Pulmonary Vein Isolation In Patients Research Articles

Comparison of the empirical linear ablation and low voltage area-guided ablation in addition to pulmonary vein isolation in patients with persistent atrial fibrillation: a propensity score-matched analysis

BackgroundThe efficacy of pulmonary vein isolation (PVI) alone is not guaranteed for persistent atrial fibrillation (PeAF), and it is unclear which type of ablation approach should be applied in addition to PVI. This study aimed to compare outcomes and prognosis between empirical linear ablation and low-voltage area (LVA) ablation after PVI for PeAF.MethodsWe enrolled 128 patients with PeAF who were assigned to the linear ablation group (n = 64) and the LVA ablation group (n = 64) using a propensity score-matched model. After PVI and cardioversion, the patients underwent either empirical linear ablation or LVA ablation during sinus rhythm. All patients in the linear ablation group underwent both roof line and mitral valve isthmus (MVI) ablations. An electrical-guided ablation targeting LVA (< 0.5 mV) was performed in the LVA group. When there was no LVA in the LVA group, only PVI was applied. We compared the procedural outcomes and recurrence after ablation between the two groups.ResultsThe baseline characteristics were well-balanced between the two groups. Fifty patients had LVA (22 and 28 patients in the linear and LVA groups). The roof and MVI lines were completed in 100% and 96.9% of the patients. During the mean follow-up of 279.5 ± 161.3 days, the LVA group had significantly lower recurrence than the linear group (15 patients [23%] vs. 29 patients [45%], p = 0.014). Thirty-five patients were prescribed antiarrhythmic drugs during the follow-up period (linear group, n = 17; LVA group, n = 18); amiodarone and bepridil were administered to most of the patients (15 and 17 patients, respectively). The difference in the prognosis was relevant among the patients with LVA, while this trend was not observed in those without LVA. The LVA ablation group demonstrated significantly lower radiofrequency energy and shorter procedural time compared to the linear ablation group. The recurrence of atrial flutter was more likely to occur in the linear group than in the LVA group (14 [22%] vs. 6 [9.4%], p = 0.052).ConclusionThe electrophysiological-guided LVA ablation is more effective than empirical linear ablation in PeAF patients with LVA. Unnecessary empirical linear ablation might have a risk of iatrogenic gap and atrial flutter recurrence.

Acute efficacy of contiguous versus temporally discontiguous point-by-point radiofrequency pulmonary vein isolation in patients with paroxysmal atrial fibrillation: a randomized study.

Durable pulmonary vein (PV) isolation (PVI) determines the clinical success of catheter ablation for atrial fibrillation. In this randomized study, we investigated whether the temporally discontiguous deployment of ablation lesions adversely affected the acute efficacy of PVI. Thirty-six consecutive patients with drug-refractory paroxysmal atrial fibrillation (aged 59 ± 11, 58% males) were randomized 1:1 to either discontiguous (D-PVI) or contiguous (C-PVI) encircling radiofrequency (RF) lesions around ipsilateral PVs. A contact force-sensing catheter was used targeting a final interlesion distance < 6mm and the ablation index of 400-450 (anterior wall) and 300-350 (posterior wall). The study endpoint was defined as failure of first-pass PVI or acute PV reconnection during a waiting time (> 30min) followed by adenosine challenge. The total RF time, number of RF lesions, and mean interlesion distance were comparable in both groups. Total endpoint rates were 1/36 (3%) in the D-PVI vs 4/36 (11%) in the C-PVI groups; P = 0.34 for superiority, P = 0.008 for non-inferiority. Adenosine-induced reconnection of right PVs was the only endpoint in the D-PVI group. In the C-PVI group, first-pass PVI failed in 2 right PVs and spontaneous reconnection occurred in 2 other circles (left and right PVs). Temporally discontiguous deployment of RF lesions is not associated with lower procedural PVI efficacy when strict criteria for interlesion distance and ablation index are applied. The development of local edema around each ablation site does not prevent effective RF lesion formation at adjacent positions. clinicaltrials.gov (NCT03332862).

Improvement of Retinal Microcirculation after Pulmonary Vein Isolation in Patients with Atrial Fibrillation-An Optical Coherence Tomography Angiography Study.

Purpose: To evaluate retinal and optic nerve head (ONH) perfusion in patients with atrial fibrillation (AF) before and after catheter ablation of AF with pulmonary vein isolation (PVI). Methods: 34 eyes of 34 patients with AF and 35 eyes of 35 healthy subjects were included in this study. Flow density data were obtained using spectral-domain OCT-A (RTVue XR Avanti with AngioVue, Optovue, Inc, Fremont, California, USA). The data of the superficial and deep vascular layers of the macula and the ONH (radial peripapillary capillary network, RPC) before and after PVI were extracted and analysed. Results: The flow density in the superficial OCT-angiogram (whole en face) and the ONH (RPC) in patients with AF was significantly lower compared to healthy controls (OCT-A superficial: study group: 48.77 (45.19; 52.12)%; control group: 53.01 (50.00; 54.25)%; p < 0.001; ONH: study group: 51.82 (48.41; 54.03)%; control group: 56.00 (54.35; 57.70)%; p < 0.001;). The flow density in the ONH (RPC) improved significantly in the study group following PVI (before: 51.82 (48.41; 54.03)%; after: 52.49 (50.34; 55.62)%; p = 0.007). Conclusions: Patients with AF showed altered ocular perfusion as measured using OCTA when compared with healthy controls. Rhythm control using PVI significantly improved ocular perfusion as measured using OCT-A. Non-contact imaging using OCTA provides novel information about the central global microperfusion of patients with AF.

Abstract 9714: Deep Learning on 12-Leads Electrocardiography Can Predict Recurrence After Pulmonary Vein Isolation in Patients with Persistent Atrial Fibrillation

Introduction: In patients with persistent atrial fibrillation (per-AF) who were treated by pulmonary vein isolation (PVI), several patients suffer from recurrence. Various methods to predict the recurrence were tried, but prognostic value of deep learning on 12-leads electrocardiography (ECG) just after PVI was not studied. Hypothesis: Deep learning on 12-leads ECG after PVI has high diagnostic performance in patients with per-AF. Methods: We enrolled consecutive 109 patients with per-AF who underwent PVI (68.8±10.0 years, 83 males) excluding failure cases. We defined recurrence in 3-12 months after PVI. From the ECG just after PVI, five beats of each lead were sampled separately. Deep learning (convolutional neural network on bitmap ECG image) was performed by transfer learning of Inception-Resnet-V2 model. Gradient weighted class activation color mapping (GradCam) was performed to detect convolutional importance in the lead. Results: Thirty-six patients showed recurrence in the period. Lead II (accuracy 0.701), aVR (0.690) were the top 2 leads of prediction, which showed larger accuracy than statistical accuracies of Non PV foci = SVC (accuracy = 0.541) and left atrial diameter &gt; 50mm (0.596). In lead II, GradCam spotlighted strong convolution of latter half of P wave in recurrent case, and former half of P wave and T wave in no-recurrent case. Conclusions: Deep learning on ECG was a powerful tool to predict recurrence of per-AF after PVI.

Visualization of thermal damage using 68\xa0Ga-FAPI-PET/CT after pulmonary vein isolation

Purpose68 Ga-fibroblast-activation protein inhibitor (FAPI) positron emission tomography (PET) is a novel technique targeting FAP-alpha. This protein is expressed by activated fibroblasts which are the main contributors to tissue remodeling. The aim of this proof-of-concept study was to assess 68 Ga-FAPI uptake in the pulmonary vein (PV) region of the left atrium after pulmonary vein isolation (PVI) with cryoballoon ablation (CBA) and radiofrequency (RFA) as a surrogate for thermal damage.MethodsTwelve PVI patients (5 RFA, 7 CBA) underwent 68 Ga-FAPI-PET 20.5 ± 12.8 days after PVI. Five patients without atrial fibrillation or previous ablation served as controls. Standardized uptake values of localized tracer uptake were calculated.ResultsFocal FAPI uptake around the PVs was observed in 10/12 (83.3%) PVI patients, no uptake was observed in 2 PVI patients and all controls. Patients after PVI had higher FAPI uptake in PVs compared to controls (SUVmax: 4.3 ± 2.2 vs. 1.6 ± 0.2, p < 0.01; SUVpeak: 2.9 ± 1.4 vs. 1.3 ± 0.2, p < 0.01). All CBA patients had an intense uptake, while in the RFA, group 2 (40%), 1 (20%), and 2 (40%) patients had an intense, moderate, and no uptake, respectively. We observed higher uptake values (SUVpeak) in CBA compared to RFA patients (4.4 ± 1.5 vs. 2.5 ± 0.8, p = 0.02).ConclusionWe demonstrate in-vivo visualization of 68 Ga-FAPI uptake as a surrogate for fibroblast activation after PVI. CBA seems to cause more pronounced fibroblast activation following tissue injury than RFA. Future studies are warranted to assess if this modality can contribute to a better understanding of the mechanisms of AF recurrence after PVI by lesion creation and gap assessment.

Nonthermal Irreversible Electroporation to the Esophagus: Evaluation of Acute and Long-Term Pathological Effects in a Rabbit Model.

BackgroundEsophageal ulceration and fistula are severe complications of pulmonary vein isolation using thermal ablation. Nonthermal irreversible electroporation (NTIRE) is a promising new technology for pulmonary vein isolation in patients with atrial fibrillation. NTIRE ablation technology has been used to treat atrial fibrillation; however, the effects of NTIRE on esophageal tissue have not been clearly described.Methods and ResultsA typical NTIRE electrical protocol was directly applied to esophagi in 84 New Zealand rabbits. Finite element modeling and histological analysis with 120 slices were used to analyze electric field intensity distribution and subsequent tissue changes. A parameter combination of 2000 V/cm multiplied by 90 pulses output is determined to be an effective ablation parameters combination. Within 16 weeks after ablation, no obvious lumen stenosis, epithelial erythema, erosion, ulcer, or fistula was observed in the esophageal tissue. NTIRE effectively results in esophageal cell ablation to death, and subsequently, signs of recovery gradually appear: creeping replacement and regeneration of epithelial basal cells, repair and regeneration of muscle cells, structural remodeling of the muscle layer, and finally the restoration of clear anatomical structures in all layers.ConclusionsMonophasic, bipolar NTIRE delivered using plate electrodes in a novel esophageal injury model demonstrates no histopathologic changes to the esophagus at 16 weeks. Data of this study suggest that electroporation ablation is a safe modality for pulsed electroporation ablation near the esophagus.

Novel cryoballoon to isolate pulmonary veins in patients with paroxysmal atrial fibrillation: one-year outcomes in a multicenter study

Abstract Background Recently, a novel cryoballoon (CB; POLARx) has been developed with increased steerability which maintains size and pressure throughout the ablation. Initial clinical data has demonstrated acute procedural safety and efficacy in de novo pulmonary vein isolation (PVI) procedures in patients with paroxysmal atrial fibrillation (AF). However, there are limited studies demonstrating the long-term efficacy of the CB. Purpose To evaluate the long-term safety and efficacy of the novel CB in treating paroxysmal AF. Methods This was a non-randomized, prospective, multi-center study. Fifty-eight consecutive patients with paroxysmal AF were enrolled at 4 centers for de novo PVI procedures. Cryoablation was delivered for 180s if time to isolation was ≤60s. Otherwise a 240s cryoablation was performed. PVI was confirmed with entrance and exit block testing. Patients were followed for 1 year with 24-hour Holter monitoring at 3, 6, and 12 months. After a 3-month blanking period, recurrence was defined as having any documented, symptomatic episode(s) of AF or atrial tachycardia. Results Acute isolation with the CB was achieved in 230 of 231 pulmonary veins (99.6%) with 5.2±1.5 cryoapplications per patient (1.3±0.6 cryoapplications per vein). There were 4 patients (6.9%) with phrenic nerve injury (3 resolved during the index procedure; 1 resolved at 6 months follow-up). One serious adverse device event was reported: femoral arterial embolism event occurring 2 weeks post index procedure (1.7%). Of the 56 patients that had complete 12-month follow-up, 43 (76.8%) were free from recurrent atrial arrhythmias. Conclusion Initial multicenter clinical experience with the novel CB has demonstrated long-term safety and efficacy of PVI in patients with paroxysmal AF. Further studies are underway to confirm these findings. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Boston Scientific

Evolution in lesion index durability using the new third generation laser balloon catheter for pulmonary vein isolation – does the mechanical innovation mean also clinical innovation?

Abstract Background The new second- and third-generation endoscopic ablation systems (EAS 2 and EAS 3) have been launched in recent years. We aimed to assess the index lesion durability as well as gap localization using the multigenerational novel technologies in patients with recurrent atrial fibrillation (AF). Methods Consecutive patients who underwent the second ablation for recurrent AF following the initial pulmonary vein isolation (PVI) with EAS 2 or EAS 3 were investigated. The persistent durability of PVI and gap localization at the second procedure were analyzed using spiral mapping catheter and three-dimensional mapping system. Results A total of 34 patients (EAS3: N=13, 50 PVs, EAS2: N=21, 82 PVs) were enrolled. Repeat procedure was performed mean 11.9±9.3 months after the initial procedure. Persistent durable isolation of all four PVs was recorded in 6 (46.2%) patients in EAS3 and 4 (19.1%) patients in EAS2 (P=0.130). Ninety-one out of 132 (68.9%) PVs were persistently isolated with a higher rate in EAS3 (EAS3: 82.0% vs. EAS2: 61.0%, P=0.0113). A total of 45 gaps were recorded in 41 PVs, of which right superior PV (RSPV) was the predominantly common reconnected vein (15 gaps in 14 PVs) irrespective of generation difference (EAS 3: 4 gaps in 3 PVs and EAS 2: 12 gaps in 11 PVs). Anterior-segment of RSPV was the most common gap distribution (EAS 3: 2 gaps and EAS 2: 6 gaps). Logistic multivariate regression analysis revealed high-dose (≥8.5W) only ablation as an independent predictor of durable PVI (adjusted OR: 3.70, 95% CI [1.408 - 10.003], P=0.008) Conclusion The multigenerational technical innovation resulted in a higher index lesion durability in EAS3 guided PVI in patients with recurrent AF. The specific gap patterns frequent at RSPV, especially at the anterior-superior segment, and the feasibility of high-dose ablation were confirmed in successor EASs. Funding Acknowledgement Type of funding sources: None.

Defining the optimal blanking period duration after cryoballoon pulmonary vein isolation in patients with atrial fibrillation who have never been treated with an antiarrhythmic drug

Abstract Background Cryoballoon (CB) pulmonary vein isolation (PVI) is an approved method for ablation in patients with paroxysmal (PAF) or persistent (PeAF) atrial fibrillation (AF). Although the first 90 days post-ablation are considered within the blanking period (BP), the optimal duration of the BP remains undefined. Purpose To objectively define the BP duration in pts undergoing CB PVI by evaluating a cohort never treated with an antiarrhythmic drug (AAD). Methods We enrolled consecutive pts with either PAF or PeAF who underwent initial CB PVI; all pts had an implantable loop recorder (ILR) for long-term ECG monitoring. No pt received an AAD either before or after ablation. We determined the time to last AF episode within the first 90 days of ablation. We then correlated this to the likelihood a patient had recurrent AF between 91 and 365 days of ablation. Results There were 45 pts (67±8 years; 26 [58%] male; 40 [89%] PAF; CHA2DS2-VASc 2.6±1.3). We defined 4 distinct groups post ablation based on whether or not they had AF in the BP: (1) no AF days 0–90 (n=19 [42%]), (2) last AF days 0–30 (n=11 [24%]), (3) last AF days 31–60 (n=3 [7%]), and (4) last AF days 61–90 (n=12 [27%]). After the 90-day BP, 15 (33%) pts had AF recurrence. Pts with no AF and those with AF only within 30 days of ablation had similar long-term outcome; however, recurrent AF more than 32 days after ablation predicted long-term ablation failure (Figure). Conclusion The post CB PVI blanking period is just a month. AF recurrences beyond a month in patients not on an AAD are associated with AF recurrence in the majority of pts. Funding Acknowledgement Type of funding sources: None. Blanking Group by AF Recurrence

Diagnostic performance of deep learning on 12-leads electrocardiography for recurrence after pulmonary vein isolation in patients with persistent atrial fibrillation

Abstract Background Several patients with persistent atrial fibrillation (per-AF) suffer from recurrence after pulmonary vein isolation (PVI). Various methods to predict the recurrence were tried, but deep learning on 12-leads electrocardiography (ECG) after PVI was not studied. Purpose To elucidate diagnostic performance of deep learning on 12-leads ECG after PVI in patients with per-AF Methods We enrolled consecutive 109 patients with per-AF who underwent PVI (68.8±10.0 years, 83 males) excluding failure cases. We defined recurrence in 3–12 months after PVI. From the ECG just after PVI, five beats of each lead were sampled separately. Deep learning (convolutional neural network on bitmap ECG image) was performed by transfer learning of Inception-Resnet-V2 model. Gradient weighted class activation color mapping (GradCam) was performed to detect convolutional importance in the lead. Results Thirty-six patients showed recurrence in the period. Lead II (accuracy 0.701), aVR (0.690) were the top 2 leads of prediction, which showed larger accuracy than statistical accuracies of Non PV foci = SVC (accuracy = 0.541) and left atrial diameter &amp;gt;50mm (0.596). In lead II, GradCam spotlighted strong convolution of latter half of P wave in recurrent case, and former half of P wave and T wave in no-recurrent case. Conclusions Deep learning on ECG was a powerful tool to predict recurrence of per-AF after PVI. Funding Acknowledgement Type of funding sources: None. Results of deep learningResults of GradCam

Impact of clinical risk factor profile vs. atrial fibrillation phenotype on outcome after pulmonary vein isolation

Abstract Aims Catheter ablation for atrial fibrillation (AF) is increasingly performed. Both clinical risk factors as well as the AF phenotype have been shown to influence ablation outcomes. The inter-relationship of the two however is incompletely understood. Methods In a retrospective analysis of a prospective registry of patients undergoing a first pulmonary vein isolation, the association of 8 predefined clinical risk factors (age &amp;gt;70 years, female gender, hypertension, BMI &amp;gt;30 kg/m2, coronary artery disease, heart failure, chronic kidney disease (CKD; eGFR&amp;lt;60ml/min/1.73m2) and diabetes mellitus) and the AF phenotype (paroxysmal vs. persistent AF) were assessed as well as their impact on AF recurrence during follow-up. Results Overall, 715 patients were enrolled (median age 63 years, 27% females, 69% paroxysmal AF). The prevalence of obesity, hypertension, heart failure and CKD was significantly higher in persistent AF, while female gender was more prevalent in paroxysmal AF. After 2 years of follow-up, overall freedom from recurrence was 46%, and was higher in paroxysmal AF compared to persistent AF (54.1% vs. 29.1%, p&amp;lt;0.001). Of the clinical risk factors, obesity (p=0.02), CKD (p=0.01) and heart failure (p=0.01) were significantly associated with lower arrhythmia-free survival, and there was a trend for hypertension and coronary artery disease (both p&amp;lt;0.2). A risk score composed of those 5 factors was associated with recurrences in patients with paroxysmal AF (p=0.04, Figure 1), but not in those with persistent AF (p=0.85, Figure 2). Conclusion Clinical risk factors predict outcome after pulmonary vein isolation in patients with paroxysmal, but not persistent AF. This is likely due to a strong association of those risk factors with the occurrence of persistent AF. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Left atrial wall thickness and its relationship with reconnection after pulmonary vein isolation in patients with atrial fibrillation evaluated using a three-dimensional wall thickness map

BackgroundThe major cause of recurrence after pulmonary vein (PV) isolation for atrial fibrillation (AF) is PV reconnection, and thicker wall could be associated with reconnection.ObjectivesThis study aimed to evaluate the wall thickness of the PV antrum in reconnection sites using a three-dimensional (3D) wall thickness map.MethodsA total of 91 patients who underwent a second ablation procedure due to AF recurrence were evaluated. The locations of the PV reconnection sites were confirmed in electroanatomical maps. A 3D atrial wall thickness (AWT) map was created using computed tomography scan data. The AWT values of the ablation lines of the index procedure were graded in each segment of the PV antrum: grade 1, 0.5 < AWT ≤ 1.0 mm; grade 2, 1.0 < AWT ≤ 1.5 mm; grade 3, 1.5 < AWT ≤ 2.0 mm; grade 4, 2.0 < AWT ≤ 2.5 mm; grade 5, AWT > 2.5 mm.ResultsA total of 281 PV reconnection sites among 1256 segments of the PV antrum in 79 patients were detected. The average AWT grades were 2.7 ± 1.0 and 2.2 ± 1.0 in the reconnected and non-reconnected segments, respectively (P < 0.01). Higher AWT grades were observed in the reconnected superior segments of the left superior PV, carina and inferior segments of the left inferior PV, superior and posterior segments of the right superior PV, and posterior and inferior segments of the right inferior PV.ConclusionThe reconnected segments of the PV antrum showed thicker myocardium than the non-reconnected ones in patients with recurrent AF after catheter ablation. A wall thickness map for PV isolation could be considered for customized ablation in order to reduce PV reconnection.

Catheter ablation for persistent atrial fibrillation: A multicenter randomized trial of pulmonary vein isolation (PVI) versus PVI with posterior left atrial wall isolation (PWI) - The CAPLA study

The success of pulmonary vein isolation (PVI) is reduced in persistent AF (PsAF) compared to paroxysmal AF. Adjunctive ablation strategies have failed to show consistent incremental benefit over PVI alone in randomized studies. The left atrial posterior wall is a potential source of non-PV triggers and atrial substrate which may promote the initiation and maintenance of PsAF. Adding posterior wall isolation (PWI) to PVI had shown conflicting outcomes, with earlier studies confounded by methodological limitations. To determine whether combining PWI with PVI significantly improves freedom from AF recurrence, compared to PVI alone, in patients with PsAF. This is a multi-center, prospective, international randomized clinical trial. 338 patients with symptomatic PsAF refractory to anti-arrhythmic therapy (AAD) will be randomized to either PVI alone or PVI with PWI in a 1:1 ratio. PVI involves wide antral circumferential pulmonary vein (PV) isolation, utilizing contact force sensing ablation catheters. PWI involves the creation of a floor line connecting the inferior aspect of the PVs, and a roof line connecting the superior aspect of the PVs. Follow up is for a minimum of 12 months with rhythm monitoring via implantable cardiac device and/or loop monitor, or frequent intermittent monitoring with an ECG device. The primary outcome is freedom from any documented atrial arrhythmia of > 30 seconds off AAD at 12 months, after a single ablation procedure. This randomized study aims to determine the success and safety of adjunctive PWI to PVI in patients with persistent AF.

Cardiac Sympathetic Activity and Rhythm Control Following Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation-A Prospective 123I-mIBG-SPECT/CT Imaging Study.

Background: Pulmonary vein isolation (PVI) and antiarrhythmic drug therapy are established treatment strategies to preserve sinus rhythm in atrial fibrillation (AF). However, the efficacy of both interventional and pharmaceutical therapy is still limited. Solid evidence suggests an important role of the cardiac sympathetic nervous system in AF. In this blinded, prospective observational study, we studied left ventricular cardiac sympathetic activity in patients treated with PVI and with antiarrhythmic drugs. Prospectively, Iodine-123-benzyl-guanidine single photon emission computer tomography (123I-mIBG-SPECT) was performed in a total of 23 patients with paroxysmal AF, who underwent PVI (n = 20) or received antiarrhythmic drug therapy only (n = 3), respectively. 123I-mIBG planar and SPECT/CT scans were performed before and 4 to 8 weeks after PVI (or initiation of drug therapy, respectively). For semiquantitative SPECT image analysis, attenuation-corrected early/late images were analyzed. Quantitative SPECT analysis was performed using the AHA 17-segment model of the left ventricle. Results: PVI with point-by-point radiofrequency ablation led to a significantly (p < 0.05) higher visual sympathetic innervation defect score when comparing pre-and post PVI. Newly emerging innervation deficits post PVI were localized predominantly in the inferior lateral wall. These findings were corroborated by semiquantitative SPECT analysis identifying inferolateral segments with a reduced tracer uptake in comparison to SPECT before PVI. Following PVI, patients with an AF relapse showed a different sympathetic innervation pattern compared to patients with sufficient rhythm control. Conclusions: PVI results in novel defects of cardiac sympathetic innervation. Differences in cardiac sympathetic innervation remodelling following PVI suggest an important role of the cardiac autonomous nervous system in the maintenance of sinus rhythm following PVI.

Cryoballoon Versus High-Power, Short-Duration Radiofrequency Ablation for Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation: A Single-Center, Prospective, Randomized Study.

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Preventing atrial fibrillation by combined right isthmus ablation and cryoballoon pulmonary vein isolation in patients with typical atrial flutter: PAF-CRIOBLAF study.

BackgroundAlthough less common, typical atrial flutter shares similar pathophysiological roots with atrial fibrillation. Following successful cavo‐tricuspid isthmus ablation using radiofrequency, many patients, however, develop atrial fibrillation in the mid‐to‐long‐term. This study sought to assess whether pulmonary vein isolation conducted at the same time as cavo‐tricuspid isthmus ablation would significantly modify the atrial fibrillation burden upon follow‐up in patients suffering from typical atrial flutter.MethodsThis was a multicenter randomized controlled study involving typical atrial flutter patients with history of non‐predominant atrial fibrillation (1 atrial fibrillation episode only, in 67% of population) who were scheduled for cavo‐tricuspid isthmus radiofrequency ablation. Patients were randomly assigned to either undergo cavo‐tricuspid isthmus ablation alone or cavo‐tricuspid isthmus plus pulmonary vein isolation (CTI+). Pulmonary vein isolation was performed using cryoballoon technology. An outpatient consultation with ECG and 1‐week Holter monitoring was performed at 3, 6 months, 1 year, and 2 years postprocedure. The primary endpoint was atrial fibrillation recurrences lasting more than 30 s at 2 years postablation.ResultsOf the patients enrolled, 36 were included in each group. At 2‐year follow‐up, the atrial fibrillation recurrence rate was significantly higher in the CTI vs CTI+group (25/36, 69% vs. 12/36, 33% respectively; P < .001), with similar typical atrial flutter recurrence rates. There were no differences in undesirable events, except for transient phrenic nerve palsy reported from three CTI+patients (8.3%).ConclusionPulmonary vein isolation using cryoballoon technology was proven to significantly reduce the atrial fibrillation incidence at 2 years postcavo‐tricuspid isthmus ablation.

Safety and Efficacy of Cryoballoon Based Pulmonary Vein Isolation in Patients with Atrial Fibrillation and a History of Cancer.

Introduction: A growing body of evidence suggests a strong association between atrial fibrillation (AF) and cancer. A relevant number of patients with a present or former malignant disease with highly symptomatic drug-refractory AF are in need of interventional therapy. Data on the safety and efficacy of catheter ablation in these patients are sparse. The present study aims to analyze the safety and efficacy of cryoballoon-based pulmonary vein isolation (CB-PVI) for symptomatic AF in patients with past or present cancer disease. Methods and Results: Consecutive patients undergoing CB-PVI for symptomatic AF at University Hospital Lübeck, Germany between July 2015 and January 2019 were included in this study. Propensity-score based matching was performed to identify comparable patients with and without cancer disease and further analyze clinical characteristics, periprocedural complications and arrhythmia-free survival. A total of 70 patients with a history of cancer undergoing CB-PVI were matched to 70 patients without a history of cancer. The frequency of complications was similar between patients with and without a history of cancer (p = 0.11), with four phrenic nerve palsies occurring in patients with a history of cancer (5.6% of the cohort) vs. one phrenic nerve palsy in patients without cancer (p = 0.36). Arrhythmia free survival after 12 months did not differ significantly in patients with and without a history of cancer (67.1 ± 5.8% vs. 77.8% ± 5.1%, p = 0.16). Conclusion: This study indicates that CB-PVI for symptomatic AF is equally safe and effective in patients with and without a history of cancer and cancer treatment.

Validation of lesion durability following pulmonary vein isolation using the new third-generation laser balloon catheter in patients with recurrent atrial fibrillation

BackgroundThe second- and third-generation endoscopic ablation systems (EAS2 and EAS3) have been launched in recent years. We aimed to assess the lesion durability as well as gap localization using the multigenerational novel technologies in patients with recurrent atrial fibrillation (AF). MethodsConsecutive patients who underwent second ablation for recurrent AF following the initial pulmonary vein isolation (PVI) with EAS2 or EAS3 were retrospectively investigated. The persistent durability of PVI, gap localization at the second procedure, and procedural/anatomical features of durable PVI were analyzed. ResultsAmong 225 patients treated with EAS3 (N = 125) and EAS2 (N = 100), 34 patients (EAS3: 13 patients, 50 PVs, EAS2: 21 patients, 82 PVs) underwent a second procedure because of recurrent AF mean 11.9 ± 9.3 months after the initial procedure. Persistent isolation of all four PVs was recorded in 6 (46.2%) patients in EAS3 group and 4 (19.1%) patients in EAS2 group (p = 0.130). Ninety-one out of 132 (68.9%) PVs were persistently isolated with a higher rate in EAS3 group (82.0% vs. EAS2 group: 61.0%, p = 0.0113). A total of 45 gaps were recorded in 41 PVs. Right superior PV (RSPV) was the predominantly common reconnected vein (15 gaps, 14 PVs) irrespective of generations (EAS3: 4 gaps in 3 PVs and EAS2: 12 gaps in 11 PVs). Logistic multivariate regression analysis revealed ablation without reduced energy dose (5.5–7 W) as an independent predictor of durable PVI [adjusted OR: 3.70, 95% CI (1.408–10.003)], p = 0.008]. ConclusionThe technical innovation resulted in a higher lesion durability in EAS3-guided PVI in patients with recurrent AF. The most common gap location was found at RSPV in successor EASs. Ablation without reduced energy was a predictor of durable PVI in successor EASs.

Prevalence and Predictors of Additional Ablation Beyond Pulmonary Vein Isolation in Patients With Paroxysmal Atrial Fibrillation.

Background: Pulmonary vein isolation (PVI) is an effective strategy in the treatment of paroxysmal atrial fibrillation (PAF). Yet, there are limited data on additional ablation beyond PVI. In this study, we sought to assess the prevalence, predictors, and outcomes of additional ablation in PAF patients.Methods: A total of 537 consecutive patients with PAF were retrospectively evaluated for the index procedure. PVI was successfully conducted in all patients, after which electrophysiological study and drug provocation were performed, and additional ablations were delivered for concomitant arrhythmias, non-PV triggers, and low voltage zone (LVZ). The prevalence, predictors, and outcomes of additional ablation were analyzed.Results: Among 537 consecutive patients, 372 addition ablations were performed in 241 (44.88%) patients, including 252 (67.74%) concomitant arrhythmias in 198 (36.87%) patients, 56 (15.05%) non-PV triggers in 52 (9.68%) patients and 64 (17.20%) LVZ modification in 47 (8.75%) patients. Lower LVEF (OR = 0.937, p = 0.015), AF episode before procedure (OR = 2.990, p = 0.001), AF episode during procedure (OR = 1.998, p = 0.002) and AF episode induced after PVI (OR = 15.958, p < 0.001) were independent predictors of additional ablation. Single-procedure free from atrial arrhythmias at 58.36 ± 7.12 months post-ablation was 70.48%.Conclusions: Additional ablations were common in patients with PAF for index procedure. Lower LVEF and AF episodes before, during the procedure, and induced after PVI predicts additional ablation.

Reconnection Sites in Redo Ablation after Cryoballoon Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation.

ResumoFundamento Na fibrilação atrial paroxística (FAP), o isolamento das veias pulmonares com criobalão (IVP-CB) tem eficácia semelhante à da ablação por radiofrequência (IVP-RF). Em procedimentos de reablação após IVP-RF, a reconexão das VPs é alta, ao passo que em pacientes com reablação após IVP-CB, as informações são escassas.Objetivo Determinar os locais de reconexão das VPs em pacientes que foram submetidos à reablação após IVP-CB inicial.Métodos Pacientes que foram submetidos a um procedimento de reablação de fibrilação atrial, após um IVP-CB inicial para FAP foram incluídos. O mapeamento eletroanatômico do AE foi utilizado. Um local de reconexão foi definido com a presença de uma voltagem de 0,3mV ou maior nas VPs e condução unidirecional ou bidirecional nas VPs durante o ritmo sinusal. Os locais de reconexão foram identificados por meio de corte paraesternal longitudinal e posteriormente ablacionados com radiofrequência.Resultados Dos 165 pacientes submetidos ao IVP inicial, 27 necessitaram reablações, dos quais 18 (66,6%) eram do sexo masculino, com média de idade de 55+12,3 anos. O tempo de recorrência foi de 8,9+6,4 meses. A reconexão das VPs foi encontrada em 21 (77,8%) pacientes. Houve um total de 132 lacunas de condução, seis por paciente, 3,6 por VP. Um número significativo de lacunas ocorreu na região ântero-superior da VP superior esquerda (VPSE) e nas regiões septal e inferior da VP superior direita (VPSD).Conclusões As VPs superiores apresentaram os locais de maior reconexão, principalmente na região anterior da VPSE e na região septal da VPSD. A razão por trás disso pode ser devido à maior espessura da parede atrial e à dificuldade em alcançar o contato de criobalão adequado.