Vein Isolation For Atrial Fibrillation Research Articles

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<0,0001) and X-ray dose (586±546cGy/cm2 vs 96,7±93 cGy/cm2, P<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.

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.

Bachmann's Bundle Modification in Addition to Circumferential Pulmonary Vein Isolation for Atrial Fibrillation: A Novel Ablation Strategy.

Bachmann's bundle (BB) is the main pathway of interatrial connection that could be involved in the development of atrial fibrillation (AF). Based on this hypothesis, we raised a novel ablation strategy, BB modification in addition to circumferential pulmonary vein isolation (CPVI-BB) in patients with AF. A retrospective cohort of patients with AF who underwent CPVI-BB or CPVI alone from March 2018 to July 2021 was enrolled in our study. Propensity score matching was performed in patients with paroxysmal AF and persistent AF, respectively, to reduce the risk of selection bias between the treatment strategies (CPVI-BB or CPVI alone). The primary endpoint was overall freedom from atrial arrhythmia recurrence through 12 months of follow-up. Our propensity score-matched cohort included 82 patients with paroxysmal AF (CPVI group: n = 41; CPVI-BB group: n = 41) and 168 patients with persistent AF (CPVI group: n = 84; CPVI-BB group: n = 84). Among patients with persistent AF, one-year freedom from atrial arrhythmia recurrence rate was 83.3% in the CPVI-BB group and 70.2% in the CPVI group (log-rank P = 0.047). Among patients with paroxysmal AF, no significant difference was found in the primary endpoint between two groups (85.4% in the CPVI-BB group vs. 80.5% in the CPVI group; log-rank P = 0.581). In addition, procedure-related complications and recurrence of atrial tachycardia or atrial flutter were similar between the two treatment groups, regardless of the type of AF. BB modification in addition to CPVI is an effective approach in increasing the maintenance of sinus rhythm in patients with persistent AF, while it does not improve the clinical outcomes of radiofrequency catheter ablation in patients with paroxysmal AF.

Predictors of pulmonary vein non-reconnection in the second procedure after ablation index-guided pulmonary vein isolation for atrial fibrillation and its impact on the outcome.

Although first-pass isolation (FPI) of the pulmonary vein (PV) has been suggested as a marker for PV isolation (PVI) durability, it has not been confirmed. Non-PV atrial fibrillation (AF) triggers were the main target in patients without PV reconnection in the second ablation procedure, but the outcome was unclear. We aimed to validate FPI as a marker of PVI durability and evaluate the outcome after the second procedure in patients without PV reconnection by comparing it to those with reconnection. Among the 2087 patients undergoing the first ablation index-guided radiofrequency AF ablation, 309 with atrial tachyarrhythmias (ATs) recurrence and undergoing the second procedure were studied. Clinical characteristics and outcomes were compared between the patients without PV reconnection (PV non-reconnection group, n = 142) and with reconnection (PV reconnection group, n = 167). FPI in both PV sides in the first ablation procedure was significantly more frequent in thePV non-reconnection group (77.5%) than in thePV reconnection group (45.5%) (p < .001). Multivariate logistic regression analysis revealed that FPI (odds ratio, 3.71 [95% confidence interval, 2.23-6.19], p < .001) was the only predictor of PV non-reconnection. Radiofrequency applications for non-PV AF triggers were more frequently performed in thePV non-reconnection group (40.8% vs. 24.6%, respectively, p < .001). Kaplan-Meier analysis revealed that AT recurrence-free rate was significantly lower in thePV non-reconnection group (1-year recurrence-free rate, 62.7% vs. 75.4%, respectively; p = .01 by log-rank test). FPI was the only independent predictor of PV non-reconnection. Despite aggressive ablation for non-PV triggers, AT recurrence was more frequent in patients with PV non-reconnection.

Real-World Cost-Effectiveness of Pulmonary Vein Isolation for Atrial Fibrillation: A Target Trial Approach

ObjectivesRandomized controlled trials of pulmonary vein isolation (PVI) for treating atrial fibrillation (AF) have proven the procedure’s efficacy. Studies assessing its empirical cost-effectiveness outside randomized trial settings are lacking. We aimed to evaluate the effectiveness and cost-effectiveness of PVI versus medical therapy for AF. MethodsWe followed a target trial approach using the Swiss-AF cohort, a prospective observational cohort study that enrolled patients with AF between 2014 and 2017. Resource utilization and cost information were collected through claims data. Quality of life was measured with EQ-5D-3L utilities. We estimated incremental cost-effectiveness ratios (ICERs) from the perspective of the Swiss statutory health insurance system. ResultsPatients undergoing PVI compared with medical therapy had a 5-year overall survival advantage with a hazard ratio of 0.75 (95% CI 0.46-1.21; P = .69) and a 19.8% SD improvement in quality of life (95% CI 15.5-22.9; P < .001), at an incremental cost of 29 604 Swiss francs (CHF) (95% CI 16 354-42 855; P < .001). The estimated ICER was CHF 158 612 per quality-adjusted life-year (QALY) gained within a 5-year time horizon. Assuming similar health effects and costs over 5 additional years changed the ICER to CHF 82 195 per QALY gained. Results were robust to the sensitivity analyses performed. ConclusionsOur results show that PVI might be a cost-effective intervention within the Swiss healthcare context in a 10-year time horizon, but unlikely to be so at 5 years, if a willingness-to-pay threshold of CHF 100 000 per QALY gained is assumed. Given data availability, we find target trial designs are a valuable tool for assessing the cost-effectiveness of healthcare interventions outside of randomized controlled trial settings.

Transthoracic Echocardiographic Characteristics of Patients Who Underwent Pulmonary Vein Isolation for Atrial Fibrillation

Transthoracic Echocardiographic Characteristics of Patients Who Underwent Pulmonary Vein Isolation for Atrial Fibrillation

The Impact of Regional Maximum Tolerated Interlesion Distance on the Long-Term Ablation Outcomes in Ablation Index Guided Pulmonary Vein Isolation for Atrial Fibrillation.

An adequate interlesion distance (ILD) applied during point-by-point pulmonary vein (PV) isolation for atrial fibrillation (AF) has never been established. We hypothesized that maximum tolerated ILD may differ between PV regions and may influence long-term ablation outcomes. A total of 260 AF patients underwent PV isolation with 3D electroanatomical platform. Postablation, ILD values were classified into 5 groups (6-5.5 mm, 5.5-5.0 mm, 5.0-4.5 mm, 4.5-4.0 mm and <4.0 mm); the number of tags in each group was calculated and correlated with postablation AF recurrence (AFR). All measurements were performed globally for the entire encirclement around each individual PV and regionally for designated PV anatomic segments. Single-procedure freedom from AF was 81% for paroxysmal and 66% for persistent AF at 12 months. Global analysis showed that AFR was not related to median ILD nor the number of lesions within each ILD tag group for any PV. Segmental analysis showed that AFR was not related to median ILD. However, the presence of tags from the 5.5-6.0 mm ILD group located on the posterior aspect of right upper PV (RUPV) correlated with AFR. This was confirmed in a multivariable logistic regression model. Maximum tolerated ILD of 6.0 mm translated into well-accepted ablation results. However, the study suggests that it may be inadequate at the posterior aspect of RUPV.

Utility of short-time electrocardiogram to assess risk for atrial arrhythmia recurrence: Impact of atrial premature beat occurrence 1 day after pulmonary vein isolation for atrial fibrillation.

Atrial premature beats (APBs) are the trigger for atrial fibrillation (AF). We sought to investigate the clinical significance of APB occurrence 1 day after pulmonary vein isolation (PVI) for AF using a short-time electrocardiogram. A total of 206 patients undergoing PVI for paroxysmal AF were included. Electrocardiogram recording for 100 consecutive beats was performed 1 day after PVI. The patients were divided into two groups: those with reproducible APBs (≥1 beat) during reassessment (APB group, n = 49) or those without (non-APB group, n = 157). Late recurrence was defined as atrial tachyarrhythmia recurrence 3-12 months after PVI. The impact of APB occurrence on outcomes was investigated. Late recurrence occurred in 19 patients (9.2%). The presence of low-voltage areas, left atrial volume, and recurrence rate were higher in the APB group than in the non-APB group. In the APB group, the patients with recurrence had lower prematurity index (PI, coupling interval of APB/previous cycle length) compared to those without. Receiver-operating characteristic analysis revealed PI (<59.3) to be a predictive factor of recurrence (area under the curve: 0.733). The study subjects were then reclassified into three groups according to the absence of APB occurrence (n = 157), presence thereof with PI ≥ 59.3 (n = 33), and presence with PI < 59.3 (n = 16). The multivariate Cox models revealed that APB with PI < 59.3 was an independent predictor for recurrence (hazard ratio, 8.735; p < 0.001). A short-time electrocardiogram enables risk assessment for arrhythmia recurrence, and APB with low PI 1 day after PVI is a powerful predictor.

Prevalence, Patterns, and Predictors Of Conduction Gaps And Reconnections After Single Ring Pulmonary Vein Isolation for Atrial Fibrillation

Prevalence, Patterns, and Predictors Of Conduction Gaps And Reconnections After Single Ring Pulmonary Vein Isolation for Atrial Fibrillation