Pulmonary Vein Reconnection Research Articles

Feasibility and safety of zero-fluoro, "apron-less" approach to repeat pulmonary vein isolation procedures using radiofrequency energy after initial cryoballoon ablation.

We aimed to investigate the feasibility and safety of zero-fluoro approach for the repeat atrial fibrillation (AF) procedures after initial cryoballoon (CB) ablation. We have performed a retrospective study on patients that have undergone repeat pulmonary vein isolation (PVI) procedures in our institution since zero-fluoro program was initiated in 2020. All patients received CB ablation for the initial procedure. Repeat procedures were performed under conscious sedation and with intracardiac echo (ICE) and 3D mapping system - without the use of fluoroscopy and lead aprons. We have analysed in total 50 patients (76% male, 57.9 ± 10.2 years old), 50% of which suffered from paroxysmal AF. All procedures were successfully performed without the use of fluoroscopy. The mean procedure time was 93.9 ± 27.1min and the mean RF time was 825 ± 468s. The mean of 0.98 ± 0.91 veins was reconnected per patient and 36% of patients did not have PV reconnections. In all patients successful PV isolation was performed, confirmed by entry and exit block. No major periprocedural complications were observed. After the mean follow up of 12.5 ± 3.4 months: 68% of mixed AF population patients were free from AF after one year. In our cohort of patients, zero-fluoro, apron-less approach for repeat PVI procedures after index cryoballoon ablation proved to be feasible and safe. Index CB ablation resulted with low rates of PV reconnections and mid-term results after repeat procedures are favourable.

Repeat Procedures After Pulsed Field Ablation for Atrial Fibrillation: MANIFEST-REDO Study.

Initial clinical studies of pulsed field ablation (PFA) to treat atrial fibrillation (AF) indicated a >90% durability rate of pulmonary vein isolation (PVI). However, these studies were largely conducted in single centers and involved a limited number of operators. The electrophysiological findings and outcomes in patients undergoing repeat ablation after an initial PF ablation for AF are incompletely understood. In the MANIFEST-REDO study, we investigated patients who underwent repeat ablation due to clinical recurrence - AF or atrial tachycardia (AT) - following first-ever PVI with a pentaspline PFA catheter (Farawave; Boston Scientific Inc). At 22 centers, 427 patients (age 64±11 years; 37% female) were included. Of note, the recurrent arrhythmia leading to the repeat ablation was paroxysmal AF (51%), persistent AF (30%), or AT (19%). At the repeat procedure, the PV reconnection rates were: 30% (LSPV), 28% (LIPV), 33% (RSPV) and 32% (RIPV). In 45% of patients all PVs were durably isolated at the beginning of the repeat procedure, with the previous use of any imaging or mapping modality being univariately associated with durable PVI. After a post-redo follow-up period of 284 [90-366] days, the primary effectiveness endpoint (freedom from documented AF/AT lasting ≥30s after 3-month blanking without class I/III antiarrhythmic drugs or symptoms) was achieved in 65% of patients, with significant differences between groups (PAF 65% vs. PersAF 56% vs. AT 76%; p=0.04). Persistent AF as recurrent arrhythmia after the initial PFA ablation predicted AT/AF recurrence after repeat ablation (HR 1.241 (95% CI 1.534-1.005 CI); p=0.045). The procedural complication rate was 2.8%. In repeat procedures for AF/AT performed after an index procedure with PFA for AF, PV reconnections are not uncommon. Repeat procedures can be performed safely and with an acceptable subsequent success rate.

Clinical Importance of Tissue Proximity Indication During Pulsed Field Ablation for Atrial Fibrillation: Insights from Initial Experience.

Pulsed field ablation (PFA) for paroxysmal atrial fibrillation (AF) has been gaining worldwide acceptance due to its efficacy and safety. A variable loop circular catheter (VLCC, VARIPULSE, Biosense Webster, Inc.) for PFA, recently launched in Japan, includes a Tissue Proximity Indication (TPI) feature to monitor catheter-tissue contact via impedance. However, the role of TPI during pulmonary vein (PV) isolation (PVI) is unclear. This study aims to evaluate TPI feasibility during PVI and its relationship with acute PV reconnection. Twenty-one paroxysmal AF patients underwent PFA (four ablations per PV at least) using the VLCC. We evaluated the association between TPI-positive site percentages, voltage, left atrial wall thickness on ADAS 3D software, and acute PVI failure sites. Four of 21 patients (8 failure sites) experienced PVI failure after primary PFA. Failure sites had significantly lower TPI-positive site percentages (0±0% vs. 63±27%, p< .001) and higher voltage (3.57±1.35 mV vs. 2.06±1.42 mV, p= .003), but not PV wall thickness. We found that a left atrial bipolar voltage amplitude ≥2.24 mV was determinants of PV gaps with an area under the curve of 0.83 calculating receiver operating characteristic curves. TPI-positive site percentages increased significantly (58±29% to 64±26%, p= .009), while PV gaps decreased from 3/28 PVs (11%) to 2/54 PVs (4%, p= .332) between the first 7 and last 14 cases. Acute PVI failure was significantly associated with poor tissue contact and higher voltage. However, acute PVI failure can be prevented with improved TPI-based contact information.

Abstract 4141875: Individualized Ablation Strategies Optimize First Pass Isolation and Minimize Pulmonary Vein Reconnection During Atrial Fibrillation Ablation

Background: First pass isolation (FPI) improves freedom from AF, while acute pulmonary vein reconnection (PVR) predicts AF recurrence. There is little data to predict FPI or acute PVR based on individual patient characteristics. Height is a risk factor for incident AF and may be associated with AF recurrence after ablation. Hypothesis: We hypothesize that patient-specific factors can predict lack of FPI and acute PVR. If such factors are identified and used to modify ablation strategies, FPI will increase and acute PVR will reduce in those undergoing paroxysmal AF ablation. Methods: Patients were ablated utilizing CARTO3 with THERMOCOOL SMARTTOUCH SF catheters at 50W, 2mm overlapping lesions. A derivation cohort of patients were treated with standard Ablation Index (AI) targets of 450 on anterior and 350 on posterior surfaces. Subsequently, ablation strategies would be modified and outcomes were reassessed. Results: In the derivation cohort, median height (&lt;172cm vs &gt; 172cm) was the strongest predictor of FPI among all variables (age, sex, height, weight, BSA, diabetes, hypertension, sleep apnea, LA size), (B=1.68 p&lt;0.01). When patients were treated with standard AI targets, patients &gt; 172cm had reduced FPI (50/107 [47%] vs 67/99 [68%] p&lt;0.01) and increased acute PVR (24/107 [22%] vs 67/99 [11%] p=0.04) compared to patients &lt;172cm. A subsequent cohort of 56 patients &gt; 172cm were treated with augmented AI targets of 550 on anterior and 350 on posterior surfaces. When compared to patients &gt; 172cm treated with standard AI targets, FPI increased (37/56 [65%] vs 50/107 [47%] p=0.02) and acute PVR decreased (1/56 [2%] vs 24/107 [22%] p&lt;0.01). There was no difference in total procedure time (01:23:31 ± 00:20:07 vs 01:23:39 ± 00:20:05 p=0.98) or FPI time (01:05:10 ± 00:17:52 vs 01:03:01 ± 00:17:10 p=0.51) between groups. Conclusions: Height is associated with a lack of FPI and increased acute PVR. Using AI guided radiofrequency ablation, height-based adjustment of AI targets increase acute FPI and reduce acute PVR without affecting procedure times. Personalized AF ablation strategies optimize acute ablation outcomes.

Optimizing ablation sites for pulmonary vein isolation reconnections: A novel approach using an emphasis map combined with the peak frequency and local activation timing map

BackgroundAlthough catheter ablation techniques for atrial fibrillation (AF) have advanced, some cases of reconnections after pulmonary vein (PV) isolation still exist. The diversity of the anatomic wall thickness and fiber orientation around the PVs might contribute to reconnections. ObjectiveThe purpose of this study was to investigate the utility of the emphasis map’s emphasize settings to determine optimal ablation sites. MethodsPatients undergoing AF ablation with the EnSite X system who had PV reconnections were included. The emphasis map (a combination of peak frequency and local activation timing [LAT] maps) was created to obtain the emphasize settings for indicating the optimal ablation site (Emphasis group). In another group, the ablation site was determined based on LAT mapping (LAT group). ResultsA total of 64 patients (age 69 ± 9 years; 50 males), and 109 PVs were found to be reconnected and analyzed. Gaps were observed at 55 and 68 points of the PV isolation in the Emphasis and LAT groups, respectively. The number of ablation points needed to successfully eliminate the gaps, and the total energy were markedly smaller (1.6 ± 1.1 vs. 6.3 ± 3.7, P <.001; 3541 ± 2060 J vs 5606 ± 3728 J, P = .001) in the Emphasis group than in the LAT group, respectively. The average optimal emphasize setting was 338 ± 67 Hz in the Emphasis group. ConclusionAdjusting the emphasize settings visualized the optimal ablation site, and the number of ablation points needed to reisolate the PV might be markedly reduced.

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.

HD grid versus circular mapping catheter for assessment of pulmonary vein (pv) reconnections

Abstract Background Traditionally, circular mapping catheters (CMC) have been considered superior to other designs for mapping pulmonary vein reconnections due to the circular shape of the PV ostium. The grid multipolar catheter produces higher definition maps potentially overcoming the disadvantage of being rectangular. Purpose We assessed the acute procedural results, comparing Grid versus CMC in the setting of PV re-isolation to understand if one was superior to the other. Methods In this multicentre randomised controlled trial, 169 patients (62% male; median age 66 years [22-83) underwent repeat ablation, between July 2021 and March 2023, for recurrent symptomatic atrial arrhythmias. We undertook two LA maps for patients, utilising the Grid and the CMC. Blinded maps were collected with both catheters, followed by randomisation to one map for analysis and ablation. The primary outcome was the radiofrequency time required to isolate the pulmonary veins. Secondary outcomes include LA mapping time and density for both catheters, ability to identify pulmonary vein sleeves and duration of the ablation procedure. Results 126 patients had PV reconnections. 66 patients (64% male; median age 65 years [22-83]) in the Grid arm and 60 patients (68% male; median age 65.5 years [31-83]) in the CMC arm. There was one pericardial effusion and one TIA. There was no significant difference (p=0.202) found in the RF time required to achieve PV isolation in both Grid (mean RF time 200 ± 232 secs) vs CMC (mean RF time 169 ± 298 secs) arms. There was no significant difference (p=0.407) found between LA mapping time for the CMC (mean 1047 ± 454 seconds) and the Grid (Median 1080 ± 440 seconds). There was no significant difference (p=0.411) found in the total procedure time for the CMC (mean 122.7 minutes) and the HD grid (130 minutes). There were significantly more (p&amp;lt;0.001) PV mapping points identified with the grid (mean 354±213 points) than the CMC (mean 234±154 points) arm. There was no significant difference in PV sleeve reconnections found (p=0.106) between the grid (120 PV sleeve reconnections with a mean 1.4±0.71 reconnections) and the CMC (98 PV sleeve reconnections with a mean 1.52±0.72 reconnections). Both maps were analysed to assess reconnections on opposing catheter arms. The grid identified 20 PV sleeve reconnections not visible on the CMC, whilst 9 were visible on the CMC and not the grid. Conclusion There was no significant difference found in RF time, mapping time and overall procedure time. The Grid identified more reconnections not seen with the CMC and had an overall improved mapping density suggesting that this configuration could be superior for LA mapping.

Clinical findings from a large endo-epicardial atrial arrhythmia ablation registry

Abstract Background Despite advances, catheter ablation success rates for persistent AF remain at 50-60%. The approach for recurrent persistent AF, beyond pulmonary vein isolation, remains contentious. Surgical maze procedures have demonstrated superior outcomes compared to catheter ablation. Catheter-based linear lesions sets have failed to demonstrate efficacy, perhaps due to a lack of consistent transmurality with endocardial radiofrequency. Objective We report our safety and clinical data of an endo-epicardial approach using high-power radiofrequency ablation for atrial arrhythmias. Methods 126 patients (80% male; mean age 65 years [43-81]) underwent redo ablation, between August 2020 and February 2024, for recurrent symptomatic atrial arrhythmias using an endo-epicardial approach. We used a standardised linear lesion set (posterior wall isolation and anterior mitral line) for recurrent persistent AF. Results Utilising an intentional coronary sinus exit and C02 insufflation technique, we achieved epicardial access in 121 anti-coagulated patients. 5 patients were found to have pericardial adhesions, prohibiting access. There were 2 LIMA punctures which were coiled, 2 cases of excess pericardial bleeding (not access related), that settled conservatively, and no surgery or death. 92% of patients received epicardial ablation. 86 anterior mitral lines (95% acute block, 79% with epi ablation), 88 roof lines (92% blocked, 50% with epi ablation) and 81 floor lines (98% blocked, 36% with epi ablation) were undertaken. 106 posterior wall isolations were performed (94% isolated, 51% epi ablation). 75 patients had a standardised lesion set and were included for recurrence analysis. 49 had persistent AF (71% male, mean age 65 years, mean LAVI 38 ml/m2, 26 PVI at baseline and 23 PV reconnections) and 26 longstanding persistent AF (92% male, median age 64 years, mean LAVI 37.1 mls/m2, 16 PVI at baseline and 10 PV reconnections). 82% with persistent AF (median follow up time 11 months) and 38% with longstanding persistent AF (median follow up time 10.1 months) maintained sinus rhythm. The submitted image demonstrates the freedom from persistent AF, for the cohort who are beyond the 3-month blanking period, as per classification of atrial arrhythmia. Conclusion In one the largest cohorts to date, we have shown that endo-epicardial atrial ablation is feasible and safe with epicardial ablation allowing improved transmurality and thus acute linear block. Clinical outcomes, using a posterior wall isolation and anterior mitral line, were favourable for persistent but not longstanding persistent AF.

Advanced mapping and ablation technologies to target pulmonary veins gaps and residual antral potentials during repeat paroxysmal AF ablation: acute and long-term follow-up

Abstract Background A comprehensive understanding of pulmonary vein (PV) reconnection and residual potentials (RAP) within the antral scar during repeat atrial fibrillation (AF) ablation, facilitated by advanced mapping and ablation technologies, is currently lacking. Optimizing radiofrequency (RF) deliveries after failed PV isolation (PVI) may enhance ablation efficiency. Purpose This study aims to assess both the acute and long-term outcomes focusing on PV gaps (PVGs) and RAPs, utilizing advanced mapping and ablation technologies during repeat PV ablation in patients (pts) with paroxysmal AF. Methods Repeat AF-CHARISMA study, a prospective, single-arm cohort study, included consecutive pts from 13 centers undergoing repeat ablation of paroxysmal AF. The Lumipoint (Boston Scientific) map-analysis tool was used sequentially on each PV component. All patients were followed-up for at least 12 months after the procedure. The ablation endpoint was PVI and electrical quiescence in the antral region. Long-term outcome was the recurrence of AT/AF over follow-up. Results One-hundred pts were included (69% after failed RF procedure, 31% after failed cryoablation procedure). A total of 276 PVGs (192 after RF ablation, 2.8±1.8/pt; 84 after cryoablation, 2.7±1.9/pt, p=0.665 vs RF) and 44 RAPs (43 after RF ablation, 0.6±1.1/pt; 1 after cryoablation, 0.03±0.2/pt, p=0.002 vs RF) were detected. In the majority of cases (75%), only PVGs were present whereas, in 21%, both PVGs and RAPs were detected (2 pts had only RAPs). In 2 pts no PVG nor RAP were identified. PVGs were most common at anterior sites (103, 37.3%), followed by posterior sites (75, 27.2%) and carina sites (49, 17.8%). PVG location sites did not differ between prior ablation approach. Only 1 pt after cryoablation showed a RAP (at carina site), whereas the 44 RAPs after RF were fairly distributed across different sites. Acute procedural success was 100%, with all PVs successfully isolated and RAPs completely abolished in all study pts. After the blanking period, over a follow-up of 480±211 days, 18 pts (18%) suffered an AT/AF recurrence (time to recurrence: 245±80 days). Previous ablation approach (HR=0.66, 95%CI: 0.2 to 2.0 for previous cryoablation, p=0.46), number of PVGs (1.05, 0.8 to 1.3, p=0.67) or number of RAPs (0.41, 0.1 to 1.2, p=0.12) were not associated to AT/AF recurrence. No major complications or adverse events occurred. Conclusion A structured ablation workflow for repeat catheter ablation, incorporating consistent high-density mapping and improved diagnostic tools to guide the procedure, demonstrated safety and efficacy in treating paroxysmal AF irrespectively of previous ablation approach. Residual potentials within the antral scar were more frequently detected after RF ablation compared to cryoablation.

Recurrent atrial flutter after radiofrequency ablation for atrial fibrillation in a patient with hypertrophic obstructive cardiomyopathy undergoing repetitive transcoronary ablation of septal hypertrophy

IntroductionWe described the clinical characteristics of a patient with hypertrophic obstructive cardiomyopathy (HOCM) who had undergone transcoronary ablation of septal hypertrophy (TASH) twice and developed atrial flutter after radiofrequency ablation for atrial fibrillation (AF) due to pulmonary vein reconnection. This case of HOCM is unique because of its complex complications and multiple complex atrial arrhythmias. The treatment of HOCM was successful and the postoperative follow-up results was good.Methods and resultsA 71-year-oldfemale, developed exertional dyspnea with palpitations 12 years ago, with a valid diagnosis of HOCM according to the echocardiography which showed an absolute increase in the interventricular septum thickness (22.8 mm). She underwent two rounds of TASH and only the second round was successful. During a visit due to recurrent palpitations, the patient was diagnosed with AF based on electrocardiographic examination. Circumferential pulmonary vein isolation (CPVI) was performed to treat AF. However, the recurrence of atrial flutter was detected on her electrocardiograms (ECGs) three years after the operation. Since the patient had an interstitial lung injury, there were relative contraindications for antiarrhythmic drugs. Due to restrictive use of antiarrhythmic drugs and continuous palpitation, the patient agreed to receive a second radiofrequency ablation. Left-sided macroreentrant circuits were identified via high-density mapping and successful ablation was performed at the isthmus.ConclusionsPerforming catheter ablation and TASH respectively in patients with HOCM associated with AF would be tricky. But taking such a comprehensive and respective clinical treatment would be beneficial to patients in the long term.

Personalized ablation strategies optimize first-pass isolation and minimize pulmonary vein reconnection during paroxysmal atrial fibrillation ablation

Personalized ablation strategies optimize first-pass isolation and minimize pulmonary vein reconnection during paroxysmal atrial fibrillation ablation

Predictors of late recurrence after second catheter ablation for persistent atrial fibrillation

BackgroundLittle has been reported on the predictors of late recurrence (LR) after second radiofrequency catheter ablation (RFCA) for persistent atrial fibrillation (AF). ObjectiveThis study aimed to identify the predictors of LR after second RFCA in patients with persistent AF. MethodsWe retrospectively analyzed 123 patients who underwent a second RFCA because of LR after the initial RFCA for persistent AF. LR was defined as a recurrence of atrial tachyarrhythmia >3 months after the ablation procedure. The initial RFCA included pulmonary vein isolation alone or pulmonary vein isolation plus cavotricuspid isthmus block. The predictors of LR were evaluated by the Cox proportional hazards model. ResultsIn the univariate analysis, elevated brain natriuretic peptide levels, absence of pulmonary vein reconnections at the beginning of the second RFCA, and presence of early recurrence (ER, defined as a recurrence of atrial tachyarrhythmia within 3 months) after the second RFCA were associated with LR (P = .025, P = .018, and P < .001, respectively). The multivariate analysis revealed that absence of pulmonary vein reconnections and presence of ER were independent predictors of LR after the second RFCA (P = .004 and P < .001, respectively). ConclusionAbsence of pulmonary vein reconnections and presence of ER were strongly associated with LR after the second RFCA in patients with persistent AF.

P-wave terminal force is related to left pulmonary vein reconnection in patients with atrial fibrillation recurrence after pulmonary vein isolation.

In patients with atrial fibrillation (AF) recurrence after pulmonary vein (PV) isolation, noninvasive markers predicting PV reconnection or PV reconnection sites have not been fully elucidated. This study investigated the relationship between the P-wave terminal force in lead V1 (PTFV1) and the PV reconnection or reconnection site in patients with AF recurrence. We retrospectively studied consecutive patients who underwent second AF ablation between April 1, 2018, and June 1, 2023. PTFV1 was investigated before the first AF ablation (pre-ablation PTFV1) and before the second AF ablation (post-ablation PTFV1). In addition, we examined the ratio of the post-ablation to pre-ablation PTFV1 (PTFV1 ratio). These values were compared between patients with and without PV reconnection, with and without left PV (LPV) reconnection, and with and without right PV (RPV) reconnection. The analysis included 56 patients. PTFV1 was reduced because of the first AF ablation. In addition, the values were more decreased in patients without PV reconnection than with PV reconnection. The PTFV1 ratio was significantly smaller in the patients without LPV reconnection than with LPV reconnection; no significant difference was observed between the patients with and without RPV reconnection. Receiver operating characteristic curve analysis showed that a PTFV1 ratio > 0.69 predicted LPV reconnection with 70.0% sensitivity and 66.7% specificity. In conclusion, the PTFV1 ratio may be a noninvasive marker predicting LPV reconnection in patients with AF recurrence.

A case of pulmonary vein reconnection after long-term success of pulmonary vein isolation for atrial fibrillation.

We describe a case where right superior pulmonary vein was not reconnected at the beginning of the third radiofrequency catheter ablation (RFCA) for atrial fibrillation but was reconnected at the beginning of the fourth RFCA. This is a case of pulmonary vein reconnection in the chronic phase after successful pulmonary vein isolation.

Radiofrequency catheter ablation of persistent atrial fibrillation by pulmonary vein isolation with or without left atrial posterior wall isolation: long-term outcomes of the CAPLA trial.

Posterior wall isolation (PWI) is commonly incorporated into catheter ablation (CA) strategies for persistent atrial fibrillation (AF) in an attempt to improve outcomes. In the CAPLA randomized study, adjunctive PWI did not improve freedom from atrial arrhythmia at 12 months compared with pulmonary vein isolation (PVI) alone. Whether additional PWI reduces arrhythmia recurrence over the longer term remains unknown. In this multicenter, international, randomized study patients with persistent AF undergoing index CA using radiofrequency (RF) were randomized to PVI+PWI versus PVI alone. Patients underwent regular follow-up including rhythm monitoring for a minimum of 3 years post CA. AF burden at 3 years post-ablation was evaluated with either 28-day continuous ambulatory ECG monitoring, twice daily single-lead ECG or from cardiac implanted device. Evaluated endpoints included freedom from any documented atrial arrhythmia recurrence after a single procedure, AF burden, need for redo catheter ablation, rhythm at last clinical follow-up, healthcare utilisation metrics and AF-related quality of life. 333 of 338 (98.5%) patients (mean age 64.3±9.4 years, 23% female) completed 3-year follow-up, with 169 patients randomized to PVI+PWI and 164 patients to PVI alone. At a median of 3.62 years post-index ablation, freedom from recurrent atrial arrhythmia occurred in 59 patients (35.5%) randomized to PVI+PWI vs 68 patients (42.1%) randomized to PVI alone (HR 1.15, 95% CI 0.88-1.51, p=0.55). Median time to recurrent atrial arrhythmia was 0.53 years (IQR 0.34-1.01 years). Redo ablation was performed in 54 patients (32.0%) in the PVI+PWI group vs 49 patients (29.9%, p=0.68) in the PVI alone group. Pulmonary vein reconnection was present in 54.5% (mean number of reconnected PVs 2.2±0.9) and posterior wall reconnection in 75%. Median AF burden at 3 years was 0% in both groups (IQR 0-0.85% PVI+PWI vs 0-1.43% PVI alone, p=0.49). Sinus rhythm at final clinical follow-up was present in 85.1% with PVI+PWI vs 87.1% with PVI alone (p=0.60). Mean AF Effect On Quality-Of-Life (AFEQT) score at 3 years post-ablation was 88.0±14.8 with PVI+PWI vs 88.9±15.4 with PVI alone (p=0.63). In patients with persistent AF, the addition of PWI to PVI alone at index RF catheter ablation did not significantly improve freedom from atrial arrhythmia recurrence at long-term follow-up. Median AF burden remains low and AF quality of life high at 3 years with either ablation strategy.

Comparative Analysis of Clinical Outcomes of High-power, Short-duration Ablation versus Low-power, Long-duration Ablation Strategy in Patients with Atrial Fibrillation: A Comprehensive Umbrella Review of Meta-analyses.

Atrial fibrillation (AF) affects around 33 million people worldwide, rendering it a common cardiac arrhythmia. Catheter ablation (CA) has evolved as a leading therapeutic intervention for symptomatic AF. This umbrella review systematically evaluates existing systematic reviews and meta-analyses to assess the safety, efficacy, and potential of high-power, short-duration (HPSD) ablation as an alternative therapy option for AF. A thorough exploration was undertaken across PubMed, the Cochrane Library, and Embase to identify pertinent studies for inclusion in this umbrella review. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method was employed to assess the overall certainty of the evidence comprehensively, and the quality of the incorporated reviews was meticulously evaluated through use of the AMSTAR 2 tool, the Cochrane Collaboration tool, and the Newcastle-Ottawa scale. In this study, we initially identified 35 systematic reviews and meta-analyses, narrowing them down to a final selection of 11 studies, which collectively integrated data from 6 randomized controlled trials and 26 observational studies. For primary efficacy outcomes, the HPSD approach led to a non-significant decrease in the risk of atrial tachyarrhythmia recurrence (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.70-1.12; I 2 = 90%; P = .31) and a significantly reduced risk of AF recurrence (RR, 0.53; 95% CI, 0.42-0.67; I 2 = 0%; P < .00001) compared to the low-power, long-duration (LPLD) approach. In terms of primary safety outcomes, the HPSD approach significantly reduced the risk of esophageal thermal injury (ETI) (RR, 0.71; 95% CI, 0.61-0.83; I 2 = 0%; P < .00001) and facilitated a non-significant decrease in the risk of other major complications (RR, 0.87; 95% CI, 0.73-1.03; I 2 = 0%; P = .10). In conclusion, HPSD therapy is safer and more effective than LPLD therapy, facilitating decreased AF recurrence rates along with reductions in ETI, total procedure duration, ablation number, ablation time, fluoroscopy time, and acute pulmonary vein reconnection.

Ablation Parameters Predicting Pulmonary Vein Reconnection after Very High-Power Short-Duration Pulmonary Vein Isolation.

Recurrences due to discontinuity in ablation lines are substantial after pulmonary vein isolation (PVI) with radiofrequency ablation for atrial fibrillation. Data are scarce regarding the durability predictors for very high-power short-duration (vHPSD, 90 W/4 s) ablation. A total of 20 patients were enrolled, who underwent 90 W PVI and a mandatory remapping procedure at 3 months. First-pass isolation (FPI) gaps, and acute pulmonary vein reconnection (PVR) sites were identified at the index procedure; and chronic PVR sites were identified at the repeated procedure. We analyzed parameters of ablation points (n = 1357), and evaluated their roles in predicting a composite endpoint of FPI gaps, acute and chronic PVR. In total, 45 initial ablation points corresponding to gaps in the ablation lines were analyzed. Parameters associated with gaps were interlesion distance (ILD), baseline generator impedance, mean current, total charge, and loss of catheter-tissue contact. The optimal ILD cut-off for predicting gaps was 3.5 mm anteriorly, and 4 mm posteriorly. Biophysical characteristics dependent on generator impedance could affect the efficacy of vHPSD PVI. The use of smaller ILDs is required for effective and durable PVI with vHPSD compared to the consensus targets with lower power ablation, and lower ILDs for anterior applications seem necessary compared to posterior points.

Pulmonary vein reconnection and repeat ablation characteristics following cryoballoon-compared to radiofrequency-based pulmonary vein isolation.

Despite advances in efficacy and safety of pulmonary vein isolation (PVI), atrial fibrillation (AF) recurrence after PVI remains common. PV-reconnection is the main finding during repeat PVI procedures performed to treat recurrent AF. To analyze pulmonary vein (PV) reconnection patterns during repeat ablation procedures in a large cohort of consecutive patients undergoing radio frequency or cryoballoon-based PVI. Retrospective analysis of PV-reconnection patterns and analysis of re-ablation strategies in consecutive index RF- and CB-based PVI and their respective re-ablation procedures during concomitant usage of both energy sources at a single high-volume center in Germany. A total of 610 first (06/2015-10/2022) and 133 s (01/2016-11/2022) repeat ablation procedures after 363 (60%) RF- and 247 (40%) CB-based index PVIs between 01/2015 and 12/2021 were analyzed. PV-reconnection was found in 509/610 (83%) patients at first and 74/133 (56%) patients at second repeat procedure. 465 of 968 (48%) initially via CB isolated PVs were reconnected at first re-ablation but 796 of 1422 initially RF-isolated PV (56%) were reconnected (OR: 0.73 [95% CI: 0.62-0.86]; p < .001). This was driven by fewer reconnections of the left PVs (LSPV: OR: 0.60 [95% CI: 0.42-0.86]; p = .005 and LSPV: 0.67 [0.47-0.95]; p = .026). PV-reconnection was more likely after longer, RF-based index PVI and in older females. Repeat procedures were shorter after CB-compared to after RF-PVI. Reconnection remains the most common reason for repeat AF ablation procedures after PVI. Our data suggest to preferentially use of the cryoballoon during index PVI, especially in older women.

Pulmonary vein isolation using pulsed field ablation vs. high-power short-duration radiofrequency ablation in paroxysmal atrial fibrillation: efficacy, safety, and long-term follow-up (PRIORI study).

Pulsed field ablation (PFA) is a novel, non-thermal, cardiac tissue-selective ablation modality. To date, radiofrequency (RF)-guided high-power short-duration (HPSD) ablation represents the gold standard besides cryo-ablation for pulmonary vein isolation (PVI). This single-centre, retrospective study investigated the efficacy of PFA-PVI vs. HPSD-RF PVI in terms of single-procedure arrhythmia-free outcome and safety in a real-world setting. Consecutive, paroxysmal atrial fibrillation (AF) patients who underwent PVI using PFA or HPSD-RF were enrolled. In group PFA, PVI was performed using a pentaspline PFA catheter. The ablation procedure in group HPSD-RF was performed with RF energy (45 W, ablation index). A total of 410 patients (group PFA, 201; group HPSD-RF, 209) were included. There was no difference between both groups regarding age, gender, and CHA2DS2-VASc score. The procedure time was significantly shorter in group PFA [61 (44-103) vs. 125 (105-143) min; P < 0.001]; fluoroscopy time and dose area product were significantly higher in group PFA [16 (13-20) vs. 4 (2-5) min; P < 0.01 and 412 (270-739) vs. 129 (58-265) μGym2; P < 0.01]. The overall complication rates were 2.9% in group PFA and 6.2% in group HPSD (P = 0.158). There was one fatal stroke in the PFA group. The 1-year Kaplan-Meier estimated freedom from any atrial tachyarrhythmia was 85% with PFA and 79% with HPSD-RF (log-rank P = 0.160). In 56 repeat ablation procedures, the PV reconnection rate was 30% after PFA and 38% after HPSD-RF (P = 0.372). Both PFA and HPSD-RF were highly efficient and effective in achieving PVI in paroxysmal AF patients. The arrhythmia-free survival is comparable. The PV reconnection rate was not different.

Efficacy and Safety of Laser Balloon Versus Irrigated Radiofrequency Ablation as Initial Therapies for Atrial Fibrillation: A Meta-Analysis.

Catheter ablation (CA) is an effective therapy for atrial fibrillation (AF) and, although radiofrequency ablation (RFA) is the standard treatment for pulmonary vein isolation (PVI), it is complex and time-consuming. Laser balloon ablation (LBA) has been introduced to simplify the conventional RFA; however, results of studies comparing LBA and RFA remain controversial. As such, this investigation aimed to comprehensively evaluate the efficacy and safety of LBA versus RFA. The PubMed, Embase, Cochrane Library, and ClinicalTrials.gov databases were searched for relevant studies. The primary endpoints were the freedom from atrial tachyarrhythmia (ATA) and procedure-related complications. Twelve studies including 1274 subjects were included. LBA and RFA yielded similar rates of freedom from ATA (72.5% vs. 68.7%, odds ratio [OR] = 1.26, 95% confidence interval [CI] 1.0-1.7, p = 0.11) and procedure-related complications (7.7% vs. 6.5%, OR = 1.17, 95% CI 0.72-1.90, p = 0.536). LBA with the second- and third-generation laser balloons (LB2/3) yielded remarkably higher rates of freedom from ATA than RFA using contact-force technology (RFA-CF) (OR = 1.91, p = 0.013). Significantly lower pulmonary vein (PV) reconnection rates (OR = 0.51, p = 0.021), but higher phrenic nerve palsy (PNP) rates (OR = 3.42, p = 0.023) were observed in the LBA group. LBA had comparable procedure (weighted mean difference [WMD] = 8.43 min, p = 0.337) and fluoroscopy times (WMD = 3.09 min, p = 0.174), but a longer ablation time (WMD = 12.57 min, p = 0.00) than those for RFA. LBA and RFA treatments were comparable in terms of freedom from ATA and postprocedural complications in patients with AF. Compared with RFA, LBA was associated with significantly lower PV reconnection rates, but a higher incidence of PNP and longer ablation time.