduction was determined and cryoapplications were performed in all reconnected PVs. Every 3 months, 7-day Holter ECG, symptom-driven transtelephonic ECG recordings, and questionnaires were collected for 12 months. Forty-seven patients underwent "redo" cryoballoon ablation. In all these patients, at least one PV with reconduction was found. Recurrent conduction was documented in 63 % of the left superior PV, 56 % of the left inferior PV, 43 % of the right superior PV, and 56 % of the right inferior PV. In 28 of the 47 patients (60 %), no AF recurrence was detectable during the 12-month follow-up (after 3 months blanking period). Rate of severe complications was low and not significantly different from that of the initial ablations. "Redo" ablation using cryoballoon technology may be an effective and safe method to treat patients with recurrence of paroxysmal AF after cryoballoon PVI.

Effect of Anxiety and Depression on the Recurrence of Paroxysmal Atrial Fibrillation After Circumferential Pulmonary Vein Ablation

Effect of Anxiety and Depression on the Recurrence of Paroxysmal Atrial Fibrillation. Whether circumferential pulmonary vein ablation (CPVA) can alleviate anxiety and depression symptoms is unknown and the effect of anxiety and depression on the recurrence of atrial fibrillation (AF) after CPVA is not clear. Two hundred and ten patients with a diagnosis of paroxysmal AF were admitted in the study. Ninety-eight patients (CPVA group) and 102 patients (medicine group) were treated with CPVA and antiarrhythmic drugs, respectively. All patients were followed up for 1 year. Zung Self-Rating Anxiety Scale (SAS), Zung Self-Rating Depression Scale (SDS), and Short-Form life survey-36 items (SF-36) were assessed before and after follow-up. In CPVA group, the scores of SAS and SDS decreased (41.69 ± 8.32 vs 37.66 ± 4.82, P < 0.001 and 45.01 ± 9.71 vs 40.05 ± 8.56, P < 0.001, respectively) and SF-36 score improved (565.29 ± 143.37 vs 606.84 ± 102.84, P = 0.021) after follow-up. Compared with the data in recurrent patients, the SAS and SDS scores were significantly lower in nonrecurrent patients at baseline (44.68 ± 8.40 vs 38.10 ± 7.55, P < 0.001 and 51.75 ± 9.41 vs 43.96 ± 8.95, P < 0.001, respectively). The results of multivariate logistic regression analysis showed normalized scores of SAS (OR = 3.20, 95% CI [3.05, 3.48], P = 0.023) and SDS (OR = 3.26, 95% CI [3.12, 3.49], P = 0.023) were the independent risk factor of AF recurrence after CPVA. CPVA can ameliorate anxiety and depression, which may contribute to improvement of quality of life in patients with paroxysmal AF. Anxiety and depression increase the recurrence risk of AF after CPVA.

Does Warfarin Help Prevent Ischemic Stroke in Patients Presenting with Post Coronary Bypass Paroxysmal Atrial Fibrillation?

This study examines the efficacy of warfarin in preventing ischemic stroke due to paroxysmal atrial fibrillation (PAF) after coronary artery bypass grafting (CABG). Postoperative PAF occurred in 151(33.5%) of 447 patients undergoing conventional CABG. The patients were divided into two groups: group I consisting of 93 patients administered two types of antiplatelet agents and group II consisting of 58 patients treated with a single antiplatelet agent and warfarin. We compared the two groups in terms of CHADS2 score, incidence of ischemic stroke, and independent risk for stroke associated with post-CABG PAF. The group I CHADS2 score (2.24 ±1.67) was significantly lower than the group II score (2.64 ± 1.22), p = 0.0452. However, 12 patients in group I (12.9%) suffered postoperative ischemic stroke, a rate significantly higher than that of group II (1 patient, 1.7%; p = 0.0173). Any recurrence of PAF or atrial fibrillation with bradycardia was assessed at the time of stroke onset. Logistic regression analysis showed that the absence of warfarin therapy constituted a risk factor for post-CABG stroke associated with PAF (Odds 13.04, p = 0.027). Warfarin therapy administered concomitantly with an antiplatelet agent dramatically reduced the incidence of ischemic stroke associated with postoperative PAF.

Epicardial Adipose Tissue and Neural Mechanisms of Atrial Fibrillation

In this issue of Circulation: Arrhythmia and Electrophysiology , Nagashima et al1 reported that there is higher epicardial adipose tissue (EAT) volume and greater serum inflammatory biomarker levels in patients with persistent atrial fibrillation (PerAF) than in patients with paroxysmal atrial fibrillation (PAF). Furthermore, they noted that high dominant frequency (DF) sites are located adjacent to EAT sites. The authors proposed 2 possible explanations for these findings. One is that EAT secretes proinflammatory cytokines that alter local atrial and pulmonary vein (PV) electrophysiology and facilitates the development of atrial fibrillation (AF). The second is that EAT contains abundant ganglionated plexi. Activation of the autonomic nerves in the ganglionated plexi facilitates the maintenance of AF. The results of the present study extended their previous observation on EAT2 by providing new data on the correlation between high DF sites and EAT sites. These novel observations provide new insights into the anatomic and physiological differences between PAF and PerAF. Article see p 676 After the initial diagnosis of PAF, there is a slow (5%–10% per year) but steady progression to chronic (permanent or persistent) AF.3 Baseline echocardiographic variables, age, cardiomyopathy, and heart rate are independently associated with progression to chronic AF. On the other hand, PerAF is also frequently the initial diagnosis without preceding PAF episodes. How often PerAF and permanent forms of AF are preceded by recurrent PAF remains unclear. Improving the understanding of PAF to PerAF progression may help secondary prevention efforts to reduce the complications associated with AF. Wijffels et al4 performed intermittent rapid atrial pacing in goats to study the progression of PAF to PerAF. They found that when AF is maintained artificially, the duration of the paroxysms progressively increases, becoming sustained after 1 to 3 weeks of AF. The transition from PAF to PerAF …

Dormant conduction revealed by adenosine to guide electrical isolation of the superior vena cava

The restoration of electrical conduction in injured, pulmonary vein (PV) tissue (dormant conduction) via adenosine-mediated hyperpolarization has been utilized to guide the need for additional ablation. The superior vena cava (SVC) and PVs have similar cardiac muscular extensions. We present a patient with recurrent paroxysmal atrial fibrillation after pulmonary vein isolation. All PVs were found to be electrically isolated, before …

Effect of Telmisartan on Paroxysmal Atrial Fibrillation Recurrence in Hypertensive Patients With Normal or Increased Left Atrial Size

Hypertension is the most prevalent and potentially modifiable risk factor for atrial fibrillation (AF). In a previous secondary prevention study, the authors observed that the angiotensin II receptor blocker telmisartan was more effective than the calcium channel blocker amlodipine in preventing AF relapse in hypertensive patients with normal atrial size. Telmisartan may be more effective than amlodipine in preventing AF recurrence in hypertensive patients with paroxysmal AF and normal or increased left atrial dimension (LAD). The authors assigned 378 mild hypertensive outpatients in sinus rhythm, but with ≥2 episodes of AF in the previous 6 months, to 1 of 2 groups. Group 1 comprised patients with LAD <40 mm in females and <45 mm in males. Group 2 comprised patients with LAD >40 mm and <45 mm in females and >45 mm and <50 mm in males. In both groups, patients were randomly treated with telmisartan or amlodipine for 1 year. Systolic and diastolic blood pressure were similarly reduced by telmisartan and amlodipine in both groups. The AF recurrence rate was significantly lower in the telmisartan-treated patients than in the amlodipine-treated patients in both group 1 (12 vs 39, P < 0.01) and group 2 (40 vs 59, P < 0.05). Under telmisartan, the AF recurrence rate was significantly lower in group 1 than in group 2 (12.9% vs 42.1%, P < 0.05). Time to a first AF relapse was significantly longer with telmisartan than with amlodipine in both group 1 (176 ± 94 days vs 74 ± 61 days, P < 0.05) and group 2 (119 ± 65 days vs 38 ± 35 days, P < 0.05). Telmisartan was more effective than amlodipine in preventing AF recurrences in hypertensive patients with paroxysmal AF.

Pulmonary vein isolation to treat paroxysmal atrial fibrillation: conventional versus multi-electrode radiofrequency ablation

For patients with symptomatic atrial fibrillation (AF), a curvilinear multi-electrode ablation (MEA) catheter has been reported to be successful to achieve pulmonary vein (PV) isolation. However, this approach has not been compared prospectively with conventional PV isolation (CPVI) using a standard circular mapping catheter and 3D electro-anatomic mapping. In this prospective non-randomized study, we compared the efficacy of these two techniques. Of 185 consecutive patients, age 54.6 ± 10.1 years, with symptomatic paroxysmal AF (PAF), 96 patients underwent PV isolation by CPVI and 89 patients underwent MEA to isolate the PVs. CPVI was performed by encircling the left- and right-sided PVs. During MEA, the PV ablation catheter (Medtronic, USA) was used to isolate PVs with duty-cycled radiofrequency energy. The mean procedure time was 171.73 ± 52.87 min for CPVI and 133.25 ± 37.99 min for MEA, respectively (P < 0.001). The mean fluoroscopy time was 31.07 ± 14.97 for CPVI and 30.07 ± 11.45 min for MEA (P = 0.651). At 12 months, 80% of patients who underwent CPVI and 82% of patients who underwent MEA were free of symptomatic PAF off antiarrhythmic drug therapy (P = 0.989). Among the variables of age, gender, duration and frequency of PAF, left ventricular ejection fraction, left atrial size, structural heart disease, and the ablation technique, only an increased left atrial size was an independent predictor of recurrent PAF. Left atrial flutter occurred after CPVI in two patients and after MEA ablation in three patients. In patients undergoing catheter ablation for PAF, MEA and CPVI proved equally efficacious.

Using omega-3 fatty acids to treat persistent atrial fibrillation: Time to fish or cut bait?

r t Recently, Kowey et al performed a controlled, prospecive, multicenter, randomized clinical trial comparing precription-grade omega-3 fatty acids (PUFAs) from fish oil o placebo to determine efficacy in preventing recurrent ymptomatic paroxysmal or persistent atrial fibrillation AF). Fish oil was ineffective when given at a dose of 8 g/d or a week followed by 4 g/d through week 24. For the 105 atients randomized with persistent AF, 33% (n 18) in the lacebo group and 50% (n 32) in the fish oil group had documented recurrent symptomatic AF. In a prior commentary, I (B.O.) stated: “It is safe to say, based on this wellcontrolled rather definitive randomized clinical trial, that PUFAs have no role in the management of recurrent symptomatic atrial fibrillation.” Similar results suggesting no enefit were found in another randomized trial and in a trial valuating the prevention of new-onset AF in the postopertive period, although data from an open-label study showed diametrically opposite results. A meta-analysis inicated no benefit from PUFAs to prevent AF. Since then, in contradistinction to these “rather definitive” data, Nodari et al reported results from a recent ouble-blind placebo-controlled study showing that PUFAs lus amiodarone conferred long-term benefit for patients ith persistent AF. Now, Kumar et al find that PUFA upplementation reduced recurrent persistent AF after carioversion. At 90 days, 38.5% of the PUFA group vs 77.5% f the control group had a recurrence of persistent AF. Not nly did more patients in the PUFA group have pharmacologic eversion to sinus rhythm compared with controls (12.1% vs .4%; P .05), but those who underwent electrical cardioverion did substantially better as well. The mean time to persisent AF recurrence was 190 days in the PUFA group vs 77 ays in the control group (P .001). The median time to ecurrence was 201 days in the PUFA group compared with 32 ays in the control group. This is nearly 7 times better. These ndings were strengthened by longer AF duration and lesser

POSTER PRESENTATIONS

POSTER PRESENTATIONS

Influence of atrial septal pacing on the attack of paroxysmal atrial fibrillation in patients with sick sinus syndrome

ObjectiveTo investigate the effects of atrial septal pacing (ASP) on the attack of paroxysmal atrial fibrillation (PAF) in patients with sick sinus syndrome (SSS).MethodsASP was performed in 12 patients of...

The effect of anxiety and depression on the recurrence of paroxysmal atrial fibrillation after circumferential pulmonary vein ablation

BackgroundWhether circumferential pulmonary vein ablation (CPVA) can alleviate the anxiety and depression symptoms of patients with AF is unknown and the effect of anxiety and depression on the recurrence of...

P Wave Signal-Averaged ECG in Normal Population and in Patients with Converted Atrial Fibrillation

Signal-averaged electrocardiography of the P wave (P wave SAECG) is a noninvasive method for evaluating the risk of atrial fibrillation (AF). We aimed to study P wave SAECG parameters in a large number of apparently healthy subjects and to compare them with patients with converted AF. We examined 591 individuals; P wave SAECG were recorded in 330 normal subjects, 31 patients with converted persistent AF and 57 patients with converted paroxysmal AF immediately after conversion, at 12 and 24 hours after conversion, then after 3 and 6 months. P wave SAECG were recorded using a commercially available machine aiming to obtain a noise level <1 μV. In the normal population the duration of the filtered P wave (PWD) was higher in men. P wave duration, RMS(40) and RMS(30) were significantly correlated with age. By comparing the normal population with patients with persistent AF converted to sinus rhythm we demonstrated significant differences in PWD and P wave integral. Patients with recurrent persistent AF had significantly higher PWD. The study of patients with paroxysmal AF, compared to the control group, showed significant increase of the same parameters: PWD and integral of the P wave. Patients with recurrent paroxysmal AF had higher PWD and lower RMS(40) , RMS(30) , RMS(20) . Filtered P wave duration was higher in men; PWD was weakly but significantly correlated with age. Patients with paroxysmal or persistent AF converted to sinus rhythm had significantly higher P wave duration and P wave integral.

Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation

Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation (AF). We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus (PVAI + CS) to pulmonary vein antral isolation (PVAI) alone in patients with paroxysmal AF. Forty-two consecutive patients with paroxysmal AF were prospectively randomized to PVAI vs. PVAI + CS. All patients were seen 3, 6, 12, and 18 months after ablation and underwent 24-h ambulatory Holter monitoring. Following a single procedure, 17 out of 22 patients (77%) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 (50%) after PVAI + CS (p < 0.01). After PVAI, three patients had recurrent paroxysmal AF, and two had atrial tachycardia, whereas after PVAI + CS, three patients had recurrent paroxysmal AF, and seven had atrial tachycardia. All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism. Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80% after 1.35 procedures in the PVAI + CS group (p < 0.01). The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia.

Restoration of Sinus Rhythm by Incarceration, not Elimination, of Focal Atrial Tachycardia in Left Atrial Substrate Post Atrial Fibrillation Ablation

While diseased regions of the atrial body commonly behave as a substrate maintaining atrial fibrillation (AF), these areas can uncommonly behave as trigger foci for atrial tachycardia (AT),1 particularly after previous ablation. Unlike venous triggers, the goal of ablation for these focal ATs is normally elimination of the tachycardia source, rather than complete isolation. We present a case of a difficult to ablate post–AF-ablation AT from the anterior left atrium (LA), in which sinus rhythm was restored by incarcerating the ongoing AT within a small, isolated region of LA myocardium. A 67-year-old man who underwent pulmonary vein isolation, electrogram-based LA ablation, and roof, left mitral and cavotricuspid isthmus ablation for permanent AF in 2002 and repeat ablation of recurrent paroxysmal AF in 2009 (details unavailable), was referred for a third ablation procedure for rate-controlled incessant AT (Figure 1A). Figure 1B shows intracardiac recordings on decapolar catheter in the coronary sinus and 3.5-mm externally irrigated tip ablation catheter in the LA during baseline AT (cycle length, 308 ms). Activation and entrainment mapping2 established the diagnosis of focal source AT arising from the ostium of the left atrial appendage (LAA) where ablation led to cycle length variation of >25% (range, 276 to 402 ms) – unstable AT (Figure 1C). Focal ablation at another site with substantial temporal gradient between the proximal and distal bipoles of the ablation catheter …

Effect of Telmisartan and Ramipril on Atrial Fibrillation Recurrence and Severity in Hypertensive Patients With Metabolic Syndrome and Recurrent Symptomatic Paroxysmal and Persistent Atrial Fibrillation

This study evaluated the effect of telmisartan, ramipril, and amlodipine on atrial fibrillation (AF) recurrence and severity in hypertensive patients with metabolic syndrome. A total of 391 hypertensive outpatients with metabolic syndrome, in sinus rhythm but with at least 2 episodes of AF in the previous 6 months were randomized to telmisartan, ramipril, or amlodipine for 1 year. At the first AF, ventricular rate (VR) and plasma cardiac troponin I (TnI) were evaluated. P-wave dispersion (PWD) and procollagen type I carboxy-terminal peptide (PIP) were evaluated before and after 12 months of treatment. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were similarly and significantly reduced by all treatments (P < .001). In all, 49% of patients treated with amlodipine had a recurrence of AF as did 25.5% of patients with ramipril and 12.9% of patients with telmisartan (P < .01 vs amlodipine and P < .05 vs ramipril). Ventricular rate and TnI at the first AF recurrence were significantly lower with telmisartan and ramipril than with amlodipine. P-wave dispersion was reduced by ramipril (-5.1 ms, P < .05) and even more by telmisartan (-11 ms, P < .01). Telmisartan and ramipril induced a similar PIP reduction (-52.8 and -49.8 µg/L, respectively, P < .01). These findings suggested that in these patients telmisartan was more effective than ramipril in reducing AF recurrence and severity as well as in improving PWD, despite a similar BP reduction and a similar improvement in cardiac fibrosis. This could be related to a specific effect of telmisartan on atrial electric remodeling.

Effect of Beta-Blocker Therapy on Recurrence after Extensive Encircling Pulmonary Vein Isolation for Paroxysmal Atrial Fibrillation

Background: Effect of beta-blocker on paroxysmal atrial fibrillation (PAF) recurrence after extensive encircling pulmonary vein isolation (EEPVI) remains unknown. It has been known to be common that PAF recurs within 3 months after EEPVI, named blanking period, even in patients in whom PAF never recur thereafter. Methods and Results: This study evaluated consecutive 39 patients (34 male Age 57±11 y/o) who underwent EEPVI for PAF. Out of 39 patients, 15 patients (38%) underwent beta-blocker therapy (mainly bisoprolol 2.5–5 mg/day) shortly after EEPVI with/without same anti-arrhythmic drugs (AAD) as prescribed before EEPVI (Group A) and the remaining patients did not beta-blocker therapy but with/without same AAD as prescribed before EEPVI (Group B). Such a drug treatment in each group remained until 24 months after EEPVI. Patient characteristics including cardiac structural parameters and treatment period of PAF before EEPVI did not differ between Groups (NS). During follow-up of blanking period, PAF recurred in 11 patients (73%) in Group A and 7 patients (29%) in Group B (NS). During further follow-ups (15±5 months) except for blanking period, AF recurred in 7 patients (47%) with Group A and 6 patients (25%) in Group B (NS). Conclusion: This study may suggest that an additional effect of beta-blocker therapy against PAF recurrence has not significant importance for both short and long term follow-ups after EEPVI.

The Effect of Arterial Stiffness on Recurrence of Paroxysmal Atrial Fibrillation after Catheter Ablation

Purpose: The aim of this study was to investigate the relationship between arterial stiffness and atrial fibrillation (AF) recurrence after catheter ablation (CA). Methods: We enrolled 94 consecutive patients (mean age: 62±9.5) undergoing circumferential pulmonary vein electrical isolation with a double lasso technique using CARTO system for paroxysmal AF. Cardio-ankle vascular index (CAVI) was determined as an index of arterial stiffness. Plasma BNP, serum aldosterone, and high sensitivity CRP were assayed, and Left atrial volume (LAV) was measured by multi-slice CT. Results: Among the 94 patients, 26 (28%) had metabolic syndrome. In simple regression analysis, CAVI were correlated with age, eGFR, BNP, and LAV (p<0.001, p<0.05, p<0.01, p<0.05, respectively). During a follow-up of 7.9±2.3 months, 21 patients experienced AF recurrence. Patients with AF recurrence had a increased CAVI (recurrence 8.9 vs non-recurrence 8.2 p<0.05) and a larger LAV (recurrence 81.3 ml vs non-recurrence 70.6 ml p<0.05) compared with patients without AF recurrence. Multivariate analysis revealed that LAV, BNP, CAVI were independently associated with AF recurrence (t-value: 2.76, 4.65, 2.28, respectively). Conclusions: CAVI was associated with age, BNP and LAV, suggesting a significant role of arterial stiffness in AF after CA.

Clinical Parameters Associated with Complete Cure of Atrial Fibrillation Undergoing Extensive Pulmonary Vein Isolation

Background: Little is known about clinical predictors for the recurrence after extensive pulmonary vein isolation (EPVI) in patients with atrial fibrillation (AF). Objectives: The purpose of this study was to investigate clinical parameters which predict complete cure of AF after EPVI. Methods and Results: A total of 152 consecutive patients with paroxysmal AF (PAF) who underwent successful EPVI were examined. We divided them into two groups, 1: Complete cure group; 103 patients who were free from PAF without any antiarrhythmic drugs and 2: recurrence group; the remaining 49 patients with recurrence of PAF. Between the two groups, we compared several clinical parameters before EPVI as follows; clinical backgrounds (presence of structural heart disease and CHADS2 score), parameters in transthoracic and transesophageal echocardiogram [left atrium (LA) dimension, systolic and diastolic LA appendage (LAA) flow velocity], LA volume assessed by multiditector CT, additional creation of cava-tricuspid isthmus block line, serum brain natriuretic peptide (BNP) level. Using multi-variate analysis, filling velocity of the LAA and BNP before EPVI were identified as the independent predictors of complete cure of PAF (p<0.001, p<0.05, respectively). Conclusion: Low BNP levels and better filling velocity of the LAA are the negative predictors for the recurrence after EPVI in patients with AF. These may relate to preserved LA function and to restricted AF substrates within PVs.