Atrial Fibrillation Undergoing Catheter Ablation Research Articles

Editorial to “Impact of frailty in patients with non‐valvular atrial fibrillation undergoing catheter ablation”

Editorial to “Impact of frailty in patients with non‐valvular atrial fibrillation undergoing catheter ablation”

Associations between stroke risk factors and left atrial low-voltage areas in patients with atrial fibrillation undergoing catheter ablation from the REAL-AF registry

Abstract Background Prior research indicates that increased left atrial low-voltage areas (LA LVA) are linked to comorbidities and CHA2DS2-VASc score in patients with persistent atrial fibrillation (PerAF) undergoing catheter ablation. However, given the heterogeneity of AF where patients may transition between paroxysmal AF (PAF) and PerAF types, it is biologically plausible that these associations span all forms of AF. Purpose To investigate the relationship of stroke demographics and comorbidities to LA LVA and AF type in a multicenter registry of patients undergoing catheter ablation. Methods The Real-world Experience of Catheter Ablation for the Treatment of Symptomatic PAF and PerAF Using Novel Contact Force Technologies registry (REAL-AF) is a prospective, observational multicenter registry of patients undergoing catheter ablation. We evaluated 6053 patients undergoing first-time catheter ablation for both PAF and PerAF to identify associations between stroke risk factors and LA LVA. LA LVA was determined in contact maps as bipolar voltage <0.50 mV. Mapping was completed using 5-spline high-density catheters before ablation. LA LVA was categorized into low (<5%) vs. high (≥5%) based on preliminary data. Analyses were conducted using independent samples t-test and Chi-square test. Results LA LVA was associated with greater CHA2DS2-VASc score (3.2 vs. 2.5, p <0.001). Age 75+ (Odds ratio (OR): 2.22, p<0.001), congestive heart failure (CHF) (OR: 2.01, p<0.001), female sex (OR): 1.51, p<0.001), vascular disease (OR: 1.50, p<0.001), age 65-74 (OR: 1.20, p=0.001), hypertension (OR: 1.38, p<0.001), history of stroke (OR: 1.29, p=0.004) and diabetes (OR: 1.25, p=0.001) were also associated with LA LVA (Table 1). These associations remained significant among a subgroup of those presenting in normal sinus rhythm (N = 3546). Patients with CHF (OR: 2.09, p<0.001), hypertension (OR: 1.89, p<0.001) and male sex (OR: 0.60, p<0.001) were more likely to have PerAF in the LVA ≥5% subgroup (n=1594) (Table 2). All other components of the CHA2DS2-VASc score were not significantly associated with AF type in this subgroup. While there was a significant association between AF type and CHA2DS2-VASc score (PAF: 3.15, PerAF: 3.42, p<0.001) in the LA LVA ≥5% subgroup, the effect size was small (Cohen’s d = -0.179). Conclusion LA LVA ≥5% was associated with all separate components and overall CHA2DS2-VASc score. In patients with LA LVA ≥5%, there were only associations between PerAF and CHF, hypertension, and male sex, implying a special role in substrate progression. Our findings suggest that LA LVA may represent a more sensitive clinical phenotyping tool of AF rather than current duration-based ones. This is the largest study to our knowledge in elucidating the relationship between increased LA LVA and stroke risk factors in the AF population.

Agreement of left atrial pressure with clinical risk scores and echocardiographic features in patients with atrial fibrillation referred for catheter ablation

Abstract Background Heart failure with preserved ejection fraction (HFpEF) frequently coexists with atrial fibrillation (AF). The diagnosis of HFpEF in AF is difficult because some diagnostic criteria for HFpEF may be associated with AF instead of HFpEF per se. Left atrial pressure (LAP) ≥15 mmHg has been used to confirm the diagnosis of HFpEF. Purpose We aimed to 1) determine LAP measurements in patients with AF undergoing catheter ablation; 2) assess the agreement between LAP measurement HFpEF risk scores and 3) determine the association between LAP measurement and clinical and echocardiographic features. Methods Consecutive patients with paroxysmal or persistent AF scheduled for catheter ablation were included. Participants were considered to have HFpEF if the mean LAP was ≥15 mm Hg. The LAP was measured only in sedated patients with spontaneous breathing. Participants had high probability of HFpEF if scored >5points in H2FPEF and/or ≥5 points in HFA-PEFF score. Results Of 107 participants, 29 (27%) had HFpEF according to mean LAP and 32 (30%) had high probability of HFpEF according to HFpEF scores. The highest agreement of HFpEF risk scores relative to elevated LAP was observed for H2FPEF score; among patients with mean LAP ≥15 mm Hg, 38% [n=11/29] of them had also high risk of HFpEF based on H2FPEF score, whereas only 10% [n=3/29] had high risk of HFpEF based on HFA-PEFF score. In multivariable analysis, the independent predictors of HFpEF were left ventricular ejection fraction (LVEF; OR 0.77, 95%CI 0,.64-0.91), intraventricular septum diameter (IVSd; OR 1.75, 95%CI 1.11-2.74), global longitudinal strain (GLS; OR 1.24, 9%CI 1.05-1.48). Conclusions More than one-fourth of patients scheduled for catheter ablation had HFpEF according to elevated LAP. The highest agreement to elevated LAP was observed for the H2FPEF score. Predictors of HFpEF diagnosis were lower LVEF, higher IVSd and GLS.

Efficacy of catheter ablation in patients with persistent atrial fibrillation on chronic ibrutinib therapy

Abstract Background Ibrutinib represents a cornerstone in the management of B-Cells malignancies and chronic lymphatic leukaemia. This drug however was associated with a 5-fold increased risk of developing atrial fibrillation (AF). The consequences of AF in this category of frailty patients such as heart failure may lead to the need of Ibrutinib withdrawal, which is considered a disease modifying therapy. Purpose This study aims to evaluate the safety and efficacy of catheter ablation in managing AF in patients on chronic ibrutinib therapy. Methods this study evaluated 20 consecutive patients from two centres in Italy who developed persistent AF during chronic therapy with Ibrutinib for chronic lymphatic leukaemia or small lymphocytic lymphoma and underwent AF catheter ablation from 2016 to 2020. Antiarrhythmic drugs were withdrawn because of side effects and drug interaction. All receive pulmonary vein (PV) isolation + isolation of left atrial posterior wall (PW) and superior vena cava. A standardized protocol was performed to confirm persistent PVI and elicit any triggers originating from non-PV sites. Ablation of non-PV sites triggering runs of atrial tachyarrhythmias was left to operator's discretion. Exclusion criteria were age<18 years and history of AF before ibrutinib therapy. Patients were monitored for arrhythmia at quarterly office visits, ECGs, 7-day Holter monitoring and event recorders during the first year followed by biannual checkups during the remaining part of the follow-up period. Results 12 patients received PV+PW+SVC isolation plus ablation of non-PV trigger (Group 1) whereas 8 receive only PV+PW+SVC isolation (Group 2). 10 (83,3%) patients in group 1 remained arrhythmia-free without the need for additional antiarrhythmic drugs while only 3 (37,5%) in group 2 maintained sinus rhythms. Non pulmonary triggers were mostly found in left atrial appendage (5/12, 41,6%), coronary sinus (4/12, 33,3%) and crista terminalis (3/12 25%). More than one trigger was found in 4 (33.3) patients. After 22.3 ±3.6 months follow-up, patients with ablation of induced non-PV triggers had a significantly higher arrhythmia control than those whose triggers were not ablated (Chi – square p value: 0.035; Log rank p value: 0.014) (Fig.1). 5 patient that received left atrial appendage isolation underwent a left atrial appendage closure with Watchman device 3 months after atrial fibrillation ablation. Conclusion Catheter ablation in this category of patients seems to be a safe and effective tool for managing atrial fibrillation in patients with persistent AF on chronic ibrutinib therapy; an ablation strategy that includes as a first line therapy non pulmonary vein triggers appears to be an effective approach when compared to pulmonary vein plus posterior wall only. This approach will allow continuation of ibrutinib treatment, which markedly enhances the prognosis and diminishes the risk of adverse cardiovascular events in this patient population.Kaplan-Meier curve showing recurrence-fr

Impact of catheter ablation on erectile dysfunction in atrial fibrillation patients

Abstract Background Previous studies suggested a consequential link between impaired diastolic function, which could be related to atrial fibrillation (AF), and a heightened susceptibility to erectile dysfunction (ED). No data exists regarding the correlation between restoration of sinus rhythm and ED. Objective This study investigates the influence of cardiac ablation on the need for phosphodiesterase-5 inhibitors (PDEF5i) medications in patients with atrial fibrillation. Methods We retrospectively investigated by chart review 220 consecutive male patients with erectile dysfunction who underwent AF catheter ablation and performed at least one follow-up visit afterward between 2019 and 2022. Exclusion criteria were considered patients older than 85 years old and those assuming non-selective beta-blockers or antidepressant medications. Patients were monitored for arrhythmia at quarterly office visits, ECGs, 7-day Holter monitoring, and event recorders during the first year. The Chi-Square test was utilized to statistically analyze the correlation between the achievement of sinus rhythm post-ablation and the discontinuation of ED medications. Results During follow-up 182 (82.7%) pts remained in sinus rhythm after one year (Group 1). Among these, 141 (77.4%) reported withdrawal of ED medication and a marked improvement in their overall sexual health and satisfaction. Whereas among the 38 (17.3%) who did not maintain stable sinus rhythm during follow-up (Group 2), only 2 (5.2%) reported a reduction in ED medication. A statistically significant difference was observed when comparing the two groups (p<0.001, OR 0,016, 95%, 0,003 - 0,061). Moreover, patients maintaining sinus rhythm for more than six months exhibited a higher tendency to stop ED medications compared to those with shorter periods of sinus rhythm or with recurrent AF episodes. Conclusion Our findings suggest a strong association between the achievement of sinus rhythm through cardiac ablation and a reduction PDEF5i in patients affected by ED medications in AF patients. This highlights the potential dual benefits of cardiac ablation in improving quality of life and in improving sexual health.

Characterization and clinical significance of hemolysis after pulsed-field ablation for atrial fibrillation: insights from a multicentric analysis

Abstract Background Pulsed-field ablation is a novel non-thermal ablation modality which is being increasingly used in clinical practice for the treatment of atrial fibrillation (AF). While the susceptibility of erythrocytes to electroporation is well-established, the effect of cardiac PFA technologies on erythrocyte destruction has not been described so far. Purpose The aim of this study was to investigate whether PFA induces clinically significant hemolysis. Methods We included 187 patients undergoing AF catheter ablation with either PFA (n=145) or RFA (n=42) at four high-volume centers. PFA was performed using a pentaspline catheter (biphasic, bipolar pulses of 2kV) and RFA with a 3.5 mm irrigated-tip catheter (40-60 W). The lesion set comprised pulmonary vein isolation (PVI) for paroxysmal AF and PVI ± additional lesions/lines for persistent AF. Established biomarkers of hemolysis, anemia and renal function were analyzed in blood samples obtained at baseline (T1), at the end of ablation (T2) and 24 hours after the procedure (T3). Results Baseline characteristics were well-balanced between groups (65.5 ± 9.6 years, 72.7% male, p>0.05). The ablation procedures comprised a mean of 61.4 ± 27.2 deliveries (PFA group) and a mean RF duration of 31.0 ± 16.3 min (RFA group). Atrial ablation in addition to PVI was performed in 55.2% vs. 61.9% patients, respectively (p=0.469). The direct hemolysis marker free plasma hemoglobin was significantly higher with PFA (592.8 ± 330.6 mg/dl) than with RFA (186.6 ± 215.8 mg/dl, p<0.001) at the end of ablation. A strong correlation was found between free plasma hemoglobin and PFA deliveries (Pearson r=0.615, p<0.001). PFA was further associated with a 2.2-fold increase in bilirubin (21.3 ± 11.3 vs. 9.6 ± 4.7 µmol/l), a 2.4-fold decrease in haptoglobin (0.5 ± 0.4 vs. 1.2 ± 0.4 g/l) and a 1.8-fold increase in LDH (352.7 ± 115.7 vs. 192.2 ± 51.6 U/l, T3 vs. T1, all p<0.001). There were no significant changes in bilirubin and haptoglobin in the RFA group (p>0.05). A slight decrease in red blood cells, hemoglobin and hematocrit was detected after both PFA and RFA (Abstract Figure), with no significant differences between groups (all p>0.05). While mean creatinine levels and glomerular filtration rates did not significantly change after ablation in either group, acute kidney injury occurred in 4/124 (3.2%) with PFA vs. 0/32 (0%) with RFA (p=0.303). Conclusion Intravascular hemolysis is a frequent finding after PFA for AF and increases with the number of PFA deliveries. While PFA was not associated with clinically significant anemia, the incidence of acute kidney injury in the present study warrants future large-scale investigations assessing the biological impact and nephrotoxicity of PFA-induced hemolysis.Abstract Figure

Increased left atrial pressure is associated with fibrosis, elevated mechanical load and ventricular diastolic dysfunction in patients undergoing AF catheter ablation

Abstract Background Increased left atrial filling pressures might be a hallmark feature of atrial cardiomyopathy which has been associated with an increased incidence of atrial fibrillation (AF) recurrence even after successful pulmonary vein isolation (PVI). The interplay between left atrial pressure, measured during the ablation procedure, and other parameters characterising atrial and ventricular remodelling in patients with AF remains elusive. Methods and Results Between 2018 and 2022, 182 patients undergoing PVI for paroxysmal or persistent AF were included in the study. Mean left atrial pressure (mLAP) was measured invasively during the ablation procedure after transseptal puncture. A mLAP higher than 15 mmHg was considered the cut-off value for LA hypertension. Bipolar high-density 3D electro-anatomical maps (Carto) obtained during the procedure were used to manually quantify low-voltage (<0.5 mV) and normal voltage areas of the LA surface and a global low-voltage/normal voltage ratio index was derived. Contemporary transthoracic echocardiography data were included to evaluate LV systolic and diastolic function and blood samples were obtained post-procedurally from all patients. In bivariate linear regression analysis, mLAP reached only modest correlation with E/e’ as an imaging marker of diastolic dysfunction (R=0.31, p=0.005) (Figure 1A), with particular differences in mLAP values between patients with marked diastolic impairment (E/e’ > 15) vs. subgroups with mild dysfunction ( 8 < E/e’ ≤ 15) or normal diastolic function (E/e’ ≤ 8 ) (Figure 1B), log NT proBNP (R=0.34, p<0.001) (Figure 1C) and low-voltage/normal voltage ratio index (R=0.21, p=0.014) (Figure 1D). For a total of 158 patients, data about 1 year recurrence of AF were available, of these 22 (13.9%) had a recurrence after two procedures using cryo-energy for the index PVI and radiofrequency ablation for the re-PVI (second procedure). A Kaplan-Meier analysis and log-rank test showed a trend but no statistical significance regarding an increased AF recurrence rate between patients with and without LA hypertension (χ2 = 2.63, p= 0.09) (Figure 2). Conclusion Direct intra-procedural invasive measurement of LA pressures can offer an important and convenient novel piece of information for patients undergoing catheter ablation procedures for AF, with potential implication for post-procedural recurrence risk stratification. Atrial hypertension is only partially related to LV diastolic impairment, atrial fibrosis and myocardial mechanical load burden.

Safety and efficacy of anticoagulation therapy post atrial fibrillation ablation

Abstract Funding Acknowledgements None. Background Thromboembolic complications can be life-threatening during atrial fibrillation (AF) catheter ablation. The aim of our single center, retrospective study was to evaluate the safety and efficacy of continuous treatment using direct oral anticoagulants (DOACs) as an alternative to uninterrupted acenocoumarol for periprocedural anticoagulation. Purpose To record the safety and efficacy of the oral anticoagulants post atrial fibrillation ablation. Methods We studied 1999 patients undergoing AF catheter ablation between June 2013 and December 2021 in our center. All patients were assigned to take acenocoumarol (group 1, 194 patients) or DOACs (group 2, 1805 patients) for ≥2 months before the procedure. We compared thromboembolic and bleeding complications between the 2 groups. Results Our analysis showed no significant difference in major and minor complications between the 2 patient groups with the exception of the occurrence of groin hematoma with a clear superiority of DOACs (2.06%-0.5%, p<0.05). Specifically, 4 of 194 patients (2.06%) using uninterrupted acenocoumarol had a major complication (3 patients [1.55%] had transient ischemic attack resolved 8 hours later and 1 [0.52%] had pericardial tamponade, and 7 patients (3.61%) had minor complications (4 [2.06%] groin hematoma and 3 [1.55%] mild pericardial efussion). In group 2, 14 of 1805 patients (0.78%) had a major complication (11 patients had transient ischemic attack (0.61%) and 3 patients (0.17%) had pericardial tamponade). In the same group, 31 patients (1.72%) had a minor complication (3 patients [0.17%] presented with pseudoaneurysm or femoral arteriovenous fistula between the femoral artery and femoral vein, 19 [1.05%] with pericardial effusion <1 cm, and 9 [0.5%] groin hematoma). Conclusions DOACs and acenocoumarol have similar safety and effectiveness regarding thromboembolic complications prevention without increasing bleeding complications with the exception of the occurrence of groin hematoma with a clear superiority of DOACs.

Abstract 2126: Impact Of Pulmonary Hypertension On In-Hospital Outcomes Among Patients With Atrial Fibrillation Undergoing Catheter Ablation: Insights From The National Inpatient Sample Database

Introduction: Catheter Ablation (CA) is a treatment option for patients with Atrial Fibrillation (AF) when medications are intolerable or are unable to control symptoms. Pulmonary hypertension is characterized by elevated pulmonary artery pressure and affects all ages, genders and races. In this study, we examine the impact of pulmonary hypertension (PH) on hospitalized patients with AF undergoing catheter ablation. Methods: Using the International Classification of Diseases, 10th edition, Clinical Modification (ICD-10-CM) diagnosis and procedure codes, we queried the National Inpatient Sample 2016 to 2020 for hospitalizations among patients ≥18 years old diagnosed with PH, and AF who underwent CA procedure. Among this cohort, we identified the percentage of all hospitalizations for AF undergoing CA and stratified this cohort into those with and without PH. Mortality and length of hospital stay were compared between those with and without PH. Results: Our study included 232,150 weighted hospitalizations among patients with atrial fibrillation who underwent catheter ablation. Of these, 28,980 (12.5%) had pulmonary hypertension, and the majority (51.1%) were males. Among this cohort, those with pulmonary hypertension were older compared to those without pulmonary hypertension (mean [SD] age: 70.0 [11.2] vs. 68.2 [11.4] years). Patients with pulmonary hypertension had a higher length of hospital stay (10.2 vs. 6.2 days, p<0.0001) and higher total hospital charges ($241,212 vs. $187,987; p<0.0001) compared to those without pulmonary hypertension. Higher in-hospital mortality was recorded among patients with pulmonary hypertension compared to those without pulmonary hypertension (3.4% vs. 1.2%, p<0.0001 ). Conclusion: Among patients with atrial fibrillation undergoing catheter ablation, pulmonary hypertension was associated with worse outcomes, including higher length of stay and mortality. Further research is needed to better understand the impact of pulmonary hypertension among patients with atrial fibrillation undergoing catheter ablation.

Predictors of systolic function recovery after atrial fibrillation ablation in heart failure patients

Introduction and ObjectivesAtrial fibrillation (AF) and heart failure (HF) often coexist. AF catheter ablation improves left ventricular ejection fraction (LVEF), but its impact varies between patients. We aimed to identify predictors of LVEF improvement in HF patients with impaired LVEF undergoing AF ablation. MethodsWe conducted a retrospective single-center study in HF patients with LVEF <50% undergoing AF catheter ablation between May 2016 and May 2022. The primary endpoint was the LVEF recovery rate (‘responders’). Secondary endpoints were one-year safety and effectiveness. We also aimed to validate a prediction model for LVEF recovery. ResultsThe study included 100 patients (79% male, median age 60 years, 70% with probable tachycardia-induced cardiomyopathy [TIC], mean LVEF 37%, 29% with paroxysmal AF). After a median follow-up of 12 months after catheter ablation, LVEF improved significantly (36±10% vs. 53±10%, p<0.001), with an 82% responder rate. A suspected diagnosis of TIC (OR 4.916 [95% CI 1.166–20.732], p=0.030), shorter QRS duration (OR 0.969 [95% CI 0.945–0.994], p=0.015), and smaller left ventricle (OR 0.893 [95% CI 0.799–0.999], p=0.049) were independently associated with LVEF improvement. Freedom from any documented atrial arrhythmia was 86% (64% under antiarrhythmic drugs), and the rate of adverse events was 2%. The prediction model had a good discriminative performance (AUC 0.814 [95% CI 0.681–0.947]). ConclusionIn AF patients with HF and impaired LVEF, suspected TIC, shorter QRS duration, and smaller LV diameter were associated with LVEF recovery following AF catheter ablation.

Structural, Functional, and Electrical Remodeling of the Atria With Reduced Cardiorespiratory Fitness: Implications for AF

BackgroundReduced cardiorespiratory fitness (CRF) is an independent risk factor for the progression of atrial fibrillation (AF). We hypothesized that reduced CRF is associated with structural, functional, and electrical remodeling of the left atrium. ObjectivesThis study sought to correlate objectively assessed CRF with functional and electrical left atrial (LA) parameters using invasive and noninvasive assessments. MethodsConsecutive patients with symptomatic AF undergoing catheter ablation were recruited. CRF was objectively quantified pre-ablation by using cardiopulmonary exercise testing. Using peak oxygen consumption, participants were classified as preserved CRF (>20 mL/kg/min) or reduced CRF (<20 mL/kg/min). LA stiffness was assessed invasively with hemodynamic monitoring and imaging during high-volume LA saline infusion. LA stiffness was calculated as ΔLA diameter/ΔLA pressure over the course of the infusion. LA function was assessed with echocardiographic measures of LA emptying fraction and LA strain. Electrical remodeling was assessed by using high-density electroanatomical maps for LA voltage and conduction. ResultsIn total, 100 participants were recruited; 43 had reduced CRF and 57 had preserved CRF. Patients with reduced CRF displayed elevated LA stiffness (P = 0.004), reduced LA emptying fraction (P = 0.006), and reduced LA reservoir strain (P < 0.001). Reduced CRF was also associated with reduced LA voltage (P = 0.039) with greater heterogeneity (P = 0.027) and conduction slowing (P = 0.04) with greater conduction heterogeneity (P = 0.02). On multivariable analysis, peak oxygen consumption was independently associated with LA stiffness (P = 0.003) and LA conduction velocities (P = 0.04). ConclusionsReduced CRF in patients with AF is independently associated with worse LA disease involving functional and electrical changes. Improving CRF may be a target for restoring LA function in AF.

Epicardial Atrial Fat at Cardiac Magnetic Resonance Imaging and AF Recurrence after Transcatheter Ablation.

The relationship between epicardial adipose tissue (EAT) and atrial fibrillation (AF) has gained interest in recent years. The previous literature on the topic presents great heterogeneity, focusing especially on computed tomography imaging. The aim of the present study is to determine whether an increased volume of left atrial (LA) EAT evaluated at routine pre-procedural cardiac magnetic resonance imaging (MRI) relates to AF recurrences after catheter ablation. A total of 50 patients undergoing AF cryoballoon ablation and pre-procedural cardiac MRI allowing quantification of LA EAT were enrolled. In one patient, the segmentation of LA EAT could not be achieved. After a median follow-up of 16.0 months, AF recurrences occurred in 17 patients (34%). The absolute volume of EAT was not different in patients with and without AF recurrences (10.35 mL vs. 10.29 mL; p-value = 0.963), whereas the volume of EAT indexed on the LA volume (EATi) was lower, albeit non-statistically significant, in patients free from arrhythmias (12.77% vs. 14.06%; p-value = 0.467). The receiver operating characteristic curve testing the ability of LA EATi to predict AF recurrence after catheter ablation showed sub-optimal performance (AUC: 0.588). The finest identified cut-off of LA EATi was 10.65%, achieving a sensitivity of 0.5, a specificity of 0.82, a positive predictive value of 0.59 and a negative predictive value of 0.76. Patients with values of LA EATi lower than 10.65% showed greater survival, free from arrhythmias, than patients with values above this cut-off (84% vs. 48%; p-value = 0.04). In conclusion, EAT volume indexed on the LA volume evaluated at cardiac MRI emerges as a possible independent predictor of arrhythmia recurrence after AF cryoballoon ablation. Nevertheless, prospective studies are needed to confirm this finding and eventually sustain routine EAT evaluation in the management of patients undergoing AF catheter ablation.

Impact of frailty in patients with non‐valvular atrial fibrillation undergoing catheter ablation

AbstractBackgroundThe relationships between frailty and clinical outcomes in elderly Japanese patients with non‐valvular atrial fibrillation (NVAF) after catheter ablation (CA) have not been established. We evaluated the frailty rate of patients undergoing CA for NVAF, examined whether CA for NVAF improves frailty, and analyzed the CA outcomes of patients with and without frailty.MethodsElderly Japanese patients (≥65 years; mean age: 72.8 years) who participated in the real‐world ablation therapy with anti‐coagulants in management of atrial fibrillation registry and who responded to the frailty screening index survey were included (n = 213). Frailty and AF recurrence were assessed preoperatively and at 3 and 6 months after CA.ResultsTwenty‐six patients (12.8%) were frail, 109 (53.7%) were pre‐frail, and 68 (33.5%) were robust. Cardiovascular (frailty: 0.5%/person‐year; pre‐frailty: 0.1%/person‐year; robust: 0.1%/person‐year) and cardiac (frailty: 0.5%/person‐year; pre‐frailty: 0.1%/person‐year; robust: 0.1%/person‐year) events, as well as major bleeding (frailty: 0.3%/person‐year; pre‐frailty: 0.1%/person‐year; robust: 0.1%/person‐year), were numerically more frequent in the frailty group. No deaths from cardiovascular or stroke/systemic thromboembolic events occurred. A large proportion of patients did not experience 3‐month (frailty: 96.2%; pre‐frailty: 96.3%; robust: 88.2%) or 6‐month (frailty: 88.5%; pre‐frailty: 91.7%; robust: 86.8%) AF recurrence after CA. Weight loss, walking speed, and fatigue improved in the frailty and pre‐frailty groups after CA.ConclusionJapanese patients aged ≥65 years with frailty or pre‐frailty had improved frailty screening index components, such as weight loss, walking speed and fatigue, after CA. Therefore, elderly patients with frailty or pre‐frailty may benefit from CA for NVAF.

Predicting reduced left atrial appendage velocity from echocardiographic left atrial function parameters in patients with atrial fibrillation undergoing catheter ablation

Decreased left atrial appendage velocity (LAAV) is considered a significant risk factor thrombus formation in the left atrial appendage (LAA). The aim of this study was to assess the role of echocardiographic left atrial (LA) function parameters in predicting LAAV in patients with persistent atrial fibrillation (AF) undergoing catheter ablation. We prospectively enrolled consecutive patients with persistent AF undergoing transesophageal echocardiography (TEE) directly before the first AF ablation in 2019–2022. Of the 150 patients enrolled in the study, 29.3% (n = 44) had reduced LAAV values defined as < 25 cm/s. Patients with decreased LAAV values exhibited significantly reduced left atrial reservoir and conduit strain (LASr and LAScd), LA emptying fraction, and average e′ values. This group also presented with a high LA stiffness index (LASI), high LA and right atrial area, and high LA volume index (LAVI) and E/e′ ratio. In multivariable logistic regression analysis, LASI and LAVI remained significant predictors of the reduced LAAV. The threshold values were 1.6 for LASI and 44.47 ml/m2 for LAVI, with area under the curve values of 0.809 and 0.755, respectively. Among all noninvasive echocardiographic parameters, LASI and LAVI were found to be the best predictors of reduced LAAV, with good sensitivity and specificity. Moreover, LASI was found to be the only significant predictor of reduced LAAV defined as < 20 cm/s as well as < 25 cm/s.

Atrial Fibrillation Catheter Ablation among Cancer Patients: Utilization Trends and In-Hospital Outcomes.

Background: Atrial fibrillation (AF) catheter ablation in cancer patients has been evaluated in very few studies. We aimed to investigate utilization trends and in-hospital outcomes of AF catheter ablation among cancer patients in a large US inpatient registry. Methods: Utilizing the National Inpatient Sample (NIS) database, patients who underwent AF catheter ablation between 2012 and 2019 were identified. Sociodemographic, clinical data, in-hospital procedures and outcomes were collected. Baseline characteristics and in-hospital outcomes were compared between patients with and without cancer. Results: An estimated total of 67,915 patients underwent AF catheter ablation between 2012 and 2019 in the US. Of them, 950 (1.4%) had a cancer diagnosis. Patients with a cancer diagnosis were older and had higher Charlson Comorbidity Index, CHA2DS2-VASc and ATRIA bleeding indices scores. A higher rate of total complications was observed in cancer patients (10.5% vs. 7.9, p < 0.001), driven mainly by more bleeding and infectious complications. However, no significant differences in cardiac or neurological complications as well as in-hospital mortality rates were observed and were relatively low in both groups. Conclusions: AF catheter ablation in cancer patients is associated with higher bleeding and infectious complication rates, but not with increased cardiac complications or in-hospital mortality in a US nationwide, all-comer registry.

Association of extra-pulmonary vein triggers with low-voltage area and clinical recurrence in patients with atrial fibrillation undergoing catheter ablation.

Although extra-pulmonary vein (PV) triggers (ExPVTs) play a role in atrial fibrillation (AF) recurrence after catheter ablation (AFCA), the mechanism is unknown. We explored whether the locations of ExPVTs were associated with low-voltage scar areas (LVAs). Among 2255 consecutive patients who underwent a de novo AFCA, 1696 (male 72.1%, median 60 years old, paroxysmal 64.7%) were included who underwent isoproterenol provocation and voltage mapping of the left atrium (LA) during their procedures. We investigated the associations between ExPVTs and their mean LA voltage and colocalization of ExPVTs within LVAs (<0.2 mV). We observed ExPVTs in 181 (10.7%) patients (60 in the LA, 99 in the right atrium [RA], 16 biatrial, and 6 unmappable). A lower mean LA voltage was independently associated with the existence of ExPVTs (OR 0.77 per 1 SD mV increase, 95% CI 0.60-0.99, p = .039). Among 76 patients who had ExPVTs[LA], 43 (56.6%) had ExPVTs within LVAs. During a median of a 42-month follow-up, patients with ExPVTs had a higher AF recurrence than those without (HR 1.87, 95% CI 1.48-2.37, Log-rank p < .001), but colocalization of ExPVTs and LVAs (Log-rank p = .544) and the anatomical location of ExPVTs (Log-rank p = .084) did not affect the rhythm outcome. The presence of ExPVTs was associated with low LA voltage and poor rhythm outcome post-AFCA, but the colocalization of ExPVTs and LVA in LA did not affect rhythm outcome.

Predictive utility of the impedance drop on AF recurrence using digital intraprocedural data linked to electronic health record data

Local impedance drop in cardiac tissue during catheter ablation may be a valuable measure to guide atrial fibrillation (AF) ablation procedures for greater effectiveness. The study sought to assess whether local impedance drop during catheter ablation to treat AF predicts 1-year AF recurrence and what threshold of impedance drop is most predictive. We identified patients with AF undergoing catheter ablation in the Mercy healthcare system. We downloaded AF ablation procedural data recorded by the CARTO system from a cloud-based analytical tool (CARTONET) and linked them to individual patient electronic health records. Average impedance drops in anatomical region of right and left pulmonary veins were calculated. Effectiveness was measured by a composite outcome of repeat ablation, AF rehospitalization, direct current cardioversion, or initialization of a new antiarrhythmic drug post-blanking period. The association between impedance drop and 1-year AF recurrence was assessed by logistic regression adjusting for demographics, clinical, and ablation characteristics. Bootstrapping was used to determine the most predictive threshold for impedance drop based on the Youden index. Among 242 patients, 23.6% (n = 57) experienced 1-year AF recurrence. Patients in the lower third vs upper third of average impedance drop had a 5.9-fold (95% confidence interval [CI] 1.81-21.8) higher risk of recurrence (37.0% vs 12.5%). The threshold of 7.2 Ω (95% CI 5.75-7.7 Ω) impedance drop best predicted AF recurrence, with sensitivity of 0.73 and positive predictive value of 0.33. Patients with impedance drop ≤7.2 Ω had 3.5-fold (95% CI 1.39-9.50) higher risk of recurrence than patients with impedance drop >7.2 Ω, and there was no statistical difference in adverse events between the 2 groups of patients. Sensitivity analysis on right and left wide antral circumferential ablation impedance drop was consistent. Average impedance drop is a strong predictor of clinical success in reducing AF recurrence but as a single criterion for predicting recurrence only reached 73% sensitivity and 33% positive predictive value.

Kiosk 7R-TC-05 - Characterization of Pericardial Effusion Using t1-mapping in Patients with Atrial Fibrillation Undergoing Catheter Ablation

Kiosk 7R-TC-05 - Characterization of Pericardial Effusion Using t1-mapping in Patients with Atrial Fibrillation Undergoing Catheter Ablation

Predictors of Low Voltage Zone and Sex Differences in Low Voltage Zone Distribution in Patients with Atrial Fibrillation.

Previous studies have revealed the left atrial (LA) low voltage zone (LVZ) are tightly linked to the recurrence of atrial fibrillation (AF). Furthermore ablation that targets the LA LVZ can improve patient prognosis. The aim of this study was to identify potential clinical predictors of the LA LVZ, to investigate possible sex differences in the distribution of LA LVZ, and to examine the relationship between LA LVZ and AF recurrence. A total of 108 patients who underwent AF catheter ablation and LA high-density electro-anatomic mapping were enrolled in the study. Of these, 56 patients with LA LVZ 5% were assigned to the LVZ group, while the remaining 52 patients with LA LVZ 5% were assigned to the non-LVZ group. Clinical characteristics and laboratory results for all patients were collected and compared between the two groups. Multivariate logistic regression analysis revealed that persistent AF (odds ratio [OR] = 4.563, 95% confidence interval [CI]: 1.194-17.431, p = 0.026), left atrial volume (LAV, OR = 1.030, 95% CI: 1.001-1.061, p = 0.044) and brain natriuretic peptide (BNP, OR = 1.010, 95% CI: 1.002-1.019, p = 0.015) were independent predictors for the presence of LA LVZ. In addition, female sex (OR = 7.161, 95% CI: 1.518-33.792, p = 0.013), LAV (OR = 1.028, 95% CI: 1.002-1.055, p = 0.035) and BNP (OR = 1.009, 95% CI: 1.001-1.016, p = 0.018) were independent predictors of severe LA LVZ (LA LVZ 20%). The extent of LVZ was significantly greater in females than in males (32.8% 15.5% vs. 23.5% 12.7%, p = 0.021), especially in the anterior (34.5% 16.7% vs. 20.0% 16.4%, p = 0.003) and septal (44.9% 17.1% vs. 29.0% 18.9%, p = 0.004) walls. During follow-up, AF recurrence was significantly higher in patients with LA LVZ than in those without LA LVZ (31.3% vs. 12.8%, respectively, p = 0.023). In this study cohort, persistent AF, LAV and BNP were independent predictors of LA LVZ. Furthermore, female sex, LAV and BNP were independent predictors of severe LA LVZ. Females had a significantly greater extent of LVZ than males, especially in the anterior and septal walls. Patients with LA LVZ had a higher risk of recurrent AF.

Impact of cardiorenal syndrome on clinical outcomes of atrial fibrillation patients undergoing catheter ablation

Abstract Background Heart failure (HF) coexists with both atrial fibrillation (AF) and chronic kidney disease (CKD) and exacerbate each other. All of them are increasing in the aging society all over the world. Little is known regarding the impact of cardiorenal syndrome (CRS) on clinical outcomes of patients with AF undergoing catheter ablation (AFCA) in the real-world setting. Purpose In the present study, we investigated clinical outcomes of CRS patients with de novo AFCA. Method: Consecutive 494 patients (68.1±11.1 yrs, male 68.0%) undergoing de novo AF catheter ablation in our hospital from April 2019 to March 2021 were enrolled. CRS was defined as having both HF and CKD. HF was defined as having a history of HF admission and/or BNP≥100 pg/mL. CKD was defined as eGFR&amp;lt; 60 ml/min/1.73m2. The primary outcome was composite outcomes of; all-cause death, redo ablation, thromboembolisms, atherosclerotic cardiovascular disease (ASCVD) events, major bleeding, HF admission, and dialysis initiation. Result The incidence of primary outcome in CRS patients during median follow-up periods of 739.5 days was significantly higher than the non-CRS patients (54.9% in CRS vs. 30.3% in non-CRS; P&amp;lt;0.01, Figure 1). In CRS patients, all-cause death, ASCVD events, and HF admission were significantly worse (7.7% in CRS vs. 0.3% in non-CRS; P&amp;lt;0.01, 10.3% in CRS vs. 1.8% in non-CRS; P&amp;lt;0.01, 11.5% in CRS vs. 0.9% in non-CRS; P&amp;lt;0.01, respectively, Table), however redo ablation, thromboembolism, major bleeding and dialysis initiation were similar compared with non-CRS patients (10.3% in CRS vs. 14.5% in non-CRS; P=0.25, 1.3% in CRS vs. 0.6% in non-CRS; P=0.59, 5.1% in CRS vs. 2.1% in non-CRS; P=0.09, 1.3% in CRS vs. 0.3% in non-CRS; P=0.24, respectively, Table). The incidence of primary outcome in CRS patients was similar in those with ejection fraction (EF)≤40% and in those with EF&amp;gt;40% (47.6% in EF≤40% vs. 54.7% in EF&amp;gt;40%; P=0.48, Figure 2), however it was significantly higher in those with eGFR&amp;lt;45 compared with those with eGFR≥45 (74.8% in eGFR&amp;lt;45 vs. 26.2% in eGFR≥45+ P&amp;lt;0.01, Figure 3). Conclusion CRS patients with AFCA had significantly worse outcomes with more all-cause death, ASCVD events and HF admission compared with non-CRS patients. In the CRS patients undergoing AFCA, worse kidney function, rather than the cardiac systolic function, had a significant prognostic impact on the over-all clinical outcomes.