Successful Atrial Fibrillation Ablation Research Articles

Clinical Features of Tachycardia-induced Cardiomyopathy in Patients with Atrial Fibrillation.

Objective Atrial fibrillation (AF) is the most common cause of tachycardia-induced cardiomyopathy (TIC). However, which patients with AF are prone to developing TIC remains unclear. In this study, we investigated the clinical features of AF patients with TIC. Methods This single-center study included 722 patients with AF (average age, 63.1±10.2 years old; 191 women) who underwent radiofrequency catheter ablation. We defined TIC as an initial left ventricular ejection fraction (LVEF) of <40% and a >20% recovery of the LVEF after successful AF ablation and compared the clinical characteristics between the TIC and control groups. Results The proportions of type 2 diabetes (30.5% vs. 14.7%), renal dysfunction (34.2% vs. 23.8%), hypertension (67.1% vs. 54.8%), and persistent AF (62.2% vs. 32.2%) were significantly higher in the TIC group (n=82) than in the control group (n=640). The atrioventricular nodal effective refractory period (AVNERP) (303±72 ms vs. 332±86 ms; p=0.017) was significantly shorter in the TIC group than in the control group. A multivariable analysis found that persistent AF [odds ratio (OR), 3.19; 95% confidence interval (CI), 1.94-5.24], renal dysfunction (OR, 1.87; 95% CI, 1.06-3.32), and type 2 diabetes (OR, 2.30; 95% CI, 1.31-4.05) were significantly associated with TIC. Conclusion Comorbid renal dysfunction and type 2 diabetes were clinical features of AF patients with TIC. Persistent AF, and short AVNERP may be involved in the development of TIC.

The anticoagulation one year after ablation of atrial fibrillation in patients with atrial fibrillation (ALONE-AF) trial: Study protocol

BackgroundThe ideal long-term antithrombotic strategy for patients after successful catheter-based atrial fibrillation (AF) ablation is still uncertain. Presently, practices vary, and the advantages of oral anticoagulation (OAC) for the post-ablation population are not clearly established. To date, no randomized trials have addressed this therapeutic question. This study aimed to evaluate whether no OAC therapy is superior to apixaban in reducing the risk of stroke, systemic embolism, or major bleeding among patients without apparent recurrent atrial arrhythmias for at least 1 year after their AF ablation procedure. MethodsThe ALONE-AF trial is a prospective, multicenter, open-label, randomized study with blinded outcome assessment. Patients with AF who have at least one non-gender stroke risk factor (as determined by the CHA2DS2-VASc score) and no documented recurrences of atrial arrhythmia for at least 12 months post-ablation will be randomly assigned to apixaban 5 mg b.i.d. or no OAC therapy. The primary endpoint is a composite outcome of stroke, systemic embolism, and major bleeding. Key secondary outcomes include clinically relevant non-major bleeding, all-cause mortality, myocardial infarction, transient ischemic attack, quality of life, and frailty analysis. Participants will be followed for a period of 2 years. The estimated total sample size is 840 subjects, with 420 subjects in each arm. ConclusionThe ALONE-AF trial aims to provide robust evidence for the optimal anticoagulation strategy for patients with stroke risk factors following successful AF ablation.

Pulmonary Vein Morphology in Patients Undergoing Catheter Ablation of Atrial Fibrillation.

Variations in the anatomy of pulmonary veins can influence selection of approaches of atrial fibrillation catheter ablation. Therefore, preprocedural evaluation and knowledge of pulmonary veins anatomy is crucial for proper mapping and the successful ablation of atrial fibrillation. The aim of this observational study was to assess CT angiography scans and perform detailed analysis of pulmonary veins morphology in patients scheduled for catheter ablation of atrial fibrillation. CT angiography was performed in 771 individuals (223 females, 548 males, mean age 58.4 ± 10.7years). Pulmonary veins anatomy was evaluated using 3D models. The patterns used for evaluation included typical anatomy with four separate pulmonary veins, a common left ostium, and various types of accessory veins either alone or in combination with common left ostia. An anatomical variant with common left ostium was observed as the most prevalent anatomy (44%). The typical variant was observed in 34.8% of patients. Accessory pulmonary veins were observed predominantly on the right side. The prevalence of anatomical variants did not differ between sexes with the exception of the unclassifiable category U (4.4% vs. 9%, p < 0.05). Our study shows that a considerable number of atypical anatomies is present in patients undergoing AF catheter ablation. This knowledge may influence the choice of instrumentation. The data could be possibly helpful also in development of new ablation techniques.

National workflow experience with pulsed field ablation for atrial fibrillation: learning curve, efficiency, and safety.

Recent data on pulsed field ablation (PFA) for atrial fibrillation (AF) ablation suggest a progressive reduction in procedural times. Real-world data regarding the relationship between the learning curve of PFA and clinical outcomes are scarce. The objective was to evaluate the PFA learning curve and its impact on acute outcomes. Consecutive patients undergoing AF ablation with the FARAPULSE™ PFA system were included in a prospective, non-randomized multicenter study. Procedural times were stratified on the operators' learning curve. Comparative analysis of skin-to-skin time was conducted with radiofrequency (RF) and cryoablation (CB) pulmonary vein isolation (PVI) procedures performed by the same operators in the previous year. Among 752 patients, 35.1% were females, and 66.9% had paroxysmal AF; mean age was 62.2 ± 10 years. A total of 62.5% of procedures were performed by operators with > 20 PFA procedures. Both time to PVI (25.6 ± 10 min vs 16.5 ± 8, p < 0.0001) and fluoroscopy time (19.8 ± 8 min vs 15.9 ± 8 min, p = 0.0045) significantly improved after 10 associated with consistent linear trend towards procedural time reduction (R2 0.92-0.68 across various procedural metrics). Current PFA skin-to-skin time was lower than the historical skin-to-skin one in 217 (62.4%) procedures; it was similar in 112 (32.2%) cases and higher than the historical skin-to-skin one in 19 (5.5%). No major complications were reported. In this nationwide multicentric experience, the novel PFA system proved to be fast, safe, and acutely effective in both paroxysmal and persistent AF patients. The learning curve appears to be rapid, as improvements in procedural parameters were observed after only a few procedures. Advanced TecHnologies For SuccEssful AblatioN of AF in Clinical Practice (ATHENA). URL: http://clinicaltrials.gov/ Identifier: NCT05617456.

Evaluation of heart rate variability at 1-month after pulsed field ablation of atrial fibrillation and comparison with radiofrequency ablation

Abstract Background Pulsed Field Ablation (PFA) of atrial fibrillation (AF) is a nonthermal novel ablative modality in which high-voltage electric pulses are delivered to generate a high myocardial tissue-specific cellular death, with negligible consequences on surrounding structures including ganglionated plexi. The impairment of the cardiac autonomic ganglia after AF ablation with radiofrequency (RF) has been associated with an increase in mean heart rate (HR) and a reduction in heart rate variability (HRV) and might influence the long-term success of AF ablation. Little data is available on the effect of PFA on cardiac autonomic nervous function. Purpose The aim of this study is to investigate whether PFA ablation could lead to different values of HR and HRV compared to RF at 1-month post-ablation 24-hour Holter monitoring. Methods Between January to September 2023, we included consecutive patients undergoing AF ablation with PFA. According to our clinical practice, all patients performed a routine 24-hour Holter monitoring at 1-month post-ablation. Consecutive AF patients treated with RF were used as controls. Patients in treatment with antiarrhythmics or with documented recurrences of AF at 1-month post-ablation Holter monitoring were excluded. Results 22 consecutive PFA patients were compared to 22 consecutive RF controls. There were no differences in demographic, clinical and echocardiographic data between the 2 groups (Table 1). At 1-month post-ablation Holter monitoring (Table 2), PFA patients had significant higher values of VarIndex (2.18±0.9 vs 1.47±0.7, p=0.01), ASDNN/5min (52.37±15.93 vs 37.17±12.96, p&amp;lt;0.01), SDANN/5min (116.50±27.97 vs 96.03±28.38, p=0.04), and SD (128.95±31.31 vs 106.30±29.56, p=0.04). There was no difference in minimum HR (47.00±6.59 vs 50.29±10.25, p=0.21), mean HR (67.77±6.63 vs 69.24±9.71, p=0.56), and maximal HR (115.41±18.12 vs 110.81±16.44, p=0.39). Conclusions PFA leads to higher values of HRV parameters (i.e., VarIndex, ASDNN/5min, SDANN/5min, and SD) at 1-month post-ablation compared to RF. These data suggest a higher preservation of cardiac autonomic function with PFA, in contrast to RF. Whether the preservation of cardiac autonomic function with PFA might lead to higher rate of long-term AF recurrences remains to be determined.Table 1Table 2

Comparative analysis of antiarrhythmic drugs following atrial fibrillation ablation

Abstract Background Atrial fibrillation (AF) ablation has become an established therapeutic modality for rhythm control. However, the optimal post-ablation pharmacological strategy remains uncertain. The present study addresses this gap by conducting a comparative analysis of four commonly used antiarrhythmic drugs (amiodarone, propafenone, sotalol, and flecainide), both as standalone treatments and in combination with beta blockers, to determine their impact on mortality, hospitalization rates, and AF recurrence. Methods A multi-center, retrospective cohort study was conducted, including patients who underwent successful AF ablation between 20010 to 2020. The study population was divided into groups based on the prescribed antiarrhythmic drug regimen: amiodarone, propafenone, sotalol, flecainide, and respective combinations with beta blockers. Patient demographics, comorbidities, and procedural details were collected. Endpoints included all-cause mortality, hospitalization due to cardiovascular events, MACE and AF recurrence. Results A total of 908 patients were included in this study. The mean age was 66 years old, and 33% (n=297) were female patients. Of 908 patients, 35% (n=316) were prescribed amiodarone, 34% (n=305) propafenone, 8% (n=76) sotalol, and 6%% (n=51) flecainide post AF ablation. Association with beta blockers were observed in 55% (n=496) of cases. Amiodarone group had a 0,3% (n=1) mortality, 9% (n=27) of hospitalizations, 2% (n=5) of major cardiovascular events (MACE) and 32% (n=101) of AF recurrence. Propafenone group had a 1,3% (n=4) mortality, 4% (n=12) hospitalizations, 2% (n=5) of MACE and 27% (n=81) of AF recurrence. Sotalol group had a 4% (n=3) mortality, 6% (n=4) of hospitalizations, 3% (n=2) of MACE and 44% (n=32) of AF recurrence. Flecainide group had 0 cases of death, 2% (n=1) of hospitalization, 0 cases of MACE and 35% of recurrence. Amiodarone is associated with a lower risk of death (p=0,018 OR 0,13). The presence of betablockers did not affect the endpoints, namely, death, hospitalization, MACE or AF recurrence. There were no other statistically significant associations between variables. Conclusion This study evaluated the effectiveness of common antiarrhythmics, such as amiodarone, propafenone, sotalol, and flecainide, with and without beta blockers, in the post-AF ablation setting. In this study, amiodarone showed a lower risk of death. There were no other statistically significant associations between either antiarrhythmic drug and each endpoint. The presence of betablocker therapy did not interfere with the endpoints. The findings contribute to the ongoing discourse on the optimal pharmacological strategy for AF management post-ablation. Further prospective studies with larger sample sizes are warranted to validate and refine these observations, paving the way for evidence-based guidelines in tailoring antiarrhythmic drug regimens for improved patient outcomes

Predicting atrial fibrillation ablation success: a novel approach using pre-procedure sinus rhythm ecg and deep learning

Abstract Introduction Pulmonary vein isolation (PVI) has been the corner stone of the treatment of patients with atrial fibrillation (AF), yet its efficacy varies notably between patient groups. Specifically, it shows reduced efficacy in individuals with persistent AF and those with atrial fibrosis. Recent advancements suggest that additional substrate modification could enhance outcomes in specific patient groups. Therefore, predicting the outcomes of lone PVI could help in stratifying patients who would benefit most from this additional substrate modification. Addressing this gap, our study explores the prognostication of PVI outcomes using pre-procedural 12-lead ECG recordings taken in Sinus rhythm, employing advanced deep learning techniques. Methods This retrospective study analyzed 209 patients with paroxysmal and persistent AF who underwent PVI. These patients were followed up for 12 months after the blanking period. Pre-procedural sinus rhythm 12-lead ECGs were processed using an innovative deep learning architecture, integrating Long Short-Term Memory and Convolutional Neural Networks with a cross-attention module. This multimodal deep learning model was trained using ECG and clinical covariates like age, sex, and BMI to predict binary outcomes – AF type (Paroxysmal or Persistent) and AF recurrence. The model's efficacy was evaluated through a 5-fold stratified cross-validation to ensure accuracy and reliability. Model was also tested using only ECG data. Results The multimodal deep learning model performed significantly better as compared to the model trained using ECG data only. The multimodal deep learning model achieved an accuracy of 75.56% and a sensitivity of 82% in prognosticating ablation outcomes. Additionally, the model demonstrated a significant capability in classifying AF into paroxysmal or persistent types with an accuracy of 86.67% and a recall of 89%. Conclusion Our deep learning approach in analyzing sinus rhythm ECG recordings shows promising results in predicting PVI outcomes and identifying AF types. This approach could offer a more accessible and cost-effective tool to stratify AF patients undergoing PVI, identifying those less likely to benefit from standard procedures. Such insights can assist physicians and patients in determining ablation candidacy and selecting the most appropriate ablation strategy and technique.Proposed StrategyDeep learning model approach

Left Atrium Volume Measured with Multislice Computed Tomography as a Prognostic Predictor for Atrial Fibrillation Catheter Ablation Outcomes.

Background: Current guidelines consider atrial fibrillation (AF) type as the prognostic factor for a recommendation of catheter ablation. We aimed to determine whether LA and LA appendage (LAA) volumes measured using multislice computed tomography (MSCT) were related to long-term outcomes in AF following radiofrequency catheter ablation (RFCA). Methods: We evaluated 152 consecutive patients with drug-refractory AF (median age, 55.8 ± 9.6 years), including 110 male patients, who underwent RFCA in a single center. All patients underwent MSCT imaging for anatomical assessment. The endpoint of this study was documented AF recurrence after RFCA. Results: The overall procedure success rate was 77.6% (n = 118) during a mean follow-up period of 12.6 months. The LA volume was significantly larger for those who experienced AF recurrence after RFCA than for the patients without recurrent AF after the procedure (153.8 ± 29.9 mL vs. 139.2 ± 34.1 mL, p = 0.025). However, LAA volumes were nearly equivalent between the patients with and without AF recurrence after RFCA (16.2 ± 6.3 mL and 14.7 ± 6.5 mL, respectively; p = 0.235). LA volume ≥ 153.2 mL was the optimal cutoff value for estimating AF recurrence after RFCA, with 94% sensitivity and 66% specificity. LA volume remained an independent predictor of both AF recurrence and permanent AF. Conclusions: LA volume as assessed by MSCT might be helpful for identifying patients likely to achieve successful AF ablation. LA volume ≥ 153.2 mL, but not LAA volume, showed good accuracy in predicting AF recurrence after RFCA.

Efficacy of dapagliflozin in improving arrhythmia-related outcomes after ablation for atrial fibrillation: a retrospective single-center study.

Atrial fibrillation (AF) is a widespread type of sustained arrhythmia that poses significant health risks. Catheter ablation is the preferred treatment; however, arrhythmia recurrence remains challenging. Sodium-glucose co-transporter 2 inhibitors, particularly dapagliflozin (DAPA), have exhibited cardiovascular benefits. However, to date, the influence of these inhibitors on AF post-ablation remains unclear. We analyzed the records of 272 patients who underwent catheter ablation for AF from January 2018 to December 2022. Patients were divided into the control (n = 199) and DAPA (n = 73) groups based on DAPA prescription post-ablation. The primary outcome was total atrial arrhythmia recurrence after a 3-month blanking period. The mean age was 72.19 ± 5.45years; 86.8% of the patients were men. At 18months post-ablation, 36.2% and 9.5% of the patients in the control and DAPA groups, respectively, reported atrial arrhythmia. Multivariate analysis revealed that DAPA use was associated with a significantly reduced risk of arrhythmia recurrence (adjusted hazard ratio [aHR]: 0.15, 95% confidence interval [CI]: 0.07-0.32, p < 0.001). After propensity score-matching (PSM) in 65 pairs, arrhythmia recurrence was lower in the DAPA group compared with the control (8.3% versus 30.8%, aHR: 0.17, 95% CI: 0.06-0.51, p = 0.002). Freedom from total arrhythmia recurrence was significantly higher in the DAPA group compared with the control group in both the overall and PSM population (log-rank test p < 0.01). DAPA administration post-ablation was associated with significantly reduced atrial arrhythmia recurrence rates, indicating its potential as an adjunct therapy for enhancing the success of AF ablation.

Mitral regurgitation improvement after successful atrial fibrillation ablation by using a 3D mapping system.

Mitral regurgitation improvement after successful atrial fibrillation ablation by using a 3D mapping system.

Intracardiac echocardiography-guided pulsed-field ablation for successful ablation of atrial fibrillation: a propensity-matched analysis from a large nationwide multicenter experience.

Intracardiac echocardiography (ICE) is increasingly employed in atrial fibrillation (AF) ablation procedures, with the potential to enhance procedural efficacy. Nevertheless, there is currently a lack of evidence assessing the impact of ICE on the efficiency, effectiveness, and safety outcomes in the context of novel pulsed-field ablation (PFA) for AF. We aimed to assess whether the use of ICE could improve procedural parameters in a large population undergoing AF ablation with FARAPULSE™ catheter. Consecutive patients who had undergone PFA of AF from nine Italian centers were included. In procedures where the ICE catheter was employed for guidance (ICE-guided group), it was used to maneuver the PFA catheter within the left atrium to achieve optimal contact with atrial structures. We analyzed 556 patients: 357 (66%) with paroxysmal AF, 499 (89.7%) de novo PVI. ICE-guided procedures (n = 138) were propensity matched with patients with a standard approach (n = 138), and their outcomes were compared. During ICE-guided procedures, no improvement in procedural metrics was recorded (ICE vs Standard, 23 ± 6min vs 18.5 ± 9min for time to PVI, p < 0.0001; 38.8 ± 7 vs 32.5 ± 5 number of PFA deliveries to achieve PVI, p < 0.0001; 68.8 ± 19min vs 71.8 ± 29min for primary operator time, p = 0.5301; 16.1 ± 8min vs 18.2 ± 10min for fluoroscopy time, p = 0.5476) except for support time (76.8 ± 26min vs 91.4 ± 37min, p = 0.0046). No major procedure-related adverse events were reported. Our findings confirmed that PFA could be consistently performed in a rapid, safe, and efficacious manner. The use of ICE to guide PFA was not associated with an improvement in procedural metrics.

Predicting success of atrial fibrillation ablation: comparing machine learning approaches of intracardiac electrograms

Abstract Introduction Machine learning (ML) and Deep learning (DL) neural networks have been used to predict which patients will respond to atrial fibrillation (AF) ablation. However, the predictive results of DL are modest compared to traditional statistical models of clinical features with or without intracardiac electrograms. Purpose To test the hypothesis that optimized ML architectures will better identify patients who respond to AF ablation using intracardiac EGM than other DL architectures in our large registry of 320 consecutive patients. Methods Our patients had age 65.1±10.4Y, were 25% women, 61.6% non-paroxysmal, with intracardiac EGM recorded from multipolar catheters and 64-pole baskets (Fig A). Patients were propensity matched into those in whom ablation terminated by ablation (N=160, "Term") and those without termination (N=160, "Non-Term"). Using a proven DL architecture, ResNet, we systematically varied the depth (i.e., number of residual layers (D)) and width (i.e., number of nodes per layer (W)). We predicted termination (Fig C), presenting EGMs to training cohorts and testing in separate cohorts in a 6-fold cross-validation which we repeated 10 times for each fold with different randomization. Results Fig B illustrates that the prediction accuracy is generally negatively correlated with the network depth but positively correlated with the width. Specifically, the deep architecture (D=4, W=256, with 265M trainable parameters, blue-circled in Fig B) predicted with AUC = 0.61±0.08. However, a shallow-narrow architecture (D=1, W=16, green-circled in Fig B) achieved same AUC (0.61±0.09, p=0.65), while reducing the number of parameters by 97% compared to the DL architecture (79K vs. 265M). Additionally, a shallow-wide architecture (D=1, W=2048, red-circled in Fig B) achieved higher AUC (0.74±0.08; p&amp;lt;0.0001), while saving 44% of the parameters (148M vs 265M) and 26% training time compared to the deep architecture. Conclusion Shallow neural network classification of raw EGMs predicted ablation response with better accuracy than other architectures. Future work should determine if deep architectures ultimately ‘overfit’ detailed EGM data, which may explain their lower success.Figure

Abstract 18056: Transhepatic and Trans-Patent Foramen Ovale Ablation of Atrial Fibrillation in the Setting of Chronic Inferior Vena Cava Occlusion: Addressing Complex Anatomic Hurdles and Achieving Therapeutic Success

Background: Rhythm control for atrial fibrillation (AF) is the preferred approach for symptomatic patients, particularly those with reduced ejection fraction. Catheter ablation primarily consists of pulmonary vein isolation via a transseptal approach. In patients with chronic occlusion of inferior vena cava (IVC), surgical ligation of IVC, or congenital venous system abnormalities, conventional femoral venous access may not feasible. Case Report: A 78-year-old male with history of Hypertension, diabetes, coronary artery disease, bilateral DVTs s/p thrombectomy, prior IVC stenting, presented with persistent, symptomatic AF on apixaban. Given a moderately reduced EF of 40-45%, amiodarone intolerance, and contraindication to other AADs, he was referred for catheter ablation. CT venogram showed chronically occluded IVC with patent hepatic veins, therefore transhepatic access to the right atrium was obtained. Transesophageal echocardiography (TEE) was planned for transseptal puncture; however, this showed an incidental PFO. This PFO was easily engaged using a manual modification of a VersaCross transseptal sheath and after entering the left atrium, the sheath was exchanged with a bi-directional sheath (Vizigo). Using this single left atrial access, pulmonary vein isolation and posterior wall isolation were performed. The transhepatic access site was closed with coil embolization to prevent track bleeding (figure 1). Conclusion: We present a case where successful AF ablation was achieved via percutaneous transhepatic approach, with improvised utilization of a conveniently located PFO. This was guided by pre-operative CT, and intra-operative TEE which allowed us to minimize any transseptal puncture related complications. The utilization of a multidisciplinary team comprising electrophysiologists, advanced imaging cardiologists and interventional radiologists is invaluable in executing complex procedures of this nature.

Abstract 17670: Double Trouble: Exploring the Rare Coexistence of Right and Left Atrial Thrombus After Left Atrial Appendage Ligation and Maze Procedure

Introduction: Left atrial appendage (LAA) harbors around 90% of thrombus in patients with Atrial Fibrillation(AF) related strokes. Incomplete surgical ligation and LAA stump are independent risk factors for stroke and thromboembolism in AF patients. To our knowledge, we report the first case of biatrial thrombus occurring within 1 week of surgery. Case Presentation: A 76-year-old man with Paroxysmal AF and three-vessel coronary artery disease presented with 3-week exertional and resting shortness of breath and chest pain. Troponins were negative, and EKG revealed AF. Cardiothoracic surgery planned coronary bypass, MAZE procedure, and LAA clipping. Intra-operative transoesophageal echocardiogram(TEE) showed ejection fraction of 35% without LAA clot. Post-operatively, despite anticoagulation(AC) and beta blocker therapy, AF recurred within a week. Subsequent TEE prior to anticipated cardioversion(CV) revealed thrombus on the superior vena cava border of right atrium, anterolateral wall of left atrium and near the mitral valve annulus. CV was deferred, and he was sent to rehab with AC. We hypothesize that the thrombus may be attributed to a stunned atrium caused by ischemic myocardial injury. Our case underscores the need for heightened suspicion of thrombus in individual cases. Discussion: Left atrial appendage occlusion (LAAO) was implemented as stroke prophylaxis strategy in AF during surgical interventions like maze and coronary bypass. while the European Society of Cardiology advises continuing AC after LAAO, studies suggest discontinuing AC in high-risk bleeding patients after successful surgical AF ablation and LAAO if sinus rhythm is maintained for ≥3 months. LAAOS III study shows economic benefit of concomitant surgical LAAO during cardiac surgery in AF patients with CHA2DS2-VASc score ≥2 for stroke prevention. When used alongside AC, it offers incremental benefits. Safety of discontinuing AC after LAAO requires further investigation.

It can be safe to discontinue oral anticoagulants after successful atrial fibrillation ablation: A systematic review and meta-analysis of cohort studies.

Current guidelines recommended that oral anticoagulants (OACs) should last for a minimum first 2 months after atrial fibrillation (AF) ablation and the long-term decision of anticoagulation after AF ablation should be based on the individual patient's risk of stroke rather than the rhythm status. There is controversy about the safety of discontinuing OACs in patients with atrial fibrillation after the blanking period due to the divergences between consensus recommendations and clinical practice. Electronic bibliographic sources (PubMed, Embase, and Web of Science) were searched until August 2023 to identify cohort studies about the safety of discontinuing OACs in patients with AF after the blanking period. The primary outcome was thromboembolism (TE). The secondary outcome was major bleeding events (MBEs). Two authors extracted articles independently using predefined data fields. The pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated based on a random-effects model. A total of 16 studies (11 prospective cohorts and 5 retrospective cohorts) enrolling 23,942 patients (14,382 OFF-OAC and 9560 ON-OAC) were included in our analysis. No significant difference emerged in the risk of TE between OFF-OAC and ON-OAC patients following AF ablation after the banking period (OR = 0.66; 95%CI, 0.43-1.01). Similar results emerged in the patients with a high risk of TE after stratification by the risk level of TE (OR = 0.72; 95%CI, 0.25-2.08). A significant reduction in incidences of major bleeding was found in the OFF-OAC patients compared with the ON-OAC patients (OR = 0.23; 95%CI, 0.12-0.42). Subgroup analyses for TE found a reduction of incidences in the subgroups who switched to antiplatelet drugs and with a follow-up duration <3 years. Subgroup analyses for MBEs found a significant reduction of incidences in all subgroups. Our study suggests it can be safe to discontinue OACs after successful AF ablation. Discontinuation of OACs may reduce the risk of MBEs while not increasing the risk of TE.

Atrial fibrillation cycle-length (AF-CL) inside the pulmonary veins predicts paroxysmal AF ablation success- the INDUCE-AF study.

A novel method to measure atrial fibrillation cycle length (AF-CL) was recently described, based on the average of 10 consecutive signals (FARS10). FARS10 accurately identified pulmonary vein isolation (PVI)-responders among patients with persistent AF. Whether this method is applicable to patients with paroxysmal AF is unknown. The aim of this study is to evaluate the prognostic value of FARS10 measurements in patients with paroxysmal AF. We enrolled paroxysmal AF patients undergoing PVI in a prospective multicenter study. After AF induction with a standardized protocol, the AF-CL was measured using FARS-10 method. The primary endpoint was AF/AT-recurrence. One-hundred and four patients were included (61 ± 14years, 25% females). After a mean follow-up of 12 ± 4months, AF/AT recurrence rate was 20%. The fastest PV CL (fPV-CL) was independently associated with the primary endpoint at multivariate analysis (HR 1.02, p < 0.001). Every 10ms increase in fPV-CL, AF recurrences increased by 20%. The value of 160ms was found to be the optimal cut-off (specificity 81%, sensitivity 76%). Patients with fPV-CL < 160ms experienced lower AF recurrences as compared to patients with fPV-CL > 160ms (8% vs. 32% at 1year; HR = 0.17, p < 0.001). Progression to persistent AF was observed in 13% of patients with fPV-CL > 160ms. fPV-CL measured with the FARS-10 method accurately predicts PVI success in paroxysmal AF patients undergoing PVI. Patients with slow PV activity (fPV-CL > 160ms) experience higher AF recurrence rate after PVI and more frequent progression to persistent AF.

ABC-AF-Stroke score predicts thromboembolism in non-anticoagulated patients following successful atrial fibrillation ablation: a report from the Chinese Atrial Fibrillation Registry.

The age, biomarkers, and clinical history (ABC)-atrial fibrillation (AF)-Stroke score have been proposed to refine stroke risk stratification, beyond what clinical risk scores such as the CHA2DS2-VASc score can offer. This study aimed to identify risk factors associated with thromboembolism and evaluate the performance of the ABC-AF-Stroke score in predicting thromboembolism in non-anticoagulated AF patients following successful ablations. A total of 2692 patients who underwent successful ablations with discontinued anticoagulation after a 3-month blanking period in the Chinese Atrial Fibrillation Registry (CAFR) between 2013 and 2019 were included. Cox regression analysis was conducted to present the association of risk factors with thromboembolism risk. The ABC-AF-Stroke score was evaluated in terms of discrimination, including concordance index (C-index), net reclassification improvement (NRI) and integrated discrimination improvement (IDI), clinical utilization by decision curve analysis (DCA), and calibration by comparing the predicted risk with the observed annualized event rate. After a median follow-up of 3.5 years, 64 patients experienced thromboembolism events. Age, prior history of stroke/transient ischemic attack (TIA), high-sensitivity cardiac troponin T (cTnT-hs), and N-terminal pro-B-type natriuretic peptide (NT-proBNP) were independently associated with thromboembolism risk. The ABC-AF-Stroke score performed statistically significantly better than the CHA2DS2-VASc score in terms of C-index (0.67, 95% confidence interval [CI]: 0.59-0.74 vs. 0.60, 95% CI: 0.52-0.67, P = 0.030) and reclassification capacity. The DCA implied that the ABC-AF-Stroke score could identify more thromboembolism events without increasing the false positive rate compared to the CHA2DS2-VASc score. The calibration curve showed that the ABC-AF-Stroke score was well calibrated in this population. In this real-world study enrolling non-anticoagulated AF patients following successful ablations, age, prior history of stroke/TIA, level of NT-proBNP, and cTnT-hs were independently associated with an increased risk of thromboembolism. The ABC-AF-Stroke score was well-calibrated and statistically significantly outperformed the CHA2DS2-VASc score in predicting thromboembolism risk.

Impact of obesity on catheter ablation of atrial fibrillation: Patient characteristics, procedural complications, outcomes, and quality of life.

Obesity is a well-known risk factor for atrial fibrillation (AF). We aim to evaluate the effect of baseline obesity on procedural complications, AF recurrence, and symptoms following catheter ablation (CA). All consecutive patients undergoing AF ablation (2013-2021) at our center were enrolled in a prospective registry. The study included all consecutive patients with available data on body mass index (BMI). Primary endpoint was AF recurrence based on electrocardiographic documentation. Patients were categorized into five groups according to their baseline BMI. Patients survey at baseline and at follow-up were used to calculate AF symptom severity score (AFSS) as well as AF burden (mean of AF duration score and AF frequency score; scale 0: no AF to 10: continuous and 9 frequencies/durations in between). Patients were scheduled for follow-up visits with 12-lead electrocardiogram at 3, 6, and 12 months after ablation, and every 6 months thereafter. A total of 5841 patients were included (17% normal weight, 34% overweight, 27% Class I, 13% Class II, and 9% Class III obesity). Major procedural complications were low (1.5%) among all BMI subgroups. At 3 years AF recurrence was the highest in Class III obesity patients (48%) followed by Class II (43%), whereas Class I, normal, and overweight had similar results with lower recurrence (35%). In multivariable analyses, Class III obesity (BMI ≥ 40) was independently associated with increased risk for AF recurrence (hazard ratio,1.30; confidence interval, 1.06-1.60; p = .01), whereas other groups had similar risk in comparison to normal weight. Baseline AFSS was lowest in normal weight, and highest in Obesity-III, median (interquartile range) 10 (5-16) versus 15 (10-21). In all groups, CA resulted in a significantimprovement in their AFSS with a similar magnitude among the groups. At follow-up, AF burden was minimal and did not differ significantly between the groups. AF ablation is safe with a low complication rate across all BMI groups. Morbid obesity (BMI ≥ 40) was significantly associated with reduced AF ablation success. However, ablation resulted in improvement in QoL including reduction of the AFSS, and AF burden regardless of BMI.

Impact of Risk Factor Control on the Success of Atrial Fibrillation Ablation by Pulmonary Vein Isolation

Impact of Risk Factor Control on the Success of Atrial Fibrillation Ablation by Pulmonary Vein Isolation

Safety of Discontinuation of Oral Anticoagulants in Patients with Atrial Fibrillation following Ablation: A Systematic Review and Meta-analysis

Abstract The safety of discontinuing oral anticoagulants (OACs) in patients with atrial fibrillation (AF) following ablation remains controversial. The European Society of Cardiology stated that the long-term continuation of anticoagulants beyond 2 months following ablation should be based on the patient’s stroke risk profile; however, the decision remains challenging considering the lack of explicit guidelines. Furthermore, a worldwide survey showed that some centers implement a policy of withdrawing OAC therapy even in the majority of patients at high risk of thromboembolic events. To address this issue, we conducted a systematic review to investigate the safety of discontinuing OACs in patients with AF following ablation. A systematic review of cohort studies was performed. A comprehensive search for relevant literature was conducted using predefined keywords in five scientific databases (PubMed, ClinicalKey, Cochrane, EBSCOhost, and ScienceDirect). Studies that compared the incidence of thromboembolic events in the off-OAC group and on-OAC group were considered. Duplicated articles were removed. Eight studies (n = 16037) were retained for the final analysis. These studies were published between 2010 and 2021. Overall, there was no difference in the incidence of thromboembolic events between the off-OAC and on-OAC groups (odds ratio [OR] 0.81; 95% confidence interval [CI] 0.52–1.29) with lower bleeding risk in patients who discontinued OAC compared to those who remained on OAC (OR 0.30; 95% CI 0.15–0.62). Patients who discontinued OAC after AF ablation generally had a similar incidence of thromboembolism (TE) to patients who remained on OAC. This review indicates that the risk-benefit ratio favors the discontinuation of OAC in patients with successful AF ablation. However, randomized controlled trials with larger samples involving a more generalizable population are warranted to address the safety and efficacy of OAC discontinuation in patients with AF undergoing catheter ablation.