Pulmonary Vein Reconnection Rate Research Articles

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.

Durability of pulmonary vein isolation after radiofrequency-balloon ablation

Abstract Aims Recently a multi-electrode radiofrequency balloon (RFB) for pulmonary vein isolation (PVI) was introduced. To the best of our knowledge no data on PVI durability has yet been published. Objectives The aim of this single-center study was to investigate the incidence of pulmonary vein (PV) reconnectionafter RFB-guided PVI. Methods Patients undergoing second ablation for recurrent atrial tachyarrhythmia (ATa) following the initial RFB-PVI were investigated. Left arial (LA) electroanatomic mapping was used. The rate of PV reconnection, the type of recurrent ATaand procedural data were analyzed. Results Among 178 patients treated with RFB, 21 patients underwent a second procedure 11 ± 6 months after the initial PVI. 67% of these patients presented with atrial fibrillation (AF), 33% with atrial tachycardia. Regarding baseline characteristics, 71% of these patients were male, mean age was 67±10, mean BMI was 28±5, 67% had hypertension and 33% had coronary artery disease. Overall, 83 PVs including one left common PV (LCPV) were assessed. The rate of PV reconnection was 28% (23/83 PVs). 57% of patients (12/21) had at least one reconnected PV. Patient with PV-reconnection had more AF recurrence and less often atrial tachycardia (AT) (AF: 75%, AT: 25%) than patients with durably isolated PVs (AF: 56%, AT: 44%). Most reconnections were detected in septal PVs. Reconnections were distributed as follows: RIPV: 8/21, RSPV: 7/21, LIPV: 5/20, LSVP: 3/20, LCPV: 0/1. Precise localization of the gaps could be identified in 15/23 PVs. Most common gap locations were at the anterior carina (4/15) for septal PVs and anterior-inferior (3/15) at the LIPV. Ablation strategy was pure PV reisolation in 8/12 patients and PV reisolation with additional linear lesions in 4/12 patients. All patients with durably isolated PVs were treated with additional substrate modification. In total, following additional lesions were set: anterior line: 6, roof line: 11, cavotricuspid isthmus (CTI): 7, LAA-Isolation: 1, free wall of the right atrium: 1. Regarding procedural data of the index procedure, the number of applications was not a statistically significant predictor of reconnection (p=0.77). Conclusion We provide the first insight into durability of PVI after radiofrequency-balloon ablation. 72% of all PVs were still isolated. Our data on gap localization might help to identify regions where optimal balloon contact is difficult to achieve. More data on this topic might reveal predictors for PV reconnections.

Acute and long-term lesion durability and reconnection patterns following hybrid atrial fibrillation ablation

Abstract Background/introduction Hybrid ablation (AF) is a well-established rhythm control strategy in non-paroxysmal AF patients and can be performed as a staged or one-step epicardial-endocardial approach. Data on need for endocardial touch-up acutely after epicardial ablation are limited, as well as long-term reconnection patterns in patients undergoing redo procedures. Purpose to evaluate the lesion transmurality detected via endocardial mapping acutely after epicardial radiofrequency (RF) ablation, as well as anatomical and clinical predictors of residual endocardial gaps in a large cohort of patients undergoing hybrid AF ablation. Furthermore, long-term lesion durability will be assessed in patients undergoing repeat endocardial ablation. Methods Hybrid procedures were performed in a one-step fashion (endocardial mapping +/- ablation immediately following left thoracoscopy epicardial ablation). Epicardial pulmonary vein (PV) isolation was achieved via a bipolar RF clamp; further epicardial linear ablation was performed with a RF bipolar linear device. Additional lesions were performed according to physician’s preference on a patient basis. At the end of the procedure, the left atrial appendage (LAA) was clipped. Results A total of 130 patients were included (mean age: 65±9.4; 72.3% males); among them, 19.2% and 55.4% had persistent or long-standing persistent AF. All patients received epicardial PV and posterior wall (PW) isolation plus additional RF applications to the LAA/posterolateral ridge. Other targets included the right inferior ganglionted plexus in 36.2% (n=47) and anterior mitral line (AML) in 3.8% (n=5). In 13.1% (n=17) epicardial lesions could not be completed due to difficult anatomy. At the end of the procedure, an attempt to clip the LAA was done in all patients, resulting in 97.7% success (3 LAA clip failures due to anatomical reasons). Acute endocardial mapping revealed a PV reconnection rate of 4.6% (n=24), left superior and right superior PVs being the veins most commonly reconnected (6.15% and 5.38%, respectively). PW and AML reconnections were documented in 8.5 % and 60% (3 out of 5 patients). Multivariate analysis showed left atrial (LA) volume and male gender as predictors for acute endocardial gaps after complete epicardial lesions. A redo procedure after first recurrence was performed in 24.6% (n=32), showing lesion durability of 100% for left PVs, 90.6% for right superior and 93.7% for right inferior PVs. PW remained isolated in 78.1% of patients. Age was a predictive factor for chronic gaps after recurrence. At a mean follow-up of 51±35 months, arrhythmia-free survival after multiple procedures was 68.5%. Conclusion In a large cohort of AF patients undergoing hybrid ablation,acute and chronic lesion durability was hight.LA volume and male gender were predictors of acute reconnection after epicardial ablation.

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

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

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

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

Rates of pulmonary vein reconnection at repeat ablation for recurrent atrial fibrillation and its impact on outcomes among females and males.

Several studies have demonstrated that females have a higher risk of arrhythmia recurrence after pulmonary vein (PV) isolation for atrial fibrillation (AF). There are limited data on sex-based differences in PV reconnection rates at repeat ablation. We aimed to investigate sex-based differences in electrophysiological findings and atrial arrhythmia recurrence after repeat AF ablation METHODS: We conducted a retrospective study of 161 consecutive patients (32% female, age 65±10 years) who underwent repeat AF ablation after index PV isolation between 2010 and 2022. Demographics, procedural characteristics and follow-up data were collected. Recurrent atrial tachycardia (AT)/AF was defined as any atrial arrhythmia ≥30 s in duration. Compared to males, females tended to be older and had a significantly higher prevalence of prior valve surgery (10vs. 2%; P=.03). At repeat ablation, PV reconnection was found in 119 (74%) patients. Males were more likely to have PV reconnection at repeat ablation compared to females (81vs. 59%; P=.004). Excluding repeat PV isolation, there were no significant differences in adjunctive ablation strategies performed at repeat ablation between females and males. During follow-up, there were no significant differences in freedom from AT/AF recurrence between females and males after repeat ablation (63vs. 59% at 2 years, respectively; P=.48). After initial PV isolation, significantly fewer females have evidence of PV reconnection at the time of repeat ablation for recurrent AF. Despite this difference, long-term freedom from AT/AF was similar between females and males after repeat ablation.

Adherence to the CLOSE Protocol and Low Baseline Generator Impedance Are Independent Predictors of Durable Pulmonary Vein Isolation.

Background: Atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI) is predominantly attributed to pulmonary vein reconnection (PVR). Predictors of AF recurrence have been widely studied; however, data are scarce on procedural parameters that predict chronic PVR. We aimed to study PVR rates and predictors of PVR. Methods: We retrospectively included 100 patients who underwent repeated ablation due to AF recurrence after initial PVI with the CARTO system. PVR was determined during the repeated procedure by electrophysiological evaluation, and initial procedural characteristics predicting PVR were studied, including adherence to the CLOSE protocol, use of high power, first-pass isolation (FPI), and baseline generator impedance (BGI). Results: Thirty-eight patients underwent initial CLOSE-guided PVI, and sixty-two underwent initial non-CLOSE PVI. A repeat procedure was performed 23 ± 16 months after the initial procedure. In total, PVR was found in 192 of 373 PVs (51.5%), and all PVs were isolated in 17/100 (17%) patients. Factors associated with all PVs being isolated were adherence to the CLOSE protocol, a higher power setting, the presence of bilateral FPI, and lower BGI (88% vs. 28%, p < 0.0001; 37.5 W vs. 30 W, p = 0.0276; 88.2% vs. 40.4%, p = 0.0007; and 127.6 Ω vs. 136.6 Ω, p = 0.0027, respectively). In initial procedures with adherence to the CLOSE protocol, the FPI rate was significantly higher (73.7% vs. 25%, p < 0.0001), while there were no significant differences in terms of procedure time and left atrial dwell time (81 vs. 85 min, p = 0.83; and 60 vs. 58 min, p = 0.08, respectively). BGI ≥ 130 Ω (AUC = 0.7403, sensitivity: 77.1%, specificity: 68.8%, p = 0.0032) was associated with a significantly higher probability of PVR (OR = 6.757; p < 0.0001). In multivariable analysis, independent predictors for PVR were non-adherence to the CLOSE protocol and BGI ≥ 130 Ω. Conclusions: Our findings indicate that adherence to the CLOSE protocol and baseline generator impedance < 130 Ω during AF ablation are independent predictors of PVI durability.

Contact force sensing manual catheter versus remote magnetic navigation ablation of atrial fibrillation: a single-center comparison

BackgroundData comparing remote magnetic catheter navigation (RMN) with manual catheter navigation in combination with contact force sensing (MCN-CF) ablation of atrial fibrillation (AF) is lacking. The primary aim of the present retrospective comparative study was to compare the outcome of RMN versus (vs.) MCN-CF ablation of AF with regards to AF recurrence. Secondary aim was to analyze periprocedural risk, ablation characteristics and repeat procedures.MethodsWe retrospectively analyzed 452 patients undergoing a total of 605 ablations of AF: 180 patients were ablated using RMN, 272 using MCN-CF.ResultsExcept body mass index there was no significant difference between groups at baseline. After a mean 1.6 ± 1.6 years of follow-up and 1.3 ± 0.4 procedures, 81% of the patients in the MCN-CF group remained free of AF recurrence compared to 53% in the RMN group (P < 0.001). After analysis of 153 repeat ablations (83 MCN-RF vs. 70 RMN; P = 0.18), there was a significantly higher reconnection rate of pulmonary veins after RMN ablation (P < 0.001). In multivariable Cox-regression analysis, RMN ablation (P < 0.001) and left atrial diameter (P = 0.013) was an independent risk factor for AF recurrence. Procedure time, radiofrequency application time and total fluoroscopy time and fluoroscopy dose were higher in the RMN group without difference in total number of ablation points. Complication rates did not differ significantly between groups (P = 0.722).ConclusionsIn our retrospective comparative study, the AF recurrence rate and pulmonary vein reconnection rate is significantly lower with more favorable procedural characteristics and similar complication rate utilizing MCN-CF compared to RMN.

Abstract 12390: Differences in the Impact of Use of Contact Force Sensing Catheters on Subsequent Rates of Pulmonary Vein Reconnection Detected Between Men and Women During Repeat Ablation of Atrial Fibrillation

Background: Radiofrequency catheter ablation (CA) is an effective treatment for atrial fibrillation (AF). Contact force (CF) sensing catheters permit tissue contact monitoring that may lead to durable pulmonary vein (PV) isolation. Objective: To assess the impact of CF-sensing catheters on PV reconnection rates at repeat AF ablation and whether there are sex-based differences. Methods: We conducted a retrospective study of patients who underwent repeat AF ablation after index PV isolation between 2010 and 2022. Patients were divided into 2 groups: Group 1 (non-CF sensing catheters) and Group 2 (CF-sensing catheters). Results: One hundred sixty-one patients were included in the study (76 in Group 1 and 85 in Group 2, 32% female, 70 ± 10 years old). Initial use of CF-sensing catheters at index ablation was associated with a lower PV reconnection rate at repeat ablation (60% for Group 2 vs 87% for Group 1; P = 0.001). There were no significant differences in locations of PV reconnection between Group 1 and Group 2. When stratified by sex, there were significantly lower rates of PV reconnection in male patients with use of CF-sensing catheters (92% for Group 1 vs 67% for Group 2; p=0.001) but not for female patients (71% for Group 1 vs 50% for Group 2; p=0.23). On multivariable logistic regression analysis, use of CF-sensing catheters at index ablation (adjusted odds ratio [aOR]: 0.28, 95% CI: 0.12 to 0.65; p=0.003) and female sex (aOR: 0.38, 95% CI: 0.17 to 0.86; p=0.02) were associated with significantly lower rates of PV reconnection found at repeat ablation. Conclusion: Use of CF sensing catheters reduced PV reconnection rate found at repeat AF ablation. Females have lower rates of PV reconnection identified at repeat ablation which suggest that non-PV triggers may be a more common cause of recurrent AF, thereby blunting the impact of CF-sensing catheters on reducing recurrent AF in females.

Pulmonary vein reconnection rates and lesion regression during repeat procedures in patients with recurrent arrhythmias after pulsed field ablation pulmonary vein isolation

Abstract Funding Acknowledgements Type of funding sources: None. Background A novel multipolar pulsed-field ablation (PFA) catheter has recently been introduced for pulmonary vein isolation (PVI). Pre-market data showed high rates for PVI-durability during mandatory remapping studies 90 days after the first procedure. Post-market data on PVI durability and lesion regression, particularly in patients with recurrent atrial arrhythmias, are limited. Purpose To characterize the findings on redo cases after previous PFA procedures. Methods Consecutive patients undergoing a redo procedure after an index PFA PVI between May 2021 and October 2022 were included. 3-D electro-anatomical maps (3D-EAM) were acquired in sinus rhythm at the beginning of the redo procedure and compared to the 3D-EAM acquired after ablation during the index procedure. PV-reconnection was assessed on a per-vein and per-patient level and the sites of reconnections were identified. Furthermore, lesions extent was compared between the two maps. Results Of 265 patients undergoing their first PFA PVI between May 2021 and August 2022, 26 (9.8%) patients with recurrent atrial tachyarrhythmia underwent a redo ablation. The phenotype prior to the first PVI was paroxysmal AF in three patients (12%), persistent AF in 85 patients (85%), and left atrial flutter in one (4%) patient. A 31 mm device was used in 81% of the patients. Posterior wall ablation in addition to PVI was performed in three patients. At the end of the first PFA procedure, 100/102 veins (98%, two common ostia) were isolated as evidenced by post ablation 3D-EAM (two LIPV’s could not be isolated). The recurring arrhythmias were AF, atypical flutter, both, and atrial tachycardia in 14 patients (54%), 5 patients (19%), 6 patients (23%) and 1 (4%) respectively. High-density 3D-EAM identified 65/100 (65%) PVs with persistent isolation. In 7 (27%) patients, all PVs were isolated. Reconnection occurred most frequently in the right inferior PV (11, 42%) followed by the left superior PV (9, 36%), the right superior PV (8, 31%), the left inferior PV (6, 27%), and the left common ostium (1, 50%). The predominant reconnection sites were located anterior of the superior veins, and on the inferior aspect of the right inferior PV (Figure). On the posterior wall, the distance between the lesions of the left pulmonary veins and the right pulmonary veins increased by a median of 5 mm [0, 10] between the index and Redo procedure. Conclusion In patients with recurrent atrial arrhythmias after PFA PVI, PV reconnections were found in 73% of the patients and in 35% of the veins. The reconnections were most prevalent on the anterior aspects of the upper veins, as well as on the inferior aspect of the right inferior vein.

Ablation of residual potentials along the circumferential line reduces acute pulmonary vein reconnection

IntroductionAcute pulmonary vein (PV) reconnection is frequently encountered in patients undergoing PV isolation (PVI) procedure for the treatment of atrial fibrillation. In this study, we investigated whether the identification and ablation of residual potentials (RPs), after the initial achievement of PVI, reduces acute PV reconnection rate. MethodsFollowing PVI in 160 patients, mapping along the ablation line was performed to identify RPs, defined as bipolar amplitude ≥0.2 mV or 0.1-0.19 mV combined with a negative component of the unipolar electrogram. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of the identified RPs (Group C). The primary study endpoint was spontaneous or adenosine-mediated acute PV reconnection after a 30-min waiting period and was also evaluated in ipsilateral PV sets without RPs (Group A). ResultsAfter isolation of 287 PV pairs, 135 had no RPs (Group A), whereas the remaining PV pairs were randomized to either Group B (n = 75) or Group C (n = 77). Ablation of RPs resulted in a reduction of spontaneous or adenosine-mediated PV reconnection rate (16.9% in Group C vs 48.0% in Group B; p < 0.001). Group A was associated with a significantly lower percentage of acute PV reconnection as compared to Group B (5.9% vs 48.0%; p < 0.001) and Group C (5.9% vs 16.9%; p = 0.016). ConclusionAfter PVI achievement, the absence of RPs along the circumferential line is associated with a low likelihood of acute PV reconnection rate. Ablation of RPs significantly reduces spontaneous or adenosine-mediated acute PV reconnection rate.

Findings from repeat ablation using high-density mapping after pulmonary vein isolation with pulsed field ablation.

Pulsed-field ablation (PFA) can offer a novel perspective for atrial fibrillation (AF) ablation. We aimed to characterize the incidence of pulmonary vein (PV) reconnection, types of recurrent atrial tachyarrhythmia (ATa) and lesion quality after PFA-guided PV isolation (PVI). Patients undergoing second ablation for recurrent ATa following the initial PVI using the pentaspline PFA catheter were investigated. The rate of PV reconnection, the features of recurrent ATa, and the amount of isolated posterior wall (PW) surface area (ISAPW%) (ratio of the isolated- to total surface area on PW) were analyzed. Among 360 patients treated with PFA, 25 patients (paroxysmal AF, n = 19) with 99 PVs underwent a second procedure 6.1 ± 4.0 months after the initial procedure. The rate of PV reconnection was 9.1% (9 PVs). Patients presented with atrial tachycardia (AT) (n = 16), AF (n = 8) and typical atrial flutter (n = 1). The mechanism of all but one AT was macro-reentry. The critical isthmus was found to be linked to the initial lesion set at the left atrial (LA) PW in eight patients and linked to pre-existing substrate at the LA anterior wall in four patients. One AT had a focal origin at the septum. In three patients, AT were unmappable. Mean ISAPW% was 72.7 ± 19.0%. We revealed a remarkable low reconnection rate with a large antral lesion at the PW after pentaspline PFA catheter-guided PVI. However, macro-reentrant AT with a critical isthmus at the LAPW linked to the PVI lesion set was commonly observed.

Abstract 11177: Pulmonary Vein Reconnections Predict Good Clinical Outcomes After a Second Catheter Ablation of Persistent Atrial Fibrillation: Insight From the EARNEST-PVI Trial

Introduction: The effect of an extensive ablation strategy in addition to pulmonary vein (PV) isolation is still controversial in persistent atrial fibrillation (AF) ablation. Electrical PV reconnection is an important confounder affecting the trial results. Objectives: To evaluate the PV reconnection rate and association between the reconnection and AF recurrence after a re-do AF ablation in the EARNEST-PVI trial (NCT03514693). Methods: The analysis was performed using the extended data of the EARNEST-PVI trial (N=512), a randomized controlled trial to evaluate ablation strategies for persistent AF, which was conducted in the Osaka region of Japan. During a median follow-up of 47 months, a total of 126 (25%) patients underwent a re-do AF ablation. Among them, 120 (median age, 68 years; 36% female; 31% long-standing persistent AF, 95% contact force-sensing catheter use) whose follow-up data were available after the 2 nd AF ablation were enrolled in this study. Results: PV reconnections were observed in 75 (63%) patients. Although there was no difference in age, gender, long-standing persistent AF, and CA strategy during the index procedure, AF recurrence within 1 year was more frequent in patients with PV reconnections (81.3% vs. 64.4%, p = 0.039). During a median follow-up of 31 months after the re-do AF ablation, patients with PV reconnections had a lower clinical recurrence rate than those without (38.7 vs. 44.4%, log-rank p = 0.047). However, additional linear ablation did not affect the recurrence rate. Even after adjustment for age, gender, long-standing persistent AF, and presence of non-PV triggers, Cox regression analysis revealed that a number of reconnected PVs of ≥2 was independently associated with a lower recurrence of AF after the 2 nd AF ablation (hazard ratio, 0.36; 95% confidence interval, 0.19-0.67; p = 0.001). Conclusions: Among patients who underwent a redo-AF ablation in the EARNEST-PVI trial, about two-thirds exhibited PV reconnections. Patients with ≥2 PV reconnections had better clinical outcomes than those with ≤1 PV reconnections. A durable PV isolation is an important pre-requisite before exploring any additional ablation strategies for persistent AF.

Ablation of residual potentials along the circumferential line reduces acute reconnection in patients undergoing pulmonary vein isolation

Abstract Introduction Acute pulmonary vein (PV) reconnection is frequently encountered in patients with atrial fibrillation (AF) subjected to PV isolation (PVI). Purpose In this prospective, multicenter, randomized study, we investigated whether the identification and ablation of sites along the circumferential line with specific electrogram criteria indicative of nontrasmurality, after initial achievement of PVI, reduces acute PV reconnection rate. Methods Patients referred for AF ablation at five European centers were enrolled. PVI with antral circumferential isolation of ipsilateral PVs was performed using a contact force sensing ablation catheter delivering 35–40W at the anterior/superior and 30W at the posterior wall with target ablation index of 550 at the anterior wall/roof and 400 at the posterior/inferior segments. Following PVI, mapping with the ablation catheter was performed to identify residual potentials (RP) along the ablation line, defined as bipolar amplitude ≥0.2 mV or 0.1–0.19 mV combined with negative component of the unipolar electrogram as recorded by the 3D mapping system. Ipsilateral PV sets with RPs were randomized to either no further ablation (Group B) or to additional ablation of RPs (Group C). The primary study endpoint was defined as spontaneous or adenosine-mediated recovery of conduction after 30-minute waiting period which was also evaluated in ipsilateral PV sets without residual potentials (Group A). Results In total, 109 patients (59.3±10.6 years, 47% hypertension, 9.3% diabetes, left atrial diameter 39.1±4.6mm) were enrolled in the study. After initial isolation of 194 PV pairs, 98 PV pairs had no RPs (Group A) while the remaining 96 with RPs were randomized to either Group B or C (48 PV pairs each). The number of sites with RPs did not differ between groups B and C (4.1±2.5 vs 4.7±3.2, p=0.27). The occurrence of the primary endpoint in Group A was 7.1%. Ablation of residual potentials resulted in significant reduction of spontaneous or adenosine mediated reconnection (14.6% vs 47.9%, p&amp;lt;0.001). Conclusion Following initial PVI achievement, ablation of RPs along the antral circumferential line reduces spontaneous or adenosine-mediated acute PV reconnection rate in patients undergoing first-time AF ablation. Therefore, scanning of the PVI line in search of weak links with specific electrogram criteria indicative of nontrasmurality, and subsequent deployment of bonus lesions, could represent a convenient and practical way to reduce acute PV reconnection. Further studies are required to assess long term effects on AF recurrence rates. Funding Acknowledgement Type of funding sources: None.

Impact of open-irrigated radiofrequency catheter with contact force measurement on the efficacy and safety of atrial fibrillation ablation: a single-center direct comparison

BackgroundIn atrial fibrillation (AF) patients, catheter ablation of pulmonary veins (PVI) is the most effective therapeutic option to maintain sinus rhythm. To improve successful PVI, contact force–sensing (CF) catheters became routinely available. Previous studies did not clearly show superior clinical efficacy in comparison with non-CF catheters.MethodsWe investigated consecutive patients, who underwent index PVI for AF at our hospital between 2012 and 2018. Three hundred and fifty-four patients were ablated without CF. After availability of CF catheters in 2016, 317 patients were ablated using CF. In case of crossover between the groups, follow-up was censored. The primary endpoint was any documented atrial tachycardia (AT) or atrial fibrillation > 30 s after a 3-month blanking period. Secondary endpoints were procedural characteristics and periprocedural complications.ResultsThere was no significant difference between the groups at baseline except hyperlipidemia. After 365 days of follow-up, 67% of patients in the CF group remained free from AF/AT recurrence compared to 59% in non-CF group (P = 0.038). In multivariable Cox regression analysis, non-CF ablation was an independent risk factor for AF recurrence besides age and persistent AF. Total fluoroscopy time (15 ± 7.6 vs. 28 ± 15.9 min) and total procedure time (114 ± 29.6 vs. 136 ± 38.5 min) were significantly lower for CF-guided PVI (P < 0.001). Complication rates did not differ between groups (P = 0.661).ConclusionsIn our study, the AT/AF recurrence rate and pulmonary vein reconnection rate is lower after CF PVI with a similar complication rate but lower total procedure time and total fluoroscopy time compared to non-CF PVI.

Comparison between High-Power Short-Duration and Conventional Ablation Strategy in Atrial Fibrillation: An Updated Meta-Analysis.

High-power short-duration (HPSD) setting during radiofrequency ablation has become an attempt to improve atrial fibrillation (AF) treatment outcomes. This study ought to compare the efficacy, safety, and effectiveness between HPSD and conventional settings. PubMed, Embase, and Cochrane Library were searched. Studies that compared HPSD and conventional radiofrequency ablation settings in AF patients were included while studies performed additional ablations on nonpulmonary vein targets without clear recording were excluded. Data were pooled with random-effect model. Efficacy endpoints include first-pass pulmonary vein isolation (PVI), acute pulmonary vein (PV) reconnection, free from AF, and free from atrial tachycardia (AT) during follow-up. Safety endpoints include esophagus injury rate and major complication rate. Effectiveness endpoints include complete PVI rate, total procedure time, PVI time, and PVI radiofrequency ablation (PVI RF) time. We included 22 studies with 3867 atrial fibrillation patients in total (2393 patients received HPSD radiofrequency ablation). Perioperatively, the HPSD group showed a higher first-pass PVI rate (risk ratio, RR = 1.10, P = 0.0001) and less acute PV reconnection rate (RR = 0.56, P = 0.0004) than the conventional group. During follow-up, free from AF (RR = 1.11, P = 0.16) or AT (RR = 1.06, P = 0.24) rate did not differ between HPSD and conventional groups 6-month postsurgery. However, the HPSD group showed both higher free from AF (RR = 1.17, P = 0.0003) and AT (RR = 1.11, P < 0.0001) rate than the conventional group 12-month postsurgery. The esophagus injury (RR = 0.99, P = 0.98) and major complications (RR = 0.76, P = 0.70) rates did not differ between the two groups. The HPSD group took shorter total procedure time (MD = −33.71 95% CI: -43.10 to -24.33, P < 0.00001), PVI time (MD = −21.60 95% CI: -25.00 to -18.21, P < 0.00001), and PVI RF time (MD = −13.72, 95% CI: -14.45 to -13.00, P < 0.00001) than conventional groups while complete procedure rate did not differ between two groups (RR = 1.00, P = 0.93). HPSD setting during AF radiofrequency ablation has better effectiveness, efficacy, and similar safety compared with the conventional setting.

Impact of catheter contact angle on lesion formation and durability of pulmonary vein isolation

PurposeThis study is aimed to evaluate the impact of catheter contact angle on lesion formation and durability of pulmonary vein isolation (PVI).MethodsBoth in vitro experiment and retrospective observational study were conducted. For in vitro experiment, radiofrequency lesions were created on explanted swine hearts in three different catheter contact angles (0°, 45°, and 90°). In the retrospective observational study, we assessed patients who had undergone repeat catheter ablation due to atrial fibrillation recurrence after initial PVI. When pulmonary vein (PV) reconnection was observed, we analyzed the previous ablation points within and without the gap area. The gap areas were where ablation had changed the PV activation sequence or eliminated the PV potential in the repeat session.ResultsIn the in vitro experiment, lesion width was the smallest (5.3 ± 0.4 mm) in perpendicular contact compared to 0° (vs 5.8 ± 0.5 mm, p = 0.040) and 45° (vs 6.4 ± 0.4 mm, p < 0.001). In the retrospective observational study, we assessed 666 tags of 16 patients with PV reconnections, and 60 tags were in the gap area. Tags in the gap area had longer interlesion distance (odds ratio [OR] 1.49, p < 0.001), greater contact force variability (OR 1.03, p = 0.008), and higher rate of perpendicular contact (OR 3.26, p < 0.001) on multivariate analysis.ConclusionsPerpendicular contact was associated with a smaller lesion and higher rate of PV reconnection.

Absence of first-pass isolation is associated with poor pulmonary vein isolation durability and atrial fibrillation ablation outcomes.

BackgroundPulmonary vein (PV) reconnection is the main cause of atrial fibrillation (AF) recurrence. This study aimed to examine the effect of first‐pass PV isolation (PVI) on PV reconnection frequency during the procedure and on AF ablation outcomes.MethodsThis retrospective study included 446 patients with drug‐refractory AF (370 men, aged 64 ± 10 years) who underwent initial PVI using an open‐irrigated contact force catheter between January 2015 and October 2016. We investigated the effect of first‐pass PVI on PV reconnection during spontaneous PV reconnection and dormant conduction after an adenosine triphosphate challenge.ResultsFirst‐pass PVI was achieved in 69% (617/892) of ipsilateral PVs, of which we observed PV reconnection during the procedure in 134 (22%) PVs. This value was significantly lower than that observed in those without first‐pass PVI (50%, 138/275) (P < .0001). We divided the subjects into two groups based on the presence or absence of first‐pass PVI in at least one of two ipsilateral PVs: first‐pass (n = 383, 86%) and non‐first‐pass groups (n = 63, 14%). The 2‐year AF recurrence‐free rate was significantly higher in the first‐pass group than in the other group (75% vs 59%, log‐rank P = .032). In 78 patients with repeat AF ablation, the PV reconnection rate in the second procedure was significantly lower in PVs that had first‐pass isolation in the first procedure (34% vs 73%, P < .0001).ConclusionsAbsence of first‐pass PVI was associated with a higher frequency of spontaneous PV reconnection and dormant conduction and poor ablation outcomes. First‐pass isolation may be a useful marker for better PVI durability.

Acute and long-term efficacy of ablation index-guided higher power shorter duration ablation in patients with atrial fibrillation: A prospective registry.

BackgroundTheoretically, targeting the same ablation index (AI) using higher power may achieve the same lesion size with a shorter ablation time. We evaluated the acute and long‐term efficacy of higher‐powered ablation guided by ablation index (HPAI) compared with conventional‐powered ablation guided by AI (CPAI) for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF).MethodsDrug refractory symptomatic AF patients who had been ablated with 40 W on the anterior/roof segments and 30 W on the posterior/inferior/carina segments were enrolled (HPAI group). We compared the HPAI group with the CPAI group who were ablated with 30 W on the anterior/roof segments and 25 W on the posterior/inferior/carina segments. The same AI was targeted (≥450 on the anterior/roof segments and ≥350 on the posterior/inferior/carina segments). We compared ablation time, acute pulmonary vein reconnection (PVR) and 1‐year AF recurrence between the two groups.ResultsA total of 118 patients were included (86 in the HPAI group and 32 in the CPAI group, paroxysmal AF, 73%). There was no significant difference in the acute PVR rate between the HPAI and the CPAI groups (3.7% vs. 4.2%, P = .580) with a 41% reduction in ablation time for PVI (38.7 ± 8.3 vs. 65.8 ± 13.7 minutes, P < .001). The 1‐year AF recurrence rate was not significantly different between HPAI and CPAI groups (12.8% vs. 21.9%, Log‐rank P = .242). There were no major complications in either group.ConclusionsIncreased power during AF ablation, using the same AI targets, reduced the procedure and ablation times, and showed a comparable acute and long‐term outcome without compromising safety.Clinical Trial Registrationhttps://www.clinicaltrials.gov. Unique identifier: NCT 04379557.

Impact of Catheter Contact Angle on Lesion Formation and Durability of Pulmonary Vein Isolation

Objectives: This study aimed to evaluate the impact of catheter contact angle on lesion formation and durability of pulmonary vein isolation (PVI). Background: Little is known on the effect of catheter contact angle on lesion formation and durability of PVI. Methods: Both in vitro experiment and retrospective observational study were conducted. For in vitro experiment, radiofrequency lesions were created on explanted swine hearts in three different catheter contact angles (0{degree sign}, 45{degree sign}, and 90{degree sign}). In the retrospective observational study, we assessed patients who had undergone repeat catheter ablation due to atrial fibrillation recurrence after initial PVI. When pulmonary vein (PV) reconnection was observed, we analyzed the previous ablation points within and without the gap area. The gap areas were where ablation had changed the PV activation sequence or eliminated the PV potential in the repeat session. Results: In the in vitro experiment, lesion width was the smallest (5.3 {plus minus} 0.4 mm) in perpendicular contact compared to 0{degree sign} (vs 5.8 {plus minus} 0.5 mm, p=0.040) and 45{degree sign} (vs 6.4 {plus minus} 0.4 mm, p<0.001). In the retrospective observational study, we assessed 666 tags of 16 patients with PV reconnections, and 60 tags were in the gap area. Tags in the gap area had longer interlesion distance (odds ratio [OR] 1.49, p < 0.001), greater contact force variability (OR 1.03, p = 0.008), and higher rate of perpendicular contact (OR 3.26, p < 0.001) on multivariate analysis. Conclusion:Perpendicular contact was associated with a smaller lesion and higher rate of PV reconnection