Pulmonary Vein Isolation Research Articles

Impact of combining ablation index-guided and very high-power short-duration ablation at posterior wall adjacent to esophagus during perioperative period on procedural factors.

The impact of combining ablation index (AI)-guided and very high-power short-duration (vHPSD) ablation on procedural factors at the posterior wall near the esophagus is unclear. Atrial fibrillation patients who underwent initial ablation using three-dimensional mapping were enrolled. Patients were classified into two groups: those who underwent only AI-guided pulmonary vein isolation (PVI) (AI group) and those who underwent vHPSD ablation at the posterior wall adjacent to the esophagus in addition to AI-guided PVI (AI + vHPSD group). Differences in myocardial injury, inflammation, procedural characteristics, and pulmonary vein (PV) reconnection patterns were assessed between the two groups. This study included 167 patients (AI group, 83 patients; AI+vHPSD group, 84 patients). No significant differences in high-sensitive troponin I or changes in inflammatory markers between pre- and Postablation were observed in either group. Total application time and total application energy were significantly lower in the AI+vHPSD group than in the AI group (p < 0.001 for both) despite no significant difference in the total number of applications between the groups. The incidence of esophagus temperature ≥40 degrees was significantly lower in the AI+vHPSD group than in the AI group (p = 0.036). However, the incidence of PV reconnections near the esophagus was significantly higher in the AI+vHPSD group than in the AI group (11.9% vs 3.6%, p = 0.046), despite no significant difference in the incidence of PV reconnections overall. The combination of AI-guided PVI and vHPSD adjacent to the esophagus demonstrated reduced application energy requirements and maintained safety and effectiveness during the perioperative period.

Ablation strategy for patients with atrial fibrillation and heart failure - a Danish nationwide cohort study

Abstract Introduction Atrial fibrillation (AF) patients with heart failure (HF) face increased risks of AF recurrence and HF admission. Catheter ablation (CA) is a recognized treatment option. Due to observed atrial remodelling and fibrosis associated with ventricular remodelling in HF patients, it could be suggested that a more comprehensive ablation strategy should be applied for these patients. Purpose To examine the risk of AF recurrence and HF admission by ablation strategy for patients with AF and HF. Method This nationwide cohort study was conducted using real-life data from Danish healthcare registries. All patients above 18 years of age, with a diagnosis of AF and HF that underwent first-time CA from January 1st 2010 to December 31st 2018, were identified and included at the date of ablation. Exposure of interest was ablation strategy - pulmonary vein isolation (PVI) or additional ablation to PVI (PVI plus). PVI plus was defined as either roofline, mitral linear ablation, posterior wall isolation, complex fractionated atrial electrograms or ganglionated plexi ablation. Primary endpoint was HF admission and AF recurrence after a 3-months blanking period. AF recurrence was defined by a composite endpoint of first-reached endpoint of either use of antiarrhythmic drugs, AF admission, electrical cardioversions, or AF re-ablation. The relative rates of recurrent AF and HF admission by ablation strategy (PVI or PVI plus) were examined by Cox proportional models using PVI as reference. The analyses were adjusted for clinically important baseline characteristics including age, sex, AF type (paroxysmal or persistent), diagnosis-to-ablation time, procedural year, body mass index, size of left atrium, as well as co-morbidities such as ischemic heart disease, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, and diabetes. Results The study cohort consisted of 1,270 patients diagnosed with AF and HF undergoing first-time CA, of which 1,119 (88%) received PVI and 151 (12%) received PVI plus. 80% where males in both groups. Median age was 62 for the PVI group and 64 for the PVI plus group. Severely enlarged left atrium, ischemic heart disease and use of amiodarone were more prevalent in the PVI plus group compared to the PVI group (Table 1). The relative risk of recurrent AF showed a hazard ratio of 1.02 (95% CI: 0.77-1.37) for the PVI plus group compared to the PVI group, and for HF admission the hazard ratio was 0.95 (95% CI: 0.55-1.65) for the PVI plus group compared to the PVI group (Figure 1). Conclusion No significant differences in AF recurrence and HF admission were observed between PVI and PVI plus strategy in AF and HF patients in this observational study. With a diagnosis-to-ablation time exceeding 3 years, it could be argued that advanced atrial remodelling may diminish the impact of reverse atrial remodelling after catheter ablation, irrespective of the ablation strategy employed.Table 1Figure 1

In-silico insights into personalised therapy selection of anti-arrhythmic drugs and ablation using patient-specific biatrial models for atrial fibrillation

Abstract Introduction Current treatment approaches for Atrial Fibrillation (AF) often lack personalisation, adopting a one-size-fits-all paradigm that disregards inter-patient diversity and its unique interplay with therapeutic responses. In-silico drug trials have demonstrated some value in the personalisation of care; however, their integration with patient-specific anatomical data and the synergistic effects of combined therapies remain unknown. Purpose To evaluate the patient-specific response to anti-arrhythmic drugs (AADs) and their efficacy both individually and in combination with pulmonary vein isolation (PVI) using personalised biatrial models created from imaging data. Methods Patient-specific biatrial models (n=70) were constructed from late gadolinium-enhanced MRI images by manual segmentation from the Atrial Segmentation Challenge (2018) dataset (Fig.1A). Models were pre-processed with landmark selection, regional assignment, and fibre allocation before simulations (Fig.1B). PVI was modelled as electrically inert rings around the pulmonary veins (Fig.1C) and AADs were administered via ionic modulation within CARPentry software (Fig.1D). Four commonly used AADs were evaluated: vernakalant, acute and chronic amiodarone, flecainide, and digoxin. Finite element simulations were performed with the addition of AADs, both individually and in combination with PVI, to evaluate their efficacy in terminating AF (Fig.2A). These simulations were post-processed to produce phase singularity (PS) density maps to evaluate changes in wavefront patterns and locations of re-entry and wavefront break-up (Fig.2B). Results The combination of digoxin with PVI and digoxin alone demonstrated the highest effectiveness in terminating AF, both achieving success in 68.4% of cases (95% CI: 67.5% to 89.3%, p≤0.0001). This efficacy significantly exceeded that of other AADs used either alone or in combination with PVI (15.8%-57.9%), whereas PVI alone demonstrated 0% efficacy (p≤0.05). The combined therapy exhibited a multi-faceted localisation pattern (Fig.2A), with AADs initially redistributing PSs to the pulmonary veins and left atrial appendage. This redistribution resulted in synergistic effects in terminating AF episodes in 52.6% more cases when combined with PVI (Fig.2B). Comparative analyses showed an inverse correlation between baseline PS density count and anatomical surface area with AF termination across all treatments, with significant correlations observed with vernakalant alone (rho=-0.55, p≤0.05) and combined with PVI (rho=-0.77, p≤0.05). Conclusions This study demonstrates the significance of personalised treatment selection in optimising patient outcomes. Combined therapeutic interventions have shown synergistic benefits in AF termination, surpassing individual therapies in this patient-specific model cohort. This shows the translational potential of using patient-specific stratification to inform treatment selection.Biatrial model generationAF therapeutic simulation and processing

The impact of body mass index for atrial fibrillation ablation; real-world data on outcomes and quality of life

Abstract Background Pulmonary vein isolation (PVI) is a cornerstone in the management of atrial fibrillation (AF). Increasing numbers of overweight and obese patients undergo PVI, despite the association between a higher body mass index (BMI) and adverse ablation outcomes. The risks of perioperative complications and quality of life have hardly been studied for the different bodyweight groups. Purpose The purpose of this study is to clarify the impact of BMI on PVI outcomes, including both perioperative complications and change in quality of life after PVI. Methods This is an observational, multicentre cohort study of prospectively collected data, covering all 15 ablation centres in the Netherlands. The study included all patients who underwent their first catheter-PVI between January 2015 and December 2021. Patients with a BMI below 18.5 kg/m2, missing BMI data, or prior ablations were excluded. Patients were categorized by BMI; normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25-29.9 kg/m2) and obesity (BMI ≥30 kg/m2). The primary outcome was repeat ablation within one year. A logistic regression model was used to adjust for patient characteristics. A generalized additive model was fitted to visualize the correlation between BMI and the risk of repeat ablation. Secondary outcomes were repeat ablation within 3 years, a composite of the periprocedural complications, and change in quality of life, assessed using the Atrial Fibrillation Effect on QualiTy-of-Life (AFEQT) questionnaire before and at one year after PVI. Results A total of 20,725 patients (33% female) were included; 72% had a paroxysmal AF pattern. Of all patients, 30% were normal weight, 47% overweight and 23% obese. Within the first year post-index PVI, obese patients had a higher incidence of repeat ablation than normal-weighing and overweight patients (17.8% versus 15.6% and 16.1%, P &amp;lt;0.05). Obesity independently predicted an increased risk of repeat ablation within 1 year (odds ratio 1.15; 95%-confidence interval 1.01-1.31, P =0.03). This increased risk was also apparent for repeat ablations within 3 years (hazards ratio 1.15; 95%-confidence interval 1.06-1.25; P &amp;lt;0.01). The composite complication rate was 3.8% in normal weighing, 3.0% in overweight, and 4.6% in obese patients, with weight class not being an independent predictor. All weight groups had a substantial improvement in quality of life one year after ablation. Post PVI, summarized AFEQT score was still lower in obese patients (81), than in normal weight (88; P &amp;lt;0.01) and overweight patients (88; P &amp;lt;0.01). Conclusions In a nation-wide contemporary cohort, obesity is an independent predictor for undergoing a repeat ablation within both 1 and 3 years. This relation is not apparent for overweight individuals. Catheter ablation can safely be performed in all weight classes. Despite an overall lower quality of life among obese individuals, substantial improvements in quality of life occur in all weight groups.Visual abstract

Atrial fibrillation ablation with temperature-controlled very high-power short-duration, with conventional-power, or with combined modes in clinical practice: 12-month outcomes from SECURE

Abstract Background/Introduction QDM is a contact force-sensing catheter optimized for temperature-controlled radiofrequency ablation in very high-power short-duration (vHPSD; 90 W/4 s), conventional-power (CP; ≤50 W), or vHPSD/CP combined modes. Purpose Evaluate 12-month (M) safety and effectiveness of atrial fibrillation (AF) ablations performed with 3 different ablation modes using the QDM catheter, a frequently used single tip catheter in Europe. Methods SECURE is an observational, prospective, post-market study collecting data on procedures performed per standard-of-care with up to 12M follow-up, in 16 enrolling sites in 8 countries across Europe and Israel. Index pulmonary vein (PV) isolation procedures are reported here. The primary safety endpoint is the incidence of primary adverse events (PAEs); the primary effectiveness endpoint is PV isolation (entrance block) of targeted PVs. Additional endpoints include acute reconnections, incidence of char and steam pop, 12M recurrence, repeat ablation, and healthcare utilization (HCU). Ablation strategy, impedance drop, and catheter stability were analysed with a cloud-based data management and artificial intelligence-powered algorithm. Results Since Feb 2021, 291 patients (70% male, 61±11 yrs, CHA2DS2-VASc 1.9±1.5) completed 12M follow-up in 11 sites. Most patients (175 [60.1%]) were treated for paroxysmal (PAF), 85 (29.2%) for persistent (PsAF), and 31 (10.7%) for long-standing persistent (LsPsAF) AF, under general anaesthesia (44.0%) or sedation (55.7%). A combined workflow was used in 66.0% of ablations, while vHPSD-only and CP-only were used in 13.4% and 20.6% of cases, respectively. Four (1.4%) patients reported a PAE; all resolved, and none were catheter related. Acute effectiveness was achieved in all targeted veins; 5.0% of PVs had acute reconnections, with the most common being the left superior PV. No steam pops were reported; 2 counts of char were noted in PsAF ablations with combined modes. Freedom from documented recurrence were 95.8% for PAF, 88.1% for PsAF, and 73.5% for LsPsAF (Fig 1). Freedom from repeat ablation post-blanking and freedom from cardioversion were both 96.8%. Cardiovascular hospitalization and emergency room visits decreased by 65.3% and 76.5% from 12M pre- to 12M post-procedure, respectively. Application-level analyses showed larger impedance drop and greater catheter stability with vHPSD. In procedures using a combined workflow, vHPSD was used preferentially for most PV segments, except anteriorly on the left wide area circumferential ablation (Fig 2). Conclusions Real-world data demonstrates that AF ablation with the QDM catheter is safe and effective with a low PAE rate, high 12M effectiveness, and reduced HCU. Most procedures were done with combined modes, where vHPSD was used preferentially, except at left anterior thicker regions. Larger impedance drop and greater catheter stability were observed with vHPSD applications.

Comparison of characteristics and acute ablation outcome of atrial fibrillation drivers detected using octaray vs. pentaray catheter

Abstract Background Atrial fibrillation (AF) driver ablation is proposed as treatment strategy beyond pulmonary vein (PV) isolation in persistent AF patients. The CARTOFINDER mapping system (Biosense Webster Inc.) can depict two types of activation patterns, focal and rotational activation, using unipolar potentials during AF. Recently, an 8-spline 48-electrodes mapping catheter (OctaRay) was developed. Purpose To evaluate the characteristics of AF drivers detected by CARTOFINDER using the OctaRay catheter and the acute termination compared to previous mapping catheter (PentaRay). Methods This is a multicenter prospective observational study from 6 hospitals where 47 persistent AF patients underwent initial catheter ablation from April to December 2023. We assessed the frequency and distribution of AF drivers in both atrium identified by CARTOFINDER using the OctaRay catheter before procedure. After PV isolation, additional ablation was performed on high-repetitive activations (focal activation&amp;gt;22 repetitions, rotational activation&amp;gt;17 repetitions) and the rate of acute AF termination was evaluated. Acute AF termination was defined as transition to sinus rhythm or atrial tachycardia (AT). The results were compared to 29 patients in whom the PentaRay catheter was used from September 2022 to March 2023. Results The mean age of OctaRay group was 72.0±8.6 years. The median AF duration was 0.7 years, and the prevalence of long-standing AF was 26%. All clinical characteristics was not significantly different between OctaRay and PentaRay group. Focal activation was more frequently identified in OctaRay group than in PentaRay group (94.1points/patient vs. 36.3points/patient, P&amp;lt;0.01), especially in anterior (P&amp;lt;0.01) and posterior (P&amp;lt;0.01) of right atrium (RA), posterior (P&amp;lt;0.01), roof (P&amp;lt;0.01) and lateral (P&amp;lt;0.01) of left atrium (LA), and PV antrum (P&amp;lt;0.01), respectively. Rotational activation was also more frequently identified in OctaRay group (54.7points/patient vs. 2.6points/patient, P&amp;lt;0.01), especially in anterior (P=0.02) and posterior (P=0.03) of RA, and anterior of LA (P=0.02), respectively. Furthermore, high-repetitive focal activation was more frequently identified in OctaRay group than in PentaRay group (P&amp;lt;0.01). On the other hand, the frequency of high-repetitive rotational activation was not significantly different between the two groups (P=0.63) (Figure A). In OctaRay group, high-repetitive focal activation was frequent in anterior of RA (72.3%) and LA appendage (48.9%) (Figure B), and had significantly shorter AF cycle length compared to the entire atrium (156ms vs. 162ms, P&amp;lt;0.01). Ablation for high-repetitive activations after PV isolation resulted in 12.8% acute AF termination in OctaRay group, significantly higher than in PentaRay group (vs. 0%, P=0.04). Conclusion The OctaRay catheter have the potential to detect more frequent and accurate AF drivers than the PentaRay catheter, leading to the improvement of acute AF termination.

Procedural findings and follow-up results of catheter ablation of atrial fibrillation in patients after radiation therapy for breast cancer

Abstract Backround Data on breast cancer radiation therapy (RT) associated atrial cardiomyopathy and its potential role in the pathophysiology of atrial fibrillation (AF) is very limited. Objectives To investigate the effect of breast cancer radiotherapy (RT) on atrial cardiomyopathy and its possible role in the pathophysiology of atrial fibrillation. What is the therapeutic success of antral pulmonary vein isolation (PVI) with possible substrate modifications (CFAE) in patients with breast cancer radiation therapy and paroxysmal or persistent atrial fibrillation. Methods We searched the institution’s data base for patients who received RT for breast cancer and underwent subsequently 3D mapping guided AF ablation. Intraprocedural mapping data and short- and long-term results of ablation were evaluated according to "no low voltage" and "low voltage" present. Low voltage amplitudes in bipolar electrograms were defined as &amp;lt;0.5 mV for endocardial maps created during SR and &amp;lt;0.3mV during AF. Ablation strategy comprised pulmonary vein isolation (PVI) ± additional substrate modification according to the mapping results. Follow Up (FU) was evaluated using repetitive 7-days Holter ECG and clinical visits. Results We included 45 patients (all female, 70.9±7.2 years) with paroxysmal or persistent AF (n=18 and n=27). In 3D mapping, 60% of the patients (27/45) showed left atrial low voltage (LV group) with the majority showing low voltage in the anterior wall of the left atrium (LA) in 18 of 45 patients (40%). PVI with ablation of complex fractionated signals (CFAE) was predominantly performed (18/27). After one ablation, 33.3% (9) of the patients in the LV group were recurrence-free and after an average of 1.9 ablations, freedom from recurrence was achieved in 21 patients with low voltage (77.8%). In 18 patients, no low voltage was detected (NLV group) and PVI only was performed in the majority (14/18). In this NLV group, 61.1% (11) of the patients were recurrence-free after one ablation and freedom from recurrence was achieved in 72.2% (13) after an average of 1.2 ablations. Conclusion Thoracic radiation therapy in patients with breast cancer can lead to low voltage in the LA with the predominant low voltage location being the anterior wall of the LA. An extended ablation strategy (PVI &amp; CFAE) can show good treatment options in these patients with atrial fibrillation, with high freedom from recurrence after a mean of two ablation procedures.Freedom from recurrence after ablationCharacteristics of left atrium (LA)

Combined PVI and LAAC is feasible using RFA or PFA in a canine model despite acute tissue edema in PFA versus RFA

Abstract Background Combined procedure with pulmonary vein isolation (PVI) using thermal energy followed by left atrial appendage closure (LAAC) has been used in select patient populations with positive results. Pulsed field ablation (PFA) is a novel non-thermal ablation modality that ablates cardiac tissue by irreversible electroporation. The effect of PFA on cardiac tissue and its interaction with a LAAC device in a single procedure has not been studied. Purpose To evaluate using transesophageal echo (TEE) imaging the acute tissue response following ablation by PFA compared to radiofrequency ablation (RFA) and its interaction with the WATCHMAN FLX Pro LAAC device when used in a combined procedure in a healthy canine model. Methods Nine mongrel canines underwent PVI using either circumferential PFA (FARAPULSE) energy application (n=6) or RFA energy (n=3). TEE imaging was obtained at the time of the procedure before and immediately after ablation energy application. The general appearance and echogenicity of the left lateral ridge was assessed and the os of the left atrial appendage (LAA) was measured in the four standard TEE views (0, 45, 90, and 135 degrees). Decisions about device sizing were made accordingly. PVI was evaluated by entry and exit block in all veins except the right inferior pulmonary vein (RIPV), which was not ablated. Following ablation, the LAAC device was implanted using TEE and fluoroscopic guidance in all animals and the percentage of compression measured. PASS criteria were assessed before the release of each device. All animals received dual antiplatelet therapy post implant. Results PVI was confirmed in all animals (except RIPV which was not targeted for ablation) using PFA and RFA. LAA dimensions (at device landing site) did not change substantially after RF ablation. With PFA, there was evidence of more diffuse edema and decrease in LAA diameter (Table). The LAAC device was implanted successfully after meeting PASS criteria in all animals within 30 minutes post ablation. The device size was decreased following PFA in two (2/6) animals, whereas there was no deviation from baseline measurements in device size for any of the RFA animals. Average LAAC device compression was higher for PFA versus RFA animals (Table). TEE post implant confirmed absence of any peri-device leaks in all animals. Conclusion Concomitant PVI using PFA (FARAPULSE) and LAAC (WATCHMAN FLX Pro) is feasible with 100% success and no residual acute peri-device leak. In the canine model, PFA is associated with more diffuse edema compared to RFA, which might affect device sizing. Long term consequences of this acute edema need to be evaluated in serial imaging and future larger clinical trials.Table

Feasibility and efficacy assessment of a novel size-adjustable cryoballoon for ablation of atrial fibrillation in a multicenter clinical setting

Abstract Background The POLARx-FIT cryoballoon (CB) system introduces a unique feature, allowing the selection of two distinct balloon sizes within a single catheter. This innovation holds promise for treating larger pulmonary veins (PV), providing increased flexibility to achieve optimal occlusions. However, there is a scarcity of clinical data supporting its application in this context. Purpose To compare the benefits and safety of the new POLARx-FIT system to those of the existing POLARx system currently in use for PV isolation (PVI) in patients with atrial fibrillation (AF). Methods The first 140 consecutive patients who underwent CB-based PVI with the POLARx-FIT system were retrospectively compared with 300 consecutive patients treated with the POLARx system. Protocol-directed cryoablation was delivered for 180 sec or 240 sec according to operator’s preference for isolation achieved in ≤60 sec, or 240 sec if isolation occurred &amp;gt;60 sec or when time to isolation was not available. The ablation endpoint was PVI as assessed by entrance and exit block. In the POLARx-FIT group the choice of balloon size (28 or 31 mm) was determined during the procedure while attempting to occlude each vein. Results Two-thousand one-hundred fifty-five cryo-applications (CBA) from 440 patients were analysed (300, 68.2% POLARx; 140, 31.8% POLARx-FIT). PVI was achieved with cryoablation only in all patients. The mean number of freeze applications per patient was similar between groups (5.0±1.4 in the POLARx-FIT vs 5.3±1.8 in the POLARx group, p=0.207) whereas the number of PVs treated in a single-shot fashion was higher in the POLARx-FIT group (444, 80.7% with one shot; 75, 13.7% with 2 shots; 31, 5.6% with more than 2 shots) than in the POLARx one (1168, 70.2% with one shot, p=0.0002; 294, 17.7% with two shots and 143, 8.6% with more than two shots). Among the POLARx-FIT cases, in 54.2% (n=298) of applications, the 31-mm diameter was employed as a first choice, while in the remaining 45.8% (n=252) of applications, the 28-mm diameter was adopted. A switch to a different balloon diameter was applied in 11.6% of cases. The first pass isolation (i.e. a single shot CBA to achieve PVI) was slightly higher when using a 31 mm diameter (n=250, 83.9%) than a 28 mm diameter (n=194, 77.0%, p=0.05). Three (0.7%) transient phrenic nerve palsy were observed (all in the POLARx group, 0.9%, p=0.554), with full recovery in the 48-h post procedure; no major procedure-related adverse events were reported at 30 days post-procedure. Conclusion In this first multicentric experience in a clinical practice setting, this novel cryo-balloon system proved to be safe and effective and resulted in a high proportion of successful single-freeze isolation. The intraprocedural flexibility of balloon size contributed to its versatility, leading to a variation in balloon diameter in about 12% of freeze applications.

Role of 3D-electro-anatomical mapping on procedural characteristics and outcomes in pulsed-field ablation for atrial fibrillation

Abstract Introduction While the utilization of dedicated 3D-electro-anatomical mapping (EAM) systems for catheter ablation of atrial fibrillation (AF) is crucial using radiofrequency, its potential benefits in pulsed-field ablation (PFA) remain uncertain. This is of particular interest, since some PFA ablation systems will soon be available with integrated 3D-EAM capabilities. Objectives To compare the procedural characteristics and outcomes of patients undergoing PFA for pulmonary vein isolation (PVI) with mapping and with no mapping. Methods We prospectively enrolled patients undergoing their first PVI at a tertary referral center. In patients undergoing PVI with mapping, a multipolar mapping catheter was used to create voltage maps during sinus rhythm pre- and post-ablation. In the non-mapping group PVI was confirmed by assessing entrance block via the PFA catheter. The first 30 cases with mapping were excluded to account for a potential learning curve. Results A total of 197 consecutive patients were included (age 65 [interquartile range (IQR) 58 – 72] years; indexed left atrial volume 40 [IQR 35 – 44] mL/m2). Among these, 127 patients (64%) underwent PVI with mapping and 70 patients (36%) with no mapping. The median procedure duration, left atrial dwell time and the fluoroscopic time for the mapping vs the non-mapping group were 55 [IQR 45 – 67] min vs. 28 [IQR 23 – 35] min (p &amp;lt; 0.001), 38 [IQR 30 – 49] min vs. 15 [IQR 11 – 21] min (p &amp;lt; 0.001), 11 [IQR 9 – 14] min vs. 8 [IQR 7 – 11] min (p &amp;lt; 0.001), respectively. In the mapping group in 9% (11/127 patients) at least 1 PV was incompletely isolated and required additional applications. Acute PVI success was 100%. There were two complications in the mapping group (one stroke, one coronary artery air embolism) and none were observed in the non-mapping group. The recurrence rate of atrial arrythmias during a median follow-up of 267 [IQR 164 – 419] days was 14% in the mapping group and 17% in the non-mapping group, p = 0.728. Conclusion In conclusion, the use of PFA with no mapping was associated with a significant decrease in procedural characteristics, while AF-recurrence was not significantly different. The routine use of mapping for PFA-PVI may not be needed.Figure 1

The long-term outcome of pulmonary vein isolation in paroxysmal atrial fibrillation is significantly influenced by diabetes mellitus in general as well as by an antidiabetic therapy

Abstract Introduction Over the last decades pulmonary vein isolation became a cornerstone in the interventional treatment of paroxysmal atrial fibrillation. Postprocedural recurrences of atrial fibrillation are present in patients with and without concomitant cardiovascular diseases. Purpose The aim of this study was to assess the influence of diabetes mellitus and an antidiabetic therapy on the long-term outcome, defined as freedom of atrial fibrillation, of pulmonary vein isolation in patients with paroxysmal atrial fibrillation Methods All patients underwent pulmonary vein isolation using the combination of a radiofrequency ablation catheter, a pulmonary mapping catheter and a 3D electroanatomic mapping system. Every procedure was carried out according to current clinical and scientific standards. Procedural, clinical and follow-up data were stored for later statistical analysis. All patients received 4 follow-ups in total. In the first 12 postprocedural months patients were followed up after 3, 6 and 12 months. Furthermore, there was one long-term follow-up up to 6 years after the procedure. Results A total of n=1282 patients were included in the study. 39.2% of the patients were female and 60,8% were male. At the timepoint of the procedure the mean age was 63.7 years. The mean follow-up time was 2.2 years. For n=1144 of the included patients the presence respectively the absence of diabetes mellitus was documented. 8.0% (n=92) of these patients had the diagnosis of diabetes mellitus, from which 73.9% (n=68) were and 26.1% (n=24) were not under an antidiabetic therapy. Regarding the long-term outcome, patients without diabetes mellitus had significantly better results (log rank p=0.039). The according Kaplan-Meier-Analysis is shown in figure 1. Patients with diabetes mellitus were significantly older (69.5 years) when compared to patients without diabetes mellitus (63.1 years). However, when data was adjusted for age and gender, diabetes mellitus was still an independent, significant predictor of the recurrence of atrial fibrillation after pulmonary vein isolation. In addition, diabetics under an antidiabetic therapy had a significantly better long-term outcome than the untreated ones (log rank p=0.011). Figure 2 shows the according Kaplan-Meier-Analysis. Conclusion Diabetes mellitus has a significant influence on the long-term outcome of pulmonary vein isolation in patients with atrial fibrillation (log rank p=0.039). Patients without diabetes mellitus showed significantly better outcomes when compared to patients with diabetes mellitus also when adjusting the data for age and gender. Furthermore, the presence of an antidiabetic therapy in diabetics influences the long-term outcomes significantly (log rank p=0.011).

Impact of conduction velocity in left atrium assessing with omnipolar technology in patients with atrial fibrillation

Abstract Background There is increased interest in exploring substrate of atrial fibrillation (AF) and recent studies have shown that atrial conduction velocity (CV) reflects the electrophysiological phenomena and plays key role in perpetuating AF. The novel omnipolar technology (OT) use three unipolar and two orthogonal bipolar signals allow us to analyze the voltage, activation direction, and CV independent of catheter position. Objective The purpose of the present study was to evaluate if the left atrium (LA) CV which assessed by OT predict the any atrial tachy-arrhythmia (AT) recurrence after initial AF ablation. Methods We enrolled 58 consecutive patients who underwent initial pulmonary vein isolation (PVI) for drug refractory AF. (mean age: 68.2±10.2 years old, 32 male(55.1%), 32 persistent AF(55.1%), CHADS2 score:1.6±0.6). After electrical PVI was achieved and remained in sinus rhythm, the LA was mapped with high density mapping catheter (Advisor HD Grid, Abott USA) utilizing with the novel OT combined with Ensite X system (Abott, USA). The conduction distance and conduction times were measured from the earliest activation site to the latest activation site in LA (Figure 1). Each conduction velocity in anterior, posterior, and septal area were also calculated as conduction distance divided by conduction time. The LA voltage was also measured. Results During a mean follow up period of 316±143 days, the recurrence of AT after initial PVI was observed in 9 (15.5%) patients. There were no significant differences in baseline demographics between AT recurrence and non-recurrence group (mean age:66±13.3 vs 68.5±10.5 years old P=0.66, CHADS2 score: 1.5±0.57 vs 1.68±0.62 P=0.59, proportion of persistent AF: 15.4% vs 15.5% P=0.82, LA volume: 102±35.9 vs 93.6±37.3ml P=0.63). The earliest activation site in LA were identified in 3 areas including anterior site of right pulmonary vein (51.7%), Bachmann bundle area (41.4%), and antero-septal area (6.89%) (Figure 2). In patients with AT recurrence, the CV in LA was significantly slower than those without AF recurrence(0.61±0.21 vs 0.81±0.16 m/s, P=0.036) whereas the whole LA voltage was not (1.52±0.75 vs 2.22±1.06 mv, P=0.28). The CV in each LA portion are similar between recurrence and non-recurrence AT group. (anterior:0.57±0.24 vs 0.81±0.23 m/s, P=0.18, posterior: 0.87±0.18 vs 1.2±0.49 m/s P=0.36, septal: 0.89±0.76 vs 1.15±0.39 m/s, P=0.41). Conclusion The earliest activation site in LA was varied in each case. The whole CV in LA is a predictor of AF recurrence after PVI whereas the CV of each LA portion and LA voltage was not.

Ppulsed field ablation and ultra-high-density mapping for PVI: use of machine learning and data augmentation to guide procedure and identify recurrent tachycardia mechanisms at one-year follow-up

Abstract Background In managing atrial fibrillation (AF), radiofrequency and cryoablation have been cornerstone techniques for achieving pulmonary vein isolation (PVI). Recently, pulsed-field ablation (PFA) has introduced a novel method for PVI. There remains a gap in knowledge regarding the permanent efficacy of ablation, related explicitly to acute lesion characteristics following PVI. Purpose Our study delves into an in-depth examination of acute lesion characteristics following PFA-PVI through ultra-high-density mapping (UHDM). We aim to identify specific clinical, anatomical, and periprocedural lesion features independently related to 1) intraoperative identification of UHDM non-isolated gaps with electrical conduction after first isolation and 2) three months follow-up recurrency of specific arrhythmias. Methods Results The present study includes 204 patients submitted to PFA-PVI for AF. UHDM guided all procedures to identify non-isolated gaps with electrical conduction. Perioperative and 3-month follow-up data were collected prospectively and analyzed. To build our prediction model, avoiding biases related to the unbalanced nature of the data, data augmentation was performed with SMOTE (Synthetic Minority Over-sampling Technique). Two machine learning (ML) models have been built, using logistic regression as learner, to predict the presence of isolation gaps identified by UHDM and follow-up recurrence of arrhythmias. A 20-fold cross-validation has been performed to train and test the models. The non-isolated gap was detected and immediately corrected in 14 (6.9%) patients and was present more often in patients with larger left atria (LA) (p&amp;lt;0.0001) and those with persistent AF (p=0.02). The ML model achieved an AUC of 0.88 in the prediction of the non-isolated gap after PFA (Precision: 0.65; Sens.: 0.90; F1: 0.76; Spec.: 0.83; NPV: 0.96). At three months follow-up, no patient experienced recurrent AF; recurrent roof-dependent atrial tachycardia was present in 10 (4.9%). Patients with recurrent atrial tachycardia had a significantly narrower remaining atrial-roof conduction bridge (p=0.01) identified intra-procedurally by UHDM, significantly larger LA (p=0.03), and non-significant trend for older age (p=0.07). The ML model achieved an AUC of 0.86, predicting recurrent tachycardia after PFA (Precision: 0.63; Sens.: 0.86; F1: 0.72; Spec.: 0.82; NPV: 0.94). Conclusions Consistent use of UHDM can help identify non-isolated gaps with electrical conduction that may occur even after PVI with updated technologies, such as PFA. Non-isolated gaps should be expected, particularly in patients with larger LA, where UHDM could be of particular use. Moreover, UHDM can help predict the eventual recurrence of arrhythmias. Again, LA size plays an essential role in such recurrencies, together with the size of the remaining conducting tissue "bridges" within the LA roof, measure by UHDM.

Comparison of continuity index for drag versus point-by-point ablation with the use of proactive esophageal cooling

Abstract Background Proactive esophageal cooling was recently FDA cleared to reduce the likelihood of esophageal injury during radiofrequency (RF) ablation for treatment of atrial fibrillation (AF). Long-term follow-up data have also shown improved freedom from arrhythmia with proactive esophageal cooling compared to luminal esophageal temperature (LET) monitoring during pulmonary vein isolation (PVI). One hypothesized mechanism is the greater lesion continuity attainable with the use of cooling, which can be quantified by the Continuity Index (which increases as continuity decreases). Increasing the Continuity Index increases gap formation, reduces isolation, and leads to greater AF recurrence; however, the difference in Continuity Index between ablating in a point-by-point fashion versus a dragging fashion has not previously been analyzed. Purpose To prospectively measure the Continuity Index of PVI cases and compare the dragging technique to point-by-point technique when using proactive esophageal cooling or LET monitoring. Methods We determined the Continuity Index for 101 patients: 77 prospectively utilizing proactive esophageal cooling, 24 retrospectively recorded using LET monitoring. Cases were completed by four operators, three utilizing point-by-point technique, and one using the drag technique. The Continuity Index was calculated by incrementing one unit for each lesion that did not border the previous lesion during the PVI (simplifying the original description of the Continuity Index). Results For cases using esophageal cooling and performing RF ablation using the drag technique, the average Continuity Index was 8.5 (range: 1 to 14). For point-by-point operators using esophageal cooling, the average Continuity Index was 1.2 (range: 0 to 9), representing a difference of 7.3 between the dragging technique and point-by-point ablation (p &amp;lt; .001). Patients receiving LET monitoring and RF ablation using the drag technique had Continuity Indices of 23.8 (range 15 to 30). Patients receiving LET monitoring and RF ablation using point-by-point ablation had Continuity Indices of 28.4 (range 16 to 50). Figure 1 compares these findings. Only 4 patients (5%) in the esophageal cooling group had a Continuity Index above 6 on either side (all in the dragging group), versus 100% (24) of patients in the LET monitoring group. Conclusion Proactive esophageal cooling during PVI is associated with a high degree of lesion continuity, as represented by the low Continuity Index. The drag technique resulted in a higher index than the point-by-point technique, but both provided significantly lower Continuity Indices (greater lesion continuity) than cases using LET monitoring. This may offer a mechanism for the greater freedom from arrhythmia seen to date with proactive cooling in long-term follow-up.Figure 1.Comparison of Continuity Index

Long-term prognosis in patients undergoing atrial fibrillation ablation

Abstract Aims The aim of the analysis was to assess the risk of atrial fibrillation (AF) recurrence in the long-term observation of contemporary patients undergoing pulmonary vein isolation (PVI), who did not have recurrence during the first year after catheter ablation. Methods Retrospective analysis has been performed. Inclusion criteria: (1) the patients undergoing their first PVI in years 2017–2022, (2) the electroanatomical system, contact force catheters and lesion indexes (Ablation Index or Lesion Size Index) were used, (3) no recurrences were observed during the first 12 months of follow-up, and (4) follow-up longer than 12 months was available. Demographic, clinical and echocardiographic data were collected. Follow-up was based on ambulatory visits with ECG/holter monitoring or implanted device interrogation, when available. Results A total of 247 patients were included. The median follow-up was 22 months (interquartile range, 16–31 months). After 24 months, ablation efficacy was 84%, and after 36 months, it was 72%. In the univariate Cox regression analysis, age, previous electrical cardioversion, glomerular filtration rate (eGFR) and the presence of coronary artery disease were linked to AF-free survival. Interestingly, nonparoxysmal AF, left atrial (LA) dimension, heart failure, hypertension or diabetes were not linked to the risk of long-term recurrences. In multivariate Cox regression analysis, presence of coronary artery disease and previous electrical cardioversion were independently linked to the risk of long-term recurrence. In 127 (51.4%) patients, information about the presence of low voltage areas (LVA) was available, and in 21 (16.5%) patients in this group, the presence of LVA was found. Survival of patients with LVA was strikingly worse than that of those without (Figure 1), log-rank test p &amp;lt;0.0001. Conclusions Patients who had no recurrences within one year after PVI, still have substantial risk of recurrence in the next 2 years. That concerns specially the patients who had LVA in the electroanatomical mapping.

High density mapping accuracy and efficiency in atrial fibrillation: real-world outcomes from the SECURE registry

Abstract Background/Introduction A high-density (HD) mapping catheter is valuable for validating pulmonary vein isolation (PVI) and analysing arrhythmic substrates of the left atrium (LA) during atrial fibrillation (AF) ablation. Multiple HD mapping catheters are available for use in clinical practice. A novel octa-spline mapping catheter with a close internal unipolar reference electrode is now available and may improve mapping efficiencies and image resolutions (Figure). Purpose This study aims to report real-world experiences with different commercially available HD mapping catheters in AF ablation and compare mapping performance. Methods SECURE is an ongoing observational, prospective, post-marketing study collecting real-world data on ablation procedures performed per standard-of-care. At the time of data extraction (Nov. 2023), 16 sites across 8 countries had enrolled 2,366 patients (pts), with 12-month follow-up data available for 828 pts. The current analysis, which included consecutive pts undergoing AF ablation, evaluated mapping efficiency and procedural outcomes with 3 HD mapping catheters: circular catheter (CC), penta-spline catheter (PSC), and octa-spline catheter (OSC). Mapping data were analysed with a cloud-based data management and artificial intelligence-powered algorithm. Results Overall, 859 pts with AF (paroxysmal AF [PAF], n=465; persistent AF [PsAF], n=240; long-standing PsAF [LS PsAF], n=154) were included in this analysis. The CC, PSC, and OSC were used in 428, 210, and 221 pts, respectively. Procedures using the OSC had a significantly higher mean mapping area (31,989.9 mm2) than those performed with the CC (23,152.2 mm2; P&amp;lt;0.0001) and PSC (29,804.6 mm2; P=0.0027), as well as a &amp;gt;3-fold higher mean mapping rate (138.4 vs 20.8 and 43.4 points/min, respectively; both P&amp;lt;0.0001). The higher number of mapping points translated to a higher mean mapping density (OSC, 0.34 vs CC, 0.05 and PSC, 0.07 points/mm2; both P&amp;lt;0.0001), with more uniform point distribution and less interpolation. With the CC, PSC, and OSC, respectively, total mean procedure times (incl PVI + other targets) were 118.0, 118.7, and 165.1 min, (P&amp;lt;0.0001 for OSC vs. both CC and PSC) and mean pre-ablation mapping times were 25.2, 25.0, and 21.5 min (P&amp;lt;0.0004 for OSC vs. both CC and PSC). The improved mapping quality and efficiency with the OSC allowed to include specific ablation targets beyond PVI. Fewer PVI-only procedures were performed with the OSC (29.4%) versus the CC (62.1%) and PSC (54.8%), while ablation of the PVI+ other targets was more common with the OSC versus the CC and PSC, including the cavotricuspid isthmus (37.1% vs 17.3% and 16.7%), LA roof (42.5% vs 13.1% and 21.4%), and LA posterior wall (21.7% vs 10.5% and 16.2%). Results were overall consistent per AF type (Table). Conclusions By providing more accurate mapping, the OSC allows for improved analysis of the arrhythmic substrate, which may improve ablation outcomes for pts with PAF and PsAF.Figure 1

Left atrial substrate modification for persistent atrial fibrillation and left atrial macro or microreentrant tachycardia using a single-shot pulsed field ablation system - a single centre case series

Abstract Background Pulsed field ablation (PFA) is a novel ablation technique for pulmonary vein isolation (PVI) in patients with paroxysmal and persistent atrial fibrillation. However, data for efficacy and safety of PFA for left atrial substrate modification in patients with long-standing persistent atrial fibrillation (AF) and macro- as well as microreentrant atrial tachycardia (AT) is scarce. Aim Here we provide a retrospective, single-centre case series regarding efficacy and safety of left atrial substrate modification, using a single-shot PFA system. Methods and Results Over a period of 6 months, 8 patients with long-standing persistent AF and AT underwent Re-PVI with left atrial substrate modification using a single-shot PFA system. Median age was 63 years (IQR 58 - 75), and 4/8 of patients were female. Time from first diagnosis of AF was 7 years (IQR 4 –10). All but 1 patient underwent previous PVI (IQR 1-3) with (5/7) or without (2/7) prior substrate modification using radiofrequency ablation. On transthoracic echocardiography, all patients showed severe left- and right-atrial enlargement, with LA volume of 58 ml/m2 (IQR 49.7–72) and RA diameter of 62 mm (IQR 55-75). In 8 patients, 9 ATs and 2 typical flutters were treated with PFA. Following PVI, additional posterior wall isolation was performed in 6/8 patients, roof in 6/8, and anterior wall (between superior mitral anulus and RSPV) in 4/8 patients. In addition, 2/8 patients had cavotricuspid isthmus ablation for typical atrial flutter. All patients received atropine prior to PVI, as well as bolus of nitro-glycerine prior to PFA of anterior wall and/or cavotricuspid isthmus. Acute success rate was 100% and all ATs as well as typical flutter terminated with PFA. After median follow-up time of 88 days (IQR 61-112), 3 patients had a documented recurrence of AF/AT, in 2 of which electrical cardioversion was necessary. We observed no acute and/or chronic complications following PFA, i.e. no pericardial effusion/tamponade, TIA/stroke, myocardial infarction, coronary artery spasm, AV-block, bleeding, or atrioesophageal fistula. Conclusion In this small, single-centre case series, left atrial substrate modification for long-standing persistent AF and AT using a single-shot PFA system was safe and showed an excellent acute success rate.

Effect of selective renal denervation guided by renal nerve stimulation on atrial remodeling

Abstract Background The renal nerves play a crucial role in regulating blood pressure (BP), and the parasympathetic nervous has been confirmed as one of the components of the renal nerves, with close connections to the central solitary nucleus. Renal nerve stimulation (RNS) can activate not only the sympathetic nerves, leading to an elevation in BP, but also the parasympathetic nerves, resulting in a reduction in BP. Multiple clinical studies have demonstrated that compared to pulmonary vein isolation (PVI), renal denervation (RDN) combined with PVI significantly increased the likelihood of freedom from atrial fibrillation, but its mechanism remains unclear. Purpose Exploring the effects of renal sympathetic denervation and renal parasympathetic denervation on atrial neural remodeling and structural remodeling from a histological perspective of atrial myocardium. Methods 24 adult healthy Kunming dogs were randomly divided into three groups: (1) RNS-guided reduced BP response sites ablation (RRA group, n=8), (2) RNS-guided elevated BP response sites ablation (ERA group, n=8), and (3) RNS only, no ablation (RSC group, n=8). Left atrial samples were obtained after a 4-week follow-up period. Results Compared to the RSC group, the ERA group showed a significant decrease in tyrosine hydroxylase (TH), while the RRA group showed a significant decrease in choline acetyltransferase (CHAT) and muscarinic acetylcholine receptor 2 (CM2) (Fig. 1A-1C). Histological results indicated that compared to the RSC group, the ERA group exhibited orderly arrangement of myocardial cells, with a significant reduction in the degree of mitochondrial swelling and a decrease in average myocardial cell area. In contrast, the RRA group showed disordered arrangement of myocardial cells, with some myofibril dissolution, noticeable swelling of cell nuclei and mitochondria, and an increase in average myocardial cell area (Fig. 1D). Further evaluation of left atrial fibrosis degree revealed that compared to the RSC group, the ERA group showed a significant decrease in Collagen I, with a reduction in interstitial fibrosis degree, while the RRA group showed a significant increase in Collagen I expression, with an increase in myocardial interstitial fibrosis degree (Fig.2). Conclusion Renal sympathetic denervation can reduce atrial sympathetic nerve, improve atrial macrostructure, ultrastructure, and fibrosis levels, which may be one of the reasons why RDN combined with PVI is more effective in maintaining sinus rhythm compared to PVI. Renal parasympathetic denervation can decrease atrial parasympathetic nerve, leading to deterioration of atrial tissue structure and exacerbation of fibrosis. This emphasizes the importance of electrical stimulation guidance during the RDN procedure to avoid "side effects" caused by renal parasympathetic nerves ablation.Figure 1Figure 2

Low conduction velocity is a key factor for localisation of reentrant drivers for atrial fibrillation

Abstract Background Atrial Fibrillation (AF) is a prevalent cardiac arrhythmia globally, associated with heightened risks of stroke, dementia, and heart failure. Catheter ablation, the sole curative therapy for AF, yields suboptimal success rates for persistent AF cases. Understanding the mechanisms and dynamics of AF remains challenging, hindering treatment advancements. Novel ablation strategies aimed at targeting substrates harbouring AF reentrant drivers (RD), such as low-voltage ablation and rotor-based ablation, have yet to demonstrate superiority over the gold standard ablation strategy – pulmonary vein isolation. Purpose The purpose of the study is to integrate in-silico 3D left atrial (LA) simulations and explainable artificial intelligence (AI) to pinpoint key factors for RD localisation in persistent AF, aiming to improve the mechanistic understanding of AF and help develop a more effective ablation strategy. Methods 3D LA models were derived from magnetic resonance images of 41 patients and combined with atrial cell electrophysiology models. Persistent AF was initiated in each patient-specific LA model with fast pacing, and five functional features (action potential duration (APD), conduction velocity (CV), wavelength, APD spatial gradient, CV spatial gradient, and wavelength spatial gradient) and three structural features (fibrotic density, fibrotic entropy, and image intensity ratio) were evaluated. A random forest AI model was trained to classify phase singularities corresponding to the RDs (PS-RD) in five distinct tissue classes (total LA tissue, healthy tissue, fibrotic border zone, dense fibrotic tissue, and PS-RD tissue) based on the functional and structural features. Shapley additive explanations (SHAP) analysis was then used to find the most influential feature in the AI model’s decision process. Results Simulations of the patient-specific LA models revealed that RDs were typically localised in regions with the lowest atrial CV, which often coincided with patches of dense fibrotic tissue. In a five-fold cross-validation, the random forest AI model achieved high accuracy in classifying PS-RD regions: a mean ROC AUC of 0.99 ± 0.010, a mean F1 score of 0.86 ± 0.034, a mean recall of 0.95 ± 0.058, and a mean precision score of 0.79 ± 0.085. The further SHAP analysis revealed that low CV was the key determinant in classifying the PS-RD regions. Conclusion Our study combined AF computational modelling and explainable AI to identify the key factors in RD localisation. Both the computational and AI models concluded that low CV was the most important determinant in localising RDs. These findings provide mechanistic evidence for the efficacy of ablation strategies that target low CV atrial areas for persistent AF patients.

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&amp;lt;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&amp;gt;0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p&amp;lt;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.