Pulmonary Vein Isolation Procedure Research Articles

How to easily detect residual conduction gaps in redo procedure of pulmonary vein isolation: Post Encircling Mapping (PEM)

Abstract Background Pulmonary vein isolation (PVI) is the cornerstone of the interventional catheter-based treatment of atrial fibrillation. Unfortunately, persistent pulmonary vein isolation is difficult to achieve, and up to 70% of pulmonary vein reconnection rate has been documented (1). Atrial mapping during pacing from CS in combination with LAT (local activation time) mapping may help to identify these residual gaps (2). Methods We collected data from consecutive radiofrequency (RF) redo PVI procedures performed in our center from 01/01/2022 to 01/10/2023. Re-isolation was obtained based on bipolar map and Local Activation Time (LAT) map during pacing from distal coronary sinus (CS) -table 1 for the workflow-. We compared data obtained from analysis of bipolar maps and LAT maps; "discrepancy" between bipolar map and LAT map was defined as a difference which may lead to a different approach to the ablation strategy (figure 1); then, we compared procedural timing (radiofrequency time, fluoroscopy time, and skin-to-skin time) with our historical cohort of RF redo PVI procedures (01/01/2011 – 31/12/2021). Results We performed 34 radiofrequency redo procedure from 01/01/2022 to 01/10/2023. In 13 out of 112 veins treated (11.6%), we observed discrepancy between bipolar map and LAT map. We observed a lower radiofrequency time for patients treated on the basis of LAT map (01-01-2022 – 01-10-2022) when compared with our historical cohort (1023.21 ± 521.51 sec vs 1358.50 +/- 746.53 sec, p= 0.038); no differences were found in terms of skin-to-skin time and fluoroscopy time. Conclusions To perform a LAT map during pacing from distal CS may help to better identify residual gaps in redo AF procedures, allowing a reduction in radiofrequency time, without increasing skin to skin time and fluoroscopy time.Discrepancy between bipolar and LAT map

Pulmonary vein isolation durability in patients undergoing very high-power short-duration temperature-controlled ablation

Abstract Background The very high-power short-duration (90W for 4 s) temperature-controlled ablation (vHPSD) improves the efficiency of pulmonary vein (PV) isolation procedures. However, atrial fibrillation (AF) recurrences directly related to PV reconnections are still a concern. Purpose The purpose of the current study was to assess PV lesion durability in patients undergoing a reablation procedure. Methods From September 2020 to July 2023, 327 patients with paroxysmal and persistent AF underwent first ablation aiming at PVI using vHPSD. During a mean follow-up of 25±11 months, 48 patients (14.7%) had an AF recurrence. Patients with reablation procedures were retrospectively consented and enrolled. Results Eighteen patients were included in this study. A PV reconnection was observed in 15/72 (21%) PVs, with a mean number of reconnected PV per patient of 0.8 ±0.7. In 7 patients no PV reconnection was observed, one PV reconnected was observed in 9 patients and 2 PVs in 3 patients. A PV reconnection was observed in 8/18 (44%) left superior PV, 1/18 (6%) left inferior PV, 3/18 (17%) right superior PV, and 3/18 (17%) right inferior PV (p=0.03). Conclusions PV isolation performed with vHPSD is highly effective and is associated with a low rate of late PV reconnection. A higher percentage of PV reconnection was observed in the left superior PV.

Focal pulsed field ablation for organised atrial tachyarrhythmias: one to rule them all

Abstract Background Focal pulsed field ablation (fPFA) has emerged as a versatile and innovative strategy for ablating atrial tachyarrhythmias (1). The primary objective of this study is to present the short-term safety characteristics, feasibility and procedural outcomes of fPFA in the management of organised atrial tachyarrhythmias. This report focuses on the commercial use of an innovative pulsed field ablation (PFA) generator, utilized in conjunction with commercially available focal, solid-tip ablation catheters, and complemented by 3D electro-anatomical mapping (3D-EAM). Methods Patients with organised atrial tachycardia treated using fPFA between August 2022 and September 2023 at our center were included in this retrospective analysis. Tachycardia mechanisms were identified with high-definition, multi-electrode mapping catheter paired with 3D-EAM system. Ablation lines, when targeting macro-reentrant arrhythmias were strategicaly positioned to adress critical isthmi when recognised or they were empirically placed between the anatomical obstacles ( including LA roof, anterior, mitral isthmus, upper septal and cavotricuspid line as deemed appropriate). Positioning of the fPFA catheter was guided by 3D-EAM, intracardiac ultrasound, and fluoroscopy (Figure 1). Bidirectional block verification was performed using standard criteria to assess acute procedural success. Glyceryl trinitrate boluses were administered prior to ablation in proximity to coronary arteries. Results In a cohort of 36 patients (median age 62 years; 12 females), we effectively mapped and treated a total of 51 distinct organised atrial tachyarrhythmias. These included 18 typical flutters, 3 roof-dependent macro-reentries, 4 posterior-wall micro-reentries, 15 peri-mitral macro-reentries, 8 anterior-wall micro-reentries and 3 biatrial macro-reentries via Bachman bundle. Our ablation strategy involved creating 21 cavotricuspid isthmus lines, 3 roof lines, 18 posterior wall lines, 11 anterior lines, 8 septal lines, and 15 mitral isthmus lines (Figure 2). Impressively, first-pass acute isolation with bidirectional block was achieved in 93% (54 of 58) of isthmus ablations and 94% (17 of 18) of left posterior wall lines. No ST segment alterations or other complications were observed during the periprocedural period. Conclusion In our cohort fPFA proved as a feasible, effective, and safe approach for treating organised atrial tacharrhythmias. The primary reason for designating this setup as our preferred choice for redo procedures lies in its versatility in addressing a wide range of arrhythmias. As ultra-fast pulmonary vein isolation (PVI) procedures become more prevalent with the expansion of PFA, the demand for an ideal setup capable of effectively targeting various substrates will become even more pronounced (2). Notably, our findings suggest superior suitability and efficacy when compared to bulkier, single-shot design PFA devices (3).Figure 1Figure 2

Treatmen of atrial fibrillation with cryoballoon pulmonary vein isolation - results of a 5-year follow-up

Abstract Background Atrial fibrillation is the most common arrhythmia in the general population and cryoballoon ablation is gradually becoming a first-line treatment. However, data regarding long-term outcomes after this procedure are still lacking. Aim The goal was to show the results of a long-term follow-up following the cryoballoon pulmonary vein isolation in patients with atrial fibrillation (AF). Methods A total of 126 patients were included in the study of which 77.0% had paroxysmal atrial fibrillation (PAF). Successful treatment outcome was defined as AF recurrence-free survival with stabile sinus rhythm during 5 years after the procedure. A treatment failure was defined as symptomatic AF recurrence with ECG verification (12 lead ECG or AF lasting >30s by Holter EKG). The patients on antiarrhythmic therapy and those who underwent a redo pulmonary vein isolation procedure were also included. Results Following cryoballoon pulmonary vein isolation in a 5-year period 52.4% of patients were in stable sinus rhythm without AF recurrence. With redo pulmonary vein procedures a total of 61.9% of patients were without AF recurrence. Together with antiarrhythmic drugs 57.9% of patients were in sinus rhythm without AF recurrence in a 5-year period. With redo pulmonary vein isolation and antiarrhythmic drugs a total of 73.8% of patients were without AF recurrence. There was a statistically significant difference regarding AF recurrence between patients who underwent redo pulmonary vein isolation and those who did not (p=0.006). In patients with PAF, 62.9% remained without AF recurrence, and 79.4% underwent a redo procedure. In patients with persistent atrial fibrillation (PersAF), 41.4% were without AF recurrence, and 55.1% underwent a redo procedure. The difference between PAF and PersAF was statistically significant (p=0.009). Conclusion Data from our center show good long-term results of cryoballoon pulmonary vein isolation in patients with atrial fibrillation. The procedure is especially successful in patients with PAF.1 The use of redo procedures is justified as it increases the long-term success rate.

Intelligent filter to remove artifact during cryo freezing for pulmonary vein isolation increases the time window for observation of time of isolation

Abstract Introduction Time to pulmonary vein isolation (PVI) during cryo balloon (CB) PVI is a critical data point in characterizing the pulmonary vein (PV) isolation status as it improves clinical outcomes. PV potentials on the circular mapping catheter may be obscured by power line artifact during the freeze process as ice forms near the electrode. This study assesses the ability of an intelligent digital filter to sample, predict and remove noise from PV electrograms during the freeze cycle to increase the time window available to observe the abolition of PV potentials. Method An intelligent filter that detects and removes power line related signal artifact was developed. The filter algorithm was then retrospectively applied to electrograms collected during delivery of cryo energy in the PVISION trial of the PVI Analyzer study previously described. The PV potential amplitude immediately before the delivery of cryo energy was recorded. During the freeze cycle, artifact amplitude was measured and the time required for the noise to exceed that of the original PV potential recorded. This operation was repeated with the application of the predictive filter. An example of an analysis of a single bipolar trace is shown in Fig 1. Results The PVISION trial included 47 patients who underwent a cryo PVI procedure (42% female, mean age 59 years, +/- 11 years). Of those, 24 cases and 68 vein cryo applications had sufficient information about when the cryo freeze cycle started and ended. Of these 68 veins treated, 33 exhibited power line noise on one or more bipolar traces during the freeze cycle (49%). The mean amplitude of PV potentials before application of energy was 0.49 mV (+/- 0.79 mV) and the mean time to artifact exceeding this level was 69 (+/-50 seconds), across all bipolar traces with freeze noise present. After application of the intelligent filter, the mean time to artifact exceeding the baseline PV amplitude increased to 82 seconds (+/- 57 seconds), across all bipolar traces with freeze noise present. In 44 veins noise amplitude never exceeded PV potential amplitude on any of the bipolar traces during the freeze after application of the intelligent filter. Paired analysis of the average time of noise exceeding the PV potential amplitude during the freeze was 116 s before application of the filter and 26 s with the filter applied. See Fig 2. for a summary of the results. Conclusion An intelligent digital filter designed to remove artifact from electrograms during cryo ablation procedures might increase the time window before noise saturates PV potentials and, in some cases, remove noise such that it never exceeds that of the PV potential.Fig 1 Example of noise and filteringFig 2. Summary of results

Validating peak frequency mapping for atrial far-field electrogram detection: insights from a pulmonary vein isolation model

Abstract Introduction Effective pulmonary vein isolation (PVI) is the cornerstone of AF ablation, and conduction block from the atrium to the pulmonary veins (PV) is the accepted method to demonstrate it. However, far-field electrograms may make challenging to establish whether PVI has been achieved. Purpose This study aimed to evaluate whether peak frequency (PF) mapping can effectively identify far-field electrograms in the superior PVs following a redo PVI procedure. Methods Left atrium and PV activation and voltage bipolar 3D electroanatomical maps were generated using a steerable catheter with a 16-grid-patterned electrode configuration (HD-Grid) during coronary sinus pacing, both before and after the redo PVI. PF maps were developed offline using specialized experimental software. Only reconnected superior PVs from the redo PVI procedure were included in the analysis. Results Twenty consecutive patients (mean age 63±12 years, 12 male) were prospectively enrolled in the study, with 15 presenting reconnected PVs after the redo PVI. Conduction gaps were identified in the superior PVs of 9 patients (7 in the left superior PV, 5 in the right superior PV). Following the redo PVI, both voltage (0.96±1.1 mV vs. 0.49±1.21, P<0.01) and PF (285±134 vs. 153±112 Hz, P<0.001) were significantly reduced in both superior PVs. This reduction was more prominent in the right superior PV (0.83±0.75 vs. 0.20±0.39 mV, 299±159 vs. 132±116 Hz) than in the left superior PV (1.08±1.32 vs. 0.83±1.67 mV, 272±105 vs. 178±101 Hz). High-voltage (>0.3 mV) electrograms remained prevalent in the right (12%) and left (37%) superior PVs after the redo PVI. However, high PF (>250 Hz) electrograms significantly decreased following PVI in both the right (64% before vs. 6% after PVI) and left (66% before vs. 22% after PVI) PVs. Only a small percentage (5.3% in the right PV and 12% in the left PV) of all electrograms exhibited both high voltage and high PF following the PVI (see figure). Conclusion PF mapping proves to be a valuable tool in distinguishing far-field electrograms from atrial activity in the PVs, offering additional insights to complement voltage mapping, particularly in the context of redo PVI procedures.

Single versus double transseptal puncture for pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation - insights from "Go for Zero Fluoroscopy" registry

Abstract Background Transseptal puncture is one of the most challenging steps in catheter ablation of atrial fibrillation (AF) because of the potential risk of complication. While single TSP reduces the puncture-related risk, double TSP simplifies the procedure (immediate signal visualization in pulmonary veins, avoidance of multiple changes of catheters through the single sheath). The purpose of this study was to analyze the impact of single versus double TSP during pulmonary vein isolation (PVI) with radiofrequency (RF) catheter ablation for AF on the fluoroscopy usage and procedure time. Methods Data reported from the international, multicenter prospective „Go For Zero Fluoroscopy Registry" performed in years 2018–2019 were analyzed. Overall 25 European electrophysiology centers from 14 countries and up to 5 operators from each center were enrolled. Only isolated PVI procedures were analyzed. Results A total data of 393 PVI RF procedures were collected from 25 centers. The median dose-area-product (DAP), fluoroscopy time and overall procedure time were: 810 (325 – 1839) cGy*cm2, 8 (4 – 14) minutes and 124 (92 – 168) minutes, respectively. Single TSP was associated with significantly higher DAP: 984 (459 – 1939) vs 667 (227 – 1469) cGy*cm2 (p=0.002), longer fluoroscopy time: 11 (6 – 19) vs 6 (3 – 11) minutes (p<0.001) and longer overall procedure time: 133 (103 – 168) vs 110 (90 – 168) minutes (p=0.003) as compared with double TSP. Single and double TSP group did not differ significantly in regards of general anesthesia usage, circular and multipolar mapping catheter use (p>0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p<0,001). Conclusions Double TSP is related with lower fluoroscopy usage and shorter overall procedure time of pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation.

Adherence to CLOSE protocol, high-power and low baseline generator impedance predicts durable pulmonary vein isolation

Abstract Background Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is predominantly attributed to pulmonary vein reconnection (PVR). Predictors of AF recurrence were widely studied. However, data are scarce on the procedural parameters that predict chronic PVR. Aims to study the PVR rates and the predictors of PVR after initial PVI procedure. Methods We included 100 consecutive patients who underwent repeated ablation due to AF recurrence after initial PVI with the CARTO system, both procedures performed between 2018 and 2023. Results The mean age of the patients was 60 ± 12 years, 36% were female, and 44% had persistent AF. Thirty-eight patients underwent initial CLOSE-guided, and sixty-two underwent initial non-CLOSE PVI. Repeat procedure was performed 21 ± 14 months after the initial procedure. In total, PVR was found in 192 of 373 PVs (51.5%) and all PVs were isolated in 17/100 (17%) patients. Factors associated with all PVs being isolated were adherence to the CLOSE protocol (39.5% vs. 3.5%, p < 0.0001), higher delivered mean power (37.5W vs 30W, p = 0.027), presence of first-pass isolation (88.2% vs 40.4%, p = 0.0007), and lower baseline generator impedance (127.6 vs 136.6 Ω, p = 0.0027; respectively). Baseline generator impedance >130 Ω (AUC = 0.7403, sensitivity: 77.1%, specificity: 68.8%, p = 0.0032) was associated with significantly higher probability of PVR (OR = 6.757; p < 0.0001). Conclusions Our findings indicate that adherence to the CLOSE protocol, higher power setting, first-pass isolation, and baseline generator impedance <130 Ω during AF ablation improves the durability of PVI and reduces the incidence of PVR.

Catheter-based pulmonary vein isolation fails to prevent transient atrial arrhythmogenic changes related to acute obstructive respiratory events in a porcine model.

Pulmonary vein isolation (PVI) is the corner stone of modern rhythm control strategies in patients with atrial fibrillation (AF). Sleep-disordered breathing (SDB) is prevalent in more than 50% of patients undergoing AF ablation and studies have indicated a greater recurrence rate after PVI in patients with SDB. Herein, we study the effect of catheter-based PVI on AF in a pig model for SDB. In 11 sedated spontaneously breathing pigs, obstructive apnoeas were simulated by 75 seconds of intermittent negative upper airway pressure (INAP) applied by a negative pressure device connected to the endotracheal tube. INAPs were performed before and after PVI. AF-inducibility and atrial effective refractory periods (aERP) were determined before and during INAP by programmed atrial stimulation. PVI prolonged the aERP by 48 ± 27 ms in the right atrium (RA) (p < 0.0001) and by 40 ± 34 ms in the left atrium (LA) (p = 0.0004). Following PVI, AF-inducibility dropped from 28 ± 26% to 0% (p = 0.0009). INAP was associated with a transient aERP-shortening (ΔaERP) in both atria, which was not prevented by PVI (INAP indued ΔaERP after PVI in the RA: -57 ± 34 ms, p = 0.0002; in the LA: -42 ± 24 ms, p < 0.0001). INAP was associated with a transient increase in AF-inducibility (from 28 ± 26% to 69 ± 21%; p = 0.0008), which was not attenuated by PVI (INAP-associated AF-inducibility after PVI: 58 ± 33% (p = 0.5)). Transient atrial arrhythmogenic changes related to acute obstructive respiratory events are not prevented by electrical isolation of the pulmonary veins, which partially explains the increased AF recurrence in patients with SDB after PVI procedures.

Safety and Efficacy of Second-Generation Cryoballoon Ablation in Patients Aged over 75 Years

Objective: The use of second-generation cryoballoon (CB2) for pulmonary vein isolation (PVI) in atrial fibrillation (AF) ablation therapy is common. This study aimed to compare the safety and efficacy of CB2 ablation for PVI in AF patients aged 75 years and older to those under 75 years old. Methods: A retrospective, observational study was conducted, including AF patients who underwent CB2 for PVI between January 2018 and December 2020 at our center. The patients were divided into two groups based on age: those aged 75 years and older (elderly group) and those under 75 years (control group). Procedural characteristics, complications, and one-year follow-up outcomes were compared between the two groups using Student's t-test or the chi-square test for univariate analysis. Results: A total of 156 AF patients treated with CB2 for PVI were included in the study, with 78 patients aged 75 years and older (elderly group, mean age = 78 years) and 78 patients aged under 75 years (control group, mean age = 66 years). The PVI procedure duration was 86.2 ± 25.8 minutes for the elderly group and 83.2 ± 20.8 minutes for the control group (p = 0.413). The elderly group showed a higher trend of complications (8/78, 10.3%) compared to the control group (2/78, 2.6%) (p = 0.049), although no serious complications were observed. One-year follow-up revealed that approximately 80% of patients in both groups did not experience AF recurrence (p = 0.656). Conclusion: CB2 ablation for PVI appears to be safe and effective in AF patients aged 75 years and older, with outcomes comparable to those in younger patients. However, special attention should be given to venous puncture in elderly patients.

Impact of nocturnal blood pressure dipping on recurrence of atrial fibrillation after pulmonary vein isolation.

Lack of the typical nocturnal blood pressure (BP) fall, i.e non-dipper, has been known as a cardiovascular risk. However, the influence of non-dipper on atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) has been unclear. We investigated the clinical impact of non-dipping as evaluated by 24-hour ambulatory BP monitoring on the long-term outcome of AF recurrence post-PVI in 76 AF patients with a history of increased BP. The PVI procedure was successful in all 76 patients (mean age, 66±9years; antihypertensive medication, 89%; non-paroxysmal AF, 24%). Twenty patients had AF recurrence during a median follow-up of 1138 days. There was no difference in BP levels between the AF recurrence and non-recurrence groups (average 24 h systolic BP:126 ± 17 vs.125 ± 14 mmHg; P = 0.84). On the other hand, the patients with non-dipper had a higher AF recurrence than those with dipper (38.9% vs.15.0%; P = 0.018). In Cox hazard analysis adjusted by age, non-paroxysmal AF and average 24-hr systolic BP level, the non-dipper was an independent predictor of AF recurrence (HR 2.78 [95%CI:1.05-7.34], P = 0.039). Non-dipper patients had a larger left atrial (LA) volume index than the dipper patients (45.9 ± 17.3 vs.38.3 ± 10.2 ml/m2, P = 0.037). Among the 58 patients who underwent high-density voltage mapping in LA, 11 patients had a low-voltage area (LVA) defined as an area with a bipolar voltage < 0.5 mV. However, there was no association of LVA with non-dipper or dipper (22.2% vs.16.1%, P = 0.555). Non-dipper is an independent predictor of AF recurrence post-PVI. Management of abnormal diurnal BP variation post-PVI may be important.

Pentaspline Pulsed Field Ablation Catheter Versus Cryoballoon for Atrial Fibrillation Ablation: Results From a Prospective Comparative Study.

Cryoballoon ablation is currently the gold standard technique for single-shot pulmonary vein isolation (PVI). Pulsed field ablation (PFA) has recently emerged as an interesting nonthermal alternative energy for PVI. The purpose of our study was to evaluate the safety and long-term efficacy of PVI using the pentaspline PFA catheter in comparison to cryoballoon ablation. Between January 2021 and December 2022, we included all consecutive patients of our center in whom a first PVI-only procedure was performed using PFA or cryoballoon. The choice of the energy was based on patients' preference between general anesthesia (PFA) and local anesthesia (cryoballoon). The primary end point was freedom from documented atrial arrhythmia recurrence after a 3-month blanking period. A total of 301 patients (paroxysmal atrial fibrillation in 220 patients) underwent a first PVI procedure performed using PFA (n=151) or cryoballoon (n=150). Complete short-term PVI was obtained in 144 of 150 patients (96%) in the cryoballoon group and in all patients of the PFA group (P=0.01). Procedure duration was significantly longer in the cryoballoon group. Transient and persistent phrenic nerve injuries were observed in the cryoballoon group only (13/150 and 2/150, respectively). One-year freedom from atrial arrhythmia was significantly higher in the PFA group compared with the cryoballoon group (87.9% versus 77.7%; adjusted hazard ratio, 0.53 [95% CI, 0.30-0.96]; P=0.037). This prospective, comparative, real-life study suggested that PFA could overcome safety limitations of cryoballoon with optimal effectiveness. Randomized controlled studies are required to further investigate the potential superiority of PFA over cryoballoon.

Procedural performance and outcome after pulsed field ablation for pulmonary vein isolation: comparison with a reference radiofrequency database.

Pulsed field ablation (PFA) is a promising ablation technique for pulmonary vein isolation (PVI) with appealing advantages over radiofrequency (RF) including speed, tissue selectivity, and the promise of enhanced durability. In this study, we determine the procedural performance, efficacy, safety, and durability of PFA and compare its performance with a dataset of optimized RF ablation. After propensity score matching, we compared 161 patients who received optimized RF-guided PVI in the PowerPlus study (CLOSE protocol) with 161 patients undergoing PFA-guided PVI for paroxysmal or persistent atrial fibrillation (AF; pentaspline basket catheter). The median age was 65 years with 78% paroxysmal AF in the PFA group (comparable characteristics in the RF group). Pulsed field ablation-guided PVI was obtained in all patients with a procedure time of 47 min (vs. 71 min in RF, P < 0.0001) and a fluoroscopy time of 15 min (vs. 11 min in RF, P < 0.0001). One serious adverse event [transient ischaemic attack] occurred in a patient with thrombocytosis (0.6 vs. 0% in RF). During the 6-month follow-up, 24 and 27 patients experienced a recurrence with 20 and 11 repeat procedures in the PFA and the RF groups, respectively (P = 0.6 and 0.09). High-density mapping revealed a status of 4 isolated veins in 7/20 patients in the PFA group and in 2/11 patients in the RF group (35 vs. 18%, P = 0.3). Pulsed field ablation fulfils the promise of offering a short and safe PVI procedure, even when compared with optimized RF in experienced hands. Pulmonary vein reconnection is the dominant cause of recurrence and tempers the expectation of a high durability rate with PFA.

The Influence of Different Multipolar Mapping Catheter Types on Procedural Outcomes in Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation.

(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping.

Long-term outcomes of left atrial appendage closure with or without concomitant pulmonary vein isolation:a propensity score matching analysis based on CLACBAC study

BackgroundThe combined procedure of left atrial appendage closure (LAAC) with concomitant pulmonary vein isolation (PVI) has demonstrated its efficacy and safety. However, there is still a lack of comparative investigations regarding the long-term benefits of the combined procedure when compared to LAAC alone. Our study aims to assess the long-term outcomes of combined procedure of LAAC with concomitant PVI in comparison with a propensity matched LAAC alone group.MethodsPropensity score matching (PSM) was employed to rectify covariate imbalances, resulting in the inclusion of 153 comparable patients from the initial cohort of 333 non-valvular atrial fibrillation (AF) patients. Clinical outcomes, encompassing thrombotic events, major cardiocerebrovascular adverse events (MACCE), re-hospitalization due to cardiovascular disease (CVD), and atrial tachycardia (AT), were juxtaposed between the two groups. Bleeding events and peri-device complications, such as residual flow, device-related thrombus, and device replacement, were also compared. Additionally, a patients group underwent PVI alone was included for comparing AF recurrence rates between the PVI alone group and the combined group.ResultsFollowing PSM, 153 patients (mean age 70.3 ± 8.9, 62.7% men) were included, with 102 undergoing the combined procedure and 51 undergoing LAAC alone. No significant differences were found in baseline characteristics between the two groups. The mean follow-up time was 37.6 ± 7.9 months, and two patients were lost to follow-up in the combined procedure group. Thrombotic events were observed in 4 (7.8%) patients in the LAAC alone group and 4 (4.0%) in the combined group (Log-rank p = 0.301). The proportion of patients experiencing MACCE, re-hospitalization due to CVD, and AT between the two groups was comparable, as were bleeding events and peri-device complications. Among patients from the combined procedure group without AF recurrence, a significant difference was noted in prior-procedure left ventricular ejection fraction (LVEF) and LVEF at the 12th month after the procedure (57.2% ± 7.1% vs. 60.5% ± 6.5%, p = 0.002).ConclusionThe concomitant PVI and LAAC procedure did not increase procedure-related complications, nor did it confer significant benefits in preventing thrombotic events or reducing other cardiovascular events. However, the combined procedure improved heart function, suggesting potential long-term benefits.

Pulsed field versus cryoballoon ablation for atrial fibrillation: areal-world observational study on procedural outcomes and efficacy.

Atrial fibrillation often necessitates catheter ablation when antiarrhythmic drug therapy fails. Single-shot technologies using thermal energy, such as cryoballoon ablation, are commonly used, but pulsed field ablation (PFA), an innovative non-thermal ablation technique, is apotential alternative. This retrospective observational study aimed to compare the safety and efficacy of cryoballoon ablation and PFA in patients undergoing their first pulmonary vein isolation (PVI) procedure for atrial fibrillation treatment. We utilised real-world data from patients who underwent PVI using cryoballoon ablation or PFA. The primary outcome encompassed procedural complications, including phrenic nerve palsy, cardiac tamponade, thromboembolic complications, bleeding complications and mortality. Secondary outcomes were procedural characteristics including procedure duration, length of hospital admission, and re-do ablation rates within 6months. Atotal of 1714 procedures were analysed: 1241 in the cryoballoon group and 473 in the PFA group. Gender distribution (p = 0.03) and estimated glomerular filtration rate (p = 0.01) differed significantly. With regard to the primary outcome, the cryoballoon group demonstrated ahigher incidence of phrenic nerve palsy compared with the PFA group (15 vs0; p = 0.02). The procedure duration was shorter in the PFA group, even after adjusting for baseline characteristics (95.0 vs 74.0 min; p < 0.001). After adjustment for baseline characteristics, admission duration differed between the groups as well (p = 0.04). The study results supported the safety and efficacy of PFA over cryoballoon ablation for PVI, highlighting advantages such as shorter procedure duration and absence of phrenic nerve palsy.

Treatment of atrial fibrillation with second-generation cryoballoon followed by contact-sensing radiofrequency catheter ablation for arrhythmia recurrences-results of a 5-year follow-up.

The aim of this study was to report the long-term follow-up results of cryoballoon (CB) ablation in patients with atrial fibrillation. All consecutive patients who underwent second-generation CB ablation from February 2015 to December 2017 were included in our study. In all procedures, we used a 28-mm CB placed via a single transseptal puncture guided by intracardiac ultrasound. A 20-mm octapolar intraluminal circular catheter was used for intracardiac recordings. A single 180-s freeze strategy was employed. Repeated procedures were performed with a 3D mapping system and radiofrequency catheters. A total of 126 patients (69.8% male, mean age 57 ± 11years), of which 77.0% had paroxysmal atrial fibrillation (PAF), were included in the study. After a 5-year period, 52.4% of patients were in sinus rhythm without AF recurrence, off antiarrhythmic drugs. A total of 61.9% of patients were free of AF recurrence when redo PVI procedures were performed. When accounting for redo pulmonary vein isolation and antiarrhythmic drugs, a total of 73.8% of the patients were without AF recurrence in long-term follow-up. The patients who underwent redo pulmonary vein isolation procedures had statistically significant lower rates of AF recurrence (p = 0.006). In patients with PAF, long-term success rates improved from 62.9 to 79.4% for patients who underwent the redo procedure (p = 0.020). In patients with persistent atrial fibrillation (PersAF), success rates went up from 41.4 to 55.1% for patients with single or repeated PVI procedure (p = 0.071). In the whole cohort, a total of 3 (2.4%) procedure-related major complications occurred which included persistent PNP, arterial pseudoaneurysm, and arteriovenous fistula. Our data suggest a favorable long-term safety and efficacy profile of second-generation CB ablation. In the mixed paroxysmal and persistent population, up to 73.8% of patients remained free of AF recurrence in the 5-year follow-up, when accounting for redo procedures and AADs. Only 2.4% of patients experienced major complications of the ablation procedure, none with permanent sequelae.

Pulmonary vein isolation durability after very high-power short-duration ablation utilizing a very-close protocol – The FAST AND FURIOUS redo study

BackgroundVery high-power short-duration (vHP-SD) radiofrequency (RF) ablation of atrial fibrillation (AF) treatment by pulmonary vein isolation (PVI) aims for safer, more effective and faster procedures. Although acute efficacy and safety for PVI was recently shown data on chronic PVI durability is limited. Here chronic PVI durability was evaluated during repeat electrophysiological procedures in patients after initial vHP-SD and conventional RF based PVI. MethodsA total of 25 consecutive patients with repeat left atrial procedures after initial vHP-SD based PVI were included in this study. Twenty-five patients with previous conventional RF based PVI and repeat left atrial procedures served as control (control group). ResultsFor index procedures the median RF time was 328 (277, 392) seconds (vHP-SD) and 1470 (1310, 1742) seconds (control); p < 0.001, the median procedure time was 55 (53, 68) minutes (vHP-SD) and 110 (94, 119) (control); p < 0.001). First pass isolation rate was 84 % (vHP-SD) and 88 % (control, p = 0.888). No differences for severe adverse events (vHP-SD: 1/25, 4 % vs. control: 0/25, 0 %; p = 0.676 were detected.Chronic durability of all PVs was assessed in vHP-SD: 16/25 (64 %) and control: 8/25 (32 %) patients (p = 0.023) and vHP-SD: 81 % and control: 62 % of PVs were found to be isolated (p = 0.003). For right PVs vHP-SD: 84 % vs. control: 60 % of PVs (p < 0.001) and for left PVs vHP-SD: 78 % vs. control: 64 % (p = 0.123) were found to be isolated. ConclusionsPVI solely utilizing vHP-SD via a very close-protocol provides fast, safe and effective acute PVI. High rates of chronically isolated pulmonary veins have been detected.

Initial clinical experience with the novel POLARx FIT cryoballoon system for pulmonary vein isolation in patients with atrial fibrillation

BackgroundThe POLARx FIT system (Boston Scientific, MA, USA) is a novel cryoballoon (CB) ablation technology in which the balloon diameter can be expanded from 28 to 31 mm. The aim of this study was to compare the benefits and safety of the new POLARx FIT system to those of the existing POLARx system currently in use for pulmonary vein (PV) isolation (PVI) in patients with atrial fibrillation. MethodsThe first 70 consecutive patients who underwent CB-based PVI with the POLARx FIT system were retrospectively compared with 200 consecutive patients treated with the POLARx system at Sakakibara Heart Institute from October 2021 to May 2023. ResultsThe POLARx FIT system yielded a higher mean ± standard deviation nadir temperature in the right inferior PV (−59.2 ± 5.29 °C vs. − 62.0 ± 5.08 °C, p = 0.006), but this required a balloon size reduction to 28 mm in 30 % of cases. No significant differences were detected in the time to isolation and thaw time of any PV between the two groups. After the CB-based PVI procedure, no residual PV carina potentials were observed with the POLARx FIT system, whereas 4/20 were with the POLARx system (p = 0.04). ConclusionsThe POLARx FIT system had comparable effectiveness and safety to the basic POLARx system. This technology may improve the ablation area, including the PV carina. However, the 31-mm balloon alone was not sufficient to isolate certain PVs.

Transesophageal echocardiography and computerized tomography angiography mismatch in left atrial appendage thrombus evaluation.

Transesophageal echocardiography (TEE) is the gold standard test for the diagnosis of left atrial appendage (LAA) thrombus. Nonetheless, computerized tomography angiography (CTA) is readily used to exclude LAA thrombus before pulmonary vein isolation (PVI) and LAA closure procedures. We aimed to assess the comparability of LAA thrombus diagnosis using chest CTA scans in patients with atrial fibrillation who underwent TEE. Retrospective collection of consecutive patients with atrial fibrillation who underwent TEE and chest CTA within 30 days and had evidence of spontaneous echo contrast (SEC) or LAA thrombus on TEE. Clinical, demographic, and echo data were collected. Prospective analysis of the CTA for evidence of LAA thrombus in the same group of patients was performed. We compared the findings of the two modalities. Out of 1550 patients with atrial fibrillation who underwent TEE examinations in the study period, 63 patients underwent TEE within 30 days of a chest CTA scan. Twenty-three patients had LAA thrombus and 40 had some degree of SEC according to TEE. On CTA, 11 were interpreted as positive with a high level of suspicion for the presence of an LAA thrombus. Six patients (26.1%) had LAA thrombus according to both CT and TEE. Therefore, low concordance was found between test results (chi-squared continuity correction = 5.5, df = 1, and P -value = 0.01902). The discrepancy between CTA and TEE results suggests these examinations might be more suitable as complementary examinations to exclude LAA thrombus.