Atrial Arrhythmia Recurrence Research Articles

Abstract 11726: Atrial Arrythmia Recurrence in Patients After Left Atrial Ablation is Associated With Epicardial Connections and Directly Correlated to Reduced Left Ventricular Ejection Fraction

Introduction: Heart Failure with Reduced Ejection Fraction has a positive association with atrial arrhythmia incidence and recurrence. However, this has not been studied in atrial fibrillation (AF) and atrial tachycardia (AT) patients who underwent left atrial radiofrequency ablation(RFA) and were subsequently found to have epicardial connections(EC). Hypothesis: Heart Failure with Reduced Ejection Fraction was associated with an increased recurrence of atrial tachyarrythmias in patients with epicardial connections. Methods: We studied 40 consecutive patients with persistent atrial arrhythmias who underwent RFA for AF and AT at our center. Epicardial connections were determined by high density mapping, missing isochrones and activation patterns. Clinical, echocardiographic and activation mapping pattern characteristics were collected. Results: Forty patients were found to have EC (Table 1). The association of EC and echocardiographic parameters were assessed. Reduced Left Ventricular Ejection Fraction was associated with an increased recurrence of atrial tachyarrhythmias in patients due to epicardial connections((HR:1.25(1.05-1.48)) (Table 2). Conclusions: Reduced Left Ventricular Ejection Fraction is positively correlated with atrial tachyarrythmia recurrence in patients due to epicardial connections.

Abstract 14281: Direct-Current Cardioversion During Ablation Predicts Recurrence of Atrial Arrhythmia During Long-Term Follow-Up

Background: The predictive value of termination of atrial fibrillation (AF) with direct-current (DC) cardioversion (CV) during catheter ablation (CA) during a long-term follow-up is not known. Methods: We studied the long-term success of CV during ablation in patients who underwent catheter ablation of AF and followed them for recurrence of AF/atrial flutter (AFL). Results: Of 187 patients (male: 75%, mean age: 60.3 ± 10.7 years), 96 (51.3%) patients required DC cardioversion during the initial CA. A mean number of 1.4 ± 0.6 ablations (p=NS) were performed during follow-up in both groups. There were no significant differences in baseline characteristics including age, gender, race, body mass index, left ventricular ejection fraction, and presence of hypertension, diabetes, and valvular disease. During a median (±1SE) follow-up of 5.23 ± 0.17 years, a significantly higher percentage of patients who needed CV during CA had recurrence of AF/AFL as compared to patients who did not need CV to terminate AF during CA (39.6 vs 16.5%, p < 0.001). Cox regression analysis confirmed DC cardioversion during ablation as a predictor of recurrence of AF/AFL at time of last follow-up (OR: 2.78, 95% CI 1.52 to 5.10, p < 0.001). Kaplan-Meier survival analysis shows significantly decreased time to recurrence in patients who had CV during initial ablation than those who did not require DC cardioversion (log-rank p <0.001). Conclusion: DC cardioversion during catheter ablation is a predictor for recurrence of AF/AFL during long-term follow-up.

Impact of first-line cryoablation for atrial fibrillation on healthcare utilization, arrhythmia disease burden and efficacy outcomes: real-world evidence from the Cryo Global Registry.

Cryoballoon ablation (CBA) is an effective first-line treatment for symptomatic atrial fibrillation (AF), as recently demonstrated by three randomized trials. This sub-analysis of the Cryo Global Registry aims to examine current clinical practices of first-line CBA. AF patients treated with first-line CBA were compared to CBA in antiarrhythmic drug (AAD)-refractory patients at 12months. Efficacy was examined using time-to-first atrial arrhythmia recurrence following a 90-day blanking period. Healthcare utilization was evaluated by repeat ablations and hospitalizations. Disease burden was examined by assessing quality of life (QOL) and patients' reporting of symptoms. Of 1394 patients, 433 (31.1%) were treated with first-line CBA, which was more frequent in high-volume centers. Serious procedure-related adverse event rates were similar. Efficacy at 12months was higher in the first-line group (87.8 vs. 81.6%, HRunadj 0.64 (95% CI 0.47-0.88); p < 0.01) regardless of the centers' CBA experience; when controlling for baseline characteristics, the difference was not significant (HRadj 0.87 (95% CI 0.56-1.37); p = 0.55). No difference was observed in repeat ablations and hospitalizations between cohorts. First-line patients experienced a larger mean reduction in symptoms and were prescribed AADs at a lower rate at 12-month follow-up (9.7 vs. 29.9%). QOL improved in both cohorts from baseline to 12months with no significant difference between groups (p = 0.29). In this global real-world experience, first-line CBA in patients with symptomatic AF is effective, with a larger symptom reduction compared with CBA after AAD failure and without a difference in healthcare utilization at mid-term follow-up. https://clinicaltrials.gov/ct2/show/NCT02752737.

Cryoballoon ablation for atrial fibrillation in patients with heart failure with mildly reduced and preserved ejection fraction.

Limited data are available on the outcomes of cryoballoon ablation (CBA)-based pulmonary vein isolation (PVI) for atrial fibrillation (AF) in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and mildly reduced ejection fraction (HFmrEF). The present study aimed to evaluate the safety and effectiveness of CBA in such patients. Consecutive patients with AF referred for CBA-based PVI from two highly experienced electrophysiology centres were included in this retrospective study. Of 651 patients undergoing CBA, 471 cases were divided into four groups: No HF (n=255), HFpEF (n=101), HFmrEF (n=78), and HF with reduced ejection fraction (n=37). Similar early recurrence of atrial arrhythmia was found among groups (16.2% vs. 15.4% vs. 14.9% vs. 12.2%, P=0.798), and no significant difference of long-term sinus rhythm (SR) maintenance was identified among the HFmrEF, HFpEF, and No HF groups (71.8% vs. 75.2% vs. 79.6%, P=0.334). CBA is safe for patients with HFmrEF and HFpEF with similar complications compared with the No HF group (3.8% vs. 4.0% vs. 3.1%, P=0.814). The reassessment of cardiac function after CBA showed that patients with HF indicated beneficial outcomes. Left atrial diameter (LAD) and left ventricular ejection fraction were significantly improved in the HFmrEF group. There were 41.6% of patients in the HFpEF group who were completely relieved from HF. LAD and New York Heart Association (NYHA) were associated with recurrence in the HFpEF and HFmrEF groups, and the maintenance of SR was an independent predictor of NYHA improvement for all HF groups. Patients with HFmrEF and HFpEF could benefit from CBA with high SR maintenance and significant HF improvement.

Catheter ablation in patients with atrial fibrillation and heart failure with preserved ejection fraction: A systematic review and meta-analysis.

Catheter ablation for atrial fibrillation (AF) is a proven alternative to pharmacologic rhythm control in patients with heart failure with reduced ejection fraction (HFrEF). Whether outcomes differ in patients with heart failure with preserved ejection fraction (HFpEF) is of interest. Medline, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched to identify relevant studies. Primary efficacy outcomes of interest include atrial arrythmia recurrence and repeat ablation. Harm outcomes of interest include all-cause mortality, all-cause hospitalizations, cardiovascular hospitalizations, stroke/transient ischemic attack, and cardiac tamponade. We included 7 observational studies comprising 2554 patients with HFpEF who underwent catheter ablation for AF. When comparing patients with HFpEF versus without HF, there was no significant difference in atrial arrhythmia recurrence (risk ratio [RR] 1.39; 95% confidence interval [CI] 0.91-2.13), stroke or transient ischemic attack (TIA) (RR 0.47; 95% CI 0.03-6.54), or cardiac tamponade (RR 1.20; 95% CI 0.12-12.20). When comparing patients with HFpEF versus HFrEF, there was no significant difference in atrial arrhythmia recurrence (RR 1.12; 95% CI 0.92-1.37), repeat ablation (RR 1.19; 95% CI 0.74-1.93), all-cause mortality (RR 0.87; 95% CI 0.67-1.13), all-cause hospitalizations (RR 1.10; 95% CI 0.94-1.30), cardiovascular hospitalizations (RR 0.83; 95% CI 0.69-1.01), stroke or TIA (RR 0.81; 95% CI 0.29-2.25), or cardiac tamponade (RR 0.98; 95% CI 0.19-5.16). Non-randomized studies suggest that catheter ablation for AF in patients with HFpEF is associated with similar arrythmia-free survival and safety profile when compared to patients with HFrEF or without heart failure.

Role of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in cryoballoon ablation outcomes for paroxysmal atrial fibrillation.

Cryoballoon ablation (CBA) is recommended for patients with paroxysmal atrial fibrillation (AF) refractory to antiarrhythmic drugs. However, only 80% of patients benefit from initial CBA. There is growing evidence that pretreatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) decreases the recurrence of AF postablation, particularly in nonparoxysmal AF undergoing radiofrequency ablation. The role of ACEIs and ARBs in patients with paroxysmal AF in CBA remains unknown. We decided to investigate the role of ACEIs and ARBs in preventing the recurrence of atrial arrhythmia (AA) following CBA for paroxysmal AF. To investigate the role of ACEIs and ARBs in preventing recurrence of AA following CBA for paroxysmal AF. We followed 103 patients (age 60.6 ± 9.1 years, 29% women) with paroxysmal AF undergoing CBA 1-year post procedure. Recurrence was assessed by documented AA on electrocardiogram or any form of long-term cardiac rhythm monitoring. A multivariable Cox proportional hazard model was used to assess if ACEI or ARB treatment predicted the risk of AA recurrence. After a 1-year follow-up, 19 (18.4%) participants developed recurrence of AA. Use of ACEI or ARB therapy was noted in the study population. Patients on ACEI/ARB had a greater prevalence of hypertension and coronary artery disease. On a multivariate model adjusted for baseline demographics and risk factors for AF, ACEI or ARB therapy did not prevent recurrence of AA following CBA (P = 0.72). Similarly, on Kaplan-Meier analysis pretreatment with ACEI/ARB did not predict the time to first recurrence of AA (P = 0.2173). In our study population, preablation treatment with an ACEI or ARB had no influence on the recurrence of AA following CBA for paroxysmal AF.

Catheter ablation for atrial fibrillation in patients with persistent left superior vena cava: Case series and systematic review.

Persistent left superior vena cava (PLSVC) is the most common form of thoracic venous abnormality. Catheter ablation (CA) for atrial fibrillation (AF) can be complicated by the existence of PLSVC, which could act as an important arrhythmogenic mechanism in AF. We reported a case series of patients with PLSVC who underwent CA for AF at our center between 2018 and 2021. A systematic search was also performed on PubMed, EMBASE, and Web of Science for research reporting CA for AF in patients with PLSVC. Sixteen patients with PLSVC were identified at our center. Ablation targeting PLSVC was performed in 5 patients in the index procedures and in four patients receiving redo procedures. One patient experienced acute procedure failure. After a median follow-up period of 15 months, only 6 (37.5%) patients remained free from AF/atrial tachycardia (AT) after a single procedure. In the systematic review, 11 studies with 167 patients were identified. Based on the included studies, the estimated prevalence of PLSVC in patients undergoing CA for AF was 0.7%. Ablation targeting PLSVC was performed in 121 (74.7%) patients. Major complications in patients with PLSVC receiving AF ablation procedure included four cases of cardiac tamponades (2%), three cases of cardiac effusion (1.5%), one case of ischemic stroke, and three cases of phrenic nerve injury (1.5%) (one left phrenic nerve and two right phrenic nerve). Pooled analysis revealed that after a median follow-up period of 15.6 months (IQR 12.0-74.0 months), the long-term AF/AT-free rate was 70.6% (95% CI 62.8-78.4%, I 2 = 0.0%) (Central illustration). Different ablation strategies for PLSVC were summarized and discussed in the systematic review. In patients with PLSVC, recurrence of atrial arrhythmia after CA for AF is relatively common. Ablation aiming for PLSVC isolation is necessitated in most patients. The overall risk of procedural complications was within an acceptable range.

Assessing the impact of blocking distal coronary sinus-left atrial muscular connection on inducible rate of atrial fibrillation and follow-up recurrence in persistent atrial fibrillation patients with different fibrotic degrees of left atrial: A retrospective study.

BackgroundThe musculature of the coronary sinus (CS), especially its distal connection with the post wall of the left atrial (LA), has been associated with the genesis and maintenance of atrial flutter (AFL) and atrial fibrillation (AF). However, the relative contributions of the distal coronary sinus (CSD)-LA connection to PersAF with various degrees of atrial fibrosis remain unknown.ObjectiveThis study aimed to explore the different roles of blocking the CSD-LA connection in the induction of acute AF and middle-term follow-up of recurrence among PersAF patients with various degrees of LA fibrosis.Methods and resultsA retrospective cohort of 71 patients with drug-refractory and symptomatic PersAF underwent ablation for the first time were studied. The population was divided into two groups according to disconnection of the CSD-LA or not. All patients enrolled accepted the unified ablation procedure (circumferential pulmonary vein isolation, non-pulmonary vein trigger ablation and ablation of the CSD-LA connection). Group A (n = 47) successfully blocked the CSD-LA electrical connection and Group B (n = 24) failed. Twenty-five patients could be induced into sustained AF in the Group A compared to 20 in the Group B (53.2 vs. 83.3%, p = 0.013). After a mean follow-up of 185 ± 8 days, 24 (33.8%) patients experienced atrial arrhythmia recurrences. The Group A had significantly fewer recurrences (25.5%) compared to Group B (50%). Meanwhile, in Group A, the ROC curve analysis suggested that in the case of blocking CSD-LA, low voltage area (LVA) of LA can act as a predictive factor for acute AF induction (AUC = 0.943, Cut-off = 0.190, P < 0.001) with sensitivity and specificity of 92.3 and 90.5%, and middle-term recurrence (AUC = 0.889, Cut-off = 0.196, P < 0.001) with sensitivity and specificity of 100 and 65.7%.ConclusionDisconnection of CSD-LA could reduce the inducible rate of acute AF and the recurrences of atrial arrhythmia during middle-term follow-up. The PersAF patients with CSD-LA muscular connection blocked, experienced a higher acute AF inducible rate with larger proportion of LVA of LA (≥19%) and a higher recurrent rate of atrial arrhythmias with a larger proportion of LA fibrosis (≥19.6%).

Prevalence of modifiable risk factors and related poor cardiovascular outcomes following atrial fibrillation ablation

Abstract Background Atrial fibrillation (AF) has become a global epidemic. Early catheter ablation and therapies modifying risk factors (RF) have been shown to improve outcomes of AF ablation. However, the time invested in pursuing risk factor modification may delay ablation, which could negate the procedural benefit. Purpose This study sought to investigate the prevalence and impact of potentially modifiable RF among AF patients undergoing catheter ablation in clinical practice. Methods This retrospective study included 724 consecutive patients undergoing AF ablation at a tertiary care center from 2012–2019. Pre-specified modifiable risks were examined, including the time from AF diagnosis to ablation, fluctuation/increase in BMI &amp;gt;5% prior to ablation, mean systolic/diastolic blood pressure &amp;gt;125/80 mmHg, obstructive sleep apnea with CPAP noncompliance, hyperlipidemia without statin therapy, tobacco use, excessive alcohol use, and diabetes mellitus with hemoglobin A1c (HbA1c) &amp;gt;6.5%. The primary outcome was a composite of recurrent atrial arrhythmias, cardiovascular (CV) hospitalizations and mortality following AF ablation. A multivariate analysis was performed. Results The mean age was 61±10 years old, 32.5% were female and 72.2% had persistent AF. Many study patients had modifiable RF, ranging from 4.7% with excessive alcohol use to 64.0% experiencing delayed AF ablation. The mean time from AF diagnosis to ablation was 4.7 years. During a mean follow-up of 1.6 years after ablation, 467 (64.5%) patients met the primary outcome. Independent RF for the primary outcome were an increase/fluctuation in BMI &amp;gt;5% (adjusted hazard ratio [AHR] 1.31, 95% confidence interval [CI] 1.07–1.60; P=0.008), diabetes with HbA1c &amp;gt;6.5% (AHR 1.50, 95% CI 1.09–2.03; P=0.014) and hyperlipidemia without statin therapy (AHR 1.30, 95% CI 1.08–1.57; P=0.005). Delayed AF ablation over 1.5 years did not alter the outcome, Figure 1. Conclusion Substantial portions of patients undergoing AF ablation have potentially modifiable RF. Increased or fluctuating BMI, diabetes with HbA1c &amp;gt;6.5%, and hyperlipidemia not treated with statin therapy portend an increased risk of recurrent atrial arrhythmia, CV hospitalizations and mortality. These findings underscore an importance pursuing RF management in patients with AF to reduce adverse outcomes after ablation. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The Jensen Family Research Sponsorship at the University of Nebraska Medical Center

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Marrouche et al (JAMA 2022;327:2296, PMID 35727277) investigated targeting atrial fibrosis detected on magnetic resonance imaging (MRI) in reducing atrial arrhythmia recurrence in persistent AF. A total of 843 patients with persistent AF were randomized to pulmonary vein isolation (PVI) plus MRI-guided atrial fibrosis ablation (421 patients) or PVI alone (422 patients). The primary end point was time to first atrial arrhythmia recurrence after a 90-day blanking period postablation. There was no significant difference in atrial arrhythmia recurrence between groups (fibrosis-guided ablation plus PVI patients, 175 [43.0%] vs PVI-only patients 188 [46.1%]; hazard ratio [HR] 0.95; P = .63).

Clinical outcomes of cryoballoon ablation for pulmonary vein isolation: Impact of intraprocedural heart rhythm.

BackgroundThe current study sought to assess the impact of the intraprocedural heart rhythm (sinus rhythm [SR] vs. atrial fibrillation [AF]) on acute procedural characteristics, durability of pulmonary vein isolation (PVI) and long-term clinical outcomes of cryoballoon (CB) ablation.MethodsA total of 195 patients with symptomatic paroxysmal (n = 136) or persistent AF (n = 59) underwent CB-based PVI. Ablation procedures were either performed in SR (SR group; n = 147) or during AF (AF group; n = 48). Persistent AF was more frequent in the AF group than in the SR group (62% vs. 20%). All other patient baseline characteristics did not differ between the two groups.ResultsThe nadir temperature during the CB applications was significantly lower in the AF group than in patients in the SR group (−49 [interquartile range, −44; −54]°C vs. −47 [−42; −52]°C, p = 0.002). Median procedure and fluoroscopy times as well as the rate of real-time recordings were not different between the two groups. Repeat ablation for the treatment of atrial arrhythmia recurrence was performed in 60 patients (SR: 44 [30%] patients; AF: 16 [33%] patients), with a trend towards a lower rate of pulmonary vein reconnections in the AF group (p = 0.07). There was no difference in 3-year arrhythmia-free survival (p = 0.8).ConclusionsCryoballoon-based PVI during AF results in lower nadir balloon temperatures and a trend towards a higher durability of PVI as compared to procedures performed in SR. The rate of real-time PVI recordings was not affected by the intraprocedural heart rhythm.

Catheter ablation and thoracoscopic ablation in long persistent atrial fibrillation with large left atrium.

BackgroundPulmonary vein antrum isolation (PVAI) is the cornerstone of atrial fibrillation (AF) ablation, but the clinical outcomes of PVAI are unsatisfactory in patients with persistent AF and a large left atrium (LA).ObjectivesWe investigated the clinical outcomes following radiofrequency ablation (RFCA), cryoballoon ablation (CBA), and thoracoscopic maze in patients with persistent AF and a large LA.MethodsWe included patients with consecutive persistent AF who had a large LA (LA diameter >50 mm) and underwent RFCA, CBA, or thoracoscopic maze surgery. In the RFCA group, additional linear ablation was performed at the physician’s discretion. The endpoint was 12 months without recurrence of an atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia, following a 90-day blanking period.ResultsWe recruited 89 persistent AF patients with a large LA who underwent RFCA (n = 32), CBA (n = 38), or the thoracoscopic maze procedure (n = 19). During the 12-month follow-up, 48 (53.9%) cases of AF recurrence were observed. There was no prognostic difference between groups (50.0% in RFCA vs. 52.6% in CBA vs. 63.2% in thoracoscopic maze, all P > 0.05). Early recurrence during the blanking period was a significant predictor of late recurrence for RFCA and CBA, but not for the thoracoscopic maze.ConclusionIn persistent AF patients with a large LA, we did not find a prognostic difference RFCA, CBA, or a thoracoscopic maze procedure in recurrence of atrial arrhythmia. Early recurrence predicted late recurrence in catheter ablation, but not in thoracoscopic maze.

Clinical impact of posterior wall isolation in catheter ablation for persistent atrial fibrillation: A systematic review and meta-analysis.

The clinical outcomes of pulmonary venous isolation alone for persistent atrial fibrillation (PerAF) remain unclear. Adjuvant posterior wall isolation (PWI) has become a potential supplementary strategy for improving the outcome of PerAF ablation. This meta-analysis aimed to evaluate the effect of PWI added to catheter ablation for PerAF. PubMed, EMBASE, and Cochrane Library databases were searched for studies comparing the outcomes of PerAF ablation with and without PWI. The efficacy outcomes were recurrence of atrial arrhythmia (AA), atrial fibrillation (AF), and atrial tachycardia (AT), and the safety outcome was adverse events. In total, eight studies with 1428 patients were included in the pooled analyses. The results showed that PWI significantly reduced the recurrence of AA (RR=0.69, 95% CI=0.55-0.87, p=.002, I2 =63%) and AF (RR=0.57, 95% CI=0.40-0.80, p =.001, I2 =70%). AT recurrence (RR=0.92, 95% CI=0.67-1.27, p =.63, I2 =42%) and adverse events (RR=1.11, 95% CI=0.67-1.84, p=.70, I2 =0%) were comparable between the two groups. In the sub-analyses, the efficacy of PWI in reducing AA recurrence was consistent in patients who underwent cryoablation or debulking ablation. PWI effectively decreased AA recurrence after PerAF ablation without increasing the risk of AT or procedure-related complications. However, more randomized studies are needed to confirm these results.

Thoracoscopic epicardial ablation of atrial fibrillation: Safety, efficacy, single center experience.

Atrial fibrillation (AF) is associated with reduced quality of life and increased risk of ischaemic cerebrovascular events. The left atrial epicardial ablation procedures have evolved towards a successful and safe rhythm control strategy for patients with symptomatic drug-refractory paroxysmal, persistent or post-ablation AF or with a high risk of catheter ablation failure. The aim was to evaluate the efficacy and safety of thoracoscopic ablation at our instituiton. We observed 81 patients undergoing thoracoscopic ablation from January 2015 to December 2019. The mean age was 61.3±8.5 years and the average duration of AF was 3.1±2.6 years. The cohort consisted of 16.5% of paroxysmal AF, 36.7% persistent, and 46.8% of long-standing AF. The procedure was completed in 79 patients; during follow-up, 15 patients (19%) received radiofrequency ablation. Freedom from atrial arrhythmia recurrence was 55.7% after a follow-up (FUP) period of 3.1 ± 1.4 years. At the follow-up visit, sinus rhythm was present in 81% of patients. No relationships between arrhythmia recurrence and BMI, LVEF, left atrial dimension, gender, and AF duration were found. Major complications were noticed in 4 patients (5.0%); 2 had peripheral embolisation, 2 patients were converted to a sternotomy. At the time of the FUP visit, 25.3% of patients were using antiarrhythmic and 74.7% were still using anticoagulants. In the majority of patients, sinus rhythm remained despite a considerable atrial tachycardia recurrence rate, with a relatively low percentage of patients on antiarrythmic drugs.

Imbalance of Pro- and Anti-inflammatory Cytokines Induced Different Types of Recurrent Atrial Arrhythmias after Drug Eluting Coronary Stent Implantation.

Atrial arrhythmias are associated with an increased risk of stroke and death in the elderly. The risk and predictive factors of recurrent atrial arrhythmias in elderly patients after coronary stenting are not well known. This research sought to investigate the roles of pro- and anti-inflammatory cytokine imbalances in different types of recurrent atrial arrhythmias in elderly patients defined as individuals aged 65 years or older after sirolimus eluting stent (Cordis, Warren, New Jersey) implantation. We measured interleukin-1β (IL-1β), interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10), interleukin-17 (IL-17), interleukin-13 (IL-13) and interleukin- 37 (IL-37) in elderly patients with recurrent atrial arrhythmias and assessed the impact of pro- and antiinflammatory cytokine imbalances on recurrent atrial arrhythmias in elderly patients after coronary stenting. Levels of IL-1 β, IL-6, IL-8, and TNF-α were remarkably increased (p<0.001), and IL-10, IL- 17, IL-13, and IL-37 were remarkably lowered (p<0.001) in elderly patients with recurrent atrial arrhythmias after coronary stent implantation. Imbalance of pro- and anti-inflammatory cytokines induced recurrent atrial arrhythmias after coronary stenting. Pro- and anti-inflammatory cytokine imbalances may be used to identify elderly patients who have an increased risk of developing recurrent atrial arrhythmias after coronary stenting. The imbalance of pro- and anti-inflammatory cytokines was associated with recurrent atrial arrhythmias in elderly patients after coronary stenting. Pro- and anti-inflammatory cytokines may be clinically useful biomarkers for predicting recurrent atrial arrhythmias in elderly patients after coronary stent implantation.

AFA-Recur: an ESC EORP AFA-LT registry machine-learning web calculator predicting atrial fibrillation recurrence after ablation.

Atrial fibrillation (AF) recurrence during the first year after catheter ablation remains common. Patient-specific prediction of arrhythmic recurrence would improve patient selection, and, potentially, avoid futile interventions. Available prediction algorithms, however, achieve unsatisfactory performance. Aim of the present study was to derive from ESC-EHRA Atrial Fibrillation Ablation Long-Term Registry (AFA-LT) a machine-learning scoring system based on pre-procedural, easily accessible clinical variables to predict the probability of 1-year arrhythmic recurrence after catheter ablation. Patients were randomly split into a training (80%) and a testing cohort (20%). Four different supervised machine-learning models (decision tree, random forest, AdaBoost, and k-nearest neighbour) were developed on the training cohort and hyperparameters were tuned using 10-fold cross validation. The model with the best discriminative performance on the testing cohort (area under the curve-AUC) was selected and underwent further optimization, including re-calibration. A total of 3128 patients were included. The random forest model showed the best performance on the testing cohort; a 19-variable version achieved good discriminative performance [AUC 0.721, 95% confidence interval (CI) 0.680-0.764], outperforming existing scores (e.g. APPLE score: AUC 0.557, 95% CI 0.506-0.607). Platt scaling was used to calibrate the model. The final calibrated model was implemented in a web calculator, freely available at http://afarec.hpc4ai.unito.it/. AFA-Recur, a machine-learning-based probability score predicting 1-year risk of recurrent atrial arrhythmia after AF ablation, achieved good predictive performance, significantly better than currently available tools. The calculator, freely available online, allows patient-specific predictions, favouring tailored therapeutic approaches for the individual patient.

Effect of Dapagliflozin on the Outcome of Radiofrequency Catheter Ablation in Patients with Type 2 Diabetes Mellitus and Atrial Fibrillation.

Dapagliflozin, one of the sodium-glucose cotransporter-2 inhibitors, has been widely used for the treatment of type 2 diabetes mellitus (T2DM) and heart failure. In this study, we sought to determine the impact of dapagliflozin on the outcome of radiofrequency catheter ablation (RFCA) for patients with T2DM and atrial fibrillation (AF). This retrospective study included patients who underwent AF ablation between January 2019 to February 2021 at the First Affiliated Hospital of Zhengzhou University. All patients had a history of T2DM and were divided into the dapagliflozin group (n = 79) and the control group (n = 247) according to whether the patients were treated with dapagliflozin after ablation. The definition of AF recurrence was documented atrial arrhythmias over 30 s after a 1-month blanking period. Cox regression models were used to analyze the risk of AF recurrence. Overall, 326 patients were analyzed (mean age, 63.7±10.0 years old; male, 58.9%; paroxysmal AF, 52.8%; recurrence rate, 40.8%). We found that hemoglobin A1c before ablation was higher in the dapagliflozin group than in the control group (7.7±1.4 vs. 7.3±1.2, P = 0.007). After a mean follow-up of 15.5±8.9 months, the dapagliflozin group had a lower recurrence rate than the control group (27.8% vs. 44.9%, P = 0.007). Treatment with dapagliflozin (HR 0.614, ±95%CI 0.387-0.974, P = 0.038) was associated with a lower risk of recurrence of atrial arrhythmias (ATa) after ablation in multivariable Cox regression models that adjusted for duration of AF, BMI, AF type, left atrial diameter (LAD), and eGFR. The Cox regression model that incorporated hemoglobin A1c and other antidiabetic agents also demonstrated a similar reduction in the risk of recurrent atrial arrhythmias with dapagliflozin treatment (HR 0.611, ±95% CI 0.379-0.985, P = 0.043). In patients with T2DM, treatment with dapagliflozin appears to be independently associated with a significant reduction in the risk of recurrent atrial arrhythmias after RFCA.

Steerable sheath visualizable under 3D electroanatomical mapping facilitates paroxysmal atrial fibrillation ablation with minimal fluoroscopy

BackgroundAdvances in technology and workflows have facilitated substantial reductions in fluoroscopy utilization and procedure times for atrial fibrillation (AF) ablations. A recently available steerable sheath, visualizable on a 3D electroanatomical map (EAM), may further simplify low/zero fluoroscopy ablation workflows by facilitating understanding of the relative positions of the catheter and sheath. The objective of this study was to demonstrate feasibility, safety, procedural efficiency, and clinical effectiveness of incorporating the new visualizable sheath into a low-fluoroscopy workflow.MethodsConsecutive de novo paroxysmal AF procedures were performed with a porous tip contact force catheter at a high-volume site between January 2018 and May 2019. Procedures performed with and without the VIZIGO™ EAM-visualizable sheath (Vizigo) were compared. All ablations employed the same standardized low-fluoroscopy workflow. Statistical analyses employed stabilized inverse probability of treatment weights (IPTW) to balance cohorts by operator and key patient characteristics.ResultsCohorts of 142 Vizigo and 173 non-Vizigo patients were similar at baseline. Use of the Vizigo sheath was associated with approximately 10% improvement in catheter stability (p = 0.0005), 16% reduction in radiofrequency time (p < 0.0001), and 7% fewer ablations that used fluoroscopy (p = 0.0030). There was one cardiac tamponade in each cohort and no deaths, atrioesophageal fistulas, or strokes. Single-procedure freedom from atrial arrhythmia recurrence through 12 months was similar between cohorts (p = 0.9556).ConclusionsUse of a 3D EAM-visualizable sheath resulted in improved catheter stability, reduced radiofrequency time, and more procedures performed without fluoroscopy, without compromise to safety or effectiveness.

Improved survival in patients with atrial fibrillation and heart failure undergoing catheter ablation compared to medical treatment: A systematic review and meta-analysis of randomized controlled trials.

Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all-cause mortality. Secondary endpoints included atrial-arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow-up duration was 32.9 ± 14.5 months. All-cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95%confidence interval [CI] 0.51-0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all-cause mortality was observed with CA. Rates of all-atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40-0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6-8.8, p < .00001). CA for AF in patients with HF decreases all-cause mortality, improves all-atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated.

Surface ECG-based complexity parameters for predicting outcomes of catheter ablation for nonparoxysmal atrial fibrillation: efficacy of fibrillatory wave amplitude.

Catheter ablation (CA) is a well-established therapy for rhythm control in atrial fibrillation (AF). However, CA outcomes for persistent AF remain unsatisfactory because of the high recurrence rate despite time-consuming efforts and the latest ablation technology. Therefore, the selection of good responders to CA is necessary. Surface electrocardiography (sECG)-based complexity parameters were tested for the predictive ability of procedural termination failure during CA and late recurrence of atrial arrhythmias (AA) after CA. A total of 130 patients with nonparoxysmal AF who underwent CA for the first time were investigated. A 10-second sECG of 4 leads (leads I, II, V1, and V6) was analyzed to compute the fibrillatory wave amplitude (FWA), dominant frequency (DF), spectral entropy (SE), organization index (OI), and sample entropy (SampEn). The study endpoints were procedural termination failure during CA and late (≥1 year) AA recurrence after CA. In the multivariate analysis, FWA in lead V1 and DF in lead I were independent predictors of successful AF termination during CA (P <.05). The optimal cut-off values for FWA in lead V1 and DF in lead I were 60.38 μV (area under the curve [AUC], 0.672; P = .001) and 5.7 Hz (AUC, 0.630; P = .016), respectively. The combination of FWA of lead V1 and DF of lead I had a more powerful odds ratio for predicting procedural termination failure (OR, 8.542; 95% CI, 2.938–28.834; P < .001). FWA in lead V1 was the only independent predictor of late recurrence after CA. The cut-off value is 65.73 μV which was 0.634 of the AUC (P = .009).These sECG parameters, FWA in lead V1 and DF in lead I, predicted AF termination by CA in patients with nonparoxysmal AF. In particular, FWA in lead V1 was an independent predictor of late recurrence of AA after CA.