Pulmonary Vein Isolation Group Research Articles

Feasibility and safety of cryoballoon ablation for atrial fibrillation and closing patent foramen ovale without implantation：A pilot study

BackgroundPatent foramen ovale (PFO) affects 20%–34% of adults and is associated with strokes and other disorders. The conventional treatment of PFO-related strokes is a closure procedure. The metal device is associated with some adverse events. ObjectiveOur aim was to investigate the efficacy and safety of PFO closure using cryoablation without implantation in patients with atrial fibrillation (AF) who underwent pulmonary vein isolation (PVI). MethodsWe divided the 22 patients with both PFO and AF who underwent PVI via cryoablation into 2 groups: standard PVI + atrial septal (AS) cryoablation group (group 1, n = 11) and standard PVI group (group 2, n = 11). The guidewire accesses the left atrium through the PFO without AS puncture during the procedure. Standard PVI via cryoablation was performed. The cryoballoon was retracted to the right atrium and inflated against the AS post-PVI. Patients in group 1 had cryoablation for 120–150 seconds, whereas patients in group 2 received sham ablation. The co-primary end points were the PFO closure rate and a composite of AF recurrence and stroke/transient ischemic attack (TIA) events. ResultsThere were no differences in procedure-related adverse events between the 2 groups. Neither group had an ischemic stroke report at 1-year follow-up. The PFO closure rate at 6 months in group 1 was significantly higher than that in group 2 (7 [63.6%] vs 1 [9.1%]; P = .002). AF recurrence post ablation was comparable in both groups at 3 months (3 [27.3%] vs 1 [9.1%]; P = .269), 6 months (0 vs 0), and 12 months (2 [18.2%%] vs 1 [9.1%]; P = .534) of follow-up. ConclusionCryoablation is a safe and effective approach to close PFO in patients with AF undergoing PVI in a single procedure.

Results of external validation for anatomical site recognition of ablation sites in atrial fibrillation using the CARTONET R12 model

Abstract Background CARTONET® is a cloud-based management system designed for retrospective analysis of ablation procedures using the CARTO system. Leveraging a proprietary machine learning model, it automates procedural information analysis. However, the efficacy and accuracy of the CARTONET R12 model's automated location identification remain unverified. Methods This study involved a total of 396 cases. Pulmonary vein isolation (PVI), including cavo-tricuspid isthmus (CTI) ablation, was performed in 313 patients (PVI group). PVI and additional ablation, such as a Box isolation and superior vena cava isolation (SVCI), was performed in 83 patients (PVI+ group). We compared the automated location identification of R12 model and the location identification of arrhythmia experts. Results In this study, 29,422 points were analyzed. The sensitivity of the pulmonary vein carina was low in both PVI group and PVI+ group. Excluding the inferior, anterior, and ridge segmentations, PVI group demonstrated significantly higher sensitivity compared to PVI + group. Regarding the ablation lines for box isolation, both the roof line and post line showed results below 30%. The pulmonary vein carina showed a low PPV in both PVI group and PVI+ group. In segmentations excluding the anterior, PVI group demonstrated significantly higher PPV compared to the group PVI+. Regarding the ablation lines for box isolation, both the roof line and post line showed results below 50%.The R12 model couldn't auto-identify CTI and SVC. Conclusion Excluding the carina, it can be said that in cases where PVI was performed, both PPV and sensitivity demonstrate high accuracy. Conversely, in cases where Box isolation was performed, accuracy decreases due to the low discrimination ability between ablation information near the roof, posterior wall, and inferior wall of the pulmonary veins and the ablation lines of Box isolation. Regarding the right atrium, it was found that the R12 model is entirely incapable of discriminating SVC and CTI, indicating a need for revisions in the current model.The segmentation of anatomyResults of the positive predict value

Efficacy of laser balloon left atrial roof ablation for patients with atrial fibrillation

Abstract Background The roof area ablation beyond pulmonary vein (PV) isolation (PVI) using a cryoballoon has been described as an effective therapy for patients with atrial fibrillation (AF). However, the effect of roof area ablation performed with a visually guided laser balloon (VGLB) remains to be elucidated. Purpose This study aims to investigate the efficacy of roof area ablation using VGLB. Methods A total of 325 patients with AF (paroxysmal AF=199, persistent AF=126) who underwent VGLB ablation from July 2018 to May 2022 were analyzed retrospectively. After initial circular isolation, VGLB was inflated to a larger size on both sides of superior PVs, and the isolation areas were extended to the roof portion. At the end of the procedure, left atrial (LA) voltage mapping was obtained to assess the LA roof scar area, and differential pacing was performed to confirm the complete conduction block. Our study population was divided into the PVI group (LB-PVI, n=228) and the roof line block beyond PVI group (LB-Roof, n=97). The efficacy endpoint was defined as freedom from atrial tachyarrhythmia (ATa) between months 3 and 12. Results One-year clinical follow-up could be obtained in 170 patients with LB-PVI and 81 patients with LB-Roof. The Kaplan-Meier survival curves are shown in Figure. At the end of the 12 months of follow-up, freedom from ATa was 80.8% in patients with LB-PVI and 91.2% in LB-Roof. The ATa freedom rate was significantly higher in the LB-Roof than in the LB-PVI (P=0.03). Conclusion The roof area ablation using VGLB was proved to be effective for patients with AF.The Kaplan-Meier survival curves

One year of atrial fibrillation ablation using pulsed-field pentaspline catheter - learning curves based on a single centre experience

Abstract Introduction Pulsed-field ablation (PFA) represents a novel nonthermal strategy for ablation of atrial fibrillation (AF). As the technology has recently emerged in routine clinical praxis, only limited data on learning curves exist so far. Hereby, we present data from our centre regarding learning curves after the first year of using PFA. Methods The ablation procedure was performed under deep sedation or general anaesthesia in patients with paroxysmal or persistent AF. No 3D mapping system was used, procedures were guided by fluoroscopy and intracardiac echocardiography. For ablation itself, a pantaspline over-the-wire catheter with a steerable sheath was used. The following parameters were analysed over the course of time: procedure time, left atrial (LA) catheter dwelling time, total fluoroscopy time, and complications. Patients who received pulmonary vein isolation (PVI) alone and those with another additive set of lesions (PVI+) were analysed separately. Procedural parameters of the first and the last 20 patients of each group were compared for statistical significance. Results A total number of consecutive 159 patients (mean age 63.20 ± 10.51 years, 69.40 % males) were included in the analysis (PVI N = 73 (45.91 %), PVI+ N = 83 (54.09 %)). Procedures were performed by 3 certified electrophysiology specialists usually in random teams of 2 operators. The mean procedure time was 62.59 ± 23.09 min (PVI 59.64 ± 27.27; PVI+ 65.09 ± 18.64 min, P = 0.15). Over time, there was a non-significant decrease in PVI group (60.30 ± 17.44 vs. 52.75 ± 16.33 min, P = 0.16), but no difference in PVI+ cohort (67.85 ± 13.31 vs. 67.65 ± 28.88 min, P = 0.97). The mean LA catheter dwelling time was 39.84 ± 13.52 min (PVI 35.04 ± 10.20 min; PVI+ 44.33 ± 14.72 min, P <0.001). Non-significant shortening of the LA dwelling time was observed in PVI patients (36.56 ± 8.0 vs. 33.37 ± 9.58 min, P = 0.29). In contrast, the LA dwelling time in the PVI+ group became non-significantly longer (42.93 ± 10.62 vs. 48.56 ± 22.28 min, P = 0.39). The mean fluoroscopy time was 9.28 ± 3.66 min (PVI 8.65 ± 3.04; PVI+ 9.80 ± 4.05 min, P = 0.043). Importantly, fluoroscopy time decreased significantly in both groups over time (PVI: 10.63 ± 3.51 vs. 6.95 ± 2.45 min, P <0.001; PVI+: 12.82 ± 4.99 vs. 9.13 ± 4.16 min, P = 0.017). Regarding complications, we observed one pulmonary oedema requiring orotracheal intubation and mechanical ventilation in the early period. Other complications were related to the femoral puncture site. Conclusion Over the course of time with the new PFA technology, we observed a significant decrease in total fluoroscopy time. However, the change in total procedure and LA dwelling time did not reach statistical significance.

LOCK PROTOCOL: A NEW ROBUST WORKFLOW FOR A VERY HIGH FIRST PASS PULMONARY VEIN ISOLATION DURING ATRIAL FIBRILLATION ABLATION

Abstract Introduction Pulmonary vein isolation (PVI) is the gold standard for atrial fibrillation (AF) ablation. First pass PVI is often demanding when a raw geometry reconstruction is used in combination with an inaccurate automarks annotation, accounting for discontinuous or non–transmural lesions and related AF recurrences. We hypothesized that a magnetic–post processing of left atrial geometry in combination with an LSI–guided high power short duration (HPSD) automarks annotation could improve procedural efficiency. Purpose Aim of the study was to determine the impact on procedural outcomes of the new “Lock PVI protocol” during AF ablation with the new voxel mode EnSite X mapping system. Methods We included in the study consecutive patients with AF scheduled for pulmonary vein isolation (PVI) at our Departement between January 2021 and December 2022. Patients were divided in two Groups, the Lock–PVI Group and the control No Lock–PVI Group. The “Lock PVI” Group was ablated with the new Ensite X System using the new protocol, which consisted in (1) performing a road map with contact–force annotation at potential PVI sites after High Density reconstruction, (2) shaving the magnetic geometry reconstruction to unearth true 3D location of contact points, (3) Use of 3D–Automarks color–coded with a Lesion Index (LSI) target of 5.5 (anterior) and 4.5 (posterior) (4) Inter–lesion distance £6 mm (5) High Power Short Duration Approach (50 W). The No–Lock PVI was represented by patients ablated with and HPSD ablation with the previous version of the EnSite Precision mapping suit as per local standard practice. Groups were compared in term of procedural duration, radiological exposure and “first pass” isolation. Results Forty–four patients (22 “Lock PVI” and 22 controls mean age 63,3±8 years, 65,9% male, 47,7% persistent AF), for a total of 88 PVI circles were enrolled. Procedural duration was similar between approaches (121,1±43,6 vs 125,3±30,1 min; P=0,72) but RF time was shorter in the “Lock PVI” group (19,6±4 vs 29,55±9,1 min; P<0,001), even if with a longer fluoroscopy (19,5±10,1 vs 13,4±4,9 min; P=0,01). Of note, first pass isolation was significantly higher in the “Lock PVI” group: 40/44 (90,9%) vs 28/44 (63,6%) circles (P=0,002). Conclusion The new “Lock PVI” approach allowed a consistently better first pass isolation (>90%) with less RF time when compared to standard of care PVI.

Additional ablation to pulmonary vein isolation for persistent atrial fibrillation does not reduce recurrence

Abstract Introduction Treatment with catheter ablation (CA) as rhythm control is increasingly used in atrial fibrillation (AF). Pulmonary vein isolation (PVI) alone is less effective in patients with persistent AF (peAF) compared to patients with paroxysmal AF (PAF). Strategies and methods to optimize outcome for peAF is still an ongoing challenge. Additional ablation to pulmonary vein isolation (PVI plus) compared to PVI alone has so far shown conflicting evidence and has yet to be tested in a large unselected, real-life population with longtime follow-up. Purpose To examine AF recurrence by PVI or PVI plus for CA for peAF. Method This nationwide retrospective registry study was conducted using large real-life data from Danish mandatory registries. All patients above 18 years of age, that underwent first-time CA for peAF from January 1st 2010 to December 31st 2018, were identified and included at the date of ablation. Exposure of interest was CA, and patients were stratified into PVI or PVI plus. PVI plus was defined as either roofline, mitral linear ablation, posterior wall isolation (PWI), complex fractionated atrial electrograms (CFAE) or ganglionated plexi ablation (GP). Primary endpoint was recurrent AF after a 3-months blanking period, defined by a composite endpoint of first-reached endpoint of either use of antiarrhythmic drugs (AAD), AF-admission, electrical cardioversions or AF re-ablation. 5-year risk of recurrent AF was examined by the Aalen-Johansen estimator, taking the competing risk of death into account. The relative rates of recurrent AF by ablation strategy (PVI or PVI plus) were examined by Cox proportional models using PVI as reference. The analysis was adjusted for clinically important baseline characteristics including age, sex, diagnosis-to-ablation time, procedural year, body mass index, size of left atrium, heart failure, ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension and diabetes. Results The study cohort consisted of 2.444 patients with peAF undergoing first-time CA, of which 2.069 received PVI and 375 received PVI plus. Median age was 63 for the PVI group and 64 for the PVI plus group. The PVI plus group had longer diagnosis-to-ablation-time and enlarged left atrium compared to the PVI group. 5-year cumulative incidence of recurrent AF was 55% for the PVI group and 71% for the PVI plus group in the unadjusted analysis (Figure 1). The relative risk of recurrent AF showed hazard ratio of 1.11 (95% CI: 0.95-1.29) for the PVI plus group compared to the PVI group (Figure 2). Conclusion Strategies to reduce AF recurrences after CA for peAF is an ongoing challenge. This study did not find any significant reduction in recurrence of AF using PVI plus strategy compared to PVI alone. The increased absolute risk of AF recurrence in the PVI plus group is most likely accounted for by longer diagnosis-to-ablation-time and enlarged left atrium compared to the PVI group.Figure 1Figure 2

Left atrial fibrosis-guided ablation in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials

Abstract Background Left atrial fibrosis is related to atrial fibrillation (AF) recurrence after AF ablation. However, the benefit of patient-specific substrate modification guided by fibrosis delineated on voltage mapping or magnetic resonance imaging (MRI) is conflicting. Objective To compare the efficacy and safety of additional modification of left atrial fibrosis [identified by low-voltage area (LVA) or late gadolinium-enhancement on MRI] vs. circumferential pulmonary vein isolation (PVI) with or without stepwise ablation not targeting fibrosis in AF. Methods A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was performed from inception to November 2022. Only randomized studies investigating the utility of fibrosis-guided substrate modification beyond conventional PVI were included. The primary outcome was a recurrence of any atrial arrhythmia. Major adverse events and procedural, fluoroscopic, and total ablation time were defined as secondary outcomes. We calculated pooled estimates of the outcomes by a random-effect model and reported them as risk ratio (RRs) and 95% confidence interval (CI). Results A total of 9 studies (8 randomized controlled clinical trials and 1 randomized design within a prospective study) and 2135 patients with AF were included. The atrial arrhythmia recurrence was lower in the additional fibrosis-guided ablation group (RR 0.82; 95% CI 0.71-0.94; p=0.006) (Figure 1A). No differences were found between fibrosis-guided substrate modification and conventional PVI group in major adverse events [RR 1.25 (0.55-2.81), p=0.598)] and mean differences of procedural time [-2.88 (-40.34 to 34.57) min], fluoroscopic time [1.82 (-1.86 to 5.49) min], and total ablation time [-14.28 (-48.70 to 20.14) min]. In the stratified analyses, there were no interactions of the lower atrial arrhythmia recurrences within the modality of fibrosis identification (LVA vs. delayed enhancement on MRI), type of AF (paroxysmal vs. persistent), the burden of LVA (no or low vs. high), and strategy of the control group (PVI only vs. PVI plus stepwise ablation) (Figure 1B). Conclusion By incorporating two modalities of left atrial substrate evaluation – voltage mapping and MRI – we conclude that the individually tailored fibrosis-guided ablation in AF is associated with a lower recurrence after catheter ablation.

PO-02-036 THE POSTERIOR WALL ISOLATION FOR PERSISTENT ATRIAL FIBRILLATION HIGH POWER SHORT DURATION (PEF-HOT) TRIAL

Treatment of persistent atrial fibrillation (PeF) remains a procedural challenge with high recurrence rate after catheter ablation. Posterior wall isolation (PWI) has emerged as a potential concomitant treatment strategy for PAF with conflicting outcomes. PWI introduces a left atrial (LA) roof and low posterior line through a series of radiofrequency (RF) applications to achieve entrance and exit block of the LA posterior wall. It remains unclear whether PWI with pulmonary vein isolation (PVI) during initial catheter ablation improves success rate over PVI alone. This study investigated whether PWI with PVI reduced recurrence rates compared to PVI alone in patients with PeF undergoing first-time radiofrequency ablation utilizing high-power-short-duration (HPSD) ablation. In this prospective, multicenter, randomized controlled trial, we randomized 67 patients with symptomatic PeF undergoing initial ablation to either PVI+PWI (n = 39) or PVI (n = 28) alone. The primary endpoint was freedom from atrial arrhythmias after a single procedure. Of the 67 study participants, the median duration of PeF was 0.67 (interquartile range, 0.25 - 2) years. The mean CHADS-VASc score was 2.7±1.6. No significant difference was found in the baseline characteristics between the two groups (Table 1). PWI was successfully achieved in all 39 patients in PVI+PWI group. Mean procedural times were 83.4±23.4 minutes for the PVI group, and 111.7±41.0 minutes for the PVI+PWI group. There was one complication of tamponade in the PVI+PWI group. At a median follow up of 12.4±3.0 months, the atrial arrhythmia recurrence rate did not significantly differ (P=0.9275) between PVI+PWI (20.5%) and PVI alone (21.4%). Kaplan-Meier analysis showed no significant difference in the overall AF recurrence (log-rank, P=0.9485). Additionally, the Cox univariate regression and multivariate Cox regression for all notable comorbidities revealed no significant association with procedural outcomes. In patients with PeF undergoing initial RF ablation, adjunctive PWI with PVI using HPSD did not significantly reduce recurrence rate of atrial arrhythmias.Tabled 1Table 1: Baseline Clinical CharacteristicsOverall (N = 67)Arm 1(N=28)Arm 2 (N=39)P-valueAge, mean (±SD)68.4 (±7.9)68.5 (±8.4)68.4 (±7.7)0.968Men, n (%)51 (76.1)20 (29.9)31 (46.3)0.445AF Duration, median (IQR)0.67 (0.25-2)1 (0.29-2)0.5 (0.25-2)0.440Comorbidities, n (%)Heart failure21 (31.3)10 (35.71)11 (28.21)0.513Hypertension49 (73.1)22 (78.6)27 (69.2)0.395Diabetes mellitus14 (20.9)8 (28.6)6 (15.4)0.190Stroke6 (9.0)3 (10.7)3 (7.7)0.669Vascular disease6 (9.0)2 (7.1)4 (10.3)0.660CHA2DS2-VASc score, mean (±SD)2.7 (±1.6)2.9 (±1.7)2.5 (±1.4)0.230Echocardiographic parameters, mean (±SD)LA dimension, cm4.7 (±0.6)4.6 (±0.6)4.8 (±0.6)0.206LA volume index, mL/m252.5 (±35.4)54.1 (±33.5)51.4 (±38.1)0.975LV ejection fraction, %52.1 (11.2)53.5 (±10.3)51.0 (±11.9)0.385 Open table in a new tab

Surgical treatment of paroxysmal atrial fibrillation concomitant to coronary artery bypass grafting: pulmonary vein isolation or maze V?

Highlights. Maze V significantly reduces the recurrence of AF compared to bipolar RFA for PVI in the short and mid-term period.Aim. To assess the effectiveness and safety of pulmonary vein isolation (PVI) in comparison with Maze V for treating paroxysmal atrial fibrillation (AF) concomitant to coronary artery bypass grafting (CABG).Methods. Medical records of 139 patients with coronary artery disease and concomitant paroxysmal AF were retrospectively analyzed. All patients were divided into two groups: Group 1 patients (n = 71) underwent CABG + bipolar radiofrequency ablation for PVI, and Group 2 patients (n = 68) underwent Maze V + CABG. Propensity score-matched (PSM) analysis with a 1:1 nearest-neighbor matching was done. 30 patients were selected from each group. The exclusion criteria were as follows: emergent CABG, concomitant valvular heart disease, non-paroxysmal AF, decompensation of chronic diseases, and cancer. On-pump CABG was performed at normothermia with warm blood hyperkalemia cardioplegia. RFA for PVI and Maze V were performed before CABG under parallel perfusion without aortic cross-clamping. The primary and secondary endpoints included recurrent AF/atrial flutter, sinus rhythm at discharge and in the long-term period, permanent pacemaker implantation, major cardiovascular and cerebrovascular events.Results. After the PSM analysis, the CABG+Maze V group and CABG+RFA for PVI differed significantly in the duration of surgery (330 [310; 375] vs. 255 [225; 270] min, p = 0.0001), cardiopulmonary bypass time (131 [113; 144] min vs. 89 [74; 98] min, p = 0.0001), duration of AF treatment (53 [44; 59] min vs. 10 [9; 12] min, p = 0.0001). The structure and rate of complications in both groups were comparable. There were no in-patient deaths. Recurrent AF/atrial flutter significantly reduced in the CABG+Maze V group compared to the CABG+RFA for PVI group (13.3% vs. 33.3%, respectively; p = 0.044). Sinus rhythm was restored in all cases. The rate of transient sinus node dysfunction (no more than 5 days) was 6.7% in the Group 1 and 16.6% in the Group 2. The difference did not reach statistical significance (p = 0.128). The 12-months cumulative freedom from AF/atrial flutter without antiarrhythmic drug therapy was significantly higher in the CABG+Maze V group compared to the CABG+RFA for PVI group (97% vs. 83.5%, respectively; p = 0.020). The freedom from MACE in both groups was 96.7%.Conclusion. Maze V for treating concomitant paroxysmal AF prolonged the duration of cardiopulmonary bypass and the surgery itself, but did not affect the postoperative period, indicating its safety and effectiveness. Maze V procedure concomitant to CABG significantly reduced the recurrence of AF compared to RFA for PVI both in the short- and mid-term period. Thus, it is reasonable to perform Maze V+CABG in patients with paroxysmal AF and a high risk of disease progression.

Cryoballoon Pulmonary Vein Isolation as First-Line Treatment for Typical Atrial Flutter

ObjectiveWe aimed to compare cryoballoon pulmonary vein isolation (PVI) with standard radiofrequency cavotricuspid isthmus (CTI) ablation as first-line treatment for typical atrial flutter (AFL).MethodsCryoballoon Pulmonary Vein Isolation as First-Line Treatment...

Complete Left-Atrial Lesion Set versus Pulmonary Vein Isolation Only in Patients with Paroxysmal AF Undergoing CABG or AVR.

Background and Objectives: In patients with paroxysmal atrial fibrillation (AF) undergoing CABG or aortic valve surgery, many surgeons are not willing to open the left atrium to perform a complete left-sided Cox-Maze lesion set. Pulmonary vein isolation (PVI) is often favored in those patients. We investigated the outcome of patients with isolated pulmonary vein isolation compared to those receiving an extended left atrial (LA) lesion set. Materials and Methods: Between 2003 and 2016, 817 patients received concomitant surgical AF ablation in our institution. A total of 268 patients with paroxysmal AF were treated by surgical ablation concomitant to AVR or CABG. Of those, 86 patients underwent a complete left-sided lesion set, while 182 patients were treated with an isolated pulmonary vein isolation. The primary endpoint was freedom from atrial fibrillation at 12 months' follow-up. Results: There were no statistically significant differences regarding baseline characteristics. No major ablation-related complications were observed in any of the groups. In the PVI group, three patients (1.6%) had an intraoperative stroke, while two (2.3%) patients experienced a stroke in the LA ablation group (p = 0.98). In-hospital mortality was 3.4% in the PVI group, and 2.8% in the extended LA group (p = 0.33). Freedom from AF at 12 months' follow-up was 76% in the extended LA ablation group and 70% in the PVI group, showing no statistically significant difference (p = 0.32). Conclusion: Surgical AF ablation concomitant to CABG or AVR in patients with paroxysmal AF is safe and effective. There was no statistically significant difference between the compared lesion sets in terms of freedom from AF, survival or stroke rate after 12 months.

Pericarditis following left atrial ablation.

We aimed to evaluate the incidence of acute pericarditis following cardioneuroablation (CNA) and to compare this with patients undergoing left atrial (LA) radiofrequency ablation for atrial fibrillation (AF). This is a single-center prospective study. During the study period, CNA for vasovagal syncope was performed in 42 patients, pulmonary vein isolation (PVI) for paroxysmal AF in 46 patients, and posterior wall isolation (PWI) in addition to PVI for persistent AF in 22 patients. Pericarditis was reported by 18 (16.4%) patients overall: 1 (2.4%) patient in CNA group, 8 (17.4%) patients in PVI group, and 9 (40.9%) patients in PWI (p < .001). On univariable logistic regression analysis, CNA was associated with a lower risk of pericarditis (odds ratio 0.11, 95% confidence interval [CI] 0.01-0.97), while ablation of PWI plus PVI was associated with a higher risk of pericarditis compared with PVI (odds ratio 3.29, 95% CI 1.05-10.3). This study shows that pericarditis is extremely uncommon following CNA and is significantly less frequent than following AF ablation. This difference is likely related to the much lower amount of LA ablation necessary in this group.

Effect of MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation on Atrial Arrhythmia Recurrence in Patients With Persistent Atrial Fibrillation

Ablation of persistent atrial fibrillation (AF) remains a challenge. Left atrial fibrosis plays an important role in the pathophysiology of AF and has been associated with poor procedural outcomes. To investigate the efficacy and adverse events of targeting atrial fibrosis detected on magnetic resonance imaging (MRI) in reducing atrial arrhythmia recurrence in persistent AF. The Efficacy of Delayed Enhancement-MRI-Guided Fibrosis Ablation vs Conventional Catheter Ablation of Atrial Fibrillation trial was an investigator-initiated, multicenter, randomized clinical trial involving 44 academic and nonacademic centers in 10 countries. A total of 843 patients with symptomatic or asymptomatic persistent AF and undergoing AF ablation were enrolled from July 2016 to January 2020, with follow-up through February 19, 2021. Patients with persistent AF were randomly assigned to pulmonary vein isolation (PVI) plus MRI-guided atrial fibrosis ablation (421 patients) or PVI alone (422 patients). Delayed-enhancement MRI was performed in both groups before the ablation procedure to assess baseline atrial fibrosis and at 3 months postablation to assess for ablation scar. The primary end point was time to first atrial arrhythmia recurrence after a 90-day blanking period postablation. The primary safety composite outcome was defined by the occurrence of 1 or more of the following events within 30 days postablation: stroke, PV stenosis, bleeding, heart failure, or death. Among 843 patients who were randomized (mean age 62.7 years; 178 [21.1%] women), 815 (96.9%) completed the 90-day blanking period and contributed to the efficacy analyses. There was no significant difference in atrial arrhythmia recurrence between groups (fibrosis-guided ablation plus PVI patients, 175 [43.0%] vs PVI-only patients, 188 [46.1%]; hazard ratio [HR], 0.95 [95% CI, 0.77-1.17]; P = .63). Patients in the fibrosis-guided ablation plus PVI group experienced a higher rate of safety outcomes (9 [2.2%] vs 0 in PVI group; P = .001). Six patients (1.5%) in the fibrosis-guided ablation plus PVI group had an ischemic stroke compared with none in PVI-only group. Two deaths occurred in the fibrosis-guided ablation plus PVI group, and the first one was possibly related to the procedure. Among patients with persistent AF, MRI-guided fibrosis ablation plus PVI, compared with PVI catheter ablation only, resulted in no significant difference in atrial arrhythmia recurrence. Findings do not support the use of MRI-guided fibrosis ablation for the treatment of persistent AF. ClinicalTrials.gov Identifier: NCT02529319.

2-year outcomes of phased radiofrequency ablation for atrial fibrillation with the second-generation PVAC Gold ablation catheter

PurposeThe second-generation multi-electrode catheter, PVAC Gold, was designed to improve the safe delivery of phased radiofrequency energy using a “single shot” approach for pulmonary vein isolation (PVI), while retaining efficacy. This large registry presents long-term performance in a daily practice setting.MethodsA total of 1011 patients undergoing first time ablation for atrial fibrillation (AF) using PVAC Gold were included, 639 patients with PVI for paroxysmal AF (PAF PVI) and 372 patients with persistent or long-standing persistent AF, divided into 175 patients receiving PVI only (PersAF PVI) and 197 patients receiving PVI with additional substrate ablation (PersAF PVI +).ResultsAt 24-month follow-up, single procedure freedom from atrial tachyarrhythmia (ATA) was 58% (368/639) in the PAF PVI group, 44% (77/175) in the PersAF PVI group, and 29% (57/197) in the PersAF PVI + group. Allowing one repeat procedure in 33% of patients, 76%, 65%, and 54% were free from ATA at 24 months, respectively. Pulmonary vein reconnection was observed in 98% of patients with recurrent arrhythmia after PVI.ConclusionsAlthough phased RF ablation with PVAC Gold is quick and safe, the efficacy outcomes are modest compared to current mainstream ablation strategies.

Association of pulmonary vein isolation and major cardiovascular events in patients with atrial fibrillation

BackgroundPatients with atrial fibrillation (AF) face an increased risk of adverse cardiovascular events. Evidence suggests that early rhythm control including AF ablation may reduce this risk.MethodsTo compare the risks for cardiovascular events in AF patients with and without pulmonary vein isolation (PVI), we analysed data from two prospective cohort studies in Switzerland (n = 3968). A total of 325 patients who had undergone PVI during a 1-year observational period were assigned to the PVI group. Using coarsened exact matching, 2193 patients were assigned to the non-PVI group. Outcomes were all-cause mortality, hospital admission for acute heart failure, a composite of stroke, transient ischemic attack and systemic embolism (Stroke/TIA/SE), myocardial infarction (MI), and bleedings. We calculated multivariable adjusted Cox proportional-hazards models.ResultsOverall, 2518 patients were included, median age was 66 years [IQR 61.0, 71.0], 25.8% were female. After a median follow-up time of 3.9 years, fewer patients in the PVI group died from any cause (incidence per 100 patient-years 0.64 versus 1.87, HR 0.39, 95%CI 0.19–0.79, p = 0.009) or were admitted to hospital for acute heart failure (incidence per 100 patient-years 0.52 versus 1.72, HR 0.44, 95%CI 0.21–0.95, p = 0.035). There was no significant association between PVI and Stroke/TIA/SE (HR 0.94, 95%CI 0.52–1.69, p = 0.80), MI (HR 0.43, 95%CI 0.11–1.63, p = 0.20) or bleeding (HR 0.75, 95% CI 0.50–1.12, p = 0.20).ConclusionsIn our matched comparison, patients in the PVI group had a lower incidence rate of all-cause mortality and hospital admission for acute heart failure compared to the non-PVI group.ClinicalTrials.gov IdentifierNCT02105844, April 7th 2014.Graphical abstract

Adding six short lines on pulmonary vein isolation circumferences reduces recurrence of paroxysmal atrial fibrillation: Results from a multicenter, single-blind, randomized trial.

Pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) is associated with a non-negligible long-term recurrence rate. The purpose of this study was to investigate whether PVI combined with 6 short ablation lines on the PVI circumferences (PVI+6L group) yields higher success rates than PVI alone (PVI group). In this multicenter, single-blind, randomized trial, a total of 390 patients with paroxysmal AF were randomly assigned to the PVI group (n = 193) or the PVI+6L group (n = 197). The primary endpoint was freedom from AF/atrial tachycardia recurrence between 91 and 365 days. Secondary endpoints included AF burden, procedural parameters, and complications. Freedom from atrial tachyarrhythmia was achieved in 160 of 197 patients (81.2%) in the PVI+6L group and 142 of 193 patients (73.6%) in the PVI group (hazard ratio 0.61; 95% confidence interval 0.39-0.97; P = .040). Mean AF burden tended to be lower in the PVI+6L group compared to the PVI group (1.95% vs 0.53%, P = .097). Procedural and ablation times were slightly longer in the PVI+6L group than in the PVI group (130 ± 25 minutes vs 121 ± 28 minutes; P = .002; and 46 ± 14 minutes vs 41 ± 16 minutes, P = .001, respectively). X-ray exposure was similar (60 ± 54 seconds vs 61 ± 60 seconds; P = .964). Complications occurred in 3 patients (1.6%) in the PVI group and 3 patients (1.5%) in the PVI+6L group. In patients with paroxysmal AF undergoing catheter ablation, adding 6 short ablation lines on the PVI circumferences could reduce the AF recurrence rate.

Outcomes of posterior wall isolation with pulmonary vein isolation for paroxysmal atrial fibrillation

Prior studies have shown that addition of posterior wall isolation (PWI) may reduce atrial fibrillation recurrence in patients with persistent atrial fibrillation. No data on PWI in paroxysmal AF (pAF) patients with normal left atrial voltage is available, to date. This study sought to evaluate the efficacy of PWI in addition to pulmonary vein isolation (PVI) in patients presenting with pAF and normal left atrial voltage. Consecutive patient registry analysis was performed on all patients with pAF and normal left atrial voltage undergoing initial radiofrequency ablation from November 1, 2018 to November 15, 2019. Primary endpoint was recurrence of atrial arrhythmia including AF, atrial tachycardia (AT), or atrial flutter (AFL). A total of 321 patients were studied, 214 in the PVI group and 107 in the PWI + PVI group. Recurrence of any atrial arrhythmia occurred in 18.2% of patients in the PVI group and 16.8% in the PVI + PWI cohort (p = 0.58). At 1 year, recurrence was 14.0% in the PVI group and 15.0% in the PWI + PVI group (p = 0.96). There was a lower AT/AFL recurrence in the PVI + PWI group, not reaching significance (3.7% in the PWI + PVI group vs. 7.9% in PVI group, p = 0.31). Need for carina lesions predicted recurrence in the PVI-only group. Addition of PWI to PVI in pAF patients undergoing their first ablation did not reduce the frequency of atrial arrhythmia recurrence. This warrants further study in a prospective trial.

Safety and efficacy of renal sympathectomy in ablation of hypertension complicated with atrial fibrillation

At present, there is limited data on the effect of renal sympathectomy combined with pulmonary vein isolation on hypertensive patients with atrial fibrillation. The purpose of this study was to explore the efficacy and safety of renal sympathectomy combined with ablation in the treatment of hypertension with atrial fibrillation. A comprehensive literature search was conducted on the treatment of hypertension complicated with atrial fibrillation. Comparing the clinical data of renal sympathetic denervation (RSDN)+pulmonary vein isolation (PVI) with that of PVI alone, we analyzed recurrence of postoperative atrial fibrillation (AF) as main outcome. Classification variables were represented by risk ratio (RR), continuous variables as average difference (MD) and 95% confidence interval (CI). A total of 7 eligible studies were included, including 734 patients (RSDN+PVI group: 340 cases; PVI group: 394 cases). The follow-up period was one year or more. Compared with the separate PVI (56%), the recurrence rate of AF in RSDN+PVI group (32%) decreased significantly (RR: 0.60, 95% CI: 0.50, 0.71, p &lt; 0.001). RSDN+PVI increased the operation time (Weighted Mean Difference (WMD): 24.92, 95% CI: 20.27, 29.57, p &lt; 0.001), but did not increase the fluoroscopy time (WMD: 1.58, 95% CI: −7.50, 10.66, p = 0.73). Six months after operation, the glomerular filtration rate in RSDN+PVI group was significantly higher than that in PVI group (WMD: 6.17, 95% CI: 3.09, 9.24, p &lt; 0.001). The control of systolic blood pressure and diastolic blood pressure in RSDN+PVI group was significantly better than that in PVI group (WMD: −9.55, 95% CI: −16.27, −2.84, p = 0.005; WMD: −6.11, 95%CI: −10.72, −1.50, p = 0.009). There was no significant difference in complications between the two groups (RR: 0.85, 95% CI: 0.32, 2.21, p = 0.73). The heterogeneity of clinical outcome was very low in atrial fibrillation and complications (I2 = 0). PVI combined with RSDN is a feasible and safe interventional therapy option for patients with hypertension complicated with atrial fibrillation, which can effectively reduce the burden of atrial fibrillation and improve the control of blood pressure and prevent further renal damage.

Catheter Ablation for Atrial Fibrillation in Patients ≤30 Years of Age

Pulmonary vein (PV) automaticity is an established trigger for paroxysmal atrial fibrillation (PAF), making PV isolation (PVI) the cornerstone of catheter ablation. However, data on triggers for atrial fibrillation (AF) and catheter ablation strategy in very young patients aged <30 years are sparse. A total of 51 young patients (mean age 24.0 ± 4.2 years, 78.4% men) with drug-refractory PAF underwent electrophysiology (EP) study and ablation at 5 EP centers. None of the patients had structural heart disease or family history of AF. EP study induced supraventricular tachycardia (SVT) in 12 patients (n=12, 23.5%): concealed accessory pathway mediated orthodromic atrioventricular reentrant tachycardia in 3 patients, typical atrioventricular nodal reentrant tachycardia in 6 patients, left superior PV tachycardia in 1 patient, left atrial appendage tachycardia in 1 patient, and typical atrial flutter in 1 patient. In patients with induced SVTs, SVT ablation without PVI was performed as an index procedure, except for the patient with atrial flutter who received cavotricuspid isthmus ablation in addition to PVI. Remaining patients underwent radiofrequency (n=15, 29.4%) or second-generation cryoballoon-based PVI (n=24, 47%). There were no major complications related to ablation procedures. Follow-up was based on outpatient visits including 24-hour Holter-electrocardiogram at 3, 6, and 12 months after ablation, or additional Holter-electrocardiogram was ordered in case of symptoms suggesting recurrence. Recurrence was defined as any atrial tachyarrhythmia (ATA) episode >30 seconds after a 3-month blanking period. A total of 2 patients with atrioventricular nodal reentrant tachycardia, 1 with left atrial appendage tachycardia, experienced AF recurrence within the first 3 months and received PVI. After the 3-month blanking period, during a median follow-up of 17.0 ± 10.1 months, 44 of 51 patients (86.2%) were free of ATA recurrence. In the PVI group, 33 of 39 patients (84.6%) experienced no ATA recurrence. In conclusion, SVT substrate is identified in around a quarter of young adult patients with history of AF, and targeted ablation without PVI may be sufficient in the majority of these patients. PVI is needed in the majority and is safe and effective in this population.

Abstract 9219: More Extensive Ablation in Addition to Pulmonary Vein Isolation Can Improve Quality of Life in Elderly Patients With Persistent Atrial Fibrillation: Insights from the Earnest-pvi Trial

Introduction: Improving the quality of life (QoL) is one of the main purposes of catheter ablation of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus). Objective: To investigate the QoL changes after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy in elderly and non-elderly patients. Methods: In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n = 512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS). Results: After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 444 patients were divided into two groups: those 65 years old and over and those under 65 years old, and assessed whether there was a difference in QoL improvement between the ablation strategies. In non-elderly patients, although there was improvement in all aspects of QoL after ablation, there was no difference between strategies. In contrast, the improvement in PCS was significantly greater in elderly patients who underwent PVI-plus. (PVI group 0.8 ± 10.3 vs. PVI-Plus group 3.8 ± 11.2, P=0.021) Conclusions: While ablation for persistent AF improved QoL regardless of strategy, more extensive ablation in addition to PVI could improve QoL in the elderly patients.