Symptomatic Paroxysmal Atrial Fibrillation Patients Research Articles

Enhancing Quality of Life in Symptomatic Paroxysmal Atrial Fibrillation Patients: A Systematic Analysis of Cognitive Behavioral Therapy Interventions.

Paroxysmal atrial fibrillation (PAF) significantly impacts patients' lives, contributing to morbidity, reduced quality of life (QoL), and psychological distress. Conventional treatment approaches primarily focus on rhythm control through pharmacologic therapy, often overlooking the patient's holistic well-being. Cognitive behavioral therapy (CBT), a well-established intervention for modifying dysfunctional thoughts and behaviors, may provide a beneficial nonpharmacological approach to improving QoL in symptomatic PAF patients. A systematic review was conducted in accordance with Cochrane methodology and PRISMA guidelines. A comprehensive search was performed using PubMed, Scopus, and Google Scholar to identify relevant studies on the effects of CBT on QoL in PAF patients. Various CBT interventions, including exposure-based, internet-delivered, and mindfulness-based approaches, were analyzed. Study quality was assessed using JBI and Cochrane tools to evaluate the risk of bias. The review found that CBT interventions led to statistically significant improvements in several QoL domains, including physical and emotional well-being. Psychological well-being and self-management skills were notably enhanced, as CBT helped address maladaptive cognitive patterns and improved coping strategies. The studies reviewed consistently demonstrated a low risk of bias, indicating reliability in the findings. CBT shows promise as a holistic, nonpharmacological intervention for managing PAF, improving both psychological and physical QoL. However, future research is needed to establish standardized protocols, increase sample sizes, and conduct long-term follow-ups to further validate its effectiveness in this population. Incorporating CBT into PAF management could substantially enhance patient outcomes and well-being.

Left atrial strain after paroxysmal atrial fibrillation linac-based cardiac radioablation in elderly population.

Catheter ablation of atrial fibrillation (AF) may increase the risk of complication in aged patients. Stereotactic arrhythmia radioablation (STAR) is a non-invasive therapeutic alternative for cardiac arrhythmia. This sub-study evaluated left atrial strain (LAS) in elderly AF patients underwent STAR. Symptomatic paroxysmal AF patients aged > 70 years, with antiarrhythmic drugs failure or intolerance, enrolled in a phase II trial that have demonstrated the feasibility of LINAC-based STAR (total dose of 25Gy single fraction delivered in 3min), performed a 15-day electrocardiogram Holter monitoring to detect AF episodes (≥ 30s) and an echocardiographic LAS evaluation before and after STAR (at 1-, 3-, 6- and 12-month). Out 18 patients underwent STAR in the trial, 16 (7 males, 78 ± 5 years) completed the follow-up for LAS study. No baseline difference in echocardiographic and LAS parameters was observed between the 9 patients with AF recurrence during follow-up and those who maintained sinus rhythm. At 6- and 12-month after STAR, LAS reservoir was lower in patients with AF episodes than those without (respectively, p = 0.039 and p = 0.001). Values of left atrial area and volume as well as LAS conduit and contractile phase were not statistically significant different by patient's outcome across evaluations. Although no baseline LAS parameter before STAR seems predict AF recurrence after treatment in elderly patients, lower values of reservoir phase were observed during follow-up in those experiencing AF episodes. More research is needed to better assess the value of LAS monitoring in paroxysmal AF patients underwent Stereotactic cardiac radioablation.

PO-05-133 PROLONGED NEUROMODULATION EFFECTS AFTER PULMONARY VEIN ISOLATION IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION: INSIGHT FROM THE NONLINEAR HEART RATE DYNAMICS

Heart rate variability (HRV) reveals information undetected by direct electrocardiogram morphology evaluation. Prior research indicated that patients with paroxysmal atrial fibrillation (PAF) had altered a short-term linear HRV after pulmonary vein isolation (PVI). However, the long-term changes in the nonlinear heart rate dynamics before and after PVI remain unclear. The objective was to investigate the long-term nonlinear HRV changes before and after PVI in PAF patients. We enrolled 42 drug-refractory symptomatic PAF patients who underwent PVI. Holter monitoring were done less than 1 year before, 1∼3, and 6∼12 months after PVI, respectively. The nonlinear HRV variables, including sample entropy (SampEn), multi-scale entropy (MSE), detrended fluctuation analysis (DFA), and Poincaré Plot analysis, were analyzed. Significant reductions in SD1, SD1/SD2, MSE 1∼5, MSE 6∼20, and SampEn occurred 6∼12 months after when compared to those before PVI, respectively. SD2, MSE slope 5, DFA slope 1 decreased 1∼3 months after PVI when compared to those before PVI, respectively, whereas increased significantly 6∼12 months after PVI when compared to those 1∼3 months after PVI, respectively. DFA slope2 increased significantly after PVI when compared to that before PVI. Detailed parameters are shown in the Table 1. As measured by DFA slope2, fractal correlation properties increased significantly following PVI. Heart rate complexity (MSE 1∼5, MSE 6∼20, and SampEn) and unpredictability of an RR time series (SD1/SD2) decreased significantly after PVI, whereas long-term RR interval (SD2) and short-term complexity (MSE slope 5) decreased in the 1∼3 months after PVI and then increased in 6∼12 months after PVI. These results indicated that the neuromodulation effects from PVI was far more prolonged and extensively than expected.Tabled 1Table 1. Serial changes in the HRV parametersPatients with PAF who underwent PVI (n = 42)< 1 year pre-PVI1∼3 months post-PVI6∼12 months post-PVISD121.16 ± 8.416.31 ± 11.08∗14.19 ± 8.63∗SD2177.58 ± 44.38134.92 ± 37∗146.46 ± 37.52∗+SD1/SD20.12 ± 0.060.12 ± 0.090.1 ± 0.06∗+DFA slope11.11 ± 0.240.8 ± 0.31∗0.94 ± 0.31∗+DFA slope21.07 ± 0.11.16 ± 0.13∗1.15 ± 0.11∗MSE 1∼55.62 ± 1.824.76 ± 1.74∗4.72 ± 1.59∗MSE 6∼2019.81 ± 5.6716.01 ± 5.6∗17.3 ± 4.75∗MSE slope50.06 ± 0.07-0.01 ± 0.09∗0.03 ± 0.07+SampEn1 ± 0.321.01 ± 0.290.9 ± 0.26∗+Data are expressed as (mean ± SD); DFA slope1: Detrended fluctuation analysis slope 1; DFA slope2: Detrended fluctuation analysis slope 2; MSE 1∼5, the summation of entropy values of scales 1 to 5; MSE 6∼20, the summation of entropy values of scales 6 to 20; MSE slope 5, the linear-fitted slope of scales 1 to 5; SD1, Poincaré plot standard deviation perpendicular the line of identity; SD2, Poincaré plot standard deviation along the line of identity; SD1/SD2, SD1-to-SD2 ratio; SampEn, sample entropy; *: p < 0.05 versus < 1 year pre-PVI; +: p < 0.05 versus 1∼3 months post-PVI Open table in a new tab

B-PO02-078 PROSPECTIVE RANDOMIZED MULTICENTER COMPARISON OF THIRD GENERATION CRYOBALLOON AND LASER BALLOON CATHETERS FOR PULMONARY VEIN ISOLATION ABLATION IN PATIENTS WITH PAROXYSMAL ATRIAL FIBRILLATION

Cryoballoon (CB) and Laser balloon (LB) catheters have emerged as alternative modalities for pulmonary vein isolation (PVI) of patients with paroxysmal atrial fibrillation (PAF). To compare clinical efficacy, safety, and procedural characteristics of 3rd generation CB (Arctic Front Advance-Short Tip; CB3) and LB (Heartlight X3; LB3) catheters for first-time PVI in PAF patients. Symptomatic PAF patients were prospectively randomized 1:1 to undergo PVI with CB3 or LB3 catheters (CB3: n=115; LB3 n=115). Follow up included 3,6, and 12 month office visits. 14-day Holter monitoring guided by symptoms. Primary efficacy endpoint was defined as freedom from atrial tachyarrhythmia (AAT) between 91 to 365 days after first-ablation procedure. Secondary endpoints included procedural parameters and procedural complications. Procedure time, left atrial time, and fluoroscopy time were based on standard definitions. 230 PAF patients underwent PVI with CB3 (n=115) and LB3 (n=115). There were no significant differences in baseline characteristics between groups. Mean age was 65.3 + 12.3 for CB3 and 63.1 + 11.5 for LB3 (p=0.158). On 9 month follow up, 17.2% of CB and 11.4% of LB3 patients (p=0.939) had recurrence of AAT after 90-day blanking period. Procedure time was 91.7 + 33.8 for CB3 vs 91.1 + 27.7 mins for LB3 (p=0.87). LA dwell time was 68.9 + 26.1 for CB3 vs 74.2 + 22.2 min for LB3(p=0.11). Fluoroscopy time was 13.8 + 7.0 vs 8.7 + 5.7 min for CB3 and LB3 groups (p<0.001), respectively. Total therapy time per PV was 6.5 + 3.9 for CB3 vs 5.6 + 2.4 min for LB3(<0.001). Of the PVs treated, 98.7% (450/456) were isolated with CB3 and 99.1% (445/449) were isolated with LB3. First pass isolation rate was 78.0% (351/450) for CB3 vs 93.7% (417/445) for LB3 (p<0.001). Hematomas occurred in four CB3 and two LB3 patients (p=0.458), respectively. No phrenic palsy events were observed in either group. Third generation CB and LB catheters offer improved safety and comparable efficacy for treatment of AAT in patients with PAF. Although procedure and LA dwell time were similar between balloon catheters, PVI with LB3 was associated with lower fluoroscopy usage, higher first pass PV isolation rate, and shorter total therapy time to achieve isolation per PV.

Self-Reported Onset of Paroxysmal Atrial Fibrillation Is Related to Sleeping Body Position.

Background: Because stretch of the atrial myocardium is proarrhythmic for atrial fibrillation (AF) and a left lateral body position increases atrial dimensions in humans, we hypothesized that left lateral recumbence is a frequent AF-triggering body position in AF patients.Methods: We performed a questionnaire study of symptomatic paroxysmal AF (episodes of AF < 1 week) patients scheduled for a first AF ablation therapy at Catharina Hospital, Eindhoven, the Netherlands and at University Hospital, Bordeaux, France.Results: Ninety-four symptomatic paroxysmal AF patients were included [mean age 61 ± 11 years, median AF history of 29(48) months, 31% were females]. Twenty-two percent of patients reported a specific body position as a trigger of their AF symptoms. The triggering body position was left lateral position in 57% of cases, supine position in 33%, right lateral position in 10%, and prone position in 5% (p = 0.003 overall difference in prevalence). Patients with positional AF had a higher body mass index compared to patients without nocturnal/positional AF [28.7(4.2) and 25.4(5.2) kg/m2, respectively, p = 0.025], but otherwise resembled these patients.Conclusion: Body position, and the left lateral position, in particular, is a common trigger of AF in symptomatic AF patients. Moreover, positional AF is associated with overweight. Understanding of the underlying mechanisms of positional AF can contribute to AF treatment and prevention.

Current Status of Atrial Fibrillation Ablation with Balloon Strategy.

Catheter ablation of atrial fibrillation (AF) has been established worldwide and is recommended for symptomatic paroxysmal AF patients according to international guidelines. Importantly, the cornerstone of any AF ablation represents pulmonary vein isolation (PVI). Traditional radiofrequency (RF) point by point ablation within a 3D electroanatomic left atrial (LA) map requires profound understanding of LA anatomy and electrophysiology. This ablation strategy can be highly efficient and safe if performed in experienced hands and centers. However, procedural complexity causes a long learning curve and has limited its wide spread utilization. In contrast, balloon based PVI ablation strategies are based on an anatomic principle. Currently, two balloon types (cryoballoon and laserballoon) have been adopted to clinical routine. Both balloons are positioned at the target PV and circumferential energy ablation is enabled. This simplified anatomic approach facilitates reaching the procedural endpoint of PVI and demonstrated less operator dependency. Therefore, balloon PVI appears to be associated with improved procedural reproducibility and safety. Importantly, large scale randomized trials proved non-inferiority of balloon guided AF ablation (cryothermal and laser energy) vs. experienced operators using traditional “gold standard” RF ablation in paroxysmal and persistent AF. Ongoing technological refinements of both balloons as well as the introduction of novel energy dosing strategies and ablation targets may potentially impact the current way of ablating AF in future. This review will summarize current clinical experience of contemporary balloon devices and will look into future developments.

Uncontrolled blood pressure affects atrial remodeling and adverse clinical outcome in paroxysmal atrial fibrillation.

To investigate the impact of uncontrolled blood pressure (BP) on left atrial (LA) remodeling and clinical outcome after pulmonary vein isolation (PVI) in paroxysmal atrial fibrillation (AF). One hundred and one symptomatic paroxysmal AF patients (85 males, 62.2±8.4-year-old) who underwent successful PVI were classified as follows: group 1 (n=46), no hypertension (HTN); group 2 (n=36), HTN with controlled BP; and group 3 (n=19), HTN with uncontrolled BP. Uncontrolled BP was defined as BP>140/90mm Hg. LA dimension was measured by echocardiography before and 6 months after PVI. LA wall thickness along the ablation line was measured using computed tomography prior to PVI. Cox regression analysis was performed for the prediction of recurrence. LA wall thickness in groups 2 and 3 was greater than that of group 1, except for the anterior right superior pulmonary vein (PV) and posterior left inferior PV. Kaplan-Meier analysis revealed a significantly higher recurrence in group 3 (52.6%). LA dimension only increased in group 3 (38.2 ± 5.6mm to 41.3 ± 6.2mm, P=0.022). At the second procedure, all group 3 recurrent patients showed substrate degradation (low voltage area and/or dense scar formation) and required substrate modification. Uncontrolled BP was an independent risk factor for recurrence (hazard ratio: 2.350, P=0.033). HTN induced heterogeneous LA hypertrophy regardless of whether HTN was controlled. Uncontrolled BP promoted atrial remodeling, and is therefore a strong predictor for recurrence of AF after PVI.

Paroxysmal atrial fibrillation recurrences and quality of life in symptomatic patients: A crossover study of flecainide and pilsicainide

BackgroundThe therapeutic goals of atrial fibrillation (AF) patients are to reduce symptoms and prevent severe complications associated with AF. This study compared the efficacy of flecainide versus pilsicainide in reducing the frequency of AF and improving quality of life (QOL) in symptomatic paroxysmal AF patients without structural heart disease. MethodsThe Atrial Fibrillation and Quality Of Life (AF-QOL) study was a prospective, multicenter, randomized, open-label crossover study that compared flecainide and pilsicainide as antiarrhythmic drug therapy. Patients were randomized to receive 3 months of treatment with flecainide twice daily or pilsicainide 3 times daily. Each treatment consisted of a dose-finding phase (weeks 1–4) and an efficacy phase (weeks 5–12). Forty-three patients completed the trial. The main outcome was the number of days with documented AF episodes using a patient-operated electrocardiogram. QOL questionnaires (SF-36 and AF-specific QOL scores) were also completed. ResultsThe median (range) AF frequencies (days/8 weeks) were 2 (0–50) in the flecainide treatment group and 1 (0–54) in the pilsicainide treatment group (no significant between-group difference). No significant difference in the first recurrence of AF during the efficacy phase was noted between flecainide and pilsicainide treatments. The frequency and severity scores of AF-related symptoms improved from baseline to the end of the treatment periods. No significant differences in SF-36 or AF-related QOL scores were noted between the treatment groups. ConclusionsThis study found no difference in AF frequency or QOL between symptomatic paroxysmal AF patients who received flecainide or pilsicainide.

Remote-controlled magnetic pulmonary vein isolation combined with superior vena cava isolation for paroxysmal atrial fibrillation: A prospective randomized study

Radiofrequency ablation (RFA) of paroxysmal atrial fibrillation (PAF) has focused on pulmonary vein isolation (PVI). However, despite initial positive results, significant recurrences have occurred, partly because of pulmonary vein (PV) reconnection or non-PV ectopic foci, including the superior vena cava (SVC). This prospective, randomized study sought to investigate the efficacy of additional SVCI combined with PVI in symptomatic PAF patients referred for ablation. From November 2011 to May 2013, RFA was performed remotely using a CARTO(®) 3 System in patients randomized to undergo PVI for symptomatic drug-refractory PAF, with (PVI+SVCI group) or without (PVI alone group) SVCI. PVI and SVCI were confirmed by spiral catheter recording during ablation. Procedural data, complications and freedom from atrial tachycardia (AT) and atrial fibrillation (AF) were assessed. Over an 18-month period, 100 consecutive patients (56±9years; 17 women) with symptomatic PAF were included in the study (PVI+SVCI, n=51; PVI, n=49); the CHA2DS2-VASc score was 0.9±1. Median duration of procedure (±interquartile), 2.5±1hours; total X-ray exposure, 13.3±8minutes; transseptal puncture and catheter positioning, 8±5minutes; left atrium electroanatomical reconstruction, 3±2minutes; and catheter ablation, 3.7±3minutes. After a median follow-up of 15±8months, and having undergone a single procedure, 84% of patients were symptom free, while 86% remained asymptomatic after undergoing two procedures. The cumulative risks of atrial arrhythmias (AT or AF) were interpreted using Kaplan-Meier curves and compared using the log-rank test. Long-term follow-up revealed no significant difference between groups, with atrial arrhythmias occurring in six (12%) patients in the PVI+SVCI group and nine (18%) patients in the PVI alone group (P=0.6). One transient phrenic nerve palsy and one phrenic nerve injury with partial recovery occurred in the PVI+SVCI group. SVCI combined with PVI did not reduce the risk of subsequent AF recurrence, and was responsible for two phrenic nerve injuries. Accordingly, the benefit-to-risk ratio argues against systematic SVCI.

Discrimination of Thoracic Vein Potentials Facilitated by Atrial Pacing during the Isolation

Although electrical thoracic vein (TV) isolation is an established strategy during atrial fibrillation (AF) ablation, discriminating TV potentials from far-field signals is critical for the achievement. One hundred consecutive drug-refractory symptomatic paroxysmal AF patients who underwent AF catheter ablation were included. All patients underwent circumferential pulmonary vein (PV) isolation during distal coronary sinus (CS) pacing with a cycle length of 600 ms. A superior vena cava (SVC) isolation was added during high right atrial (HRA) pacing with the same cycle length in 79 patients in whom SVC potentials were identified. The interval between the near-field PV potentials and far-field atrial signals significantly prolonged more during distal CS pacing than sinus rhythm (SR) in the left superior (26.0 [18.5-32.8] ms to 36.0 [24.3-55.5] ms, P < 0.01) and left inferior PVs (21.0 [14.0-30.0] ms to 40.0 [23.0-56.0] ms, P < 0.01), but not in the right superior (34.0 [20.0-40.0] ms to 23.0 [18.0-36.0] ms, P = 0.13) and right inferior PVs (22.0 [16.0-28.0] ms to 25.0 [18.0-38.0] ms, P = 0.05). The interval between the SVC potentials and far-field atrial signals significantly prolonged more during HRA pacing than SR (20.0 [0-32.0] ms to 34.0 [24.0-46.0] ms, P < 0.01). Electrical isolation was successfully achieved in all TVs without any complications except for transient right phrenic nerve palsy in two patients. Discrimination of ipsilateral left PVs and SVC potentials is facilitated by pacing from the distal CS and HRA, respectively. Better recognition of TV potentials would help to achieve electrical isolation.

Denervation as a Common Mechanism Underlying Different Pulmonary Vein Isolation Strategies for Paroxysmal Atrial Fibrillation: Evidenced by Heart Rate Variability after Ablation

Backgrounds. Segmental and circumferential pulmonary vein isolations (SPVI and CPVI) have been demonstrated to be effective therapies for paroxysmal atrial fibrillation (PAF). PVI is well established as the endpoint of different ablation techniques, whereas it may not completely account for the long-term success. Methods. 181 drug-refractory symptomatic PAF patients were referred for segmental or circumferential PVI (SPVI = 67; CPVI = 114). Heart rate variability (HRV) was assessed before and after the final ablation. Results. After following up for 62.23 ± 12.75 months, patients underwent 1.41 ± 0.68 procedures in average, and the success rates in SPVI and CPVI groups were comparable. 119 patients were free from AF recurrence (SPVI-S, n = 43; CPVI-S, n = 76). 56 patients had recurrent episodes (SPVI-R, n = 21; CPVI-R, n = 35). Either ablation technique decreased HRV significantly. Postablation SDNN and rMSSD were significantly lower in SPVI-S and CPVI-S subgroups than in SPVI-R and CPVI-R subgroups (SPVI-S versus SPVI-R: SDNN 91.8 ± 32.6 versus 111.5 ± 36.2 ms, rMSSD 47.4 ± 32.3 versus 55.2 ± 35.2 ms; CPVI-S versus CPVI-R: SDNN 83.0 ± 35.6 versus 101.0 ± 40.7 ms, rMSSD 41.1 ± 22.9 versus 59.2 ± 44.8 ms; all P < 0.05). Attenuation of SDNN and rMSSD remained for 12 months in SPVI-S and CPVI-S subgroups, whereas it recovered earlier in SPVI-R and CPVI-R subgroups. Multivariate logistic regression analysis identified SDNN as the only predictor of long-term success. Conclusions. Beyond PVI, denervation may be a common mechanism underlying different ablation strategies for PAF.

A Prospective, Randomized Comparison of Modified Pulmonary Vein Isolation Versus Conventional Pulmonary Vein Isolation in Patients with Paroxysmal Atrial Fibrillation

Pulmonary vein isolation (PVI) is the primary ablation therapy in patients with atrial fibrillation (AF). We hypothesized that high dominant frequency (DF) sites (AF nests during sinus rhythm [SR]) adjacent to the PV ostia are associated with the atrial substrate that maintains AF, and PVI incorporating the high-frequency AF nests may have a higher efficacy. In a prospective and randomized comparison, 126 symptomatic paroxysmal AF patients that underwent PVI were enrolled. We compared the efficacy of a modified PVI (ablation line: 1.0-1.5 cm from the PV ostium with encircling the AF nests [spectral analysis with DF >70 Hz during SR, Group II]) versus the anatomy-guided conventional PVI (Group I). In Group II, the DF value along the PV ostium was lower than 70 Hz after the PVI. The primary endpoint was the freedom from symptomatic atrial arrhythmias after a single procedure. We also followed the autonomic function by a time-domain analysis of the heart rate variability. In both groups, AF nests were observed and electric isolation was successfully obtained in all patients. With a mean duration of 16 ± 6.1 months of follow-up, Group II had a higher single procedure efficacy without drugs (78.7% vs 66.1%, log-rank test: P = 0.02), and fewer repeat procedures (6.6% vs 23%; P = 0.04), as compared to Group I. PVI incorporating the high frequency AF nests adjacent to the PV ostia had a better single procedure efficacy.

Paroxysmal atrial fibrillation and health-related quality of life: the importance of keeping score

This editorial refers to ‘Impact of the control of symptomatic paroxysmal atrial fibrillation on health-related quality of life’ by L. Guedon-Moreau et al ., on page 634. Atrial fibrillation (AF) causes more impairment of health-related quality of life (QOL) than many physicians appreciate. Although rarely a life-threatening disease, the distress caused by the onset of AF symptoms can be severe. For patients with paroxysmal atrial fibrillation (PAF), QOL as measured by a generic scale (SF-36) has been found to be comparable to that of post-MI patients.1 Poorer QOL can be mostly attributed to AF symptoms; however, QOL is also influenced by patient factors and side effects of AF therapies.2 In the absence of a gold standard method to treat AF patients, relief of symptoms and improving QOL are often the primary goals of therapeutic management.3 In the study conducted by Guedon-Moreau et al .,4 217 symptomatic PAF patients were classified into two groups (‘controlled’ vs. ‘uncontrolled’) and treated with … *Corresponding author. Tel: +1 416 864 5104; fax: +1 416 864 5283, Email: dorianp{at}smh.toronto.on.ca

Impact of pulmonary vein isolation on the autonomic modulation in patients with paroxysmal atrial fibrillation and prolonged sinus pauses

The efficacy of catheter-based pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) and prolonged sinus pauses [bradycardia-tachycardia syndrome (BTS)] has been already described. However, the effects of PVI on autonomic modulation in BTS patients remain to be determined. We, therefore, examined the alteration in the autonomic modulation through the PVI procedure by using a heart rate variability (HRV) analysis of 24 h ambulatory monitoring. This study consisted of 26 symptomatic paroxysmal AF patients either with prolonged sinus pauses on termination of AF (>3.0 s, BTS group, n = 11) or without any evidence of sinus node dysfunction (control group, matched for sex and age, n = 15) who underwent PVI. All 11 BTS patients became free from both AF and prolonged sinus pauses without pacemaker implantation (23 +/- 14 months of observation). The mean heart rate significantly increased in the control group (P < 0.05), but not in the BTS group after the PVI procedure, although the HRV parameters of root-mean-square successive differences in the adjacent NN intervals, standard deviation of the NN intervals, and high frequency did significantly decrease in both groups (P < 0.05). Although the parasympathetic modulation was significantly attenuated after the PVI procedure, the mean heart rate did not increase in the BTS patients, probably due to the pre-existing sinus node dysfunction.

Right atrial preventive and antitachycardia pacing for prevention of paroxysmal atrial fibrillation in patients without bradycardia: a randomized study

To investigate the efficacy of preventive and antitachycardia pacing (ATP) in patients with symptomatic paroxysmal atrial fibrillation (AF) without bradyarrhythmias. In this randomized cross-over pilot study, we randomized 38 symptomatic paroxysmal AF patients 'without' bradyarrhythmias to atrial pacing lower rate 70 ppm and prevention and ATP therapies ON or to atrial pacing lower rate 34 ppm and prevention and ATP therapies OFF during 12 weeks with a 4 week washout period in between. The atrial lead was preferably placed in the inter-atrial septum. Antiarrhythmic drugs were continued during the study. Primary endpoint was AF burden. Mean age was 62 +/- 9 years and 27 (71%) patients had lone AF. Septal lead placement was accomplished in 26 (68%) patients. During the treatment ON, there was a trend for AF burden reduction [from median 3.3% (1.0-15.2) to 2.4% (0.2-12.2), P = 0.06, reduction 27%]. If septal lead placement was accomplished, AF burden reduction was statistically significant [44% reduction, from median 2.5% (1.0-8.0) to 1.4% (0.2-8.4), P = 0.03]. Quality of life and symptoms did not change, also not in the septal group. A hybrid therapy of preventive and ATP pacing and antiarrhythmic drugs may significantly reduce but not abolish AF burden if septal pacing is realized.

Pulmonary Vein Isolation by Robotic-Enhanced Thoracoscopy for Symptomatic Paroxysmal Atrial Fibrillation

Pulmonary vein isolation (PVI) has been shown to be effective treatment of patients with symptomatic paroxysmal atrial fibrillation (PAF). The percutaneous approach is currently the technique of choice. Unfortunately, this procedure has limitations and complications that lead to fluctuating success rates. We explored an alternative technique of robotic-enhanced, closed-chest PVI with an endoscopic microwave-based catheter. Seven symptomatic PAF patients were included in the study. The pulmonary veins were isolated through right (only) robotic-enhanced thoracoscopy on the beating heart. Six patients underwent successful endoscopic PVI. In 1 patient the operation was converted into small right thoracotomy. Operative assessment of the ablation line showed a successful electric block in every patient. Three months after the procedure, the first 5 patients were in permanent sinus rhythm. The 2 other patients had AF but had less frequent and less symptomatic episodes compared with the preoperative situation. On the basis of this preliminary experience, we believe that in the near future endoscopic right-chest robotic-enhanced PVI on the beating heart may become a valid option in the treatment of symptomatic PAF patients. This procedure allows for more-reproducible ablation lines and may avoid many of the pitfalls and drawbacks of the percutaneous approach. Therefore this technique deserves larger prospective evaluation in the treatment of AF.

Evaluation of the effect of bepridil on paroxysmal atrial fibrillation: relationship between efficacy and the f-f interval in surface ECG recordings.

Bepridil, a multi-ion channel blocker, is effective for some types of cardiac arrhythmias, and so its effect on the paroxysmal atrial fibrillation (PAF) was evaluated in the present study, comparing it with class Ic antiarrhythmic drugs. The relationship between efficacy and the f-f interval in the surface ECG recording was also analyzed. Sixty-one symptomatic PAF patients were randomized to a bepridil group (200 mg/day, n=23) or class Ic drug group (flecainide 100-200 mg/day or pilsicainide 75-150 mg/day, n=38). The drug was considered effective for PAF prevention when symptomatic episodes of PAF were decreased to less than 50% during the follow-up period of 2-6 months. The f-f interval in the surface 12-lead ECG trace was evaluated during a PAF episode. Both bepridil and the class Ic drugs were effectively prevented PAF (15/23 (65.2%) vs 24/38 (63.1%) patients, NS). In the class Ic drug group, the f-f interval was longer in the effective cases (114+/-48 ms) than in the non-effective cases (68+/-26 ms, p=0.0002). In contrast, in the bepridil group the f-f interval was shorter in the effective cases (85+/-26 ms) than in the non-effective ones (152+/-45 ms, p=0.0005). When comparing the non-effective cases in the 2 groups, the bepridil group showed a significantly longer f-f interval than the class Ic drug group (p=0.0003). As a result of drug administration, the class Ic drugs prolonged the f-f interval from 78+/-33 ms to 128+/-46 ms (p=0.0004) whereas bepridil showed no change (109+/-39 ms vs 135+/-47 ms). For clinical PAF prevention, the effect of bepridil matched that of class Ic antiarrhythmic drugs. Because bepridil was effective in PAF patients with relatively shorter f-f intervals without prolonging the f-f interval, bepridil is considered to work mainly as a class III antiarrhythmic drug.