Treatment Of Paroxysmal Atrial Fibrillation Research Articles

The treatment of paroxysmal atrial fibrillation in UK primary care

ObjectiveTo determine whether patients with paroxysmal atrial fibrillation (AF) are less likely to be treated with anticoagulants than patients with persistent/permanent AF and to investigate trends in treatment between 2000...

Cryoballoon vs. open irrigated radiofrequency ablation for paroxysmal atrial fibrillation: long-term FreezeAF outcomes

BackgroundEffective treatment of paroxysmal atrial fibrillation (AF) is essential for reducing the risk of stroke and heart failure. Cryoballoon (CB) ablation has been developed as an alternative to the use of radiofrequency (RF) energy for electrical isolation of the pulmonary veins. Herein, we provide long-term data regarding the efficacy of CB ablation in comparison to RF.MethodsFreezeAF was a randomised non-inferiority study comparing CB ablation with RF ablation for the treatment of patients with drug-refractory paroxysmal AF. Procedural success for the long-term follow-up (30 months) was defined as freedom from AF with an absence of persistent complications.ResultsOf the 315 patients that were randomised and received catheter ablation, 292 (92.7%) completed the 30-month follow-up (147 in the RF group and 145 in the CB group). The baseline characteristics of the RF and CB groups were similar. Single-procedure success was achieved by 40% of patients in the RF group and 42% of the CB group (p < 0.001 for non-inferiority). When including re-do procedures in the analysis, the multiple procedure success rate was 72% in the RF group and 76% in the CB group.ConclusionThe data provide long-term evidence that CB ablation is non-inferior to RF ablation, with high proportions of patients reporting freedom from AF 30 months after the index procedure.Trial registrationClinicalTrials.gov Identifier: NCT00774566; first registered October 16, 2008; first patient included October 20, 2008.

Prescribing dronedarone for paroxysmal atrial fibrillation: how is it done across the UK and is it safe?

Dronedarone, a useful treatment for paroxysmal atrial fibrillation, is often only prescribed in secondary care. To support a protocol shared between primary and secondary care, dronedarone use was audited in...

Antiarrhythmic medication is superior to catheter ablation in suppressing supraventricular ectopic complexes in patients with atrial fibrillation

BackgroundSupraventricular ectopic complexes (SVEC) originating in the pulmonary veins are known triggers of atrial fibrillation (AF) which led to the development of pulmonary vein isolation for AF. However, the long-term prevalence of SVEC after catheter ablation (CA) as compared to antiarrhythmic medication (AAD) is unknown. Our aims were to compare the prevalence of SVEC after AAD and CA and to estimate the association between baseline SVEC burden and AF burden during 24months of follow-up. MethodsPatients with paroxysmal AF (N=260) enrolled in the MANTRA PAF trial were treated with AAD (N=132) or CA (N=128). At baseline and 3, 6, 12, 18 and 24months follow-up patients underwent 7-day Holter monitoring to assess SVEC and AF burden. We compared SVEC burden between treatments with Wilcoxon sum rank test. ResultsPatients treated with AAD had significantly lower daily SVEC burden during follow-up as compared to CA (AAD: 19 [6–58] versus CA: 39 [14–125], p=0.003). SVEC burden increased post-procedurally followed by a decrease after CA whereas after AAD SVEC burden decreased and stabilized after 3months of follow-up. Patients with low SVEC burden had low AF burden after both treatments albeit this was more pronounced after CA at 24months of follow-up. ConclusionAAD was superior to CA in suppressing SVEC burden after treatment of paroxysmal AF. After CA SVEC burden increased immediately post-procedural followed by a decrease whereas after AAD an early decrease was observed. Lower SVEC burden was highly associated with lower AF burden during follow-up especially after CA.

Should Ablation Be First-Line Therapy for Patients with Paroxysmal AF?

Atrial fibrillation is the most common cardiac arrhythmia and the number of patients is expected to continuously increase in the next years. Catheter ablation is an effective, safe, and well-established treatment for patient with symptomatic and drug-resistant paroxysmal atrial fibrillation (PAF). Over the last decade, there was an increasing body of evidence demonstrating superiority of catheter ablation over antiarrhythmic drugs (AADs) in maintaining sinus rhythm. However, randomized clinical trials have not been conclusive to consider catheter ablation as a first-line therapy for PAF. The encouraging results of RAAFT Trial were not confirmed in the MANTRA-PAF Trial and in the RAAFT-2 Trial. Recent meta-analyses showed that catheter ablation is more effective than AAD therapy as a first-line treatment for PAF. In particular, relatively young patients and patients with no or minimal cardiovascular disease are the subpopulation that benefitted more from catheter ablation. On the other hand, the meta-analysis showed that catheter ablation causes more severe side effects than AAD therapy, underling the importance of patient selection and operator experience. To date, there are no univocal evidences to consider catheter ablation as a first-line therapy for PAF. Apart from patients' preference and avoidance of toxicity of AADs, the published data are supportive to consider a first-line catheter ablation in a peculiar subpopulation of patients. In particular, younger patients, patients with sinus node dysfunction related to AF, and patients with tachycardiomyopathy are the subgroups that seem to be good candidates for catheter ablation as a first-line therapy for PAF.

Efficacy and safety of the second generation cryoballoon ablation for the treatment of paroxysmal atrial fibrillation in patients over 75 years: a comparison with a younger cohort

In this double centre, retrospective study, we aimed to analyse the 1-year efficacy and safety of cryoballoon ablation (CB-A) in patients older than 75 years compared with those younger than 75-years old. Fifty-three consecutive patients aged 75 years or older with drug-resistant paroxysmal AF (PAF) who underwent pulmonary vein isolation (PVI) by the means of second generation CB-A, were compared with 106 patients aged <75 years. The mean age in the study group (>75 years) was 78.19 ± 2.7 years and 58.97 ± 8.5 in the control group. At 1-year follow-up the global success rate was 83.6% and did not significantly differ between older (10/53) and younger patients (16/106) (81.1 vs. 84.9%, P = 0.54). Transient phrenic nerve palsy was the most common complication which occurred in eight patients in the younger group and in three in the older group (7.5 vs. 5.7%, respectively, P = 0.66). The results of our study showed that CB-A for the treatment of PAF is a feasible and safe procedure in elderly patients, with similar success and complications rates when compared with a younger population.

PROSPECTIVE CRYOBALLOON DOSING STUDY BASED ON TIME-TO-ISOLATION

Background: Cryoballoon ablation is an effective treatment for Paroxysmal Atrial Fibrillation (PAF). Optimal dosing of the second-generation cryoballoon (CB2; Arctic Front AdvanceTM, Medtronic Inc) is still unclear. Time-to-effect (TTE) is the physiologic end-point when acute pulmonary vein signals

Vagal denervation in atrial fibrillation ablation: A comprehensive review

Although pulmonary vein isolation is accepted as an established interventional treatment in paroxysmal atrial fibrillation (AF), alternative modalities are being investigated because of the high recurrence rates of nonparoxysmal forms. One of the alternative ablation approaches is ablation or modification of vagal ganglionated plexi (VGP). The technique has not only been used in vagally mediated AF but also investigated in paroxysmal and nonparoxysmal AF. Clinical studies demonstrate significant discrepancy related with detection of VGP sites or ablation targets and definition of procedurel end-points, so far. In this review, we aimed to discuss the current data on the role of VGP in the pathogenesis of AF and potential therapeutic implications of ablation of these ganglia.

Scar-based catheter ablation for persistent atrial fibrillation.

Percutaneous catheter ablation can be an effective treatment for paroxysmal atrial fibrillation. However, catheter ablation for the treatment of persistent atrial fibrillation or long-standing persistent atrial fibrillation is associated with success rates of 45-50% at 1 year. To address the challenge of ablating patients with persistent atrial fibrillation, several approaches have been proposed. Atrial scar-based catheter ablation is a promising strategy for ablation of persistent atrial fibrillation. In this review, we outline the role of atrial scar/fibrosis in the pathophysiology of atrial fibrillation and how this encouraged clinical studies assessing the atrial substrate using scar-based mapping. We highlight current approaches to voltage mapping of atrial scar in patients with atrial fibrillation. The characteristics, techniques, and outcomes of recently published studies evaluating scar-based catheter ablation strategies for the treatment of atrial fibrillation are discussed. Finally, we explore the role of noninvasive tools such as delayed enhancement MRI to assess the atrial fibrillation substrate. In summary, the optimal catheter ablation strategy for persistent atrial fibrillation remains unknown. Current data highlight the need for a better understanding of the substrate and mechanisms of arrhythmia maintenance in this population. Atrial scar-based catheter ablation has recently emerged as a promising strategy for ablation of atrial fibrillation. However, the available data have limitations that preclude definitive conclusions regarding the utility of this strategy. Further research is needed to assess the role of scar-based ablation for persistent atrial fibrillation.

Hybrid ablation for atrial fibrillation: current approaches and future directions.

Catheter ablation of atrial fibrillation has rapidly evolved during the past decade: although the treatment of paroxysmal atrial fibrillation via a transcatheter approach has been consistently successful, persistent and long-standing atrial fibrillation still represents a major clinical challenge with less favorable outcomes to date. Because novel, minimally invasive surgical approaches have been developed for atrial fibrillation ablation, the aim of the present review is to analyze the current evidence surrounding the integration of surgical and transcatheter strategies in a hybrid fashion for the treatment of atrial fibrillation. Long-standing persistent, atrial fibrillation requires further understanding. Wide antral circumferential ablation of the pulmonary veins represents the cornerstone of any ablation therapy. Additional linear lesions and/or targeting complex fractionated atrial electrograms may also be considered. One of the limitations is achieving a transmural lesion. The combined endocardial and epicardial approach may represent a superior approach. Hybrid ablation of atrial fibrillation represents a novel therapeutic strategy for the treatment of complex scenarios, such as long-standing persistent atrial fibrillation. A specialized team including dedicated surgeons and cardiologists appears to be crucial in order to achieve durable and satisfactory outcomes following hybrid ablation of atrial fibrillation.

Atrial fibrillation beyond the arrhythmia: hypercoagulability, adipose tissue, and fibrotic remodelling.

![Graphic][1] Atrial fibrillation is the most common sustained arrhythmia, and its treatment continues to be a challenge. Its managment has recently been reviewed extensively in the 2016 ESC Guidelines on Atrial Fibrillation.1 Current concepts focus on the atrial substrate and triggers from the pulmonary veins as its primary mechanisms. Remodelling of artrial tissue appears to provide the substrate upon which the atrial arrhythmia can develop. In their review article ‘ Magnetic resonance imaging of atrial fibrosis: redefining atrial fibrillation to a syndrome ’,2 Pim Gal and Nassir F. Marrouche from the University of Utah School of Medicine in Salt Lake City, USA remind us that delayed enhancement-magnetic resonamce imaging (DE-MRI) has recently been introduced in the diagnosis and treatment of atrial fibrillation for the assessment of atrial fibrosis, which is considered the hallmark of the arrhythmogenic substrate in atrial fibrillation. Atrial fibrosis is an independent predictor of arrhythmia recurrences. Post-ablation DE-MRI allows for the assessment of the total scar burden, the degree of complete encirclement of pulmonary veins, and the assessment of residual fibrosis, all strong predictors of arrhythmia recurrences post-ablation. Current pathophysiological perspectives for atrial fibrillation are heavily based on the adage ‘AF begets AF’. Potentially, atrial fibrosis as such is a disease process that triggers the initiation and maintenance of atrial fibrillation While anticoagulation with vitamin K antagonists and currently mostly with novel oral anticoagulants (NOACs) prevents the most important complication of atrial fibrillation,3,4 the arrhythmia itself is managed either with drugs or with catheter ablation. Indeed, catheter ablation has become an effective treatment of paroxysmal atrial fibrillation;5 however, its use in patients with persistant atrial fibrillation is less well established. In a second clinical review entitled ‘ Catheter ablation in patients with persistent atrial fibrillation ’, Paulus Kirchhof … [1]: /embed/inline-graphic-1.gif

HotBalloon Ablation of the Pulmonary Veins for Paroxysmal AF: A Multicenter Randomized Trial in Japan

BackgroundPoint-by-point catheter ablation is an established treatment for drug-refractory paroxysmal atrial fibrillation (PAF). However, it is time consuming, requires excellent technique to achieve complete pulmonary vein (PV) isolation, and is associated with severe complications. ObjectivesThe purpose of this study was to evaluate the safety and effectiveness of a HotBalloon ablation (HBA) compared with antiarrhythmic drug therapy (ADT) for the treatment of PAF. MethodsA prospective multicenter randomized controlled study was conducted in Japan. Patients with symptomatic PAF refractory to antiarrhythmic drugs (Class I to IV) were randomized to HBA or ADT at a 2:1 ratio and assessed for effectiveness in a comparable 9-month follow-up period. ResultsA total of 100 patients in the HBA group and 43 patients in the ADT group received treatment at 17 sites. HBA procedure produced acute complete PV isolation in 98.0% (392 of 400) of the PVs and in 93.0% (93 of 100) of patients in the HBA group. The chronic success rates after the 9-month effective evaluation period were 59.0% in the HBA group (n = 100) and 4.7% in the ADT group (n = 43; p < 0.001). The incidence of major complications was 11.2% (15 of 134 patients). The incidences of PV stenosis (>70%) and transient phrenic nerve injury were 5.2% and 3.7%, respectively. The mean fluoroscopy time was 49.4 ± 26.6 min (n = 134), and the mean procedure duration was 113.9 ± 31.9 min (n = 133). ConclusionsThis study demonstrates the superiority of HBA compared with ADT for treatment of patients with PAF, and a favorable safety profile.

P-90 Movement against arrhythmia – a comprehensive behavioural program for the treatment of paroxysmal atrial fibrillation

Aim Published data, mainly from studies LEGACY and CARDIO-FIT shows the positive contribution of intervention the lifestyle factors on the frequency, duration and intensity of the episodes of paroxysmal atrial fibrillation (AF). Target Data presentation of the pilot group of patients with paroxysmal AF. Methods Multicenter intervention study. Consequent patients in outpatient clinic of internal medicine in the city over 300,000 inhabitants and heart rhytm disorders clinic in area cardiocentre with paroxysmal AF. All offered the option of an annual program depending on physiotherapy intervention leading to a gradual increase in regular physical activity, according to FITT ( EFSMA). Furthermore, treatment of blood pressure, lipids, symptoms of anxiety and stress management, nutrition intervention. Evaluation of the frequency, intensity and duration of episodes of AF, according to the questionnaire AFSS. Simultaneously is evaluated total duration of AF by the weekly loop monitor. Cohort 23 patients, 66 ± 3.2 years, 10 men/13 women, BMI 31.1 ± 5.3, total cholesterol 4.7 ± 1.1 mmol/l, fasting blood glucose of 5.5 +/−1.2 mmol/l. Maximum performance evaluated by exercise test 7.0 ± 2.9 METs. The mean LVEF is 52.3 ± 2.7%. The average duration of AF was 97 ± 32 min per week. Initial evaluation of the severity of AF by AFSS 27.2 ± 10.2 points. Results Initial 3 month intensive intervention have completed up to date August the 15 th 2016 18 patients. We have observed the improvement in cardiovascular fitness by 0.5 ± 0.1 METs. There was a decrease in weight for 1.9 ± 0.5 kg. 1 patient left the program due to “time-consuming reason”. We have signed the decrease in AF severity by AFSSA 11.2 ± 3.5 points. Conclusion We present pilot group data of the patients with paroxysmal AF, to which in addition to optimal pharmacological therapy we have intervened risk lifestyle factors - physical activity, structure and energy content of diet, stress management, smoking cessation, treatment of hypertension and dyslipidemia. The pilot set in the initial 3-months demonstrates the feasibility and sustainability of the program for all motivated patients with AF.

Invasive management of atrial fibrillation

AbstractAtrial fibrillation (AF), the most common sustained cardiac arrhythmia, affects 1% of the general population with increased incidence in the elderly population and is an important contributor to population morbidity and mortality. This article reviews the current invasive management of AF. Pulmonary vein isolation (PVI) is the cornerstone of current ablation techniques for the treatment of paroxysmal atrial fibrillation (AF). Despite proven PVI, a subset of patients still experience recurrent arrhythmia, mostly due to a higher prevalence of non‐PV triggers. PVI is associated with worse arrhythmia‐free survival in patients with persistent AF than those with paroxysmal AF. Accumulating data have shown that elimination of atrial fibrillation 9 (AF) sources (rotors or rotational activity, drivers, electrograms with continuous activity) should be the goal in persistent AF ablation. Pulmonary vein isolation, linear lesions, and complex fractionated atrial electrograms (CFAEs) ablation have shown limited efficacy in patients with persistent AF. A combined approach using voltage, CFAEs, and dominant frequency (DF) mapping may be helpful for the identification of AF sources and subsequent focal substrate modification. The fibrillatory activity is maintained by intramural reentry centered on fibrotic patches. Voltage mapping may assist in the identification of fibrotic areas. Stable rotors display the higher DF and possibly drive AF. Furthermore, the single rotor is usually consistent with organized AF electrograms without fractionation. It is therefore quite possible that rotors are located at relatively “healthy islands” within the patchy fibrosis. This is supported by the fact that high DF sites have been negatively correlated with the amount of fibrosis. CFAEs are located in areas adjacent to high DF. In conclusion, patchy fibrotic areas displaying the maximum DF along with high organization index and the lower fractionation index are potential targets of ablation. Prospective studies are required to validate the efficacy of substrate modification in left atrial ablation outcomes.Answer questions and earn CME: https://wileyhealthlearning.com/Activity2/4469458/Activity.aspx

Long-term efficacy of catheter ablation as first-line therapy for paroxysmal atrial fibrillation: 5-year outcome in a randomised clinical trial

ObjectiveThe Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation (MANTRA-PAF) trial compared radiofrequency catheter ablation (RFA) with antiarrhythmic drug therapy (AAD) as first-line treatment for paroxysmal atrial fibrillation...

Novel P Wave Indices to Predict Atrial Fibrillation Recurrence After Radiofrequency Ablation for Paroxysmal Atrial Fibrillation.

BackgroundCircumferential pulmonary vein isolation (CPVI) is a widely used treatment for paroxysmal atrial fibrillation (AF). Several P wave duration (PWD) parameters have been suggested to predict post-ablation recurrence, but their use remains controversial. This study aimed to identify novel P wave indices that predict post-ablation AF recurrence.Material/MethodsWe selected 171 consecutive patients undergoing CPVI for paroxysmal AF. Electrocardiography (ECG) recordings were obtained at the beginning and the end of ablation. PWD was measured in all 12 leads. The PWD variation was calculated by subtracting the pre-ablation PWD from the post-ablation PWD.ResultsPWD was significantly shortened in leads II, III, aVF, and V1 after ablation. During a mean follow-up of 19.96±4.32 months, AF recurrence occurred in 32 (18.7%) patients. No significant differences in baseline characteristics or pre- or post-ablation PWD were observed between the AF recurrence and non-recurrence groups. Patients with AF recurrence exhibited a smaller PWD variation in leads II (1.21(−0.56, 2.40) vs. −5.77(−9.10, −4.06) ms, P<0.001), III (−5.92(−9.87, 3.27) vs. −9.44(−11.89, −5.57) ms, P=0.001) and V1 (−4.43(−6.64, −3.13) vs. −6.33(−8.19,−4.59) ms, P=0.003). Multivariable logistic regression analysis demonstrated that smaller PWD variations in lead II and III were independent risk factors for AF recurrence. PWD variation ≥−2.21 ms in lead II displayed the highest combined sensitivity and specificity (85.29% and 83.94%, respectively) for predicting post-ablation AF recurrence. A PWD variation ≥0 ms displayed the best practical value in predicting AF recurrence.ConclusionsPWD variation in lead II is an effective predictor of post-ablation AF recurrence.

Reduction of radiation exposure in cryoballoon ablation procedures: a single-centre study applying intracardiac echocardiography and other radioprotective measures

The population treated with cryoballoon (CB) ablation is relatively young, and radiation protection is of major importance. We aimed to demonstrate that radiation exposure can be markedly reduced by intracardiac echocardiography (ICE) and optimized settings of the X-ray system. We analysed 100 patients undergoing CB pulmonary vein isolation (PVI) for treatment of paroxysmal atrial fibrillation. In 50 consecutive patients (25 male, 59 ± 13 years; Group 1), we used ICE, skipped PV angiography prior to CB inflation, and avoided fluoroscopy whenever possible. Furthermore, we reduced the frame rate, minimized distance between patient and detector, and consequently applied collimation. These patients were compared with 50 similar preceding patients in Group 2 (29 male, 61 ± 12 years). Total fluoroscopy time was reduced from 18 ± 6 min in Group 2 to 12 ± 5 min in Group 1 (P < 0.001). Moreover, the dose area product was significantly lower (1555 ± 1219 vs. 4935 ± 2094 cGycm2, P < 0.001), total freezing time was significantly shortened (1855 ± 399 vs. 2121 ± 756 s, P = 0.031), and contrast media use was significantly reduced (66 ± 25 vs. 109 ± 27 mL, P < 0.001). At the same time, total procedure duration and complication rates did not differ significantly between both groups. After a 12 months follow-up, a similar percentage of patients was free from recurrences (74% in Group 1 vs. 78% in Group 2, P = 0.640). Radiation exposure in CB PVI can be markedly reduced without prolonging procedure times, affecting the outcome or complication rates. Moreover, ICE seems to shorten total freezing time.

Focal impulse and rotor modulation as a stand-alone procedure for the treatment of paroxysmal atrial fibrillation: A within-patient controlled study with implanted cardiac monitoring

Focal impulse and rotor modulation (FIRM) has been proposed as a novel approach for the treatment of atrial fibrillation (AF). This study aimed to investigate the efficacy of FIRM as a stand-alone procedure for the treatment of paroxysmal AF. A total of 27 patients with paroxysmal AF underwent sequential biatrial computational mapping. Sites with repetitive centrifugal or spiral reentry-like activity were considered to be AF-sustaining sources and targeted by irrigated radiofrequency (RF) ablation. All patients were seen in the outpatient clinic after 1, 3, and 6 months and thereafter every 6 months. Cardiac monitors were implanted 3 months before ablation in 17 patients (63%). Repetitive activity interpreted as sustained AF sources was found in all patients, with an average of 3.0 ± 1.1 sources located in the left atrium and 0.6 ± 0.6 sources in the right atrium. The majority of sources were rotors (95%). The total source-ablation radiofrequency time was 20.0 ± 9.0 minutes. At 15.2 ± 3.9 months of follow-up, the prespecified end point of <1% AF burden (outside a 3-month blanking period) was achieved in 2 of the 17 continuously monitored patients (12%). Of all the 27 patients who underwent FIRM, AF episodes of ≥30 minutes were recorded in 23 (85%), while AF episodes ≥60 minutes were recorded in 21 patients (78%). This study suggest that biatrial ablation of localized patient-specific sources alone, as detected by this method, is not sufficient to reduce paroxysmal AF burden in the majority of patients.

Эффективность антиаритмической терапии в раннем послеоперационном периоде катетерной изоляции устьев легочных вен для лечения пароксизмальной формы фибрилляции предсердий

Эффективность антиаритмической терапии в раннем послеоперационном периоде катетерной изоляции устьев легочных вен для лечения пароксизмальной формы фибрилляции предсердий

Catheter ablation in atrial fibrillation: a state-of-the-art review

Catheter ablation in atrial fibrillation: a state-of-the-art review Antonio Sorgente,1 Riccardo Cappato2 1Heart and Vascular Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; 2Arrhythmia and Electrophysiology Research Center, IRCCS Humanitas Clinical and Research Center, Rozzano, Milan, Italy Abstract: There are no doubts that paroxysmal atrial fibrillation is driven by triggers located at the ostia of pulmonary veins. Cardiac electrophysiologists have to thank the seminal work of Dr Haissaguerre in demonstrating for the first time this finding in human hearts in 1998. On this premise, atrial fibrillation ablation performed through pulmonary vein electrical isolation has become a mainstay of the non-pharmacological treatment of this arrhythmia. The scope of this brief and concise review is to provide a state-of-the-art of catheter ablation of atrial fibrillation, considering the obvious different outcomes in different varieties of atrial fibrillation. If the results in the treatment of paroxysmal atrial fibrillation are really promising, it is clear that more research and more clinical trials are warranted for the cure of non-paroxysmal atrial fibrillation, which cause seems to be more multifactorial and less dependent on electrical triggers. Keywords: atrial fibrillation, arrhythmia, sinus rhythm, pulmonary veins, anticoagulation, catheter ablation