Radiofrequency Catheter Ablation Group Research Articles

Comparison of Postprocedural P-Wave Vector Magnitude on 12-Lead Electrocardiogram Between Cryoballoon and Radiofrequency Ablation

Pulmonary vein isolation (PVI) causes changes in P-wave parameters. However, the difference in changes in P-wave parameters including P-wave vector magnitude (Pvm) between radiofrequency catheter ablation (RFCA) and cryoballoon ablation (CBA) remains unknown. Paroxysmal atrial fibrillation (PAF) patients who underwent only PVI were enrolled. Pvm was calculated by the square root of the sum of the squared P-wave amplitude in leads II and V6 and one-half of the P-wave amplitude in V2. The patients were divided into two groups: RFCA and CBA. ΔPvm was calculated as ΔPvm (mV)=(Pvm at pre-PVI)-(Pvm at post-PVI).The following factors were evaluated: (1) differences in the ΔPvm between the two groups, (2) relationship between late arrhythmia recurrence and ΔPvm in both RFCA and CBA groups and (3) the impact of relevant factors on ΔPvm. The study population included a total of 426 PAF patients (RFCA, 167 patients; CBA, 259 patients). ΔPvm was significantly larger in CBA than RFCA (p<0.001). Kaplan-Meier analysis showed late arrhythmia recurrence was significantly higher in patients with low ΔPvm (<0.019mV) than high ΔPvm (≥0.019mV) in RFCA (Log-rank p<0.001), and low ΔPvm (<0.033mV) than high ΔPvm (≥0.033mV) in CBA (Log-rank p<0.001). Multiple regression analysis showed that CBA and heart rate change were independently and significantly associated with ΔPvm (p<0.001 and p<0.001, respectively). In conclusion, ΔPvm was significantly larger in CBA than RFCA during procedure. Low ΔPvm had a higher risk of late arrhythmia recurrence in both RFCA and CBA.

Catheter ablation of atrial fibrillation: three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pre-interventioal pulmonary vein imaging (8-year follow-up)

Abstract Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 240 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 110 patients, persistent AF: 130 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 230/240 patients (95.8 %). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.9 (cryo group), 3.9 (radiofrequency catheter ablation group)). At 96-month follow-up, 64.6 % of all patients were free from an arrhythmia recurrence (cryo group: 70.0 %, Carto group: 60.0 %). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Efficacy of Radiofrequency Catheter Ablation versus Antiarrhythmic Drugs in Treating High Burden Premature Ventricular Contractions in Children with Structurally Normal Heart

Abstract Background Scarce literature on whether antiarrhythmic drugs (AADs) or radiofrequency catheter ablation (RFCA) is more efficacious when treating idiopathic high burden premature ventricular contractions (PVCs) in children with many questions remain unanswered in this age group. Objectives To compare the efficacy of RFCA versus AADs on high burden idiopathic PVCs in children. Methods A total of 60 eligible child ≤18 years with High burden PVCs (≥10% of total beats per day) that were treated by either AADs (group A) or RFCA (group B). Both Baseline and followup clinical symptoms were collected, Physical examination, repeat standard ECG, standard or 12-lead Holter recording, and echocardiography were performed. Results Among RFCA (n = 30) and AADs (n = 30) groups, treatment success was 80.0% and 20.0% respectively, while AADs medications cessation was 73.3% and 26.7% respectively, the differences were statistically significant. Conclusion RFCA appears to be more efficacious than AADs in PVC reduction and consequently AADs medications cessation postablation. Performing RFCA in children with classical mapping and navigation was a safe and highly effective therapeutic option. Abbreviations AADs: antiarrhythmic drugs; BBB: bundle branch block; CCB: calcium channel blocker; ECG: electrocardiogram; LVEDD: left ventricular end-diastolic dimension; LVEF: left ventricular ejection fraction; LVESD: left ventricular end-systolic dimension; LVOT: left ventricular outflow tract; NSVT: non sustained ventricular tachycardia; PVC: premature ventricular contraction; RFCA: radiofrequency catheter ablation; RV: right ventricular/ventricle; RVOT: right ventricular outflow tract

Efficacy of two-stage approach for interventional treatment of coexistent atrial fibrillation and typical atrial flutter for sinus rhythm maintenance in long-term: a prospective controlled clinical trial

Background: Atrial fibrillation (AF) and coexistent typical atrial flutter (AFL) interventional treatment strategy remains unresolved in cardiology and cardiovascular surgery. Results of this approach remain suboptimal. There are several approaches to the interventional treatment of patients with coexistent AF and AFL: simultaneous pulmonary vein isolation (PVI) and cavotricuspid isthmus (CTI) radiofrequency catheter ablation (RFCA), PVI or CTI RFCA only and two-stage approach. To our knowledge, cumulative efficacy of two-stage approach has not been previously reported. The aim. This study aimed to evaluate the efficacy of two-stage approach for interventional treatment of coexistent AF and AFL for sinus rhythm maintenance in long-term. Methods: Patients (pts) (n=34) with AF and AFL aged 41–82 years (11 women) were divided into two groups (1:1): «One-stage Approach» (group 1; n=17): PVI+СTI RFСA and «Two-stage approach» (group 2; n=17): first stage — CTI RFCA (group 2.1); second stage — PVI in case of AF recurrence after RFCA (group 2.2). Primary endpoint (PEP) was defined as any recurrent atrial tachyarrhythmia at the end of follow-up; group 2 events have been considered after PVI. Secondary endpoint (SEP) — recurrent any atrial tachyarrhythmia in groups 1 and 2 after CTI RFCA in group 2. PEP and SEP were evaluated at the end of the «blind period» (3 months after procedure). Results: Registered recurrent atrial tachyarrhythmia in pts who reached PEP or SEP was AF. AFL has not been detected in any cases. PEP was noted in 8 (47.06%) pts in group 1 and 1 (5.88%) pts in group 2. Further, SEP was observed in 3 pts (17.65%) in group 1 and in 4 (23.53%) pts in group 2 (p=0.671). The probability of long-term maintenance of sinus rhythm was significantly higher in «Two-stage approach» than in «One-stage approach» (94.12% and 52.94%, respectively, p=0.001). Significant differences in procedure length and fluoroscopy time have been found. Those were longer in group 1 compared to group 2.1 (p 0.001) and in group 2.2 compared to group 2.1 (procedure duration — p 0.001; fluoroscopy time — p=0.013). No differences were noted in length of procedure and fluoroscopy time between groups 1 and 2.2 (p=0.374 and p=0.028, respectively). Conclusion: The «two-stage approach» for interventional treatment of coexistent AF and AFL results in better long-term arrhythmia-free survival than «one-stage approach» (94.12% and 52.94%, respectively, p=0.001). CTI RFCA alone in pts with coexistent AF and AFL cause 23.53% AF recurrence rate and associated with shorter procedure duration and fluoroscopy time compared to simultaneous PVI and CTI RFCA (p 0.001).

Long term outcome in patients who refused radiofrequency ablation for atrial fibrillation

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Rhythm control is a therapeutic approach to restore sinus rhythm from atrial fibrillation (AF). Current studies have demonstrated efficacy of rhythm control with radiofrequency catheter ablation (RFCA) for survival, however there is lack of data regarding the long term outcome of patients who refused RFCA. Purpose This study was aimed to compare outcomes, consist of death and stroke, in patients who refused RFCA. Method Patients with AF who had been proposed for RFCA but refused and also any rhythm control strategy were enrolled. The primary outcome was all cause death and incidence of stroke, compared with patients with AF who had been treated with RFCA. Results A total 174 patients who refused AF, 175 patients treated with RFCA were enrolled. Median follow up duration was 1125.1 ± 799.0 days. Of refused AF group, 39 (22.3%) were paroxysmal AF at the time of diagnosis. During follow-up, 9 patients in refused RFCA and 11 patients treated with RFCA group had died (4.1% vs 6.1%, p=0.3 by log rank test). Incidence of stroke was significantly higher in patients who refused RFCA, compared with RFCA group (12.0% vs 1.1% , p =0.001 by log-rank test). Cox Regression model showed refusing RFCA was an independent risk factor for the incidence of stroke (Hazard ratio 6.7, 95% Confidence Interval 1.48 – 30.3, p=0.013). Conclusion In AF patient who had refused rhythm control, incidence of stroke was significantly higher in patients who refused RFCA and rhythm control, compared with who had been treated with RFCA. There was no difference in all-cause mortality between two groups.

Long-term outcome of thoracoscopic ablation and radiofrequency catheter ablation for persistent atrial fibrillation as a de novo procedure

Limited data are available regarding the efficacy of thoracoscopic ablation as the first procedure for persistent atrial fibrillation (AF). We sought to compare the long-term efficacy of thoracoscopic ablation vs. radiofrequency (RF) catheter ablation as the first procedure for persistent AF. Between February 2011 and December 2020, 575 patients who underwent ablation for persistent AF were studied. Among them, thoracoscopic ablation was performed in 281 patients, RF catheter ablation in 228, and hybrid ablation in 66. Rhythm, clinical, and safety outcomes during 7-year follow-up were compared. The patients who underwent thoracoscopic ablation were older, had a higher prevalence of stroke, and had a larger left atrial volume than those who underwent RF catheter ablation. In the propensity score-matched population (n = 306), incidences of atrial tachyarrhythmia recurrence were 51.4% in the thoracoscopic ablation group and 62.5% in the RF catheter ablation group [adjusted hazard ratio (HR) 0.869, 95% confidence interval (CI) 0.618-1.223, P = 0.420]. Stroke and total procedural adverse events were not significantly different between thoracoscopic and RF catheter ablation (2.7 vs. 2.5%, P = 0.603, and 7.1 vs. 4.8%, P = 0.374, respectively). The hybrid ablation group showed similar rhythm outcomes compared with both the thoracoscopic and the RF catheter ablation groups. At the redo procedure, pulmonary vein gaps were more frequently observed in the RF catheter ablation group (32.6%) than in the thoracoscopic ablation group (7.9%) and in the hybrid ablation group (8.8%) (P < 0.001). As a first procedure in persistent AF, thoracoscopic ablation and RF catheter ablation showed comparable efficacy, clinical, and safety outcomes during long-term follow-up.

Catheter ablation of atrial fibrillation in heart failure with impaired systolic function: An updated meta-analysis of randomized controlled trials.

The recent Atrial Fibrillation Management in Congestive Heart Failure With Ablation trial did not reveal any benefit of catheter ablation in patients with atrial fibrillation (AF), advanced heart failure (HF), and severely reduced left ventricular ejection fraction (LVEF). We hypothesized that radiofrequency catheter ablation (RFCA) could improve outcomes in HF patients with AF and impaired left ventricular systolic function (LVEF <50%) as compared with only medical therapy. We searched the literature for randomized clinical trials (RCTs) that compared RFCA to medical therapy in this population. Compared with the medical therapy group, the RFCA group had significantly less all-cause mortality, HF hospitalization, and AF recurrence rates. The RFCA group had significantly higher peak oxygen consumption (VO 2max ), a better quality of life (Minnesota Living with Heart Failure Questionnaire score), and improved LVEF. However, RFCA for AF failed to reduce all-cause mortality in a specific meta-analysis of four RCTs that enrolled patients with LVEF ≤35%. Compared with medical therapy, RFCA for AF in the setting of HF with impaired systolic function is associated with better clinical (HF hospitalization and all-cause mortality), structural (LVEF improvement), functional (VO 2max ), and quality of life outcomes. However, RFCA for AF failed to reduce all-cause mortality in RCTs that enrolled patients with LVEF ≤35% and thereby indicated the necessary stratification to identify patients who may benefit more from RFCA.

Efficacy and safety of cryoballoon pulmonary vein isolation for paroxysmal and persistent atrial fibrillation: A comparison with radiofrequency ablation

BackgroundCryoballoon ablation was established as an effective and safe modality to achieve pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (PAF). However, its role in persistent atrial fibrillation (PersAF) remains unclear.ObjectiveThis study aimed to evaluate the efficacy and safety of cryoballoon PVI in PAF and PersAF comparing conventional radiofrequency catheter ablation (RFCA).MethodsTwo hundred patients undergoing cryoballoon ablation for symptomatic AF were consecutively enrolled in this retrospective study. For comparison, 210 patients undergoing RFCA in the same period were included. The primary outcome was a recurrence of any atrial tachyarrhythmias (ATas) after the index ablation. 12-lead ECG and 24-hour Holter monitoring were obtained at 1,3,6 and 9–12 months.ResultsPVI by cryoablation alone was achieved in 197 patients (98.5%). ATas-free survival at 12 months post-ablation was 72.7% in the cryoablation and 80.6% in the RFCA group (P = 0.123), respectively. The cryoablation showed comparable efficacy maintaining sinus rhythm compared with RFCA in PAF (P = 0.539), whereas in PersAF, ATas-free survival was significantly lower in cryoablation (P = 0.039). PV reconnection was observed in the majority of patients (14/16, 87.5%) who receive redo RFCA. Complications were encountered in 10 patients, including femoral arteriovenous fistula (n = 1), transient phrenic nerve palsy (n = 8), and minimal amount pericardial effusion (n = 1).ConclusionThe efficacy of cryoballoon PVI is comparable with conventional RFCA in PAF, whereas PVI alone using cryoballoon may not be insufficient to maintaining sinus rhythm in PersAF. The safety of cryoballlon PVI is tolerable.

Radiofrequency vs. Cryoballoon vs. Thoracoscopic Surgical Ablation for Atrial Fibrillation: A Single-Center Experience.

Background and Objectives: Cryoballoon ablation (CBA) and totally thoracoscopic surgical ablation (TTA) have emerged as alternatives to radiofrequency catheter ablation (RFCA) for atrial fibrillation. In this study, we describe our experience comparing patient characteristics and outcomes of RFCA, CBA, and TTA. Materials and Methods: We retrospectively analyzed data from patients who underwent RFCA, CBA, or TTA. Both atrial fibrillation (AF)- and atrial tachyarrhythmia (ATa)-free survival rates were compared using time to recurrence after a 3-month blanking period (defined by a duration of more than 30 s). All patients were regularly followed using 12-lead ECGs or Holter ECG monitoring. Results: Of 354 patients in this study, 125 underwent RFCA, 97 underwent CBA and 131 underwent TTA. The TTA group had more patients with persistent AF, a larger LA diameter, and a history of stroke. The CBA group showed the shortest procedure time (p < 0.001). The CBA group showed significantly lower AF-free survival at 12 months than the RFCA and TTA groups (RFCA 84%, CBA 74% and TTA 85%, p = 0.071; p = 0.859 for TTA vs. RFCA, p = 0.038 for RFCA vs. CBA and p = 0.046 for TTA vs. CBA). There were no significant differences in ATa-free survival among the three groups (p = 0.270). There were no procedure-related adverse events in the RFCA group, but some complications occurred in the CBA group and the TTA group (6% and 5%, respectively). Conclusions: RFCA and CBA are effective and safe as first-line treatments for paroxysmal and persistent AF. In some high-risk stroke patients, TTA may be a viable option. It is important to consider patient characteristics when selecting an ablation method for AF.

B-PO03-100 CARDIAC ENZYME ELEVATION AND SHORT TERM CLINICAL OUTCOME AFTER CRYOBALLOON ABLATION OF LEFT ATRIAL POSTERIOR WALL FOR PERSISTENT ATRIAL FIBRILLATION

The effectiveness of left atrial posterior wall (LAPW) ablation using cryoballoon (CB) ablation was not sufficiently evaluated. We aim to compare the degree of myocardial injury and early clinical outcome of LAPW or roof line using CB ablation to those using RFCA (radiofrequency catheter ablation). A total of 100 patients with persistent atrial fibrillation (AF) (66.7% long standing persistent AF, 49 CB and 51 RFCA) were enrolled from 2017 to 2020. Patients underwent pulmonary vein isolation (PVI) with LAPW using CB or RFCA. Acute successful ablation of LAPW was defined as complete elimination of local electrical activities in LAPW. The completeness of roof line was assessed by bidirectional conduction block by differential pacing. The main outcomes were level of cardiac enzyme (troponin-I) elevation after procedure and early recurrence of atrial fibrillation or flutter. Acute successful ablation of LAPW or roof line was achieved in 64.5% of RFCA group and 69.4% of CB group (P=0.698). Total procedure time (CB 145.6 ± 54.5 min vs. RF 184.0 ± 62.1 min, P=0.003) and ablation time (CB 2324.5 ± 660.2 min vs. RF 2855.3 ± 1101.3 min, P=0.005) was shorter in CB group. Troponin-I at one day after the procedure was more elevated in CB group compared with RFCA group (CB 11.6 ± 6.8 ng/mL vs. RFCA 5.0 ± 3.8 ng/mL, p<0.001). Rate of freedom from atrial tachyarrhythmia (AF for atrial flutter) at 3months were comparable between 2 groups (CB 59.2% vs. RFCA 66.7%, P=0.57). In patients with persistent AF who underwent PVI and LAPW ablation or roof line ablation, cardiac enzyme elevation is more prominent and short term clinical outcome is comparable in CB ablation group compared with RFCA group.

Feasibility, efficacy, and safety of ethanol infusion into the vein of Marshall for atrial fibrillation: A meta-analysis.

Contemporary radiofrequency catheter ablation (RFCA) approaches for atrial fibrillation (AF) have reached an efficacy "ceiling". Ethanol infusion into the vein of Marshall (EI-VOM) has shown potential in preliminary studies. Data on EI-VOM are largely limited to small single-center reports, and clinical benefits and risks have not been systematically examined. Therefore, we performed a meta-analysis to assess the feasibility, efficacy, and safety of EI-VOM for AF. All studies evaluating EI-VOM for AF were initially searched from four electronic search engines: PubMed, Web of Science, Cochrane Library, and SinoMed. We used RevMan5.4 to calculate pooled outcomes of randomized controlled trial and cohort studies. We also performed single-arm meta-analyses using Open Meta-Analyst. We included a total of 10 studies with 1322 patients. Successful EI-VOM was performed in 86.7% (95% CI 81.9-91.4%) of patients. For persistent AF patients, the recurrence of AF and/or atrial tachycardia (AT) was significantly lower in the EI-VOM combined with RFCA group compared with RFCA alone group (RR 0.58, 95% CI 0.35 to 0.96, p=0.04). EI-VOM combined with RFCA significantly increased the rate of bidirectional mitral isthmus block compared with RFCA alone in AF patients (RR 1.50, 95% CI 1.34 to 1.67, p<0.001). There were nine cardiac tamponades observed in 644 patients (PR 0.8%, 95% CI 0.1-1.5%) who were performed EI-VOM combined with RFCA. Our meta-analysis brings encouraging evidence that adjuvant EI-VOM reduces AF and/or AT recurrence rate in persistent AF patients and increases the success rate of bidirectional mitral isthmus block.

Abstract 17296: Arrhythmia Recurrence and Subsequent Heart Failure Hospitalization in Atrial Fibrillation Patients Undergoing Catheter Ablation: A Landmark Analysis From the Kansai Plus Atrial Fibrillation (KPAF) Registry

Background: Heart failure (HF) is the leading cause of death in patients with atrial fibrillation (AF). Radiofrequency catheter ablation (RFCA) of AF is effective for maintaining sinus rhythm though its impact on heart failure still remains controversial. Purpose: We sought to elucidate whether AF recurrence following RFCA was associated with subsequent HF hospitalizations. Methods: We conducted a large-scale, prospective, multicenter, observational study. A total of 4931 consecutive patients who underwent an initial RFCA for AF with longer than 1-year of follow-up in 26 centers were enrolled (average age, 64±10 years; non-paroxysmal AF, 35.7%). The median follow-up duration was 2.9 years. The primary endpoint was an HF hospitalization more than 1-year after the index RFCA. We compared the patients without AF recurrences (group A) to those with AF recurrences within 1-year post RFCA (group B). Results: The 1-year cumulative incidence of AF recurrences after a single procedure was 30.7% (group A=3418, group B=1513 patients). Group B had a lower body mass index (group A vs. group B,24.1±3.6 vs. 23.8±3.4 kg/m 2 , p=0.014), longer history of AF (1.9 vs. 3.1 years, p&lt;0.0001), higher prevalence of non-paroxysmal AF (32.1% vs. 33.9%, p&lt;0.0001), and valvular heart disease (5.9% vs. 7.8%, p=0.013). They also had a lower ejection fraction (63.7±9.4% vs. 62.8±9.6%, p=0.0043) and larger left atrial dimeter (39.7±6.6 vs. 40.6±7.0 mm, p&lt;0.0001) on echocardiography. Hospitalizations for HF were observed in 57 patients (1.14%) more than 1-year after the RFCA and were significantly higher in group B than group A (group A vs. group B, 0.91% vs 1.72%, log-rank p=0.019). Conclusions: Among AF patients receiving RFCA, those with AF recurrences were at a greater risk of subsequent heart failure hospitalizations than those without AF recurrences. Recognition that AF recurrence following RFCA is a risk factor for a subsequent HF-related hospitalization is appropriate in clinical practice.

Outcome of contact force-guided radiofrequency catheter ablation or second generation cryoballoon ablation for paroxysmal atrial fibrillation: propensity score matched analysis

Abstract Background Little has been reported on the outcome of contact force (CF)-guided radiofrequency catheter ablation (RFCA) and second generation cryoballoon ablation (CBA). Purpose The purpose of this study was to compare the outcome of CF-guided RFCA and second generation CBA for paroxysmal atrial fibrillation (PAF). Methods We enrolled the consecutive 364 patients with PAF who underwent initial ablation between September 2014 and July 2018 in our hospital. We compared the late recurrence of atrial tachyarrhythmia more than three months after ablation between RFCA group and CBA group. All RFCA procedures were performed using CF-sensing catheter and all CBA procedures were performed using second generation CB. Results There were significant differences in background characteristics: chronic kidney disease, serum brain natriuretic peptide level, and left ventricular ejection fraction. After propensity score matched analysis (Table), atrial tachyarrhythmia free survival was significantly higher in CBA group than in RFCA group (Figure). Conclusions Second generation CBA showed a significantly lower late recurrence rate compared to CF-guided RFCA. Kaplan-Meier Curve Funding Acknowledgement Type of funding source: None

Three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pulmonary vein imaging prior to catheter ablation of atrial fibrillation: extended long-term follow-up

Abstract Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 150 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 65 patients, persistent AF: 85 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 144/150 patients (96.0%). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.8 (cryo group), 4.0 (radiofrequency catheter ablation group)). At 48-month follow-up, 69.3% of all patients were free from an arrhythmia recurrence (cryo group: 75.4%, Carto group: 64.7%). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients. Funding Acknowledgement Type of funding source: None

P1375Catheter ablation of atrial fibrillation: three-dimensional transesophageal echocardiography versus magnetic resonance imaging for pulmonary vein imaging (periprocedural results and long-term follow-u

Abstract Catheter ablation has become the first line of therapy in patients with symptomatic, recurrent, drug-refractory atrial fibrillation (AF). However, it is still challenging because of the high degree of variability of the pulmonary vein (PV) anatomy. Three-dimensional transesophageal echocardiography (TEE) is a promising new technique for cardiac imaging. Therefore, we have evaluated the usefulness of 3-D TEE for analysing the left atrial anatomy prior to an ablation procedure in comparison to magnetic resonance imaging (MRI). Methods In 120 patients, 3-D TEE and cardiac MRI were performed immediately prior to an ablation procedure (paroxysmal AF: 50 patients, persistent AF: 70 patients). The image quality provided by 3-D TEE and by cardiac MRI was compared in all patients. Two different ablation strategies were used. In patients with paroxysmal AF, the cryoablation technique was used. In the other patients, a circumferential pulmonary vein ablation was performed using a three-dimensional mapping system. Results A 3-D TEE and a cardiac MRI could be performed successfully in all patients prior to the ablation procedure. Several variations of the PV anatomy could be visualized precisely by 3-D TEE and cardiac MRI (e.g. accessory PVs, common PV ostia, varying diameter of the left atrial appendage and its distance to the left superior PV). The image quality was good in the majority of patients even if AF with rapid ventricular response was present during the examination. The image quality provided by 3-D TEE was acceptable in 116/120 patients (96.7 %). The TEE findings correlated well with the PV angiographies performed using cardiac MRI. There was a good correlation with regard to the diameter of the PV ostia assessed by these two imaging techniques. All ablation procedures could be performed successfully (mean number of completely isolated PVs: 3.9 (cryo group), 4.0 (radiofrequency catheter ablation group)). At 42-month follow-up, 70.0 % of all patients were free from an arrhythmia recurrence (cryo group: 76.0 %, Carto group: 65.7 %). There were no major complications. Conclusions AF ablation procedures can be performed safely and effectively based on prior 3-D TEE imaging. The image quality was acceptable in the vast majority of patients.

Long-term Clinical Outcomes of Radiofrequency Catheter Ablation versus Permanent Pacemaker Implantation in Patients with Tachycardia-Bradycardia Syndrome.

Background and ObjectivesPacemaker (PM) implantation is a well-accepted treatment option for patients with paroxysmal atrial fibrillation (AF) and related tachycardia-bradycardia syndrome (TBS). Data on the long-term clinical outcomes after radiofrequency catheter ablation (RFCA) or PM implantation are sparse.MethodsThe medical records of 217 patients with TBS were retrospectively assessed. Outcomes in patients who underwent RFCA (n=108, 49.8%) were compared to those with PM implantation (n=109, 50.2%). The clinical outcomes were sinus rhythm maintenance, conversion to persistent AF, additional procedure or crossover, and the composite of cardiovascular hospitalization and death.ResultsDuring the follow-up period (mean 3.5±2.0 years), the RFCA group, compared to the PM group, showed better sinus rhythm maintenance (adjusted hazard ratio [aHR], 0.27; 95% confidence interval [CI], 0.15–0.46; p=0.002) and less progression to persistent AF (aHR, 0.20; 95% CI, 0.06–0.63; p=0.006). Additional procedure or crossover did not differ significantly between the groups (aHR, 2.07; 95% CI, 0.71–6.06; p=0.185 and aHR, 0.69; 95% CI, 10.8–2.67; p=0.590, respectively). Most RFCA patients (92.6%) did not require pacemaker implantation during long term follow-up period (>3.5 years). The composite endpoint of cardiovascular rehospitalization and death was not significantly different between the groups (aHR, 0.92; 95% CI, 0.50–1.66; p=0.769).ConclusionsRFCA is an effective alternative to PM implantation in patients with TBS. In these patients, successful RF ablation of AF is related to a higher rate of sinus rhythm maintenance compared to PM implantation, and the composite outcome of cardiovascular rehospitalization and death is similar.

PCV39 RADIOFREQUENCY CATHETER ABLATION WITH WARFARIN VERSUS ANTIARRHYTHMIC DRUGS WITH NEW ORAL ANTICOAGULANTS FOR THE TREATMENT OF PAROXYSMAL ATRIAL FIBRILLATION IN CHINA: A COST- EFFECTIVENESS ANALYSIS

To evaluate the cost-effectiveness of radiofrequency catheter ablation (RFCA) using contact-force catheter (Thermocool SmartTouch®) + warfarin versus antiarrhythmic drugs (AAD) + new oral anticoagulants (NOAC) in paroxysmal atrial fibrillation (PAF) patients from third-party payer's perspective in China. A two-part model was developed to estimate the cost-effectiveness of these two treatments. The short-term part was a decision-tree (1 year) including surgery-related complications and drug toxicity. The long-term was a Markov chain (lifetime) including the health states of normal sinus rhythms, AF recurrence, heart failure, stroke, post stroke, intracranial hemorrhages (ICH), post ICH, myocardial Infarction (MI), post MI, gastrointestinal bleeding and dead. Clinical efficacy, utility and cost data were obtained from published literature. The model calculated quality-adjusted life-years (QALYs) and total costs per patient. One-way and probabilistic sensitivity analyses were conducted. Captured by lifetime Markov model plus 1-year decision tree model, the total costs per patient for RFCA vs. AAD groups were ¥107,497 vs. ¥149,764; QALYs 8.16 vs. 7.58. From the 7th year, RFCA + warfarin became cost-effective (the incremental cost-effectiveness ratios at 7th year was ¥98,579/QALY, lower than the recommended threshold, 3xGDP/capita in China, ¥178,980). Furthermore, RFCA became cost-saving from the 9th year till lifetime with better effectiveness and lower overall costs compared with AAD. Both one-way and probabilistic sensitivity analyses confirmed the robustness of the results. Compared with AAD + NOAC, RFCA using contact force catheter + warfarin is cost-saving in long term for the treatment of PAF in China.

Diastolic wall strain predicts progression from paroxysmal to persistent or permanent atrial fibrillation in structurally normal hearts

BackgroundAtrial fibrillation (AF) is characterized by a progression from paroxysmal to persistent or permanent AF. Recent studies have shown that AF progression is related to a worse morbidity and mortality, and poorer outcomes of radiofrequency catheter ablation (RFCA). We previously showed that left ventricular (LV) compliance assessed by diastolic wall strain (DWS) was a strong determinant of prevalent AF. Methods and resultsWe studied 306 paroxysmal AF patients with structurally normal hearts. The DWS was non-invasively measured with echocardiography. During a follow-up of 35±19 months, AF progression occurred in 60 of 172 (35%) patients treated with medications only (medication group), and 3 of 134 (2%) who underwent RFCA (RFCA group) (p<0.001). In the medication group, patients with a DWS <0.38 had a higher incidence of AF progression than those without (log-rank p<0.001), while the AF progression rate was low irrespective of the DWS in the RFCA group. In a multivariate analysis, the DWS and left atrium volume index (LAVI) were independent predictors of AF progression in the medication group (hazard ratio, 1.13 per 0.01 decrease; 95% CI: 1.08–1.18; p<0.001, and 1.04 per 1mm increase; 95% CI: 1.01–1.08; p=0.012, respectively). In the medication group, AF progression occurred in only 5 of 61 (8%) patients with a DWS ≥0.38, whereas 27 of 40 (68%) with a DWS <0.38 and LAVI >34mL/m2 progressed to persistent or permanent AF. ConclusionsThe LV compliance estimated by the DWS was independently associated with AF progression. The DWS would be useful to stratify patients at risk of AF progression who could benefit from an earlier RFCA intervention.

Radiofrequency Catheter Ablation Versus Cryoballoon Ablation in the Treatment of Paroxysmal Atrial Fibrillation: A Cost-effectiveness Analysis in China

PurposeThe aim of this study was to evaluate the cost-effectiveness of radiofrequency catheter ablation (RFCA) compared with cryoballoon (CB) ablation in the treatment of patients with paroxysmal atrial fibrillation (PAF) from the payer's perspective in China. MethodsWe constructed a cohort model, combining a 12-month decision-tree model with a lifetime Markov state-transition model, in a hypothetical cohort of patients with drug-refractory PAF managed with either RFCA or CB ablation, to compare the cost-effectiveness of the 2 procedures. Data related to clinical outcomes and costs in this model were obtained from a retrospective 12-month follow-up study in patients in China and from related literature. The incremental cost-effectiveness ratio (ICER) over a 10-year time period was calculated and compared against the willingness-to-pay (WTP) threshold. We used a 1-way sensitivity analysis and a probabilistic sensitivity analysis (PSA) to access the structural uncertainty and the parameter uncertainty, respectively. FindingsOver a 10-year time horizon, the total costs per patient of RFCA and CB ablation were ¥98,164.04 (US $15,339.57; €13,058.94) and ¥107,542.37 ($16,805.07; €14,306.55), respectively, and quality-adjusted life-years (QALYs) gained were 5.47 and 5.43, respectively. The ICER ratio was –¥224,365.01 (–$35,060.32; –€29,847.68) per QALY, indicating that RFCA is associated with greater QALYs and lower costs than CB ablation. The 1-way sensitivity analysis demonstrated that the model results were most sensitive to the odds ratio of the atrial fibrillation recurrence within 12 months in the RFCA group versus the CB ablation group, the cost of RFCA, and the perioperative stroke risk with RFCA. According to the results of the PSA, RFCA was associated with a high probability of being cost-effective (99.48%) compared with CB ablation at a WTP threshold of ¥161,940 ($25,305.50; €21,543.17) per QALY. ImplicationsOur analysis indicates that RFCA is cost-saving compared with CB ablation in the treatment of patients with PAF in China, based on better QALYs and lower costs over a 10-year time horizon, from the payer's perspective.

Staged hybrid procedure versus radiofrequency catheter ablation in the treatment of atrial fibrillation.

The treatment effect of the hybrid procedure, consisting of a thoracoscopic ablation followed by an endocardial radiofrequency catheter ablation (RFCA), is unclear. A total of 117 ablation-naïve patients who underwent either the staged hybrid procedure (n = 72) or RFCA alone (n = 105) for drug-refractory, non-valvular persistent or long-standing persistent atrial fibrillation (AF) were enrolled. The primary outcome is occurrence of total atrial arrhythmia, defined as a composite of AF, sustained atrial tachycardia (AT), and atypical atrial flutter (AFL) after index procedure. The mean age was 52.7 years. Eighty-four percentage of the patients were male. Patients with prior history of stroke and long-standing persistent AF were more prevalent in the hybrid group than RFCA group. The left atrial volume index was larger in the hybrid group (P<0.001). During 2.1 years of median follow-up, the incidence of total atrial arrhythmia was not different between the two groups (32.5% vs. 35.7%; adjusted hazard ratio: 0.64; 95% confidence interval: 0.36–1.14; P = 0.13). The AF recurrence was significantly lower in the hybrid group than in the RFCA group (29.6% vs. 34.9%; adjusted HR: 0.53; 95% CI: 0.29–0.99; P = 0.046). The hospital stay was longer in the hybrid group than in the RFCA group (11 days vs. 4 days; P<0.001). A staged hybrid procedure may be an alternative choice for drug-refractory persistent AF, but it is no more effective than RFCA alone to eliminate atrial arrhythmias. Considering the long-length of stay and the morbidity, careful consideration should be given in selection of treatment strategy.