Pulmonary Vein Isolation Group Research Articles

Isolating the entire pulmonary venous component versus isolating the pulmonary veins for persistent atrial fibrillation: A propensity-matched analysis.

The outcomes of pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) are suboptimal. The entire pulmonary venous component (PV-Comp), consisting of the pulmonary veins, their antra, and the area between the antra, provides triggers and substrate for AF. PV-Comp isolation is an alternative strategy for persistent AF ablation. Among 328 patients with persistent AF who underwent a first radiofrequency ablation procedure, 200 patients (PVI, n=100; PV-Comp isolation, n=100) were selected by propensity score matching. Both groups were followed up for 1 year. At 6- and 12-month follow-up, atrial tachyarrhythmia (AF/atrial tachycardia) recurred in 41 and 61 patients in PVI group and 22 (P=.006) and 33 patients (P<.001) in PV-Comp isolation group, respectively. PV-Comp isolation was associated with longer mean time to recurrence (PVI: 8 months, PV-Comp isolation: 10 months, log-rank P<.001) and a lower probability of recurrence (odds ratio [OR]=0.32; 95% confidence of interval [CI]=0.18-0.56, P<.001), with no increase in procedural complications (PVI: 5 of 100, PV-Comp isolation: 6 of 100, P=.76). Procedure duration was longer in PV-Comp isolation group (PVI: 186 ± 42min, PV-Comp isolation: 238 ± 44min, P<.001), as well as fluoroscopy time (PVI: 22 ± 16min, PV-Comp isolation: 31 ± 21min, P=.001). PV-Comp isolation for persistent AF reduced atrial tachyarrhythmia recurrence up to 1 year compared with PVI alone. While procedure and fluoroscopy time increased, there was no difference in procedural complications.

P2846Focal impulse and rotor modulation ablation versus pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation (FIRMAP AF study)

Abstract Background Based on the assumption of trigger elimination, pulmonary vein isolation (PVI) currently presents the gold standard of atrial fibrillation (AF) ablation. Recently, rapidly spinning rotors or focal impulse formation has been raised as a crucial sustaining mechanism of AF. Ablation of these rotors may potentially obviate the need for trigger elimination with PVI. Purpose This study sought to compare the safety and effectiveness of Focal Impulse and Rotor Modulation (FIRM) guided catheter ablation only with the gold standard of pulmonary vein isolation (PVI) in patients with paroxysmal AF. Methods This was a post-market, prospective, single-blinded, randomized, multi-center trial. Patients were enrolled at three centers and equally (1:1) randomized between those undergoing conventional RF ablation with PVI (PVI group) vs. those treated with FIRM-guided RF ablation without PVI (FIRM group). Data was collected at enrollment, procedure, and at 7-day, 3-month, 6-month, and 12-month follow-up visits. The study was closed early by the sponsor. At the time of study closure, any pending follow-up visits were waived. Results From February 2016 until February 2018, a total of 51 (out of a planned 170) patients (mean age 63±10.6 years, 57% male) were enrolled and randomized. Four patients withdrew from the study prior to treatment, resulting in 23 patients allocated to the FIRM group and 24 in the PVI group. Only 13 patients in the FIRM group and 11 patients in the PVI group completed the 12-month follow-up. Statistical analysis was not completed given the small number of patients. Single-procedure effectiveness (freedom from AF/atrial tachycardia recurrence after blanking period) was 52.9% (9/17) in the FIRM group and 85.7% (12/14) in the PVI group at 6 months; and 31.3% (5/16) in the FIRM group and 80% (8/10) in the PVI group at 12 months. Repeat procedures were performed in 45.8% (11/24) patients in the FIRM group and 7.4% (2/27) in the PVI group. The acute safety endpoint [freedom from procedure-related serious adverse events (SAE)] was achieved in 87% (20/23) of FIRM group patients and 100% (24/24) of PVI group patients. Procedure related SAEs occurred in three patients in the FIRM group: 1 femoral artery aneurysm and 2 injection site hematomas. No additional procedure-related SAEs were reported &gt;7 days post-procedure. Conclusions These partial study effectiveness results reinforce the importance of PVI in paroxysmal atrial fibrillation patients and suggest that FIRM-guided ablation alone (without PVI) is not an effective strategy for treatment of paroxysmal AF in most patients. Further study is needed to understand the effectiveness of adding FIRM-guided ablation as an adjunct to PVI in this patient group. Acknowledgement/Funding Abbot

Bilateral left lateral ridge ablation increases the long-term success of patients ablated for atrial fibrillation.

Pulmonary vein isolation (PVI) is the cornerstone of catheter ablation in paroxysmal atrial fibrillation (PAF). Studies reported that the PVI single procedure was able to achieve durable sinus rhythm without the need of antiarrhythmic drugs in 60-80% of patients with PAF. In this study, we report data regarding bilateral left lateral ridge ablation for PAF. We retrospectively collected data of 120 consecutive patients (mean age 56 ± 10 years; 62% male) referred to our center to perform PVI. In 60 patients we performed PVI (group 1) and in 60 patients performed PVI and bilateral left lateral ridge ablation (group 2). All patients performed a clinical follow-up after 24 months from the ablation procedure. PVI was achieved in all patients. The mean radiofrequency time to perform ablation on the left atrial appendage ostium was 216 ± 49 s. In all patients of group 2 we obtained disappearance of local electrograms and the loss of local capture during pacing on posterior wall of left atrial appendage ridge. No significant differences were found between the two groups regarding mean contact force during ablation (14 ± 4 vs. 15 ± 4 g; groups 1 and 2, respectively, P = 0.34). At 24-month follow-up, single procedure success rate was significantly higher in group 2 compared with group 1 (88 vs. 74%, respectively; P = 0.03). No significant procedural complications were documented. Bilateral left lateral ridge ablation is a safe technique able to improve the success rate of PVI in patients with PAF.

Prophylactic pulmonary vein isolation during cavotricuspid isthmus ablation for atrial flutter: A meta-analysis.

Atrial arrhythmias (AA), including atrial fibrillation (AF), have been reported in patients after cavotricuspid isthmus (CTI) ablation for typical atrial flutter (AFL). Several studies have examined the effect of performing concomitant pulmonary vein isolation (PVI) with CTI on recurrent AA. These studies were analyzed to determine the overall effect of this approach on recurrent AA. PubMed and Google Scholar were searched for randomized trials comparing the incidence of AA after CTI versus CTI + PVI until June 2018. Only patients without prior history of AF were included in the recurrent AA analysis. All patients were included in the analyses of other clinical outcomes. Four randomized control trials were included in the meta-analysis. In the recurrent AA analysis, a total of 314 patients were randomized in the studies (n=158 CTI, n=156 CTI + PVI). Freedom from AA at 1 year was significantly higher in the CTI + PVI group versus CTI alone (odds ratio [OR] 0.25 [0.14, 0.44] 95% confidence interval [CI], P<0.00001). A total of 550 patients (n=336 CTI, n=214 CTI + PVI) were included in analyses for procedure time, fluoroscopy time, and complications rates. Procedure time and fluoroscopy time were significantly longer in the CTI + PVI group (mean difference [MD]: 103.31 min [94.40, 112.23] 95% CI, P<0.00001) and (MD: 16.47 min [14.89, 18.05] 95% CI, P<0.00001), respectively. Total complications were statistically similar between groups. This meta-analysis shows addition of a prophylactic PVI during CTI ablation significantly reduces recurrent AA at 1 year without significantly increasing major complications.

Changes in heart rate variability in patients with atrial fibrillation after pulmonary vein isolation and ganglionated plexus ablation.

Pulmonary vein isolation (PVI) is the cornerstone in the treatment of patients with paroxysmal atrial fibrillation (PAF). Some research has suggested studies have shown that modification of ganglionated plexuses (GP), performed with PVI, could lead to even better outcomes. The aim of this study was to determine the effect of PVI on the autonomic system. Heart rate variability (HRV) was used as a marker of autonomic system activity. Twenty-six PAF patients underwent PVI (PVI group) and twenty patients underwent PVI plus a GP ablation (GP group). In each group, 5 min long ECG signals obtained before and after the electrophysiology EP study were analyzed. Time and frequency domain parameters were evaluated. Vagal responses during ablation were observed in 15 (58 %) patients in the PVI group and in 12 (60 %) patients in the GP group. The change in normalized power in the low frequency (LF) and in the LF/HF ratio, before and after ablation, was statistically significant in both groups (LF/HF 2.6+/-1.6 before vs. 1.4+/-1.7 after ablation in PVI group and LF/HF 3.3+/-2.6 before vs. 1.8+/-1.9 after ablation in the GP group). Relative to heart rate variability parameters, there were no differences between PVI and PVI + plus GP ablation.

Renal sympathetic denervation improves clinical outcomes in patients undergoing catheter ablation for atrial fibrillation and history of hypertension: A meta-analysis.

Currently, there is limited data regarding the impact of adjunctive renal sympathetic denervation (RSDN) with pulmonary vein isolation (PVI) in hypertensive patients with atrial fibrillation (AF). A comprehensive literature search for studies comparing RSDN + PVI vs PVI alone for AF and history of hypertension until 1 January 2019 was performed. The results were expressed as risk ratio (RR) for the categorical variables and mean difference (MD) for the continuous variables with 95% confidence intervals (CIs). A total of six eligible (four randomized and two prospective nonrandomized) studies consisting of 432 patients (306 paroxysmal AF and 126 persistent AF) were included (RSDN + PVI group: 186 patients and PVI group: 246 patients). Follow-up is more than or equal to 1 year. Compared with PVI, RSDN + PVI significantly decreased the risk of AF recurrence (RR = 0.58, 95% confidence interval [CI] = 0.47-0.72, P < 0.00001) on follow-up. Fluoroscopy (MD = +5.53 minutes, 95% CI = 0.76-10.31, P = 0.02) and procedure time (MD = +34.85 minutes, 95% CI = 23.55-46.16, P < 0.00001) was significantly longer with the PVI + RSDN group compared with PVI alone. There were no significant differences in complications between both groups. Test of heterogeneity was low for all clinical outcomes (I2 = 0%). Our meta-analysis demonstrates that RSDN as an adjunct to PVI appears to be safe and improves clinical outcomes in both paroxysmal and persistent AF and history of hypertension.

Ganglionated plexi ablation with pulmonary vein isolation after testing dormant pulmonary vein conduction and excluding non-pulmonary triggers in patients with paroxysmal atrial fibrillation

Background. Pulmonary vein isolation (PVI) is the gold standard of interventional atrial fibrillation (AF) treatment, however, it doesn't provide a stable clinical effect and durable PVI in the long-term follow-up due to reconnections within the ablation line. To increase the efficacy of surgery, modulation of the autonomic nervous system can be combined with pulmonary vein isolation.Aim. The study was focused on the evaluation of efficacy of ganglionated plexi (GP) ablation combined with PVI, and intraoperative drug testing of dormant pulmonary vein conduction and exclusion of non-pulmonary vein triggers in patients with paroxysmal atrial fibrillation.Methods. There hundred sixty-seven patients with paroxysmal AF scheduled for catheter ablation were initially screened. PVI was performed in all patients. After testing with adenosine triphosphate and isoprenaline for dormant conduction following PVI and exclusion of non-pulmonary vein triggers, 194 patients with a positive response to high-frequency stimulation in the main GP sites of the left atrium were randomized in two groups: PVI (group I, n = 97), PVI with anatomical GP ablation (group II, n = 97). To perform continuous ECG monitoring, 53 patients received implantable cardiac monitors. The primary endpoint of the study was the freedom from any atrial tachyarrhythmias after 12 months of follow- up as recorded by 24-hour Holter monitoring. The secondary endpoints included AF burden based on implantable cardiac monitors data and predictors of AF recurrences. The patients were followed 3, 6, 9, 12 months after the ablation procedure.Results. The mean follow-up was 12.5±2.2 months. By the end of the follow-up, 79 (81.4%) patients in the PVI with GP ablation group and 58 (59.8%) patients in the PVI only group were free from any atrial tachyarrhythmia (р=0.0012; log-rank test, HR 0.41, 95% CI [0.23–0.72], р=0.002; Cox regression). Implantable cardiac monitors data revealed that AF burden was significantly lower in the PVI with GP group as compared with the PVI only group (14.8±1.7% and 5.4±0.7%, р&lt;0.001). According to the multivariable regression analysis, the independent predictors of AF recurrences were AF duration and presence of diabetes mellitus, while GP ablation reduced the risk of AF recurrence by 61%.Conclusion. Ganglionated plexi ablation combined with pulmonary vein isolation confirmed by testing dormant conduction and excluding non-pulmonary triggers provides higher efficacy in maintaining the sinus rhythm as compared with PVI only in patients with paroxysmal atrial fibrillation. Received 17 July 2018. Revised 7 August 2018. Accepted 10 August 2018. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and study design: Yu.S. Krivosheev, L.I. Vilenskiy, V.N. KolesnikovData collection and analysis: Yu.S Krivosheev, D.I. Bashta, A.A. SimonyanDrafting the article: Yu.S. Krivosheev, A.A. Simonyan, D.I. Bashta, S.Yu. KrasilnikovaCritical revision of the article: V.N. KolesnikovFinal approval of the version to be published: Yu.S. Krivosheev, D.I. Bashta, A.A. Simonyan, S.Yu. Krasilnikova, L.I. Vilenskiy, T.A. Myznikova, Z.A. Mishodzheva, V.N. Kolesnikov

Age- and Obesity-related Epicardial Adipose Tissue Accumulation Remodels Autonomic Balance in Paroxysmal Atrial Fibrillation Patients - Analysis of Heart Rate Variability

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.

Diabetes mellitus and atrial remodelling in patients with paroxysmal atrial fibrillation: Role of electroanatomical mapping and catheter ablation.

Complex fractionated atrial electrograms (CFAEs) are related to atrial fibrosis, but their ablation has not yet shown superiority. The aim of the study was to compare, in terms of clinical outcome, two strategies of paroxysmal atrial fibrillation (AF) ablation in patients with type 1 diabetes mellitus (DM): pulmonary vein isolation (PVI) vs. PVI + CFAEs. Compared to an historical population of patient with paroxysmal AF and without DM, a higher percentage of patients with DM showed more than 25% of atrial area interested by CFAEs (study population, 58% vs historical group, 15%; p < 0.05). In PVI group, recurrences rate was similar in patients with HbA1c ⩽ 7.5% vs HbA1c > 7.5% (30% vs 22%; p = not significant), but a greater AF burden was observed in patients with HbA1c > 7.5% (6 ± 2 vs 1 ± 2; p < 0.05). In hazard ratios analysis PVI+CFAEs seems more effective than PVI alone in patients with HbA1c > 7.5% (hazard ratio, 1.28; p < 0.05), more than 25 years from DM diagnosis (hazard ratio, 1.25; p < 0.05) and more than five AF episodes/year (hazard ratio, 1.2; p < 0.05). Type 1 DM patients had complex atrial 'substrate', as documented by wider CFAEs areas. Despite this, 1-year follow-up recurrence rate was similar between two ablation approaches (PVI 27% vs. PVI+CFAEs 21%; p = not significant). In our study, only specific subgroups, like patients with disglycaemic state (HbA1c > 7.5%), long diabetes mellitus history and high AF burden, benefit from PVI+ CFAEs approach.

Pulmonary vein isolation alone and combined with renal sympathetic denervation in chronic kidney disease patients with refractory atrial fibrillation

BackgroundAtrial fibrillation (AF) commonly occurs in association with chronic kidney disease (CKD), resulting in adverse outcomes. Combining pulmonary vein isolation (PVI) and renal sympathetic denervation (RSD) may reduce the recurrence of AF in patients with CKD and hypertension. We considered that RSD could reduce the recurrence of AF in patients with CKD by modulating sympathetic hyperactivity. Our goal was to compare the impact of PVI + RSD with that of PVI alone in patients with concurrent AF and CKD. MethodsThis was a single-center, prospective, longitudinal, randomized, double-blind study. Forty-five patients with controlled hypertension, symptomatic paroxysmal AF and/or persistent AF, stage 2 or 3 CKD, and a dual-chamber pacemaker were enrolled from January 2014 to January 2015. We assessed the 30-second recurrence of AF recorded by the pacemaker, 24-hour ambulatory blood pressure measurements, estimated glomerular filtration rate, albuminuria, echocardiographic parameters, and safety of RSD. ResultsNo patient developed procedural or other complications. The ambulatory blood pressure measurements did not differ within the PVI + RSD group or between the PVI + RSD and PVI groups throughout the study. Significantly more patients in the PVI + RSD group than in the PVI group were free of AF at the 12-month follow-up evaluation. The PVI group had an unacceptable response to ablation with respect to changes in echocardiographic parameters, whereas these parameters improved in the PVI + RSD group. ConclusionPVI + RSD were associated with a lower AF recurrence rate than PVI alone; it also improved renal function and some echocardiographic parameters. These encouraging data will serve as baseline information for further long-term studies on larger patient populations.

Efficacy of Left Atrial Voltage-Based Catheter Ablation of Persistent Atrial Fibrillation.

Low-voltage zones (LVZs) represent fibrotic tissue and are substrates for atrial fibrillation (AF). We hypothesized that LVZ-based substrate modification along with pulmonary vein isolation (PVI) would improve outcomes in persistent AF (PeAF) patients with LVZs, whereas PVI alone would work in patients without LVZs. Voltage mapping of the left atrium (LA) was performed during sinus rhythm in 101 PeAF patients in whom LVZ was defined as an area with bipolar electrograms <0.5 mV. Thirty-nine patients had LVZs and underwent ablation of the entire LVZ area after PVI (LVZabl group). In the remaining 62 patients without LVZs, PVI alone was performed with no further substrate modifications (PVI group). An additional group of 16 consecutive PeAF patients with LVZ did not undergo any substrate modification after PVI and were used as a comparison group (LVZnon-abl group) despite having similar size of LVZs to that in the LVZabl group. After a single session, 28 (72%) patients in the LVZabl group had no recurrence, whereas 49 (79%) patients in the PVI group had no recurrence during 18 ± 7 months of follow-up (log-rank, P = 0.400). In the LVZnon-abl group, only 6 patients (38%) had no recurrence during 32 ± 7 months of follow-up, even after a mean number of sessions of 1.8 (log-rank, P < 0.001, compared with the LVZabl group). Additional LVZ-based substrate modification after PVI improved the outcome in PeAF patients with LVZs, whereas PVI alone worked in patients without LVZs, even in those with PeAF.

Linear Ablation Following Pulmonary Vein Isolation in Patients with Atrial Fibrillation: A Meta-Analysis.

Previous studies have given conflicting data regarding the long-term adjunctive efficacy of linear lesions (LLs) on top of pulmonary vein isolation (PVI) as an ablation strategy in patients with atrial fibrillation (AF). The aim of this meta-analysis was to provide a detailed analysis of the available randomized controlled trials (RCTs) regarding the efficacy of LL following PVI in AF patients. Current databases were searched until October 2015. The primary outcome end point of the meta-analysis was recurrence of any symptomatic or documented episode of AF or atrial tachycardia after a single ablation procedure with or without the use of antiarrhythmic drugs. Ten RCTs with a total of 1,446 patients were included in the meta-analysis. The pooled analysis of five trials concerning persistent AF (PeAF) patients (400 in PVI plus LL group and 182 in PVI alone group) suggested that the addition of LL following PVI does not lead to a significant reduction in recurrent atrial tachyarrhythmias compared with PVI alone (relative ratio [RR] = 0.73, 95% confidence interval [CI]: 0.44-1.21, P = 0.22). Similarly, there was no incremental benefit of additional LL in long-term outcomes in paroxysmal AF (PAF) patients (RR = 0.85, 95% CI: 0.68-1.05, P = 0.13). Pooling the results of all eligible trials suggested that PVI plus LL compared with PVI alone significantly increased radiofrequency time (P = 0.0002), fluoroscopy time (P < 0.00001), and procedure time (P < 0.0001). This meta-analysis suggests that LL following PVI does not provide additional benefit to sinus rhythm maintenance in patients with PeAF and PAF.

The impact of B-type natriuretic peptide levels on the suppression of accompanying atrial fibrillation in Wolff-Parkinson-White syndrome patients after accessory pathway ablation

BackgroundAtrial fibrillation (AF) often coexists with Wolff-Parkinson-White (WPW) syndrome. We compared the efficacy of Kent bundle ablation alone and additional AF ablation on accompanying AF, and examined which patients would still have a risk of AF after successful Kent bundle ablation. MethodsThis retrospective multicenter study included 96 patients (56±15 years, 72 male) with WPW syndrome and AF undergoing Kent bundle ablation. Some patients underwent simultaneous pulmonary vein isolation (PVI) for AF. The incidence of post-procedural AF was examined. ResultsSixty-four patients underwent only Kent bundle ablation (Kent-only group) and 32 also underwent PVI (+PVI group). There was no significant difference in the basic patient characteristics between the groups. Additional PVI did not improve the freedom from residual AF compared to Kent bundle ablation alone (p=0.53). In the Kent-only group, AF episodes remained in 25.0% during the follow-up (709 days). A univariate analysis showed that age ≥60 years, left atrial dimension ≥38mm, B-type natriuretic peptide (BNP) ≥40pg/ml, and concomitant hypertension were predictive factors for residual AF. However, in the multivariate analysis, only BNP ≥40pg/ml remained as an independent predictive factor (HR=17.1 and CI: 2.3–128.2; p=0.006). ConclusionsAmong patients with WPW syndrome and AF, Kent bundle ablation alone may have a sufficient clinical impact of preventing recurrence of AF in select patients. Screening the BNP level would help decide the strategy to manage those patients.

Fluoroscopy integrating technology in a 3D mapping system during ablation of atrial arrhythmias: first experiences.

IntroductionAblation of the cavotricuspid isthmus (CTI) in patients with atrial flutter (AFL) and pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF) are both common therapies. As the demand for ablative treatments rises, total radiation exposure times of staff increase concomitantly. Here, we report on our first experiences with a new fluoroscopy integrating system (FIS) integrated into a current 3D mapping system (3DMS).Material and methodsThe study population consisted of 59 consecutive patients who underwent PVI or CTI ablation (26 and 33 patients with and without FIS respectively). Total procedure time (PT), fluoroscopy exposure time (FT) and dose-area product (DAP) were monitored.ResultsAll procedures were successfully completed without major complications. Employing FIS in the PVI group, FT and DAP were both significantly reduced after completing a short learning curve of 6 cases (respectively 361.6 ±181 s vs. 530.3 ±156.7 s, p = 0.039; 801.9 ±439.15 cGycm² vs. 1495 ±435.2 cGycm², p = 0.002). Mean PT was not significantly affected (121 ±26.7 min vs. 135.6 ±23.2 min, p = 0.21). The same holds true for CTI ablation: FT (99.29 ±51.4 s vs. 153.9 ±76.6 s, p = 0.022) and DAP (269 ±128.7 cGycm² vs. 524.3 ±288.4 cGycm², p = 0.002) were significantly reduced, leaving PT not significantly affected (29.5 ±10 min vs. 35.2 ±16.3 min, p = 0.23).ConclusionsThe introduction of the new FIS with a current 3DMS results in a significant reduction of both the total FT and DAP without affecting PT. The initial learning curve for adopting this method is considerably short.

Impact of Complete Versus Incomplete Circumferential Lines Around the Pulmonary Veins During Catheter Ablation of Paroxysmal Atrial Fibrillation: Results From the Gap-Atrial Fibrillation-German Atrial Fibrillation Competence Network 1 Trial.

Ablation of atrial fibrillation (AF) is an established treatment option for symptomatic patients. It is not known whether complete pulmonary vein isolation (PVI) is superior to incomplete PVI with regard to the patients' clinical outcome. Patients with drug-refractory, symptomatic paroxysmal AF were randomly assigned to either incomplete (group A) or complete PVI (group B). In group A, a persistent gap was intentionally left within the circumferential ablation line, whereas in group B, complete PVI without any gaps was intended. At 3 months, all patients underwent invasive reevaluation to assess the rate of persistent PVI. Clinical follow-up was based on daily 30-s transtelephonic ECG transmissions. Primary study end point was the time to first recurrence of (symptomatic or asymptomatic) AF. A total of 233 patients were enrolled (116 in group A and 117 in group B). AF recurrence within 3 months was observed in a total of 161 patients (136 [84.5%] with symptomatic and 25 [15.5%] with asymptomatic AF); AF recurred in 62.2% of group B patients and 79.2% of group A patients (P<0.001), for a difference in favor of complete PVI of 17.1% (95% confidence interval, 5.3%-28.9%). Invasive restudy in 103 group A patients and 93 group B patients revealed conduction gaps in 92 (89.3%) and 65 (69.9%) patients, respectively. This study proves the superiority of complete PVI over incomplete PVI with respect to AF recurrence within 3 months. However, the rate of electric reconduction 3 months after PVI is high in patients with initially isolated PVs. URL: http://clinicaltrials.gov; Unique identifier: NCT00293943.

Abstract 18649: Long-term Outcome and the Mechanisms of Pulmonary Antrum Radial-linear Ablation in Patients With Paroxysmal Atrial Fibrillation

Objectives: The aim of this study was to determine the mechanisms and effectiveness of pulmonary antrum radial-linear (PAR) ablation in comparison with pulmonary vein isolation (PVI) in patients with paroxysmal atrial fibrillation (AF) after a long-term follow-up. Background: The one-year follow up data suggested that PAR ablation appeared to have a better outcome over the conventional PVI for paroxysmal AF. Methods: The enrollment occurred between March, 2011, and August, 2011, with the last follow-up in May, 2014. A total of 133 patients with documented paroxysmal AF were enrolled from 5 centers and randomized to PAR group or PVI group. Event ECG recorder and Holter monitoring were conductedduring the follow-up for all patients. Results: The average procedure time was 151±23 min in PAR group and 178±43 min in PVI group ( P &lt;0.001). The average fluoroscopy time was 21±7 min in PAR group and 27±11 min in PVI group ( P= 0.002). AF triggering foci were eliminated in 59 patients (89.4%) in PAR group, whereas, only 4 patients (6.0%) in PVI group (P&lt;0.001).At median 36 (37-35) months of follow-up after single ablation procedure, 43 of 66 patients in PAR group (65%) and 28 of 67 patients in PVI group (42%) had no recurrence of AF off antiarrhythmic drug (AAD) (P=0.007); and 47 of 66 patients in PAR group (71%) and 32 of 67 patients in PVI group (48%) had no recurrence of AF with AAD (P=0.006). At the last follow-up, the burden of AF was significantly lower in PAR group than in PVI group (0.9% ± 2.3% vs 4.9% ± 9.9%;90th percentile, 5.5% vs 19.6%; P=0.008). No major adverse event (death, stroke, PV stenosis) was observed in all the patients except one case of pericardial tamponade. Conclusions: PAR ablation is a simple, safe, and effective strategy for the treatment of paroxysmal AF with better long-term outcome than PVI. PAR ablation might exhibit the beneficial effect on AF management through multiple mechanisms. Registration: ChiCTR-TRC-11001191

Adenosine triphosphate-guided pulmonary vein isolation for atrial fibrillation: the UNmasking Dormant Electrical Reconduction by Adenosine TriPhosphate (UNDER-ATP) trial.

Most of recurrent atrial tachyarrhythmias after pulmonary vein isolation (PVI) for atrial fibrillation (AF) are due to reconnection of PVs. The aim of the present study was to evaluate whether elimination of adenosine triphosphate (ATP)-induced dormant PV conduction by additional energy applications during the first ablation procedure could reduce the incidence of recurrent atrial tachyarrhythmias. We randomly assigned 2113 patients with paroxysmal, persistent, or long-lasting AF to either ATP-guided PVI (1112 patients) or conventional PVI (1001 patients). The primary endpoint was recurrent atrial tachyarrhythmias lasting for >30 s or those requiring repeat ablation, hospital admission, or usage of Vaughan Williams class I or III antiarrhythmic drugs at 1 year with the blanking period of 90 days post ablation. Among patients assigned to ATP-guided PVI, 0.4 mg/kg body weight of ATP provoked dormant PV conduction in 307 patients (27.6%). Additional radiofrequency energy applications successfully eliminated dormant conduction in 302 patients (98.4%). At 1 year, 68.7% of patients in the ATP-guided PVI group and 67.1% of patients in the conventional PVI group were free from the primary endpoint, with no significant difference (adjusted hazard ratio [HR] 0.89; 95% confidence interval [CI] 0.74-1.09; P = 0.25). The results were consistent across all the prespecified subgroups. Also, there was no significant difference in the 1-year event-free rates from repeat ablation for any atrial tachyarrhythmia between the groups (adjusted HR 0.83; 95% CI 0.65-1.08; P = 0.16). In the catheter ablation for AF, we found no significant reduction in the 1-year incidence of recurrent atrial tachyarrhythmias by ATP-guided PVI compared with conventional PVI.

Does left atrial appendage closure improve the success of pulmonary vein isolation? Results of a randomized clinical trial.

The combination of left atrial appendage (LAA) occlusion with pulmonary vein isolation (PVI) potentially represents a comprehensive treatment for atrial fibrillation (AF), controlling symptoms while at the same time reducing the risk of stroke and the need for chronic anticoagulation. The aim of this randomized clinical trial was to assess the impact of LAA closure added to PVI in patients with high-risk AF. Patients with a history of symptomatic paroxysmal or persistent AF refractory to ≥ 2 antiarrhythmic drugs, CHA2DS2-VASc score ≥ 2, and HAS-BLED score ≥ 3 were randomized to PVI-only (n = 44) or PVI with LAA closure (n = 45). Six patients in PVI + LAA closure group crossed over to PVI-only group due to failure of LAA closure device implantation. On-treatment comparisons at the 24 month follow-up revealed that 33 (66%) of the 50 PVI group and 23 (59%) of the 39 PVI with LAA closure group were AF-free on no antiarrhythmic drugs (p = 0.34). The PVI + LAA closure treatment was significantly associated with a higher AF burden during the blanking period: 9.7 ± 10.8 vs 4.2 ± 4.1% (p = 0.004). At the end follow-up, there were no serious complications and no strokes or thromboembolic events in either group. The combination of LAA closure device implantation with PVI was safe but was not observed to influence the success of PVI in patients with symptomatic refractory AF. Early AF after ablation, however, is increased by LAA closure. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01695824.

Pulmonary vein triggers play an important role in the initiation of atrial flutter: Initial results from the prospective randomized Atrial Fibrillation Ablation in Atrial Flutter (Triple A) trial.

The incidence of atrial fibrillation (AF) after ablation of a cavotricuspid isthmus (CTI)-dependent atrial flutter (AFL) is high. The purpose of this study was to test the hypothesis that AFL and AF may be initiated by pulmonary vein triggers. This prospective randomized trial tested the efficacy of a standalone pulmonary vein isolation (PVI) in patients with AFL but without AF. Patients with AFL but without documented AF were randomly assigned to 1 of 3 treatment groups: (1) antiarrhythmic drugs (AAD), (2) CTI ablation, or (3) circumferential PVI. The primary end-point was defined as any recurrent atrial tachyarrhythmia and the secondary end-point as recurrence of AFL. In case of tachyarrhythmia recurrence in the PVI group, a second PVI was performed to close gaps in the ablation lines. Of the 60 patients, 17 were randomized to AAD, 23 to CTI ablation, and 20 to PVI. During follow-up of 1.42 ± 0.83 years, 14 of 17 patients (82.4%) in the AAD group, 14 of 23 patients (60.9%) in the CTI group, and 2 of 20 patients (10%) in the PVI group reached the primary end-point (P <.001) after a mean of 1.4 PVI procedures per patient. AFL reoccurred in 9 patients (52.9.%) in the AAD group, in 2 patients (8.7%) in the CTI group, and after a single PVI in 3 patients (15%) in the PVI group (P = .003). After closure of gaps, 1 patient (5%) in the PVI group presented with recurrent AFL. Pulmonary vein triggers play an important role in AFL. PVI can prevent the recurrence of AFL, even without CTI ablation.

Efficacy and safety of novel epicardial circumferential left atrial ablation with pulmonary vein isolation in sustained atrial fibrillation.

The aim of this study was to examine the efficacy and safety of this novel epicardial circumferential left atrial ablation (CLAA) with pulmonary vein isolation (PVI) in sustained atrial fibrillation (AF). Thirty domestic pigs were divided equally into 3 groups: AF without ablation (AF group), AF with PVI (PVI group), and AF with CLAA and PVI (CLAA+PVI group). AF was induced by rapid atrial pacing. After AF was induced, CLAA and PVI were performed for pigs in CLAA+PVI group, and PVI was performed for pigs in PVI group. AF vulnerability, AF duration, and histology were performed in all groups. All pigs developed sustained AF after 6.27±0.69weeks of rapid atrial pacing. All pigs successfully underwent isolated PVI or CLAA with PVI on the beating heart in PVI group or CLAA+PVI group. Isolated PVI terminated AF in 3 of 20 pigs (15%), and CLAA with PVI terminated AF in 5 of 8 pigs (62.5%, P=0.022). Compared with AF group (10/10), the incidence of sustained AF by burst pacing was significantly decreased in PVI group (3/10, P=0.003) or CLAA+PVI group (0/10, P<0.001). There was no significant difference between PVI group and CLAA+PVI group (P=0.211). AF duration was significantly decreased in CLAA+PVI group (734.70±177.81s, 95% CI 607.51-861.89) compared with PVI group (1217.90±444.10s, 95% CI 900.21-1535.59, P=0.008). Also, AF duration was significantly decreased in PVI group (P=0.003) or CLAA+PVI group (P<0.001) in comparison with AF duration in AF group (average 1800s). Epicardial CLAA could ablate the left atrial roof and posterior wall together safely and reliably. Compared with PVI alone, CLAA with PVI may be able to improve the rate of acute termination of persistent AF. It may be useful in selecting the best ablation approaches for patients with persistent AF.