Prevention Of Atrial Fibrillation Recurrence Research Articles

Extensive ablation for persistent atrial fibrillation patients with mitral regurgitation: Insights from the EARNEST-PVI prospective randomized trial

BackgroundExtensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients. MethodsThis post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications. ResultsThe trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54–1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22–0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms. ConclusionsFor persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management.

Colchicine for prevention of atrial fibrillation recurrence following catheter ablation: Identification of sex-specific differences

Colchicine for prevention of atrial fibrillation recurrence following catheter ablation: Identification of sex-specific differences

Oral flecainide therapy and myocardial pacing: preliminary data from a prospective multicenter registry

Abstract Background Antiarrhythmic drugs, class I are widely used for prevention of atrial fibrillation recurrence. However, previous studies found that these drugs could affect pacing thresholds among pacemaker recipients. Aim of the study: evaluate short -term effect on myocardial pacing following therapy with oral flecainide (200 mg/daily). Methods 45 consecutive pacemaker recipients were prospectively enrolled in a multicenter registry. These patients had preserved left ventricular ejection fraction, a dual chamber pacemaker with symptomatic sustained high-rate atrial fibrillation episodes and stable output atrial and ventricular thresholds. Patients were followed with ambulatory and/or remote monitoring. Results mean age was 74±1 years, 48% pts were male and AF burden was 8±16%. Pacemaker implantation was performed 3.9±0.3 year before study enrollment. Three (6%) out of 45 patients were excluded due to drug sided effects including dyspnea (n=1), diplopia (n=1) and toxicity during acute renal insufficiency (n=1). Flecainide treatment was associated with a significant reduction of atrial fibrillation burden (from 8±16% to 5±12%, p<0.01). At 30 days follow-up since Flecainide starting therapy both atrial and ventricular sensing significantly decreased (3.6 ± 2.2 vs 3.4 ± 2.1mV p=0.01; 12.5±6.6 vs 11.8±6.3 mV p=0.01), while there was a slight increase of both atrial and ventricular capture thresholds (0.77±0.61V@0.4ms vs 0.80±0.42V@0.4ms p=0.01; 0.80±0.53V @0.4ms vs 0.83±0.33V @0.4ms p=0.01). No patient required pacemaker parameters reprogramming. Conclusions oral flecainide therapy among pacemaker recipients at 30 days follow-up seems to be safe and do not affect device function. Further studies with additional follow-up data are warranted.

Identifying patients with reduced risk of recurrences after ablation for persistent atrial fibrillation

Abstract Background Catheter ablation (CA) is a well-established treatment option for recurrent atrial fibrillation (AF), and has shown to outperform antiarrhythmic drugs in prevention of AF recurrences in numerous studies. However, up to 50% of patients with persistent AF (peAF) will experience recurrences after first-time CA. Improving treatment for these patients involves, choosing the right patients for the ablation procedure, optimizing the timing of the procedure, and using the most effective ablation strategy. This will benefit not only the patients, but also target recourse use in the healthcare system. Purpose To identify characteristics and comorbidities of patients with peAF associated with a reduced risk of recurrence after CA. Additionally, to investigate the optimal timing and ablation strategy. Methods This observational cohort study was conducted using real-life data from the Danish healthcare registries. All patients with peAF, >18 years of age, who were assigned to first-time AF ablation, were included within the study period from January 1st 2010 to December 31st 2018. A composite endpoint for AF recurrences was defined as either AF admission, electric cardioversion, use of antiarrhythmic drugs or re-ablation after a 3-month blanking period. We followed the patients in the registries for up to 5 years. A Cox proportional hazards analysis was performed to identify specific patient characteristics, comorbidities, timing of ablation and ablation strategy associated with reduced risk of AF recurrences after ablation. Results The study cohort consisted of 2,123 patients with peAF undergoing first-time CA. Median age was 63 years [IQR: 56.10;68.90], 77.7% were male, and mean BMI was 28.40 (SD: 4.97). Mean diagnosis-to-ablation-time (DAT) was 3.56 years (SD: 4.25) and mean follow-up time was 928.3 days (SD: 829.62). Most prevalent co-morbidities were hypertension (59.1%), ischemic heart disease (16.9%), and heart failure (HF) (27.7%) (Table 1). Patients characterized by male sex (HR: 0.80, 95% CI 0.69-0.93), age 60-70 (HR: 0.79, 95% CI 0.67-0.93), and absence of co-morbidities such as HF (HR: 0.81, 95% CI 0.70-0.94) and chronic obstructive pulmonary disease (COPD) (HR: 0.58, 95% CI 0.44-0-75), were observed with a significantly reduced relative risk of recurrent AF. Short DAT(<1 year) was associated with a 24% lower risk of recurrence compared to longer (>2 years). Furthermore, PVI Plus (additional ablation to PVI) was not significantly associated with a reduced risk of recurrences (HR: 1.10, 95% CI 0,92-1.31) (Figure 1). Conclusion To obtain rhythm control for patients with peAF is a great challenge. This observational study with more than 2,000 patients, identifies patients most likely to benefit from CA. Lower recurrence rates were observed in younger patients (<70 years), absence of especially HF and COPD, and early ablation (<1 year). Notably, PVI plus did not reduce the risk of recurrences.

Effectiveness of cryoballoon ablation for atrial fibrillation in patients with left common pulmonary vein variant: insights from a national multicenter catheter ablation registry

Abstract Background Pulmonary vein isolation (PVI) is the most effective therapy to achieve rhythm control in atrial fibrillation (AF). Yet, data regarding the safety and effectiveness of this procedure in left common pulmonary vein (LCPV) variant is limited. Purpose To explore the effectiveness of cryoballoon AF ablation in patients with LCPV variant. Methods A prospective cohort, based on a multicenter registry that included patients who underwent PVI during the years 2019-2021. The study end points were acute isolation success of the pulmonary veins (PVs), AF recurrence and the need for a repeat ablation procedure at 12 months. Results Seventy-four patients with LCPV variant and 822 patients with standard four pulmonary veins (PVs) were included in the study cohort. The acute isolation success rates of the left pulmonary veins were significantly lower in the LCPV variants compared to the standard 2 left PVs; 95.9% versus 98.9% respectively (P=0.03). The acute isolation success rates of the right pulmonary veins were not different among patients with LCPV versus standard anatomy; 98.6% versus 98.5% respectively (P=0.9). The rates of AF recurrence at 12 months were numerically higher in the LCPV variant compared to the standard anatomy group; 17.6% versus 11.1% respectively, but did not reach statistical significance (P=0.09) (Figure 1). The rates of repeat ablation did not differ between the study groups; 8.1% versus 6.2% respectively (P=0.51) (Figure 2). Conclusion In our study cohort, the acute isolation success rate of the LCPV was significantly lower compared to standard two left PVs, this finding emphasizes the challenge of isolating LCPV variants using cryoballoon PVI. However, in spite of the lower isolation success rates in the LCPV variants, the clinical effectiveness to prevent AF recurrences was preserved.Figure 1Figure 2

Synergistic Effects of Weight Loss and Catheter Ablation: Can microRNAs Serve as Predictive Biomarkers for the Prevention of Atrial Fibrillation Recurrence?

In atrial fibrillation (AF), multifactorial pathologic atrial alterations are manifested by structural and electrophysiological changes known as atrial remodeling. AF frequently develops in the context of underlying cardiac abnormalities. A critical mechanistic role played by atrial stretch is played by abnormal substrates in a number of conditions that predispose to AF, including obesity, heart failure, hypertension, and sleep apnea. The significant role of overweight and obesity in the development of AF is known; however, the differential effect of overweight, obesity, cardiovascular comorbidities, lifestyle, and other modifiable risk factors on the occurrence and recurrence of AF remains to be determined. Reverse remodeling of the atrial substrate and subsequent reduction in the AF burden by conversion into a typical sinus rhythm has been associated with weight loss through lifestyle changes or surgery. This makes it an essential pillar in the management of AF in obese patients. According to recently published research, microRNAs (miRs) may function as post-transcriptional regulators of genes involved in atrial remodeling, potentially contributing to the pathophysiology of AF. The focus of this review is on their modulation by both weight loss and catheter ablation interventions to counteract atrial remodeling in AF. Our analysis outlines the experimental and clinical evidence supporting the synergistic effects of weight loss and catheter ablation (CA) in reversing atrial electrical and structural remodeling in AF onset and in recurrent post-ablation AF by attenuating pro-thrombotic, pro-inflammatory, pro-fibrotic, arrhythmogenic, and male-sex-associated hypertrophic remodeling pathways. Furthermore, we discuss the promising role of miRs with prognostic potential as predictive biomarkers in guiding approaches to AF recurrence prevention.

Effect of Flecainide and Ibutilide Alone and in Combination to Terminate and Prevent Recurrence of Atrial Fibrillation.

There is a need for improved approaches to rhythm control therapy of atrial fibrillation (AF). The effectiveness of flecainide (1.5 µmol/L) and ibutilide (20 nmol/L), alone and in combination, to cardiovert and prevent AF recurrence was studied in canine-isolated coronary-perfused right atrioventricular preparations. We also examined the safety of the combination of flecainide (1.5 µmol/L) and ibutilide (50 nmol/L) using canine left ventricular wedge preparations. Sustained AF (>1 hour) was inducible in 100%, 60%, 20%, and 0% of atria in the presence of acetylcholine alone, acetylcholine+ibutilide, acetylcholine+flecainide, and acetylcholine+ibutilide+flecainide, respectively. When used alone, flecainide and ibutilide cardioverted sustained AF in 40% and 20% of atria, respectively, but in 100% of atria when used in combination. Ibutilide prolonged atrial and ventricular effective refractory period by 15% and 8%, respectively, at a cycle length of 500 ms (P<0.05 for both). Flecainide increased the effective refractory period in atria by 27% (P<0.01) but by only 2% in the ventricles. The combination of the 2 drugs lengthened the effective refractory period by 42% in atria (P<0.01) but by only 7% (P<0.05) in the ventricles. In left ventricular wedges, ibutilide prolonged QT and Tpeak-Tend intervals by 25 and 55%, respectively (P<0.05 for both; cycle length, 2000 ms). The addition of flecainide (1.5 µmol/L) partially reversed these effects (P<0.05 for both parameters versus ibutilide alone). Torsades de Pointes score was relatively high with ibutilide alone and low with the drug combination. In our experimental model, a combination of flecainide and ibutilide significantly improves cardioversion and prevents the recurrence of AF compared with monotherapies with little to no risk for the development of long-QT-mediated ventricular proarrhythmia.

Abstract 17589: Efficacy of Sacubitril-Valsartan Compared With Angiotensin-Converting Enzyme Inhibitor or Angiotensin-Receptor Blocker for Preventing Atrial Fibrillation Recurrence After Catheter Ablation: A Systematic Review and Meta-Analysis

Introduction: Among patients with atrial fibrillation (AF) who underwent catheter ablation, it is unclear whether AF recurrence is lower in those who receive Sacubitril-Valsartan (SV) than in those who receive ACEi (angiotensin-converting enzyme inhibitor) or ARB (angiotensin-receptor blocker). Hypothesis: Is SV more effective than ACEi/ARB in decreasing AF recurrence after catheter ablation? Methods: We systematically searched PubMed, Embase, and Cochrane Library for randomized controlled trials (RCTs) and propensity-matched cohorts (PMC), evaluating the efficacy of SV for preventing AF recurrence in patients who underwent catheter ablation. The outcomes of interest were AF recurrence and structural remodeling, assessed by Left Ventricular Ejection Fraction (LVEF) and Left Atrial Volume Index (LAVi). Statistical analysis was performed using RevMan 5.1.7. Heterogeneity was assessed with I 2 statistics. Results: We included 2 RCTs and 1 PMC, comprising 517 patients, of whom 256 were treated with SV, 101 received ARB, and 155 ACEis. AF recurrence was significantly lower in the SV group (RR 0.50; 95% CI 0.37-0.68; p&lt;0.00001; I 2 =0%; Figure 1A), even considering only RCTs (RR 0.55; 95% CI 0.34-0.91; p=0.03; I 2 =0%). Also, SV was associated with a significant decrease in LAVi (MD -5.34 mL/m 2 ; 95% CI -8.77 to -1.91; p=0.002; I 2 =57%; Figure 1B) compared to ARB. LVEF was similar between groups (MD 1.24 %; 95% CI -0.12 to 2.60; p=0.07; I 2 =0%). Conclusions: SV therapy was associated with a decreased risk of AF recurrence compared to ACEi or ARB, and was superior to ARB in attenuating atrial structural remodeling in patients submitted to catheter ablation.

Persistent left superior vena cava isolation in patients with atrial fibrillation: Selective or empirical?

Persistent left superior vena cava (PLSVC) is the most prevalent form of thoracic venous abnormality and can serve as a significant arrhythmogenic source in atrial fibrillation (AF). Among the 3950 patients who underwent radiofrequency ablation for AF between September 2014 to April 2020, 17 patients (mean age 59.4±8.0 years, 64.7% male) with PLSVC were identified. Among them, nine patients (52.9%) had a prior history of pulmonary vein isolation (PVI) alone. Eight out of nine patients who experienced AF recurrence underwent PLSVC isolation with or without pulmonary vein (PV) reconnection. For the remaining eight patients (47.1%), PVI plus PLSVC isolation were performed during the index procedure. Ectopy originating from PLSVC was documented in 11 patients (64.7%) and successful PLSVC isolation was achieved in 16 patients (94.1%). After a median follow-up of 28.3 months, freedom from AF/ atrial tachycardia (AT) was observed in 13 patients (76.5%). Empirical PLSVC isolation beyond PVI appears to be a feasible and safe strategy to prevent AF recurrence in patients with concomitant PLSVC.

Feasibility of mapping and ablating ectopy-triggering ganglionated plexus reproducibly in persistent atrial fibrillation.

Ablation of autonomic ectopy-triggering ganglionated plexuses (ET-GP) has been used to treat paroxysmal atrial fibrillation (AF). It is not known if ET-GP localisation is reproducible between different stimulators or whether ET-GP can be mapped and ablated in persistent AF. We tested the reproducibility of the left atrial ET-GP location using different high-frequency high-output stimulators in AF. In addition, we tested the feasibility of identifying ET-GP locations in persistent atrial fibrillation. Nine patients undergoing clinically-indicated paroxysmal AF ablation received pacing-synchronised high-frequency stimulation (HFS), delivered in SR during the left atrial refractory period, to compare ET-GP localisation between a custom-built current-controlled stimulator (Tau20) and a voltage-controlled stimulator (Grass S88, SIU5). Two patients with persistent AF underwent cardioversion, left atrial ET-GP mapping with the Tau20 and ablation (Precision™, Tacticath™ [n = 1] or Carto™, SmartTouch™ [n = 1]). Pulmonary vein isolation (PVI) was not performed. Efficacy of ablation at ET-GP sites alone without PVI was assessed at 1year. The mean output to identify ET-GP was 34mA (n = 5). Reproducibility of response to synchronised HFS was 100% (Tau20 vs Grass S88; [n = 16] [kappa = 1, SE = 0.00, 95% CI 1 to 1)][Tau20 v Tau20; [n = 13] [kappa = 1, SE = 0, 95% CI 1 to 1]). Two patients with persistent AF had 10 and 7 ET-GP sites identified requiring 6 and 3min of radiofrequency ablation respectively to abolish ET-GP response. Both patients were free from AF for > 365days without anti-arrhythmics. ET-GP sites are identified at the same location by different stimulators. ET-GP ablation alone was able to prevent AF recurrence in persistent AF, and further studies would be warranted.

Ablation therapies for paroxysmal atrial fibrillation: a systematic review and patient-level network meta-analysis

Abstract Background Despite numerous promising trials, catheter ablation is still regarded as a second-line alternative to antiarrhythmic drugs (AAD) in the treatment of paroxysmal atrial fibrillation (PAF). There remains a role for a broad comparison of the effectiveness of various ablation therapies against each other, and versus AAD. Purpose To conduct a systematic review and network meta-analysis of ablation therapies and AAD in the treatment of PAF. Ablation therapies were hypothesized to be superior to AAD in preventing atrial fibrillation (AF) recurrence. Methods An electronic literature search was conducted to retrieve randomized controlled trials or propensity score-matched studies comparing freedom from AF recurrence among any combination of ablation modalities or AAD. Kaplan-Meier curves and risk tables for this outcome were graphically reconstructed to extract individual patient data (IPD). A Frequentist network meta-analysis (NMA) was performed using the derived hazard ratios (HRs) of each study to compare various ablation therapies and AAD. Two separate NMAs were also conducted with restricted mean survival time (RMST) analysis, using RMST absolute differences and ratios, in light of violation of the proportional-hazards assumption. Treatment strategies were ranked using P-scores. Pairwise comparisons were also performed between treatment pairs with three or more studies reporting direct comparisons. Results Across 24 studies comparing six ablation therapies, comprising 5274 patients, Frequentist NMA-derived HRs of AF recurrence compared to AAD were 0.35 (95% CI: 0.26–0.48) for cryoballoon ablation (CBA), 0.33 (95% CI: 0.25–0.45) for radiofrequency ablation (RFA), 0.21 (95% CI: 0.09–0.49) for combined CBA and RFA, 0.20 (95% CI: 0.11–0.39) for hot-balloon ablation (HBA), 0.44 (95% CI: 0.16–1.22) for laser-balloon ablation, and 0.33 (95% CI: 0.19–0.56) for pulmonary vein ablation catheter. RMST-based NMAs similarly showed a significant benefit of all ablation therapies over AAD in preventing AF recurrence. Although none of the HRs between pairs of ablation modalities were significant, P-scores for HBA and combined CBA and RFA were consistently higher than those of other treatments. Independent pairwise comparisons of RFA and CBA versus AAD were greatly in favor of ablation (shared-frailty HR=0.24, 95% CI: 0.19–0.31, p&amp;lt;0.001; shared-frailty HR=0.44, 95% CI: 0.35–0.56, p&amp;lt;0.001, respectively). Conclusions To our knowledge, this is the first network meta-analysis comparing a wide range of ablation therapies to AAD, synthesizing IPD from high-quality studies in three separate NMA models. The advantage of ablation therapies over AAD in preventing AF recurrence was consistently found across all three models. This strongly suggests that ablation should replace AAD as the first-line treatment for PAF in patients who are fit for the procedure. Moreover, the promising results of HBA underscore the need for more high-quality trials to be conducted. Funding Acknowledgement Type of funding sources: None.

PO-624-06 THE DIELECTRIC IMAGING SYSTEM IS SUPERIOR TO FLUOROSCOPY IN PREVENTING ATRIAL FIBRILLATION RECURRENCE AFTER CRYOABLATION

Dielectric imaging system allows a better visualization of pulmonary veins anatomy and occlusion assessment without dye use. Outcome data is still limited for this imaging system. We aim to analyze short-term atrial fibrillation (AF) recurrence outcomes when using dielectric imaging system mapping during cryoablation procedures. We retrospectively analyzed 32 patients who underwent cryoablation procedure in a single institution. Of those, 19 procedures were performed using dielectric imaging system while 13 procedures were performed using fluoroscopy (control group). Short-term 3-month recurrence outcomes were collected for all patients. Both groups were comparable in terms of sex (47% vs 38% males, p=0.62), age (61 vs 67 years, p=0.10), congestive heart failure (p=0.33), diabetes mellitus (p=0.31), history of stroke (p=0.79), history of coronary artery disease (p=0.46), hyperlipidemic profile (p=0.06). However, hypertension was more frequent in the control group than the dielectric imaging system group (p=0.03). On 3-month follow-up, 2 patients in the dielectric imaging system group had AF recurrence post-ablation, while 6 patients had AF recurrence in the control group. There was significant difference in AF recurrence rates between both groups (10% in the dielectric imaging system group vs 54% in the control group, p=0.007). Dielectric imaging system is superior to fluoroscopy during cryoablation procedure in preventing AF recurrence. Long-term larger prospective studies are needed to confirm the efficacy of the dielectric imaging system.

Efficacy of amiodarone for the prevention of atrial fibrillation recurrence after cardioversion.

The restoration and maintenance of sinus rhythm is a desirable strategy for many patients with atrial fibrillation (AF) since it has been associated with improvement in symptoms and a better quality of life. Sinus rhythm can be achieved by pharmacological or electrical cardioversion or after catheter ablation of AF. Despite high rates of successful cardioversion, AF recurrence remains a major challenge. Anti-arrhythmic drug therapy currently plays a significant role in maintaining sinus rhythm after cardioversion. Amiodarone is the most commonly prescribed anti-arrhythmic drug for patients with AF. This is due to its particular electrophysiological properties and superior anti-arrhythmic effects in comparison with other anti-arrhythmic drugs. Understanding the cardiac electrophysiology and arrhythmogenesis mechanisms may result in identification of new targets for anti-arrhythmic therapy. The aim of this article was to review amiodarone's clinical pharmacology and evaluate evidence supporting amiodarone for treatment and prevention of AF recurrence after cardioversion.

Abstract 10951: Clinical Outcome of Maze Procedure for Atrial Fibrillation Combined with Mitral Valve Disease and Tricuspid Regurgitation

Introduction: The surgical strategy for atrial fibrillation (AF) combined with mitral valve (MV) disease are still controversial whether biatrial or left atrial maze procedure should be performed concomitantly. Hypothesis: Our retrospective study aimed to evaluate the long-term results of two kinds of maze procedure combined with MV surgery and identify the factors involved in AF recurrence. Methods: We enrolled 88 patients from January 2010 to December 2020 who underwent MV surgery with maze procedure concomitantly. The patients were divided into two groups; biatrial maze, group F: n=42 and left atrial maze, group L: n=46). Primary endpoint was AF recurrence and we also evaluated early and late complication and preoperative and operative factors related to AF recurrence. The average follow-up term was 2.8 years. Results: Preoperative factors of long-standing AF and TR grade were significantly higher in group F than group L (P=0.004, 0.02, respecively). Consequently, tricuspid annuloplasty (TAP) was performed significantly frequent in group F than group L (P=0.002). We encountered 2 hospital deaths (4.4%) due to postoperative cerebral hemorrhage and AMI in group L. There was 1 case (2.2%) required pacemaker implantation (PMI) during hospitalization in group L and 3 cases (7.1%) requiring PMI in Group F in late-period. The AF recurrence rates at 1 and 5-year follow-ups between Group F and Group L were not significantly different (24.4% and 28.4% vs. 22.9% and 32.4%, P =0.79). However, the AF recurrence rate in group L with TAP is significant high than those of the other groups (group F 24.4% and 28.4%, group L with TAP 44.3% and 56.7%, and group L without TAP 7.7% and 14.3% at 1 and 5 years, respectively p =0.005). Subject with group L with TAP were associated with a high risk of AF recurrence, with an adjusted OR of 2.4 (95% CI: 1.31-4.45, P =0.005). Conclusions: Our study demonstrated that both concomitant maze procedure was effective for preventing AF recurrence. However, it is also revealed that left atrial maze with TAP significantly increased AF recurrence. It was suggested that preoperative right atrial load was involved in primary occurrence of AF and left atrial maze alone might not control AF recurrence in such situation.

Left atrial appendage velocity as an instrument of predicting atrial fibrillation recurrence after successful catheter ablation – a useful tool?

Abstract Introduction Catheter ablation for the treatment of Atrial Fibrillation (AF) is a modality of treatment in growing expansion. However the sustained long term response in preventing AF recurrence is poor for most patients, namely in those with a dilated left atrium. Purpose Our aim was to assess the utility of an echocardiographic parameter for left atrium function, the left atrial appendage velocity (LAAV), in predicting recurrences after catheter ablation. Methods We performed a 9 year retrospective analysis of all patients who underwent a successful catheter ablation for the treatment of atrial fibrillation and had a valid pre-procedural transesophagic echocardiogram in a single expert centre. Medical records were analysed for demographic, procedural data and outcomes. Results Seventy-three (73) patients fulfilled all inclusion criteria and were analysed. The mean age was 62±11 with a male preponderance (58,7%). The majority of patients (82,7%) had preserved left ventricle ejection fraction. Only 46% of patient had a volumetric assessment of the left atrium dimensions prior to ablation, with slight, moderate and severe dilation of the left atrium in 20%; 8,6% and 28,6% of patients. Of the patients subjected to an AF ablation the average LAAV was 50,6±19 cm/s, with 78% of patients with normal atrial appendage velocities. Patients with low LAAV (&amp;lt;40cm/s) had a higher proportion of AF recurrences at 3 and 6 months (58,3 vs 12,8% and 89% vs 21,7%; p&amp;lt;0,05 for all) with a linear correlation between the presence of recurrences and LAAV (LAAV of 39,1 vs 57,5 cm/s; p&amp;lt;0,05 OR 0,91 (CI 95% = 0,85–0,97); r2=0,34 at 3 months and LAAV of 43,5 vs 59 cm/s; p=0,01; OR 0,94 (CI 95% = 0,89–0,99); r2=0,24 at 6 months respectively). There was a trend towards association with recurrences at 1 year although it did not reach statistical significance. There was no significant difference in the use of antiarritmic drugs, either prior or post ablation, in both groups. It was not possible to assess the additive predictive value to the left atrium dimensions due to the low percentage of volumetric assessment of left atrium prior to AF ablation. Conclusions Patients with low left atrial appendage velocities had a lower long term success rate of catheter ablation, with higher rates of recurrence at 3 and 6 months and a trend towards higher recurrences at 1 year, with linear correlation which hypothesises the use of the left atrial appendage velocity as novel predictive parameter for an integrative model. Funding Acknowledgement Type of funding sources: None.

Impact of initial rhythm control with cryoballoon ablation versus drug therapy on atrial fibrillation recurrence and quality of life: results from the Cryo-FIRST study

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Medtronic OnBehalf The Cryo-FIRST Investigators Background Cryoballoon ablation (CBA) as a first-line rhythm control strategy is superior to antiarrhythmic drugs (AADs) for preventing atrial arrhythmia recurrence; however, the impact of first-line CBA specifically on atrial fibrillation (AF) recurrence and quality of life (QoL) has not been well characterized. Purpose To compare AF recurrence and QoL following first-line CBA vs. AAD therapy in patients with paroxysmal AF within the CryoFIRST trial (NCT01803438). Methods Patients with recurrent symptomatic paroxysmal AF who had not been administered class I or III AAD therapy for &amp;gt;48 hours were enrolled at 18 sites in 9 countries. Patients were randomized (1:1) to CBA or AAD treatment (Class I or III). Subjects were followed by 7-day Holter at 1, 3, 6, 9, and 12 months. Time-to-first AF recurrence outside of a 90-day blanking period was estimated by Kaplan-Meier analysis. QoL was evaluated using the Atrial Fibrillation Effect on Quality of Life (AFEQT) and 36-Item Short Form Health Survey (SF-36) v2 questionnaires. Results Of the 218 randomized subjects, 187 (86%) completed the 12-month follow-up. By intention-to-treat (ITT) analysis, freedom from AF after blanking was achieved in 86.6% in the CBA and 74.5% in the AAD group (p = 0.023). There was no difference in the time-to-first serious adverse event between groups. In total, 84.3% of patients in the CBA vs. 75.0% of patients in the AAD arm had a clinically important improvement (≥5 points) in the AFEQT summary score. The adjusted mean difference in the AFEQT summary score at 12 months was 9.9 points higher in the CBA group (95% CI: 5.5-14.2; P &amp;lt; 0.001). All AFEQT subscale scores were more favorable in the CBA vs. AAD group at 12 months. There were no significant group differences in any of the SF-36 health domain scores at 12 months in the ITT analysis. In the per-protocol analysis, clinically important and significant group differences in favor of CBA were observed at 12 months for 3 of 8 SF-36 health domain scores (physical functioning, general health and social functioning). Conclusion CBA is superior to AAD for preventing AF recurrence and improving AF-specific QoL in patients with paroxysmal AF. AFEQT Scores at Baseline and 12 MonthsAFEQT Score, Mean ± Standard DeviationCBAAADAdjusted Mean Difference at 12 Months (CBA vs. AAD)p-valueBaseline12 MonthsBaseline12 MonthsDaily Activities65.3 ± 25.887.8 ± 17.161.0 ± 27.976.6 ± 25.48.9 (3.2-14.6)0.002Symptoms59.9 ± 24.888.8 ± 15.658.4 ± 25.280.9 ± 22.27.1 (1.5-12.7)0.014Treatment Concern59.9 ± 23.189.8 ± 14.060.4 ± 24.577.7 ± 22.212.7 (7.9-17.5)&amp;lt;0.001AFEQT, Atrial Fibrillation Effect on Quality of Life questionnaire. CBA, cryoballoon ablation. AAD antiarrhythmic drug.Abstract Figure. Freedom From Atrial Fibrillation

Angiotensin Receptor Blocker and Calcium Channel Blocker Preventing Atrial Fibrillation Recurrence in Patients with Hypertension and Atrial Fibrillation: A Meta-analysis.

Background Atrial fibrillation (AF) is the most common serious cardiac rhythm disturbances and is responsible for substantial morbidity and mortality in general population. Hypertension is the most prevalent and potentially modifiable risk factor for AF. This study is aimed at evaluating the effect of angiotensin receptor blocker (ARB) or calcium channel blocker (CCB) on AF recurrence among patients with hypertension and AF. Methods The PubMed, EMBASE, Medline, and Cochrane Collaboration of Controlled Clinical Trials registry databases were searched from their inception to September 2020. Results A total of 7 randomized controlled trials (RCTs) enrolling 1495 patients were included in our study. This finding showed that ARB had a statistically significant superiority in preventing AF recurrence (OR: 0.43, 95% CI: 0.30-0.72, P = 0.0006) and persistent AF (OR: 0.41, 95% CI: 0.24-0.71, P = 0.001) compared to CCB. Subgroup analysis showed that there was a significant difference in telmisartan subgroup (OR: 0.54, 95% CI: 0.23-1.29, P = 0.17) and nontelmisartan subgroup (OR: 0.42, 95% CI: 0.23-0.77, P = 0.005). Subgroup analysis indicated that nifedipine subgroup did not show a statistically significant difference on AF recurrence between ARB and CCB (OR: 0.88, 95% CI: 0.46-1.68, P = 0.69), but amlodipine subgroup showed that ARB had a significant superiority in prevention of AF recurrence (OR: 0.39, 95% CI: 0.27-0.56, P < 0.0001) compared with CCB. Conclusions This study suggests that ARB is superior to CCB for preventing the AF recurrence and persistent AF among patients with hypertension and AF.

Renin-Angiotensin System Inhibitors for the Prevention of Atrial Fibrillation Recurrence After Ablation - A Meta-Analysis.

Atrial fibrillation (AF) recurrence remains a tricky problem in patients undergoing ablation. This meta-analysis aimed to summarize the current literature to clarify whether renin-angiotensin system inhibitors (RASIs) prevent AF recurrence after ablation.Methods and Results:Relevant studies were searched on Pubmed and EMBASE through December 2019. Pooled relative risk (RR) of AF recurrence was calculated. Subgroup analyses according to study design, race, and follow-up duration were further performed. A total of 15 studies examining 4,300 patients were included, with 3 randomized controlled trials and 12 cohort studies. Overall analysis showed that RASIs significantly reduced AF recurrence after ablation (RR=0.83; 95% confidence interval (CI) 0.70-0.98, P=0.028; I2=68.9%). Subgroup analysis further indicated that positive results were found in randomized controlled trials (RR=0.51, 95% CI 0.37-0.70, P<0.001; I2=4%), studies conducted in Asia (RR=0.59, 95% CI 0.46-0.76, P<0.001; I2=30.7%), and studies with follow-up duration ≥1 year (RR=0.82, 95% CI 0.70-0.95, P=0.01; I2=59.1%); negative results were found in cohort studies, studies conducted in Europe or the USA, and studies with follow-up duration <1 year. RASIs can potentially prevent AF recurrence after ablation under selected conditions. However, more studies are required to confirm this finding due to the variation in current evidence.

The Efficacy of Anti-inflammatory Agents in the Prevention of Atrial Fibrillation Recurrences.

Several studies have indicated an association between inflammation and the recurrence of Atrial Fibrillation (AF), especially after ablation, which is a therapeutic option leading to local inflammation. On the other hand, each AF can lead to another AF, as a general rule. Thus, preventing recurrences of AF is extremely important for patient outcomes. In this paper, we attempted to review the effect of medicinal agents with anti-inflammatory properties on the prevention of AF recurrence. There are several randomized controlled trials (RCTs) and meta-analyses on the prevention of AF recurrence using agents with anti-inflammatory properties, which include steroids, colchicine, statins, and n-3 fatty acids (n-3 FA). Clinical trials evaluating the efficacy of anti-inflammatory drugs in preventing the recurrence of AF led to inconsistent results for corticosteroids, statins and n-3 FAs. These results may be related to the fact that inflammation is not the only factor responsible for triggering recurrences of AF. For example, the presence of structural, mechanical and electrical remodeling could potentially be the most important factors that trigger recurrences of AF but these factors have not been addressed in most of the reported studies. Therefore, future clinical trials are needed to compare the efficacy of anti-inflammatory drugs in AF patients with, or without other factors. For colchicine, a potent anti-inflammatory drug, there are limited studies. However, all the studies investigating colchicine in the context of AF were consistent and promising, especially when colchicine was used on a short-term basis following ablation in patients with paroxysmal AF. Therefore, colchicine could be a promising candidate for further clinical studies involving recurrent AF.

The efficacy of combination of transcatheter atrial septal defects closure and radiofrequency catheter ablation for the prevention of atrial fibrillation recurrence through bi-atrial reverse remodeling.

Atrial fibrillation (AF) often coexists with atrial septal defects (ASD). Each of the transcatheter closure for ASD and radiofrequency catheter ablation (RFCA) for AF have been established as the first-line therapy. However, there are limited data about therapeutic effect RFCA plus transcatheter ASD closure on AF recurrence in AF patients with ASD. The aim of the current study was to investigate the clinical impact of ASD closure following RFCA on AF recurrence. Forty-two ASD patients (17 males and 54 ± 20 years old) were enrolled and classified into three groups: ASD occlusion-sinus rhythm (ASO-SR) (n = 26), no AF history prior to ASD closure; ASO-AF-RFCA (n = 11), RFCA was performed due to AF history before ASD closure; and ASO-AF-anti-arrhythmic drug (ASO-AF-AAD) (n = 5), AF was treated with AAD before and after ASD closure. AF occurrence among the 3 groups was evaluated. Kaplan-Meier analysis showed that ASO-SR and ASO-AF-RFCA groups showed a lower AF occurrence ratio than ASO-AF-AAD group during the 14- ± 9-month follow-up periods (P = 0.013). AF occurrence in ASO-SR and ASO-AF-RFCA groups was comparable (P = 0.480). Bi-atrial reverse remodeling, such as decrease in left atrial volume index (P = 0.049) and right atrial area (P = 0.046), and significant decrease in high-sensitivity C-reactive protein levels (P = 0.049) were identified in ASO-AF-RFCA group, but not in ASO-AF-AAD group. A combination of two percutaneous therapies was proven to be effective and induced bi-atrial reverse remodeling in association with inflammatory reaction.