Reduction In Atrial Fibrillation Recurrence Research Articles

Four-year follow-up of outcomes of the hybrid epicardial-endocardial ablation: A single-center experience

BackgroundThe CONVERGE trial demonstrated that hybrid epicardial and endocardial ablation was more effective than catheter ablation for the treatment of persistent atrial fibrillation (AF) at 1 year. Long-term real-world outcome data are scarce. ObjectiveWe described a single-center experience by evaluating the long-term effectiveness and safety of hybrid epicardial-endocardial ablation. MethodsThis is a retrospective single-center study. Patients were followed up to 4 years. The primary end point was the rate of AF recurrence up to 4 years postablation. Secondary end points included reduction in antiarrhythmic therapy use, the effect of the ligament of Marshall removal, epicardial posterior wall, 3-dimensional mapping during epicardial ablation, and left atrial appendage exclusion as adjunct intraoperative interventions for AF recurrence. ResultsOf the 170 patients, 86.5% had persistent AF and 13.5% had long-standing persistent AF. AF-free survival was 87.6% at 1 year, 76.9% at 2 years, 70.4% at 3 years, and 59.3% at 4 years. Antiarrhythmic drug use was 87.6% at baseline and reduced to 21%, 20.6%, 18%, and 14.1% at year 1, 2, 3, and 4, respectively (P < .01 for all). Three-dimensional epicardial mapping showed a significant reduction in combined recurrence from 42% to 25% over 4 years of follow-up (P = .023). Ligament of Marshall and left atrial appendage exclusion showed numerical reduction in AF recurrence from 35% to 26% (P = .49) and from 44% to 30% (P = .07). ConclusionThe hybrid convergent procedure reduces AF recurrence and the need for antiarrhythmic drugs and, while maintaining a good safety profile, for the treatment of persistent and long-standing persistent AF.

Impact of atrial fibrillation type on outcomes following aerobic exercise training: analysis from the ACTIVE-AF Trial

Abstract Background The ACTIVE-AF study demonstrated that aerobic exercise prescription promotes the maintenance of sinus rhythm in patients with atrial fibrillation (AF). However, it is unclear whether these benefits are observed in patients with both paroxysmal and persistent AF. Purpose Compare efficacy of exercise intervention on arrhythmia recurrence between paroxysmal (ParAF) and persistent (PerAF) patients. Methods This study was a prospective, randomized, controlled trial of patients with symptomatic paroxysmal or persistent AF, referred for consideration of AF ablation. Randomization was 1:1 to either aerobic exercise intervention or usual medical care for a period of 6 months with a further 6 months follow-up. The exercise intervention was delivered in a hybrid format of weekly supervised exercise sessions coupled with prescribed home exercise, up to a total of 210 minutes per week. The intervention was led by a clinical exercise physiologist. Management of arrhythmia was at the discretion of a cardiologist blinded to patient randomisation. The primary endpoint reported here is recurrent AF without rhythm control strategies. Results Of the 120 patients enrolled in the study, 74 (62%) had a history of ParAF. Patients with PerAF typically had higher body mass index (32.0±6.6 versus 29.5±5.2 Kg/m2, p=0.02) and left atrial volume (38.0±9.4 versus 28.1±6.5 mL/m2, p&amp;lt;0.001) but similar prevalence of hypertension, diabetes mellitus, coronary artery disease and obstructive sleep apnea. Baseline peak oxygen consumption (VO2peak) was similar between ParAF and PerAF groups (20.0±6.0 versus 19.6±5.4mL/kg/min). Over the 12-month follow-up, AF recurrence in the ParAF patients was lower in the exercise group compared to control group (Hazard Ratio 0.42, 95% CI: 0.23-0.77, p=0.005). However, we did not find evidence of any between-group difference amongst patients with PerAF (HR 0.65, 95% CI: 0.34-1.23). Conclusions In this post-hoc analysis of a randomised controlled trial comparing the efficacy of exercise intervention versus standard medical care amongst patients with symptomatic AF, we observed a reduction in AF recurrence for patients with ParAF, but not amongst those with PerAF. These findings support the need for early lifestyle modification amongst patients with AF, before progression to PerAF occurs. Future studies should explore whether the exercise prescription can be modified to improve outcomes for patients with more advanced AF.

Abstract 13366: Effectiveness and Safety of Short-Term Outpatient Amiodarone Followed by Catheter Ablation in Management of Atrial Fibrillation

Introduction: Atrial fibrillation (AF) is the most common arrythmia with significant health system burden and emergency room/hospital admissions. We conducted this study to understand the efficacy of managing AF with first line short term outpatient amiodarone followed by catheter ablation (pulmonary vein isolation). Amiodarone was continued for 6 months post catheter ablation (CA). We looked at a primary end point of recurrence of AF and the drug side effects during the year post CA. Hypothesis: If this strategy of short-term amiodarone with early ablation of AF is effective, then we could incorporate this in an AF management care plan. Methods: In this retrospective cohort study, we used TriNetX database to collect data on patients with amiodarone initiation with CA and those who were given Dofetilide or Sotalol, followed by CA. We collected data between March 1, 2020, and June 1, 2021. We created a propensity score matching of a 1:1 to match on the covariates: Age, Male, Female, CAD, Heart Failure, Diabetes, COPD, BMI. The endpoint is occurrence of AF within 365 days of medication initiation. Results: A total of 40,640 patients were included in the analysis. Of those patients, Cohort 1 comprised amiodarone initiation with catheter ablation (n=176) compared to Dofetilide or Sotalol which had (n=40,474). After the propensity match, we included 176 individual patients in each cohort. The amiodarone group had more men (79.5% vs 58.8, P&lt;0.001) and were with higher comorbidities of CAD, Heart Failure, Diabetes, COPD. At 365 days Amiodarone group had a reduction of 12.6%, P&lt;0.001 of AF compared to Dofetilide or Sotalol patients. There has been no reported side effects requiring discontinuation of Amiodarone. Conclusions: We are excited to report a statistically significant 12.6% reduction in AF recurrence in Cohort 1 with short term outpatient Amiodarone initiation with CA compared to inpatient Dofetilide or Sotalol initiation with CA. There have been no safety issues with Amiodarone use for 6-12 months post PVI. This strategy avoids occupying beds for initiation of class III antiarrhythmic (Dofetilide or Sotalol), thus significantly reducing the burden on the health system.

Standard vs Augmented Ablation of Paroxysmal Atrial Fibrillation for Reduction of Atrial Fibrillation Recurrence

Recurrent atrial fibrillation (AF) commonly occurs after catheter ablation and is associated with patient morbidity and health care costs. To evaluate the superiority of an augmented double wide-area circumferential ablation (WACA) compared with a standard single WACA in preventing recurrent atrial arrhythmias (AA) (atrial tachycardia, atrial flutter, or atrial fibrillation [AF]) in patients with paroxysmal AF. This was a pragmatic, multicenter, prospective, randomized, open, blinded end point superiority clinical trial conducted at 10 university-affiliated centers in Canada. The trial enrolled patients 18 years and older with symptomatic paroxysmal AF from March 2015 to May 2017. Analysis took place between January and April 2022. Analyses were intention to treat. Patients were randomized (1:1) to receive radiofrequency catheter ablation for pulmonary vein isolation with either a standard single WACA or an augmented double WACA. The primary outcome was AA recurrence between 91 and 365 days postablation. Patients underwent 42 days of ambulatory electrocardiography monitoring after ablation. Secondary outcomes included need for repeated catheter ablation and procedural and safety variables. Of 398 patients, 195 were randomized to the single WACA (control) arm (mean [SD] age, 60.6 [9.3] years; 65 [33.3%] female) and 203 to the double WACA (experimental) arm (mean [SD] age, 61.5 [9.3] years; 66 [32.5%] female). Overall, 52 patients (26.7%) in the single WACA arm and 50 patients (24.6%) in the double WACA arm had recurrent AA at 1 year (relative risk, 0.92; 95% CI, 0.66-1.29; P = .64). Twenty patients (10.3%) in the single WACA arm and 15 patients (7.4%) in the double WACA arm underwent repeated catheter ablation (relative risk, 0.72; 95% CI, 0.38-1.36). Adjudicated serious adverse events occurred in 13 patients (6.7%) in the single WACA arm and 14 patients (6.9%) in the double WACA arm. In this randomized clinical trial of patients with paroxysmal AF, additional ablation by performing a double ablation lesion set did not result in improved freedom from recurrent AA compared with a standard single ablation set. ClinicalTrials.gov Identifier: NCT02150902.

Low voltage area guided substrate modification in nonparoxysmal atrial fibrillation: A systematic review and meta-analysis.

Low voltage areas (LVAs) on left atrial (LA) bipolar voltage mapping correlate with areas of fibrosis. LVAs guided substrate modification was hypothesized to improve the success rate of atrial fibrillation (AF) ablation particularly in nonparoxysmal AF population. However, randomized controlled trials (RCTs) and observational studies yielded mixed results. The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to August 2022. Relevant studies comparing LVA guided substrate modification (LVA ablation) versus conventional AF ablation (nonLVA ablation) in patients with nonparoxysmal AF were identified and a meta-analysis was performed (Graphical Abstract image). The efficacy endpoints of interest were recurrence of AF and the need for repeat ablation at 1-year. The safety endpoint of interest was adverse events for both groups. Procedure related endpoints included total procedure time and fluoroscopy time. A total of 11 studies with 1597 patients were included. A significant reduction in AF recurrence at 1-year was observed in LVA ablation versus nonLVA ablation group (risk ratio[RR] 0.63 (27% vs. 36%),95% confidence interval [CI] 0.48-0.62, p < .001]. Also, redo ablation was significantly lower in LVA ablation group (RR 0.52[18% vs. 26.7%], 95% CI 0.38-0.69, p < .00133). No difference was found in the overall adverse event (RR 0.7 [4.3% vs. 5.4%], 95% CI 0.36-1.35, p = .29). LVA guided substrate modification provides significant reduction in recurrence of all atrial arrhythmias at 1-year compared with non LVA approaches in persistent and longstanding persistent AF population without increase in adverse events.

Mechanisms and Therapeutic Opportunities in Atrial Fibrillation in Relationship to Alcohol Use and Abuse.

Excessive drinking has detrimental effects on the cardiovascular system. Atrial fibrillation (AF) after alcohol binge drinking, also named "holiday heart syndrome," is well established. However, chronic lower levels of alcohol intake also may increase AF risk. In this review, we aim to provide a comprehensive overview of the epidemiology and pathophysiology by which alcohol may be responsible for AF and discuss whether alcohol abstinence is required for optimal rhythm control as well as to maintain sinus rhythm in patients with AF. The pathophysiologic mechanisms responsible for the relationship between alcohol consumption and AF may include both direct and chronic effects increasing AF burden. Acute effects may include arrhythmogenic changes (such as shortening in atrial refractoriness, slowing in conduction velocity, and increased atrial ectopy) and an autonomic imbalance. Chronic changes contributing to the development of an arrhythmogenic substrate involve atrial structural and functional remodelling processes due to atrial dilation, elevated pressures, and fibrosis formation. In addition, alcohol consumption contributes to developing concomitant AF risk factors such as obesity, sleep-disordered breathing, and hypertension. Alcohol abstinence is associated with a reduction in AF recurrence and overall burden and moreover improves AF risk factor development such as obesity, hypertension, sleep apnea, and AF-related consequences such as stroke. In conclusion, alcohol consumption is associated with atrial arrhythmia and a wide range of cardiovascular comorbidities. Although further evidence is needed, current knowledge indicates that there might not be a safe level of alcohol consumption that does not increase AF risk.

Augmented wide area circumferential catheter ablation for reduction of atrial fibrillation recurrence (AWARE) trial: Design and rationale

Recurrence of atrial fibrillation (AF) after a pulmonary vein isolation procedure is often due to electrical reconnection of the pulmonary veins. Repeat ablation procedures may improve freedom from AF but are associated with increased risks and health care costs. A novel ablation strategy in which patients receive "augmented" ablation lesions has the potential to reduce the risk of AF recurrence. The Augmented Wide Area Circumferential Catheter Ablation for Reduction of Atrial Fibrillation Recurrence (AWARE) Trial was designed to evaluate whether an augmented wide-area circumferential antral (WACA) ablation strategy will result in fewer atrial arrhythmia recurrences in patients with symptomatic paroxysmal AF, compared with a conventional WACA strategy. The AWARE trial was a multicenter, prospective, randomized, open, blinded endpoint trial that has completed recruitment (ClinicalTrials.gov NCT02150902). Patients were randomly assigned (1:1) to either the control arm (single WACAlesion set) or the interventional arm (augmented- double WACA lesion set performed after the initial WACA). The primary outcome was atrial tachyarrhythmia (AA; atrial tachycardia [AT], atrial flutter [AFl] or AF) recurrence between days 91 and 365 post catheter ablation. Patient follow-up included 14-day continuous ambulatory ECG monitoring at 3, 6, and 12 months after catheter ablation. Three questionnaires were administered during the trial- the EuroQuol-5D (EQ-5D) quality of life scale, the Canadian Cardiovascular Society Severity of Atrial Fibrillation scale, and a patient satisfaction scale. The AWARE trial was designed to evaluate whether a novel approach to catheter ablation reduced the risk of AA recurrence in patients with symptomatic paroxysmal AF.

EFFECTS OF CHRONIC STATIN THERAPY ON LEFT ATRIAL STRUCTURE AND FUNCTION AND RECURRENCE OF ATRIAL FIBRILLATION AFTER CATHETER ABLATION

TOPIC: Cardiovascular Disease TYPE: Original Investigations PURPOSE: Acute post atrial fibrillation (AF) ablation treatment with HMG-COA reductase inhibitors (statins) has been shown to improve left atrial (LA) function and decrease recurrence of AF. Effects of chronic, pre-ablation statin therapy on LA function and AF recurrence post- ablation have not been well investigated METHODS: The study cohort included 111 consecutive pts who underwent initial radiofrequency PVI with successful restoration of normal sinus rhythm. End-systole, P-wave onset, and end-diastole 3D LA volumes were assessed with transthoracic echocardiogram <48 hours after the procedure; reservoir, conduit, and booster function were calculated. AF recurrence was documented by 12-lead ECG or an event recorder RESULTS: The study included 33% females, 63+/-10 years old, with HTN in 69%, CHF in 14%, treated diabetes in 15%, CAD in 13%, and chronic lung disease in 6%. Most of statin treated patients had CAD (93 vs. 7% in non-statin group, p<0.001) and a significant proportion had CHF (22 vs. 7%, p=0.028). There were no significant differences in LA reservoir (maximal volume) and LA conduit (passive emptying) function according to the statin therapy status. However, post-ablation LA booster function was significantly lower in statin patients (16+/-12.5 vs. 23.5+/-0.2%, p=0.009).AF recurred in 37% during 26+/-13 months post ablation. Despite increased co-morbidities and decreased post-ablation LA booster function in statin treated patients, rates of AF recurrence were similar in statin and non-statin groups (38 vs. 36%, respectively, p=ns). In logistic regression analysis, CAD, CHF, statin therapy, and indexed by BSA LA volumes were not predictive of AF recurrence. However, increased LA booster function (>30%) was associated with significant reduction in AF recurrence (HR 0.094. 95%CI 0.021-0.411, p<0.002) CONCLUSIONS: Patients of chronic statin therapy referred for AF ablation have significantly increased rates of CAD and CHF, and significantly lower LA booster function immediately post ablation. Despite of that, patients on chronic statin therapy derive similar benefit from AF ablation and experience long-term AF recurrence rates similar to non-statin treated patients CLINICAL IMPLICATIONS: Statin therapy is still vital regardless of its effects on AF and LA booster, and definitely should be continued for all the benefits supported by the fact that it does not affect the AF recurrence rates. DISCLOSURES: No relevant relationships by Majd Al-Ahmad, source=Web Response No relevant relationships by Mikhail Torosoff, source=Web Response

Atrial Fibrillation (Part 1): Pathophysiology, Risk Factors, and Therapeutic Basis.

ResumoA fibrilação atrial é a arritmia sustentada mais comum na prática clínica com predileção pelas faixas etárias mais avançadas. Com o envelhecimento populacional, as projeções para as próximas décadas são alarmantes. Além de sua importância epidemiológica, a fibrilação atrial é destacada por suas repercussões clínicas, incluindo fenômenos tromboembólicos, hospitalizações e maior taxa de mortalidade. Seu mecanismo fisiopatológico é complexo, envolvendo uma associação de fatores hemodinâmicos, estruturais, eletrofisiológicos e autonômicos. Desde os anos 1990, o estudo Framingham em análises multivariadas já demonstrou que, além da idade, a presença de hipertensão, diabetes, insuficiência cardíaca e doença valvar é preditor independente dessa normalidade do ritmo. Entretanto, recentemente, vários outros fatores de risco estão sendo implicados no aumento do número de casos de fibrilação atrial, tais como sedentarismo, obesidade, anormalidades do sono, tabagismo e uso excessivo de álcool. Além disso, as mudanças na qualidade de vida apontam para uma redução na recorrência de fibrilação atrial, tornando-se uma nova estratégia para o tratamento de excelência dessa arritmia cardíaca. A abordagem terapêutica envolve um amplo conhecimento do estado de saúde e hábitos do paciente, e compreende quatro pilares principais: mudança de hábitos de vida e tratamento rigoroso de fatores de risco; prevenção de eventos tromboembólicos; controle da frequência; e controle do ritmo. Pela dimensão de fatores envolvidos no cuidado ao paciente portador de fibrilação atrial, ações integradas com equipes multiprofissionais estão associadas aos melhores resultados clínicos.

Concomitant Pulmonary Vein and Posterior Wall Isolation Using Cryoballoon With Adjunct Radiofrequency in Persistent Atrial Fibrillation.

The aim of this multicenter, randomized, single-blind study was to prospectively evaluate the short-and long-term outcomes of pulmonary vein isolation (PVI) versus PVI with concomitant left atrial posterior wall isolation(PWI) using the cryoballoon in patients with symptomatic persistent/long-standing persistent atrial fibrillation (P/LSP-AF). Some studies have suggested a clinical benefit associated with PVI+PWI in patients with P/LSP-AF. However, there are limited safety and efficacy data on this approach using cryoballoon ablation. The immediate and long-term outcomes in patients with P/LSP-AF randomized to PVI (n=55) versus PVI+PWI (n=55) using the cryoballoon were prospectively examined. Baseline characteristics were similar. PVI was achieved in all patients (21 ± 11min). PWI was attained using 23 ± 8min of cryoablation. Adjunct radiofrequency ablation was required in 4 of 110 patients (7.3%) to complete PVI (3 ± 2min) and in 25 of 55 patients (45.5%) to complete PWI (4 ± 6min). Although left atrial dwell time (113 ± 31min vs. 75 ± 32min; p<0.001) and total procedure time (168 ± 34min vs. 127 ± 40min; p<0.001) were longer with PVI+PWI, this cohort required fewer intraprocedural cardioversions (89.1% vs. 96.4%; p=0.04). Adverse events occurred in 5.5% in each group (p=1.00). However, the incidence of recurrent atrial fibrillation at 12months was significantly lower with PVI+PWI (25.5% vs. 45.5%; p=0.028). Additionally, in a multivariate analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial fibrillation (odds ratio: 3.67; 95% confidence interval: 1.44 to 9.34; p=0.006). In patients with P/LSP-AF, PVI+PWI using the cryoballoon is associated with a significant reduction in atrial fibrillation recurrence, but similar safety, as compared with PVI alone.

Effect of combined renal denervation and pulmonary vein isolation in atrial fibrillation recurrence in hypertensive patients: A meta-analysis.

Atrial Fibrillation (AF) is the most common cardiac arrhythmia and hypertension is the most common risk factor associated with AF. The addition of renal sympathetic nerve denervation (RSDN) to pulmonary vein isolation (PVI) in AF patients with hypertension has been reported to improve clinical outcomes. A systematic search was performed for studies on patients with AF and hypertension that compared RSDN with PVI versus PVI-alone. Risk ratio (RR) for categorical variables and mean difference (MD) for continuous variables with 95% confidence intervals were used. Seven studies with a total of 734 patients were included. A total of 340 patients were in the RSDN+PVI group (46.32%) and 394 (53.67%) in the PVI group. A total of 608 patients had paroxysmal AF (83%) while 126 patients had persistent AF (17%). At 12 months follow-up, RSDN+PVI decreased the overall risk of AF recurrence in hypertensive patients with RR 0.60 [95% CI 0.50-0.72, P<.00001]. A subgroup analysis performed in patients with drug-resistant hypertension showed a similar reduction in AF recurrence with RR 0.61 [95% CI: 0.47-0.79, P=.0002). Procedure duration MD +28.05 min [95% CI: 18.88-37.23, P<.00001] and fluoroscopy duration MD +5.59 min [95% CI: 3.31-8.19, P<.00001] were significantly longer with the RSDN+PVI group. There was no significant difference in complications between the two groups. The addition of RSDN to PVI in patients with AF and hypertension appears safe and decreases AF recurrence. Similar results were observed in patients with drug-resistant hypertension. Larger trials are needed to confirm these results.

Left atrial appendage isolation in atrial fibrillation catheter ablation: A meta-analysis.

A significant proportion of patients’ experience recurrence of atrial fibrillation (AF) despite pulmonary venous isolation (PVI), especially those with persistent AF. Isolation of the left atrial appendage (LAA) may reduce AF recurrence. The aim of this study was to assess the efficacy of LAA isolation in addition to PVI compared with PVI alone. We conducted a comprehensive search of electronic databases, up to April 21st, 2017, for all studies comparing the effect LAA electrical isolation or ligation in addition to PVI, as opposed to PVI alone, on the recurrence of atrial fibrillation after catheter ablation. We used random‐effects meta‐analysis models to summarize the studies. One RCT and four observational studies enrolling 781 patients were retained. Four studies assessed the added effect of LAA catheter ablation, and one study evaluated the effect of LAA ligation with the aim of LAA electrical isolation. Four studies exclusively enrolled patients with persistent atrial fibrillation and one study predominantly enrolled patients with persistent atrial fibrillation. Follow‐up ranged from 12 to 15 months. The addition of LAA isolation to PVI reduced AF recurrence compared with the latter alone (odds ratio (OR) = 0.19; 95% confidence intervals (CI) = 0.10‐0.37; P < 0.00001). Left atrial appendage isolation was also associated with a reduction in AF recurrence after repeat ablation (OR = 0.40; CI = 0.25‐0.65; P = 0.0003). The addition of LAA isolation to PVI was associated with a decrease in AF recurrence in patients with persistent AF. Further studies are needed to assess the effect on long‐term risk of stroke.

Cost effectiveness of focal impulse and rotor modulation guided ablation added to pulmonary vein isolation for atrial fibrillation.

Although ablation with focal impulse and rotor modulation (FIRM), as an adjunct to pulmonary vein isolation (PVI), has been shown to decrease atrial fibrillation (AF) recurrence, cost-effectiveness has not been assessed. We aimed to evaluate the cost effectiveness of FIRM-guided ablation when added to PVI in a mixed AF population. We used a Markov model to estimate the costs, quality-adjusted survival, and cost effectiveness of adding FIRM ablation to PVI. AF recurrence rates were based on 3-year data from the CONFIRM trial. Model inputs for event probabilities and utilities were obtained from literature review. Costs were based on Medicare reimbursement, wholesale acquisition costs, and literature review. Three-year total costs FIRM+PVI versus PVI alone were $27,686versus $26,924. QALYs were 2.338versus 2.316, respectively, resulting in an incremental cost-effectiveness ratio (ICER) of $34,452 per QALY gained. Most of the cost (65-81%) was related to the index ablation procedure. Lower AF recurrence generated cost offsets of $4,266, primarily due to a reduced need for medications and repeat ablation. Probabilistic sensitivity analysis demonstrated ICER below $100,000/QALY in 74% of simulations. Based on data from the CONFIRM study, the addition of FIRM to PVI does have the potential to be cost-effective due to higher quality-adjusted life years and lower follow-up costs. Value is sensitive to the incremental reduction in AF recurrence, and FIRM may have the greatest economic value in patients with greater AF symptom severity. Results from ongoing randomized trials will provide further clarity.

Adjunctive ablation strategies improve the efficacy of pulmonary vein isolation in non-paroxysmal atrial fibrillation: a systematic review and meta-analysis

ABSTRACTBackground: Pulmonary vein (PV) isolation (PVI) has suboptimal outcomes in patients with non-paroxysmal atrial fibrillation (AF). Adjunctive strategies employed to ablate non-PV triggers have shown favorable outcomes.Aims: To delineate the incremental benefit of adjunctive ablation in patients with non-paroxysmal AF through a meta-analysis.Methods and results: Database searches through August 2016 identified five non-randomized and seven randomized controlled trials (enrolling 1694 patients). The adjunctive strategies employed for non-PV ablation included focal impulse and rotor modulation; empirical linear lines, ablation of complex fractionated atrial electrograms and ganglionated plexi. The risk ratio (RR) for AF recurrence, calculated with random effects meta-analysis showed a 36% reduction of AF recurrence at a median follow up of 12 months (RR: 0.64, 95% Confidence interval: 0.48 to 0.85; p = 0.003). The benefits persisted during longer follow up when assessed in subgroup analysis.Conclusions: Addition of adjunctive ablation to PVI improves outcomes.

Effectiveness of hybrid therapy versus radiofrequency ablation alone in decreasing recurrence after ablation of atrial fibrillation

Introduction Atrial fibrillation (AF) represents an important public health problem. Catheter ablation has emerged as effective therapy. Recurrence after ablation is still around 20–40%. The long-term use of anti-arrhythmic drugs (AAD) after AF ablation has been traditionally reported to reduce late AF recurrences; but has never been supported by randomised trials. Objective To test if routine continuation of the previously unsuccessful AAD beyond blanking period reduces AF recurrence at one year after AF ablation. Patients and method This randomised controlled clinical trial was conducted between January 2013 and January 2015 in Critical Care Medicine Department – Cairo University. Patients with symptomatic, drug refractory AF were enrolled. All patients underwent pulmonary vein isolation ± left atrial ablation according to AF type. The previously unsuccessful AAD was continued for at least 3 months after ablation, after which patients were randomised to either continue or stop that drug. Patients were regularly followed up for at least additional 9 months. The primary endpoint was reduction of AF recurrence. Secondary endpoints included identification of predictors of recurrence and rate of complications. Results Thirty-one patients with paroxysmal (80.6%) and persistent (19.4%) AF were enrolled. Pulmonary vein isolation was achieved in all patients. Seventeen patients were randomized to continue AAD (54.8%) beyond blanking period. After 12 months, there was no statistically significant difference of AF recurrence between the two groups (35.3% vs. 21.4%, P=0.46). The same was observed for paroxysmal AF patients (30.8% vs. 8.3%, P=0.32). Persistent AF and early AF recurrence were associated with late recurrence. Only 2 patients had major complications. Conclusion Routine continuation of previously unsuccessful AAD did not reduce AF recurrence, over a period of 12 months. Persistent AF and recurrence during blanking period were associated with later recurrence.

Benefits of Atrial Substrate Modification Guided by Electrogram Similarity and Phase Mapping Techniques to Eliminate Rotors and Focal Sources Versus Conventional Defragmentation in Persistent Atrial Fibrillation.

This prospective study compared the efficacy of atrial substrate modification guided by a nonlinear phase mapping technique with that of conventional substrate ablation. The optimal ablation strategy for persistent atrial fibrillation (AF) was unknown. In phase 1 study, we applied a cellular automation technique to simulate the electrical wave propagation to improve the phase mapping algorithm, involving analysis of high-similarity electrogram regions. In addition, we defined rotors and focal AF sources, using the physical parameters of the divergence and curvature forces. In phase 2 study, we enrolled 68 patients with persistent AF undergoing substrate modification into 2 groups, group-1 (n= 34) underwent similarity index (SI) and phase mapping techniques; group-2 (n= 34) received complex fractionated atrial electrogram ablation with commercially available software. Group-1 received real-time waveform similarity measurements in which a phase mapping algorithm was applied to localize the sources. We evaluated the single-procedure freedom from AF. In group-1, we identified an average of 2.6 ± 0.89 SI regions per chamber. These regions involved rotors and focal sources in 65% and 77% of patients in group-1, respectively. Group-1 patients had shorter ablation procedure times, higher termination rates, and significant reduction in AF recurrence compared to group-2 and a trend toward benefit for all atrial arrhythmias. Multivariate analysis showed that substrate mapping using nonlinear similarity and phase mapping was the independent predictor of freedom from AF recurrence (hazard ratio: 0.26; 95% confidence interval: 0.09 to 0.74; p= 0.01). Our study showed that for persistent AF ablation, a specified substrate modification guided by nonlinear phase mapping could eliminate localized re-entry and non-pulmonary focal sources after pulmonary vein isolation.

Perindopril for the prevention of atrial fibrillation recurrence after radiofrequency catheter ablation: One-year experience

Recurrence of atrial fibrillation (AF) after ablation is still high. Perindopril plays an essential role in AF induction and maintenance. We aimed to prove that perindopril (8 mg) could prevent recurrence after pulmonary vein isolation. Patients with paroxysmal AF who received radiofrequency ablation were randomized to a 3-month course of perindopril 8 mg once daily (perindopril group) or placebo (placebo group). Angiotensin-II (Ang-II) therapy and standard transthoracic echocardiography were performed. All 256patients with paroxysmal AF who received radiofrequency ablation were randomized. And we followed them for complete 1 year. The 3-month recurrence and the 1-year recurrence were compared between the 2 groups. The 3-month recurrence of AF was observed in 33 (26.19%) of 126 patients in the placebo group vs 19 (14.62%) of 130 patients who received perindopril 8 mg once daily (χ2, P = .021). One-year recurrence of AF was observed in 36 (28.5%) of 126 patients in the placebo group as compared with 21 (16.2%) of 130 patients who received perindopril after 1 year (P = .017). The κ value was 0.94 in the control group (P < .001) and 0.96 in the perindopril group (P < .001) between 3-month and 1-year recurrence. The Ang-II level was related to the left atrial distance with the reduction in AF recurrence (r = 0.17, P = .005 at 3 months; r = 0.25, P < .001 at 1 year). Perindopril is an effective and safe treatment for the prevention of AF recurrence after radiofrequency catheter ablation. This effect seems to be strongly associated with a significant decrease in Ang-II level and left atrial distance.

Abstract 12012: Relation Between Colchicine and Epicardial Adipose Tissue Volume Surrounding Left Atrium in Atrial Fibrillation Recurrence After Ablation

Background: Immediate recurrence of atrial fibrillation (AF) after AF ablation was related with inflammatory process. Colchicine treatment after AF ablation can reduce AF recurrence by suppression of such inflammatory reactions. The epicardial adipose tissue (EAT) has been shown to release activated pro-inflammatory cytokines and to associate with the development of AF. However, it is unclear whether colchicine treatment affects recurrence of AF according to EAT volume of left atrium (LA-EAT volume). The purpose of this study was to evaluate the relation between reduction of AF recurrence by colchicine treatment after AF ablation and LA-EAT volume. Methods: One hundred twenty two consecutive AF patients who underwent AF ablation and in whom multi-detector computed tomography was performed before ablation were included. Colchicine was prescribed to patients who approved colchicine treatment and was started at 0.5 mg/day for 2 weeks after AF ablation. We divided the study patients into larger LA-EAT group and smaller LA-EAT group according to the median (22.4 cm3) of LA-EAT volume. LA-EAT volume was obtained by semi-automatically tracing axial images from the bifurcation of the pulmonary artery to the coronary sinus and EAT was recognized using threshold attenuation values of -50 to -200 HU. In each group, we compared incidences of AF recurrence (AF &gt; 30 sec) in 3 months and 12 months after ablation between colchicine group and non-colchicine group. Results: Forty-two patients received colchicine. In larger LA-EAT group (&gt; 22.4 cm3) (n=60) incidence of AF recurrence in colchicine group showed lower tendency in 12 months after ablation (10.5% vs. 34.2%, p=0.06) while in smaller LA-EAT group (&lt; 22.4 cm3) (n=62), incidence of AF recurrence was similar between colchicine group and non-colchicine group (Table). Conclusion: Colchicine treatment after AF ablation may reduce mid-term AF recurrence in AF patients with larger LA-EAT volume.

Effect of Obstructive Sleep Apnea Treatment on Atrial Fibrillation Recurrence: A Meta-Analysis

ObjectivesThis study aimed to evaluate the cumulative effect of treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) on atrial fibrillation (AF) recurrence. BackgroundOSA is a known predictor for onset and recurrence of AF. The effect of treatment with CPAP on AF recurrence has been evaluated in small studies with varied outcomes. MethodsWe searched MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Trials Register for relevant studies. Evaluation of AF recurrence in CPAP users and nonusers in patients with OSA was the primary outcome evaluated in this study. The secondary outcome was evaluation of AF recurrence in CPAP users and nonusers after pulmonary vein isolation (PVI). ResultsSeven prospective cohort studies with a total of 1,087 patients met the inclusion criteria. Across all patient groups, the use of CPAP was associated with a significant reduction in AF recurrence (relative risk: 0.58, 95% confidence interval: 0.51 to 0.67; heterogeneity chi-square p = 0.91, I2 = 0%). The beneficial effect of CPAP use was statistically significant in both groups of patients: those who underwent catheter ablation with PVI and those who did not undergo ablation and were managed medically. No other study covariates had any significant association with these outcomes of AF reduction. ConclusionsThe use of CPAP is associated with significant reduction in recurrence of AF in patients with OSA. This effect remains consistent and similar across patient populations irrespective of whether they undergo PVI.

WITHDRAWAL: Effect of Obstructive Sleep Apnea Treatment on Atrial Fibrillation Recurrence: A Meta-Analysis

This study aimed to evaluate the cumulative effect of treatment of obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) on atrial fibrillation (AF) recurrence. OSA is a known predictor for onset and recurrence of AF. The effect of treatment with CPAP on AF recurrence has been evaluated in small studies with varied outcomes. We searched MEDLINE, EMBASE, CINAHL, Google Scholar, Cochrane Database of Systematic Reviews, and Cochrane Trials Register for relevant studies. Evaluation of AF recurrence in CPAP users and nonusers in patients with OSA was the primary outcome evaluated in this study. The secondary outcome was evaluation of AF recurrence in CPAP users and nonusers after pulmonary vein isolation (PVI). Seven prospective cohort studies with a total of 1,087 patients met the inclusion criteria. Across all patient groups, the use of CPAP was associated with a significant reduction in AF recurrence (relative risk: 0.58, 95% confidence interval: 0.51 to 0.67; heterogeneity chi-square p = 0.91, I 2 = 0%). The beneficial effect of CPAP use was statistically significant in both groups of patients: those who underwent catheter ablation with PVI and those who did not undergo ablation and were managed medically. No other study covariates had any significant association with these outcomes of AF reduction. The use of CPAP is associated with significant reduction in recurrence of AF in patients with OSA. This effect remains consistent and similar across patient populations irrespective of whether they undergo PVI.