Vein Isolation For Atrial Fibrillation Research Articles

Sex differences in overweight and obese patients undergoing high-power short-duration pulmonary vein isolation for atrial fibrillation: an observational cohort study.

Atrial fibrillation (AF) is the most common heart rhythm disorder worldwide. As treatment methods evolve, optimizing personalized therapy based on patient characteristics, such as sex, becomes crucial. This study investigates sex differences in high-power short-duration (HPSD) pulmonary vein isolation (PVI) in overweight and obese patients. We analyzed data from 189 overweight and obese patients who underwent HPSD PVI for AF, comparing demographic information, procedural details, outcomes, and complications between male and female patients. Our analysis revealed fewer women underwent PVI compared to men, with women typically older and showing more pronounced changes in the left atrial substrate. Despite these differences, the safety and efficacy of PVI were comparable between sexes, including in the BMI ≥ 30kg/m2 subgroup and after age adjustment. The findings emphasize the need for early AF screening in women to prevent treatment delays and show that considering sex-specific differences in fat distribution can improve procedural outcomes. These insights support the need for tailored management strategies for AF in overweight and obese populations, addressing sex-specific risks and anatomical variations.

Meta-analysis of Renal Denervation Therapy During Pulmonary Vein Isolation in Atrial Fibrillation

Pulmonary vein isolation (PVI) has been established as a first-line therapy for symptomatic atrial fibrillation (AF) in selected patients with symptomatic AF as well as in those who failed antiarrhythmic drugs. However, AF recurrence rates following PVI remain high, prompting the exploration of adjunct therapies such as renal denervation (RDN) to improve outcomes. This meta-analysis aims to assess the efficacy of RDN as an adjunct to PVI in reducing AF recurrence. A comprehensive search of randomized controlled trials (RCTs) comparing RDN plus PVI to PVI alone was conducted, yielding nine studies with 955 patients. The primary endpoint was freedom from AF at 12 months. Results showed that 61.7% of patients in the RDN+PVI group were free from AF, compared to 52.6% in the PVI-alone group (RR 1.32, 95% CI 1.07–1.61, I²=48%). These findings support the potential of RDN to enhance PVI efficacy; however, further large-scale RCTs with standardized methodologies and longer follow-up periods are necessary to confirm these results and establish the role of RDN in the treatment of AF.

Impact of left atrial stiffness measurement as a pre-procedural predictor of an extensive left atrial low-voltage area

Abstract Background The presence of a left atrial (LA) low-voltage area (LVA) after pulmonary vein isolation for atrial fibrillation (AF) is a strong predictor of recurrence and LVAs are often an additional ablation target. However, predicting the presence of an LVA before the procedure remains challenging. Purpose To assess the LA stiffness index as a preprocedural predictor of an extensive LVA. Methods We prospectively evaluated 74 patients who underwent catheter ablation for AF and high-density bipolar LA voltage mapping during sinus rhythm or high right atrial pacing. "LVA" was defined as an area with bipolar electrograms (<0.5 mV), while "extensive LVA" was defined as the presence of an LVA that covered more than 15% of the LA surface. Echocardiographic measurements, including the LA volume index (LAVi), E/e' ratio, LA reservoir strain (LASr), and LA stiffness index, calculated as the ratio of E/eʹ to LASr, were performed prior to catheter ablation in all patients. Results Overall, 17 patients (23.0%) had an extensive LVA. Patients with extensive LVAs were older (73 ± 7 vs. 66 ± 8 years; P=0.003), predominantly female (59% vs. 23%; P=0.01), and more frequently showed persistent AF (59% vs. 30%; P=0.04) in comparison to patients without extensive LVAs. According to a receiver operating characteristic curve analysis, the LA stiffness index was more accurate than the LAVi or LASr for predicting extensive LVAs (Figure), allowing using a cutoff value ≥0.6 with 73% sensitivity and 91% specificity. A multivariate logistic regression analysis revealed that the LA stiffness index was an independent predictor of an extensive LVA (odds ratio [OR], 44.11; 95% CI 3.83–507.47, P=0.002). Conclusion The LA stiffness index was a robust predictor of the extent of LVAs in AF patients and thus could be useful for the preprocedural selection of candidates for catheter ablation and to determine the most effective ablation strategies.

A case of pulmonary vein reconnection after long‐term success of pulmonary vein isolation for atrial fibrillation

A case of pulmonary vein reconnection after long‐term success of pulmonary vein isolation for atrial fibrillation

Pulmonary Vein Isolation vs Sham Intervention in Symptomatic Atrial Fibrillation

There are concerns that pulmonary vein isolation for atrial fibrillation may have a profound placebo effect, but no double-blind randomized clinical trials have been conducted. To determine whether pulmonary vein isolation is more effective than a sham procedure for improving outcomes in atrial fibrillation. Double-blind randomized clinical trial conducted at 2 tertiary centers in the UK between January 2020 and March 2024 among patients with symptomatic paroxysmal or persistent atrial fibrillation. Major exclusion criteria included long-standing persistent atrial fibrillation, prior left atrium ablation, other arrhythmias requiring ablative therapy, a left atrium of 5.5 cm or larger, and ejection fraction of less than 35%. Participants were randomly assigned to receive pulmonary vein isolation with cryoablation (n = 64) or a sham procedure with phrenic nerve pacing (n = 62). The primary end point was atrial fibrillation burden at 6 months, excluding a 3-month blanking period. Secondary outcomes included quality-of-life measures, time to events, and safety. Atrial fibrillation burden was measured by an implantable loop recorder. A total of 126 participants were randomized (mean age, 66.8 years; 89 men [70.63%]; 20.63% with paroxysmal atrial fibrillation). The absolute mean atrial fibrillation burden change from baseline to 6 months was 60.31% in the ablation group and 35.0% in the sham group (geometric mean difference, 0.25; 95% CI, 0.15-0.42; P < .001). The estimated difference in the overall Atrial Fibrillation Effect on Quality of Life score at 6 months, favoring catheter ablation, was 18.39 points (95% CI, 11.48-25.30 points). The Short Form 36 general health score also improved substantially more with ablation, with an estimated difference of 9.27 points at 6 months (95% CI, 3.78-14.76 points). Pulmonary vein isolation resulted in a statistically significant and clinically important decrease in atrial fibrillation burden at 6 months, with substantial improvements in symptoms and quality of life, compared with a sham procedure. ClinicalTrials.gov Identifier: NCT04272762.

Voltage-guided pulmonary vein isolation for atrial fibrillation

BackgroundBipolar voltage amplitude is capable of helping determine the ideal lesion size index (LSI) setting during radiofrequency ablation for atrial fibrillation (AF). ObjectiveWe aimed to determine whether voltage-guided pulmonary vein isolation (PVI) is noninferior to conventional LSI-guided PVI in patients with nonvalvular AF. MethodsThis was a multicenter randomized trial conducted during a period of 12 months. The primary efficacy end points of the study were AF recurrence, atrial flutter, and atrial tachycardia, and the noninferiority margin was set at a hazard ratio of 1.4. The primary safety end point was a composite of procedure-related complications. ResultsA total of 370 patients underwent randomization; 189 and 181 were assigned to the voltage (underwent voltage-guided PVI) and control (underwent conventional LSI-guided PVI) groups, respectively. The primary efficacy end point occurred in 22 patients (12.0%) in the voltage group and 23 patients (12.9%) in the control group (1-year Kaplan-Meier event-free rate estimates, 88.0% and 87.1%, respectively; hazard ratio, 1.00; 95% confidence interval, 0.80–1.25). The primary safety end points were 4.8% in the voltage group and 6.6% in the control group (P = .2791). PVI time was significantly shorter in the voltage group (35.7 ± 14.5 minutes vs 39.7 ± 14.7 minutes; P < .001). ConclusionVoltage-guided PVI was noninferior to conventional LSI-guided PVI with respect to efficacy in the treatment of patients with AF, and its use significantly reduced procedure time.UMIN Clinical Trials Registry: UMIN000042325

Pressure-guided evaluation of pulmonary vein occlusion during cryoballoon pulmonary vein isolation for atrial fibrillation compared to contrast-guided approach

Abstract Introduction Single-shot ablation devices (e.g. cryoballoon [CB] technique) have simplified pulmonary vein isolation (PVI) for interventional treatment of atrial fibrillation (AF). Vein occlusion is mainly assessed utilizing contrast media (CM) during CB ablation. However, this approach entails possible risks, including renal impairment and adverse contrast-related allergic reactions. Furthermore, the assessment of pulmonary venography is often challenging and necessitates fluoroscopy exposure. Purpose The primary objective of this study is to compare procedural data and outcome of pressure-guided (PG) vs. conventional (CM) assessment of vein occlusion. Methods and results From 07/2018 to 12/2022, 915 patients with AF (59% paroxysmal) undergoing CB-PVI at our hospital were prospectively enrolled (single-center experience). 369 (40,3%) patients (age 64,5 ± 10 years; 154 females 41,7%) underwent PVI with the use of CM (CM group), while in 546 (59,7%) cases (age 65,3 ± 10 years; 222 females 40,6%) pressure curve assessment (PG group) was exclusively used to guide the procedure (and no contrast was given). Compared with the CM approach, pressure-guided procedures had lower X-ray time (9,5±5min vs 6,4±3,5min, P&amp;lt;0,0001) and X-ray dose (586±546cGy/cm2 vs 96,7±93 cGy/cm2, P&amp;lt;0,0001). Procedure time (PG: 90,3±20,1min, CM: 92,7±22,7 min, p:0,1 ) and ablation time (PG: 1352 ± 365 min, CM: 1393 ± 651 min, p: 0,2) were not different between groups. There was no significant difference observed in the BMI between the two groups, with a mean value of ca. 28.2 ± 4 kg/m2. In 79 redo-procedures, persistent isolation of all pulmonary veins was observed in 11/45 (25%) patients in the CM group and 21/34 (61%) patients in the PG group (p: 0.001). Conclusion Compared to current (CM) assessment of vein occlusion, pressure monitoring is associated with less X-ray exposure during the index procedure and more frequent durable isolation of all PVs during repeat study for recurrence.

Examination of pituitary adenylate cyclase-activating polypeptide (PACAP) in patients with atrial fibrillation undergoing pulmonary vein isolation

Abstract Introduction Pituitary adenylate cyclase-activating polypeptide (PACAP) is a cardioprotective neuropeptide. It has previously been shown that plazma PACAP level increases in myocardial infarction and decompensated heart failure, whereas it decreases in chronic heart failure. Patient material and method We examined blood samples from patients (n=46) undergoing pulmonary vein isolation for atrial fibrillation. We collected 5 ml blood samples from the femoral vein at the beginning, from the right atrium before the septal puncture, from the left atrium before and after the ablation, from the femoral vein at the end of the procedure and the next day from the cubital vein. PACAP levels were determined by ELISA. Patients were divided into intact (n=29) and scarred (n=17) left atrial groups by electroanatomical map. PACAP levels were compared in the total population and in the two groups and correlated with left atrial size and different comorbidity data. Results Significantly higher levels of PACAP were detected in atrial blood and in post-operative femoral vein samples compared to peripheral blood collected at the beginning and 1 day after the procedure. We measured decreased PACAP levels in the left atrium after ablation compared to samples from left atrium before the ablation. Although we found lower PACAP levels in the left atrium after ablation in patients with scarred atrium compared to the intact group, the PACAP levels showed significant elevation in the femoral vein after the ablation in patients with intact atria. Conclusions Our study was the first to show a difference between PACAP levels in atrial and peripheral blood samples. The elevated PACAP levels measured in atrial samples may be due to myocytes and neurons, whose PACAP production decreases depending on the degree of scarring following ablation-induced injury in the left atrium. Transient systemic elevation of PACAP levels is demonstrated in the periphery, suggesting a potential biomarker role for PACAP in these pathologies.

Comparing cryoballoon and contact-force guided radiofrequency ablation in pulmonary vein isolation for atrial fibrillation in patients with hypertrophic cardiomyopathy.

Pulmonary vein isolation (PVI) employing cryoballoon (CB) or contact force-guided radiofrequency (CF-RF) catheter ablation has been established as an effective strategy for managing atrial fibrillation (AF). However, its efficacy in hypertrophic cardiomyopathy (HCM) remains to be further explored. This retrospective study analyzed 60 consecutive AF patients with HCM (average age 67 ± 10 years; 41 men) who were consecutively admitted to our hospital from January 2014 to December 2022 and underwent initial PVI. The patients were treated with CB (26 patients) or CF-RF (34 patients). Successful PVI was achieved in both groups without significant complications. In the CF-RF group, additional ablations were performed on the cavotricuspid isthmus (14.7% of patients) and the anterior line (2.9%). The CB group benefited from reduced procedural times (93 ± 31 vs. 165 ± 60min, p < 0.05) and decreased saline irrigation requirements (77.5 ± 31.4 vs. 870 ± 281.9 mL, p < 0.0001). Using a contrast medium was exclusive to the CB group (33.8 ± 4.2 mL). In a 12-month follow-up, the atrial tachyarrhythmia recurrence-free rates in the CB and CF-RF groups were comparable (77% and 76%, respectively; p = 0.63 according to the log-rank test). Notably, pulmonary vein reconnection was prevalent in most (7 out of 8) patients requiring a secondary ablation procedure. PVI is feasible as a strategy for AF in patients with HCM employing either CB or CF-RF techniques. While the recurrence-free rates were comparable in both groups, differences were noted in procedure duration, saline usage, and the need for a contrast medium.

Pulmonary Vein Isolation for Atrial Fibrillation: Comparison of a Very High-Power Very Short-Duration (vHPvSD) Ablation Protocol versus a Hybrid Ablation Approach-Procedural and Mid-Term Outcome Data.

Background: Pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) is a standard-of-care treatment in the rhythm control strategy of symptomatic atrial fibrillation (AF). Ablation protocols, varying in the power and duration of energy delivery, have changed rapidly in recent years. Very high-power very short-duration ablation (vHPvSD) is expected to shorten procedural times compared to conventional ablation approaches. However, the existing data suggest that this might come at the cost of lower first-pass isolation rates, a predictor of poor ablation long-term outcomes. This study aims to compare a vHPvSD protocol to a hybrid strategy, in which the power and duration of the energy transfer are adapted depending on the anatomical location. Methods: We retrospectively analyzed procedural and outcome data from 93 patients (55 vHPvSD vs. 38 hybrid) scheduled for de novo pulmonary vein isolation. A vHPvSD ablation protocol (90 Watt (W), 4 s) was compared to a hybrid protocol using vHPvSD on the posterior wall and 50 W HPSD (high-power short-duration) ablation guided by the Ablation Index along the remaining spots. Results: Ablation times were significantly shorter in the vHPvSD cohort (5.4 min. vs. 14.2 min, p < 0.001), thus resulting in a significant reduction in the overall procedural duration (91 min vs. 106 min, p = 0.003). The non-significant slightly higher first-pass isolation rates in the vHPvSD cohort (85% vs. 76%, p = 0.262) did not affect freedom from AF 6 months after the procedure (83% vs. 87%, p = 0.622). Conclusions: vHPvSD helps in shortening the PVI procedural duration, thus neither affecting first-pass isolation rates nor freedom from atrial tachyarrhythmia recurrence at 6 months after the index procedure.

The Influence of Different Multipolar Mapping Catheter Types on Procedural Outcomes in Patients Undergoing Pulmonary Vein Isolation for Atrial Fibrillation.

(1) Background: During pulmonary vein isolation (PVI) for atrial fibrillation (AF), multipolar mapping catheters (MMC) are often used. We aimed to compare the procedural outcomes of two MMCs, specifically a circular-shaped and a five-spline-shaped MMC. (2) Methods: We enrolled 70 consecutive patients in our prospective, observational trial undergoing PVI procedures for paroxysmal AF. The initial 35 patients underwent PVI procedures with circular-shaped MMC guidance (Lasso Group), and the procedures for the latter 35 cases were performed using five-spline-shaped MMC (PentaRay Group). (3) Results: No significant differences were identified between the two groups in total procedure time (80.2 ± 17.7 min vs. 75.7 ± 14.8 min, p = 0.13), time from femoral vein puncture to the initiation of the mapping (31.2 ± 7 min vs. 28.9 ± 6.8, p = 0.80), mapping time (8 (6; 13) min vs. 9 (6.5; 10.5) min, p = 0.73), duration between the first and last ablation (32 (30; 36) min vs. 33 (26; 40) min, p = 0.52), validation time (3 (2; 4) min vs. 3 (1; 5) min, p = 0.46), first pass success rates (89% vs. 91%, p = 0.71), left atrial dwelling time (46 (37; 53) min vs. 45 (36.5; 53) min, p = 0.56), fluoroscopy data (time: 150 ± 71 s vs. 143 ± 56 s, p = 0.14; dose: 6.7 ± 4 mGy vs. 7.4 ± 4.4 mGy, p = 0.90), total ablation time (1187 (1063; 1534) s vs. 1150.5 (1053; 1393.5) s, p = 0.49), the number of ablations (78 (73; 93) vs. 83 (71.3; 92.8), p = 0.60), and total ablation energy (52,300 (47,265; 66,804) J vs. 49,666 (46,395; 56,502) J, p = 0.35). (4) Conclusions: This study finds comparable procedural outcomes bet-ween circular-shaped and five-spline-shaped MMCs for PVI in paroxysmal AF, supporting their interchangeability in clinical practice for anatomical mapping.

Association between left atrial low-voltage area and induction and recurrence of macroreentrant atrial tachycardia in pulmonary vein isolation for atrial fibrillation.

The relationship between induction and recurrence due to atrial tachycardia (AT) and left atrial (LA) matrix progression after atrial fibrillation (AF) ablation remains unclear. One hundred fifty-two consecutive patients with paroxysmal and persistent AF who underwent pulmonary vein isolation (PVI) and cavo-tricuspid isthmus (CTI) ablation and achieved sinus rhythm before the procedure were classified into three groups according to the AT pattern induced after the procedure: group N (non-induced), F (focal pattern), and M (macroreentrant pattern) in 3D mapping. The total rate of AT induction was 19.7% (30/152) in groups F (n = 13) and M (n = 17). Patients in group M were older than those in groups N and F, with higher CHADS2/CHA2DS2-VASc values, left atrial enlargement, and low-voltage area (LVA) size of LA. The receiver operating characteristic curve determined that the cut-off LVA for macroreentrant AT induction was 8.8 cm2 (area under the curve [AUC]: 0.86, 95% confidence interval [CI]: 0.75-0.97). The recurrence of AT at 36months in group N was 4.1% (5/122), and at the second ablation, all patients had macroreentrant AT. Patients with AT recurrence in group N had a wide LVA at the first ablation, and the cut-off LVA for AT recurrence was 6.5 cm2 (AUC 0.94, 95%CI 0.88-0.99). Adjusted multivariate analysis showed that only LVA size was associated with the recurrence of macroreentrant AT (odds ratio 1.21, 95%CI 1.04-1.51). It is important to develop a therapeutic strategy based on the LVA size to suppress the recurrence of AT in these patients.

Very-high-power Short-duration Ablation versus Conventional Ablation for Pulmonary Vein Isolation in Atrial Fibrillation: Systematic Review and Meta-analysis.

The aim of this study was to compare the effectiveness and safety of very-high-power short-duration (VHPSD) ablation (70-90 W/4-7 s) with conventional ablation (30-40 W/>20 s, 50 W/7-11 s) for pulmonary vein isolation (PVI) in patients with AF. A total of 13 studies were included in this analysis (1,527 patients). AF recurrence occurred in 14% (95% CI [11-18%]) of the VHPSD group. VHPSD was associated with lower AF recurrence (OR 0.65; 95% CI [0.48-0.89]; p=0.006) compared with the conventional ablation group. Subgroup analysis showed that additional ablation beyond PVI had a similar rate of AF recurrence (16% versus 10%) compared with PVI alone. Procedure and ablation durations were significantly shorter in the VHPSD group with a mean differences of -14.4 minutes (p=0.017) and -14.1 minutes (p<0.001), respectively. Complications occurred in 6% (95% CI [3-9%]) of the VHPSD group, and the rate was similar between the two groups (OR 1.03; 95% CI [0.60-1.80]; p=0.498). VHPSD ablation resulted in less AF recurrence and a shorter procedure time. Additional ablation beyond PVI alone in VHPSD may not provide additional benefits.

Sex-based differences and outcomes in patients undergoing pulmonary vein isolation for atrial fibrillation

Abstract Introduction Some studies have suggested that the risk of atrial fibrillation (AF) recurrence after catheter ablation (CA) is greater in women than in men, which suggests that sex may be an independent risk factor for AF recurrence. However, the impact of gender on time to AF recurrence after CA is unknown. Methods Retrospective, single-centre study including all patients who underwent a first AF ablation procedure between 2017 and 2021. Late recurrence (LR) was defined as any AF recurrence at least 90 days after ablation, while early recurrence (ER) occurred &amp;lt;90 days after ablation. The effect of sex on the cumulative freedom from LR was estimated using the Kaplan-Meier method and compared using the log-rank test and Cox proportional hazards model. In a subgroup of patients, cardiac adipose tissue was quantified using cardiac computerized tomography (CT) scans. Results 656 patients were included, of whom 32% were women. Average follow-up after ablation was 26 months. In comparison to male patients, women undergoing CA were more likely to be older, have a higher body mass index and were more likely to have comorbid hypertension, thyroid dysfunction and valvular disease. After model adjustment, women had a greater risk of LR (HR 1.78, 95% CI 1.20-2.62). A reanalysis was conducted using a time-split at one year of follow-up, which showed that risk of LR was greater in women more than 12 months after CA (HR 2.70, 95% CI 1.60-4.57), but not during the first year after CA (HR 1.22, 95% CI 0.74-2.02). Persistent AF was also an independent predictor of LR (HR 2.05, 95% CI 1.45-2.91). In a subgroup of patients who underwent cardiac adipose tissue analysis (n = 348; 37% women), increased epicardial and pericardial adipose tissue volume was associated with an increased risk of LR in univariate analysis, but not after co-variate adjustment. Conclusions Women are referred later and less frequently to CA than men. LR after CA is more frequent in women, particularly after one year. Epicardial adipose tissue volume was associated with LR in women, but this effect was not maintained after model adjustment. Further studies are needed to better understand the mechanisms responsible for the increase in LR in women undergoing pulmonary vein isolation.

Quality of life before and after pulmonary vein isolation for atrial fibrillation: results of a multicenter cohort study in the Netherlands

Abstract Background In the treatment of patients with symptomatic atrial fibrillation (AF) reducing AF-related symptoms and improving health-related quality of life (HRQol) are important drivers in the decision for pulmonary vein isolation (PVI). Eventhought the majority of PVI patients has improved HRQoL after PVI, up to a third of patients do not. We aim to assess the association between various patient characteristics, intervention and outcome variables and HRQol both prior to and one-year after PVI with specific attention for those groups that did not improve or were still impaired in HRQoL after PVI. Methods In this observational, retrospective multicenter cohort study, we used data from 8 hospitals participating within the Netherlands Heart Registration (NHR), a non-profit organisation facilitating high-quality registration of patients undergoing cardiac interventions within the Netherlands. Patients who underwent PVI between January 2016 and December 2019 and completed the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire both prior to and one-year after were included (N=2534). To interpret the relevance of findings, accepted cut-off values for the AFEQT Overall summary score were used; &amp;lt;80 points for impaired HRQoL and a delta of ≥5 points for clinically meaningful improvement. Results The majority of the population were men (65.7%) with normal left ventricular ejection fraction (87.1%), paroxysmal AF (77.1%) and a low median CHA₂DS₂-VASc score of 1 (interquartile range, 1–2). The mean AFEQT score was 55.6 ± 19.7 prior to intervention and 79.8 ± 20.2 one-year after PVI. Despite this major increase in mean AFEQT score, we found 39.5% of the population still impaired in HRQol (&amp;lt;80 points) one-year after PVI and 19.2% of the population failed to achieve a clinically meaningful improvement (delta of ≥5 points). Lower baseline AFEQT score (odds ratio [OR], 0.96 [per 1-point increase]; 95% CI, 0.96-0.97; P&amp;lt;0.001) and female sex (odds ratio [OR], 1.42; 95% CI, 1.16-1.75; P&amp;lt;0.001) found to be the most prominent related factors with impaired HRQol one-year after PVI. For failure to achieve clinically meaningful improvement higher baseline AFEQT score (odds ratio [OR], 1.04 [per 1-point increase]; 95% CI, 1.04-1.05; P&amp;lt;0.001) was strongly associated. Other independent risk factors were age (impaired HRQol); BMI (impaired HRQOL); CHA₂DS₂-VASc score (failure to achieve clinically meaningful improvement) and prior catheter ablation for AF (impaired HRQOL and failure to achieve clinically meaningful improvement). Conclusion Despite a major increase in HRQol across the population after PVI, over one third of patients were still impaired in HRQoL after PVI. Several factors were identified which could guide patient counseling for the best fitting treatment for atrial fibrillation.

Abstract 13542: Electrical Delay, LA Electromechanical Delay, and LA Volume Contribute to Increased LA Stiffness in Relatively Elderly Patients With Pulmonary Vein Isolation for Atrial Fibrillation

Background: Atrial dysfunction occurs after pulmonary vein isolation (PVI) for atrial fibrillation (AF), and some reports suggest that electrical conduction delay (ECD) via the Bachmann bundle could be a contributing factor. However, the relationship between ECD in the atria and LA function after PVI remains unclear. The LA reservoir strain (LARS) by speckle-tracking echocardiography (STE) is used to assess LA booster function, with a decrease indicating increased LA stiffness. Purpose: We aim to investigate ECD, LA electromechanical delay (LAEMD), and LA function in patients after PVI for AF. Methods: This single-center retrospective study included 74 patients (Mean age at 70.4 ± 9.1 years, 44 males, left ventricular ejection fraction (LVEF): 62.9 ± 6.8 %, LA volume index: LAVI 39.0 ± 10.8 ml/m 2 ) who were in sinus rhythm at the echocardiographic examination. ECD on the ECG was defined as the presence of biphasic P waves, which were classified into those not observed (group A; n=42), those observed only in III lead (group B; n=23), and those observed in all lower wall leads (II, III, aVF) (group C; n=9). LAEMD was defined as the time interval between the top of the R wave on the ECG and the start of the late diastolic wave (a') on the tissue doppler imaging, and the lateral (a' lateral) and septum (a' septum) time differences (a’ sep-lat time) were calculated. To evaluate the LA function, two-dimensional STE was analyzed. Results: Mean observation period was 19.2 months after PVI. Groups B and C showed significant differences in a' sep-lat time compared to group A. LARS was markedly reduced in all groups (average: 19.0 ± 6.3). LARS and LAVI showed a significant difference between groups A and C. Multivariate analysis of factors leading to LARS showed correlations with a', E/e'. Conclusion: These results suggest that in relatively elderly post-PVI AF patients with preserved LVEF, the ECD and LAEMD as well as LAVI may affect LA function long after PVI and contribute to increased LA stiffness.

Abstract 12295: The Timing of Appearance of Untimely Dissociated Potentials After Pulmonary Vein Isolation for Atrial Fibrillation is Related to the Respiratory Phase

Introduction: Ectopic beats originating from the pulmonary vein (PV) trigger atrial fibrillation (AF). However, the mechanism and timing of Ectopic beat occurrence remain unclear. Hypothesis: The dissociated potentials (DPs) after pulmonary vein isolation (PVI) for AF are related to the respiratory phase and left atrial pressure (LAP). Methods: 93 patients underwent AF ablation under deep sedation and BiPAP ventilation. [Study1] Respiratory waveforms of 20 patients were recorded simultaneously with LAP. [Study2] In 73 patients, DPs after PVI or left atrial posterior wall (LAPW) isolation were recorded simultaneously with respiratory waveforms for 3 min, and the preceding coupling intervals (CI) of all DPs were measured. Sites with DPs frequencies &lt;10/min were defined as rare DPs sites. In sites with DPs frequencies ≧10/min, sites where the number of DPs with CI shorter than the mean - SD of CI was greater than the number of DPs with CI longer than the mean + SD of CI were defined as short-coupling DPs sites, and long-coupling DPs sites were defined in the opposite cases. Results: [Study1] Respiratory waveforms showed fluctuations similar to LAP, and LAP increased within the respiratory interval in all patients (Fig.1). [Study2] The incidence of DPs on the left PV was lower than that on the right PV and LAPW (28 of 61 left PV 46%, 41 of 66 62%, 3 of 3 100%, P=0.0306). Additionally, the CI of DPs on the left PV was longer (3.1±5.4sec, 2.0±2.8, and 1.6±0.5, P&lt;0.0001). The timing of appearance of DPs was not related to the respiratory phase in all DPs assessments (2126 beats during the respiratory interval and 2155 beats during the rest interval). However, inopportune DPs appeared during the specific respiratory phases: the respiratory interval for short-coupling DPs, and the rest interval for long-coupling DPs and rare DPs sites (P=0.016, Fig.2). Conclusions: The timing of appearance of untimely DPs is related to the respiratory phase and may be associated with an increase in LAP.

Abstract 13916: Patient Outcomes 6 Months Following Pulmonary Vein Isolation for Atrial Fibrillation With a Novel RF Catheter: Initial Data From NEwTON AF

Introduction: The combination of local impedance (LI), a direct measure of electrical resistance at the catheter tip, and contact force (CF) may facilitate treatment of atrial fibrillation (AF). This trial is designed to examine the safety and effectiveness of a novel RF catheter that allows measurement of both LI and CF. Hypothesis: Demonstrate the safety and effectiveness of a novel radiofrequency catheter with LI and CF for treatment of drug refractory, recurrent, symptomatic Paroxysmal AF (PAF). Methods: NEwTON AF is a multi-center, global, prospective, single arm study. Patients received index treatment for PAF with the study catheter. The present 6-month endpoint analysis was prospectively planned. Results: The study treated 299 patients at 45 sites in North America, Europe, and Asia. Patients were 39.5% female with a mean age of 62yrs (±12), and had a mean LVEF of 59% and an LA diameter of 3.9cm. Procedure time, LA dwell, and fluoroscopy times were 166, 136, and 15 minutes, respectively. High-power short-duration (HSPD, 45-50W) was exclusively used in 210 cases, which had notably shorter procedure times than the 82 cases that used conventional power, 148 vs 208 min, respectively. Acute procedural success was observed in 98.3% of cases. As of 6 months, freedom from documented recurrence of any atrial arrhythmia was 79.9% (Figure). Recurrence in relation to LI shows that pts with a 20Ω LI drop (in at least 60% of lesions) had better 6m outcomes (84.2% vs 73.3, p=0.04). The freedom from safety event rate at 30d was 96.0%; events included pericarditis (6), access complications (2), pulmonary edema (2), embolism (2), cerebrovascular accident (1), tamponade (1). Pericarditis was higher in pts with a history of COVID at enrollment, 16.3% vs 5.9%, p=0.025. Conclusions: This data suggests that patient outcomes and safety for this novel catheter are promising. Further data from this study, including 12m outcomes, and detailed analysis of local impedance data are forthcoming.

Prevention of cerebral thromboembolism by oral anticoagulation with dabigatran after pulmonary vein isolation for atrial fibrillation: the ODIn-AF trial

Background and objectivesLong-term oral anticoagulation (OAC) following successful catheter ablation of atrial fibrillation (AF) remains controversial. Prospective data are missing. The ODIn-AF study aimed to evaluate the effect of OAC on the incidence of silent cerebral embolic events and clinically relevant cardioembolic events in patients at intermediate to high risk for embolic events, free from AF after pulmonary vein isolation (PVI).MethodsThis prospective, randomized, multicenter, open-label, blinded endpoint interventional trial enrolled patients who were scheduled for PVI to treat paroxysmal or persistent AF. Six months after PVI, AF-free patients were randomized to receive either continued OAC with dabigatran or no OAC. The primary endpoint was the incidence of new silent micro- and macro-embolic lesions detected on brain MRI at 12 months of follow-up compared to baseline. Safety analysis included bleedings, clinically evident cardioembolic, and serious adverse events (SAE).ResultsBetween 2015 and 2021, 200 patients were randomized into 2 study arms (on OAC: n = 99, off OAC: n = 101). There was no significant difference in the occurrence of new cerebral microlesions between the on OAC and off OAC arm [2 (2%) versus 0 (0%); P = 0.1517] after 12 months. MRI showed no new macro-embolic lesion, no clinical apparent strokes were present in both groups. SAE were more frequent in the OAC arm [on OAC n = 34 (31.8%), off OAC n = 18 (19.4%); P = 0.0460]; bleedings did not differ.ConclusionDiscontinuation of OAC after successful PVI was not found to be associated with an elevated risk of cerebral embolic events compared with continued OAC after a follow-up of 12 months.Graphical abstract

Durability of pulmonary vein isolation for atrial fibrillation: a meta-analysis and systematic review.

Pulmonary vein isolation (PVI) plays a central role in the interventional treatment of atrial fibrillation (AF). Uncertainties remain about the durability of ablation lesions from different energy sources. We aimed to systematically review the durability of ablation lesions associated with various PVI-techniques using different energy sources for the treatment of AF. Structured systematic database search for articles published between January 2010 and January 2023 reporting PVI-lesion durability as evaluated in the overall cohort through repeat invasive remapping during follow-up. Studies evaluating only a proportion of the initial cohort in redo procedures were excluded. A total of 19 studies investigating 1050 patients (mean age 60 years, 31% women, time to remap 2-7 months) were included. In a pooled analysis, 99.7% of the PVs and 99.4% of patients were successfully ablated at baseline and 75.5% of the PVs remained isolated and 51% of the patients had all PVs persistently isolated at follow-up across all energy sources. In a pooled analysis of the percentages of PVs durably isolated during follow-up, the estimates of RFA were the lowest of all energy sources at 71% (95% CI 69-73, 11 studies), but comparable with cryoballoon (79%, 95%CI 74-83, 3 studies). Higher durability percentages were reported in PVs ablated with laser-balloon (84%, 95%CI 78-89, one study) and PFA (87%, 95%CI 84-90, 2 studies). We observed no significant difference in the durability of the ablation lesions of the four evaluated energies after adjusting for procedural and baseline populational characteristics.