Catheter ablation vs. antiarrhythmic drug treatment of persistent atrial fibrillation: a multicentre, randomized, controlled trial (SARA study) Impact of computed tomography image and contact force technology on catheter ablation for atrial fibrillation. Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction: The CAMERA-MRI Study. Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction Atrial Fibrillation Catheter Ablation Versus Surgical Ablation Treatment (FAST): A 2-Center Randomized Clinical Trial Efficacy and safety of catheter ablation for long-standing persistent atrial fibrillation in women. Approaches to catheter ablation for persistent atrial fibrillation. The impact of CT image integration into an electroanatomic mapping system on clinical outcomes of catheter ablation of atrial fibrillation. Asymptomatic Cerebral Infarction During Catheter Ablation for Atrial Fibrillation: Comparing Uninterrupted Rivaroxaban and Warfarin (ASCERTAIN). Improved endothelial function in patients with atrial fibrillation through maintenance of sinus rhythm by successful catheter ablation. Catheter ablation of atrial fibrillation in patients with diabetes mellitus type 2: results from a randomized study comparing pulmonary vein isolation versus antiarrhythmic drug therapy. The usefulness of global left atrial strain for predicting atrial fibrillation recurrence after catheter ablation in patients with persistent and paroxysmal atrial fibrillation. Radiofrequency Catheter Ablation and Antiarrhythmic Drug Therapy: A Prospective, Randomized, 4-Year Follow-Up Trial: The APAF Study Cryoballoon ablation for persistent atrial fibrillation - Large single-center experience. Effects of Alpha Lipoic Acid on Multiple Cytokines and Biomarkers and Recurrence of Atrial Fibrillation Within 1 Year of Catheter Ablation. Pericardial effusion in atrial fibrillation ablation: a comparison between cryoballoon and radiofrequency pulmonary vein isolation. Uninterrupted rivaroxaban vs. uninterrupted vitamin K antagonists for catheter ablation in non-valvular atrial fibrillation Neuropsychological Effects of MRI-Detected Brain Lesions After Left Atrial Catheter Ablation for Atrial Fibrillation: Long-Term Results of the MACPAF Study Mesh ablator vs. cryoballoon pulmonary vein ablation of symptomatic paroxysmal atrial fibrillation: results of the MACPAF study. Efficacy and Safety of Rivaroxaban and Warfarin in the Perioperative Period of Catheter Ablation for Atrial Fibrillation　- Outcome Analysis From a Prospective Multicenter Registry Study in Japan. Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Radiofrequency Ablation of Atrial Fibrillation: Is the Persistence of All Intraprocedural Targets Necessary for Long-Term Maintenance of Sinus Rhythm? Periprocedural Stroke and Bleeding Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation With Different Anticoagulation Management: Results From the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) Rand
Background Catheter ablation ( CA ) is a highly effective therapy for the treatment of paroxysmal atrial fibrillation ( AF ) when compared with antiarrhythmic drug therapy ( ADT ) . No r and omized studies have compared the two strategies in persistent AF . The present r and omized trial aim ed to compare the effectiveness of CA vs. ADT in treating persistent AF . Methods and results Patients with persistent AF were r and omly assigned to CA or ADT ( excluding patients with long-st and ing persistent AF ) . Primary endpoint at 12-month follow-up was defined as any episode of AF or atrial flutter lasting > 24 h that occurred after a 3-month blanking period . Secondary endpoints were any atrial tachyarrhythmia lasting > 30 s , hospitalization , and electrical cardioversion . In total , 146 patients were included ( aged 55 ± 9 years , 77 % male ) . The ADT group received class Ic ( 43.8 % ) or class III drugs ( 56.3 % ) . In an intention-to-treat analysis , 69 of 98 patients ( 70.4 % ) in the CA group and 21 of 48 patients ( 43.7 % ) in the ADT group were free of the primary endpoint ( P = 0.002 ) , implying an absolute risk difference of 26.6 % ( 95 % CI 10.0–43.3 ) in favour of CA . The proportion of patients free of any recurrence ( > 30 s ) was higher in the CA group than in the ADT group ( 60.2 vs. 29.2 % ; P < 0.001 ) and cardioversion was less frequent ( 34.7 vs. 50 % , respectively ; P = 0.018 ) . Conclusion Catheter ablation is superior to medical therapy for the maintenance of sinus rhythm in patients with persistent AF at 12-month follow-up . Clinical Trial Registration Information NCT00863213 ( http:// clinical trials.gov/ct2/show/NCT00863213 ) AIM To investigate the impact of using computed tomography ( CT ) and contact force ( CF ) technology on recurrence of atrial tachyarrhythmia after atrial fibrillation ( AF ) ablation . METHODS This non-r and omized study included 2 groups of patients . All patients had symptomatic recurrent paroxysmal or persistent AF and were treated with at least 1 anti arrhythmic medication or intolerant to medication . The first group included 33 patients who underwent circumferential pulmonary veins isolation ( PVI ) for AF during 2012 and 2013 guided by CT image integration ( Cartomerge , Biosense Webster , Diamond Bar , CA , United States ) of left atrium and pulmonary veins into an electroanatomic mapping ( EAM ) system ( CT group ) using st and ard irrigated radiofrequency catheter ( ThermoCool , Carto , Biosense Webster , Diamond Bar , CA , United States ) or irrigated catheter with integrated CF sensor ( Smart Touch , Carto , Biosense Webster , Diamond Bar , CA , United States ) . The second group included immediately preceding 32 patients who had  circumferential PVI by st and ard irrigated catheter ( ThermoCool ) using only EAM ( Carto ) system ( EAM group ) . Linear lesions were performed according to the discretion of operator . RESULTS Sex , age , and persistent AF were not different between groups . PVI was achieved in all patients in both groups . Linear ablations including cavo-tricuspid isthmus and or roof line ablation were not different between groups . Free of atrial tachyarrhythmia during follow-up of 24 mo was significantly higher among CT group compared to EAM group ( 81 % vs 55 % ; respectively ; P = 0.027 ) . When 11 patients from CT group who had ablation using Smart Touch catheter were excluded , the difference between CT group and EAM became non significant ( 73 % vs 55 % ; respectively ; P = 0.16 ) . Sub analysis of CT group showed that patients who had ablation using Smart Touch catheter tend to be more free of atrial tachyarrhythmia compared to patients who had ablation using st and ard irrigated catheter during follow-up ( 100 % vs 73 % ; respectively ; P = 0.07 ) . Major complications ( pericardial effusion , cerebrovascular accident/transient ischemic attack , vascular access injury requiring intervention ) did not occurred in both groups . CONCLUSION These preliminary results suggest that CT image integration and CF technology may reduce the recurrence of atrial tachyarrhythmia after catheter ablation for AF BACKGROUND Atrial fibrillation ( AF ) and left ventricular systolic dysfunction ( LVSD ) frequently co-exist despite adequate rate control . Existing r and omized studies of AF and LVSD of varying etiologies have reported modest benefits with a rhythm control strategy . OBJECTIVES The goal of this study was to determine whether catheter ablation ( CA ) for AF could improve LVSD compared with medical rate control ( MRC ) where the etiology of the LVSD was unexplained , apart from the presence of AF . METHODS This multicenter , r and omized clinical trial enrolled patients with persistent AF and idiopathic cardiomyopathy ( left ventricular ejection fraction [ LVEF ] ≤45 % ) . After optimization of rate control , patients underwent cardiac magnetic resonance ( CMR ) to assess LVEF and late gadolinium enhancement , indicative of ventricular fibrosis , before r and omization to either CA or ongoing MRC . CA included pulmonary vein isolation and posterior wall isolation . AF burden post-CA was assessed by using an implanted loop recorder , and adequacy of MRC was assessed by using serial Holter monitoring . The primary endpoint was change in LVEF on repeat CMR at 6 months . RESULTS A total of 301 patients were screened ; 68 patients were enrolled between November 2013 and October 2016 and r and omized with 33 in each arm ( accounting for 2 dropouts ) .  The average AF burden post-CA was 1.6 ± 5.0 % at 6 months . In the intention-to-treat analysis , absolute LVEF improved by 18 ± 13 % in the CA group compared with 4.4 ± 13 % in the MRC group ( p < 0.0001 ) and normalized ( LVEF ≥50 % ) in 58 % versus 9 % ( p = 0.0002 ) . In those undergoing CA , the absence of late gadolinium enhancement predicted greater improvements in absolute LVEF ( 10.7 % ; p = 0.0069 ) and normalization at 6 months ( 73 % vs. 29 % ; p = 0.0093 ) . CONCLUSIONS AF is an underappreciated reversible cause of LVSD in this population despite adequate rate control . The restoration of sinus rhythm with CA results in significant improvements in ventricular function , particularly in the absence of ventricular fibrosis on CMR . This outcome challenges the current treatment paradigm that rate control is the appropriate strategy in patients with AF and LVSD . ( Catheter Ablation Versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction [ CAMERA-MRI ] ; ACTRN12613000880741 ) Purpose It is still unknown whether left ventricular ejection fraction ( LVEF ) might affect the magnitude of improvement after atrial fibrillation ( AF ) ablation on cardiac function in persistent or longst and ing persistent AF ( CAF ) patients . Method We performed echocardiography in 35 patients with CAF before and after catheter ablation ( CA ) .  Patients were stratified by LVEF into two groups prior to CA — normal LVEF ( ≥50 % LVEF , N group , n = 24 ) and a low LVEF group ( < 50 % LVEF , L group , n = 11 ) . Patients were followed at 1 month , 3 months , 6 months , 1 year , and 2 years after ablation . Results After 15.8 ± 7.4 months follow-up , the L group showed greater improvement in LVEF and left atrial ejection fraction ( LAEF ; N group vs L group : LVEF difference ( % ) , 5 ±8 vs 20± 13 , p < 0.01 ; LAEF difference ( % ) , 11 ± 12 vs 21 ± 10 , p < 0.05 ) . LA maximal volume and E/e′ showed the same tendency after ablation , although the extent of improvement was not statistically significant . Both groups showed almost the same time course of improvement up to 2 years , although the L group showed earlier recovery in LVEF . Conclusion The greater improvement in several cardiac functions was seen in patients with greater LV dysfunction , after the CA for CAF Background — Catheter ablation ( CA ) and minimally invasive surgical ablation ( SA ) have become accepted therapy for antiarrhythmic drug – refractory atrial fibrillation . This study describes the first r and omized clinical trial comparing their efficacy and safety during a 12-month follow-up . Methods and Results — One hundred twenty-four patients with antiarrhythmic drug – refractory atrial fibrillation with left atrial dilatation and hypertension ( 42 patients , 33 % ) or failed prior CA ( 82 patients , 67 % ) were r and omized to CA ( 63 patients ) or SA ( 61 patients ) . CA consisted of linear antral pulmonary vein isolation and optional additional lines . SA consisted of bipolar radiofrequency isolation of the bilateral pulmonary vein , ganglionated plexi ablation , and left atrial appendage excision with optional additional lines . Follow-up at 6 and 12 months was performed by ECG and 7-day Holter recording . The primary end point , freedom from left atrial arrhythmia > 30 seconds without antiarrhythmic drugs after 12 months , was 36.5 % for CA and 65.6 % for SA ( P=0.0022 ) . There was no difference in effect for subgroups , which was consistent at both sites . The primary safety end point of significant adverse events during the 12-month follow-up was significantly higher for SA than for CA ( n=21 [ 34.4 % ] versus n=10 [ 15.9 % ] ; P=0.027 ) , driven mainly by procedural complications such as pneumothorax , major bleeding , and the need for pacemaker . In the CA group , 1 patient died at 1 month of subarachnoid hemorrhage . Conclusion — In atrial fibrillation patients with dilated left atrium and hypertension or failed prior atrial fibrillation CA , SA is superior to CA in achieving freedom from left atrial arrhythmias after 12 months of follow-up , although the procedural adverse event rate is significantly higher for SA than for CA . Clinical Trial Registration — URL : http:// clinical trials.gov . Unique identifier : NCT00662701 OBJECTIVES It is uncertain whether gender affects the outcomes of catheter ablation ( CA ) for atrial fibrillation ( AF ) . The objective of the study is to evaluate the efficacy and safety of CA for long-st and ing persistent AF in women . METHODS Between January 2010 and May 2011 , 220 consecutive patients ( 73 females , 33.2 % ) , with long-st and ing persistent AF who underwent CA were prospect ively recruited . Gender-related differences in clinical presentation , periprocedural complications , and outcomes were compared . RESULTS Women were less likely to have lone AF than men ( 27.4 % vs 47.6 % ; P = 0.004 ) . The incidence of rheumatic heart disease was higher in women ( 19.2 % in women vs 1.4 % in men ; P < 0.001 ) . Women had a lower initial ablation success rate than men ( 35.6 % vs 57.1 % ; P = 0.003 ) . Hematomas occurred more often in women ( 6.8 % in women vs 0.7 % in men ; P = 0.027 ) . A Cox regression analysis demonstrated total duration of AF ( per month , hazard ratio [ HR ] 1.003 , confidence interval [ CI ] 1.001 - 1.006 ; P = 0.006 ) and gender ( HR 1.663 , CI 1.114 - 2.485 ; P = 0.013 ) as the independent predictors for recurrence after the first CA . CONCLUSIONS Women and long AF duration were closely related to the recurrence of AF after the first ablation in patients with long-st and ing persistent AF . Women also had a higher risk of vascular complications BACKGROUND Catheter ablation is less successful for persistent atrial fibrillation than for paroxysmal atrial fibrillation . Guidelines suggest that adjuvant substrate modification in addition to pulmonary-vein isolation is required in persistent atrial fibrillation . METHODS We r and omly assigned 589 patients with persistent atrial fibrillation in a 1:4:4 ratio to ablation with pulmonary-vein isolation alone ( 67 patients  ) , pulmonary-vein isolation plus ablation of electrograms showing complex fractionated activity ( 263 patients  ) , or pulmonary-vein isolation plus additional linear ablation across the left atrial roof and mitral valve isthmus ( 259 patients ) . The duration of follow-up was 18 months . The primary end point was freedom from any documented recurrence of atrial fibrillation lasting longer than 30 seconds after a single ablation procedure . RESULTS Procedure time was significantly shorter for pulmonary-vein isolation alone than for the other two procedures ( P<0.001 ) . After 18 months , 59 % of patients assigned to pulmonary-vein isolation alone were free from recurrent atrial fibrillation , as compared with 49 % of patients assigned to pulmonary-vein isolation plus complex electrogram ablation and 46 % of patients assigned to pulmonary-vein isolation plus linear ablation ( P=0.15 ) . There were also no significant differences among the three groups for the secondary end points , including freedom from atrial fibrillation after two ablation procedures and freedom from any atrial arrhythmia . Complications included tamponade ( three patients ) , stroke or transient ischemic attack ( three patients ) , and atrioesophageal fistula ( one patient ) . CONCLUSIONS Among patients with persistent atrial fibrillation , we found no reduction in the rate of recurrent atrial fibrillation when either linear ablation or ablation of complex fractionated electrograms was performed in addition to pulmonary-vein isolation . ( Funded by St. Jude Medical ; Clinical Trials.gov number , NCT01203748 . ) BACKGROUND A detailed appreciation of left atrial/pulmonary vein ( LA/PV ) anatomy may be important in improving the safety and success of catheter ablation ( CA ) for atrial fibrillation ( AF ) . OBJECTIVES The aim of this nonr and omized study was to determine the impact of computerized tomography ( CT ) image integration into a 3-dimensional ( 3D ) mapping system on the clinical outcome of patients undergoing CA for AF . METHODS Ninety-four patients ( age : 56 + /- 10 years ) with AF ( paroxysmal 46 , persistent 48 ) underwent wide encirclement of ipsilateral PV pairs using irrigated radiofrequency ablation with the endpoint of electrical isolation . Ablation was guided by 3D mapping alone ( electroanatomic 24 , noncontact 23 ) in 47 ( 3DM group ) patients and by CT image integration ( Cartomerge ) in 47 ( CT group ) . In persistent AF , a combination of linear ablation and targeted ablation of complex fractionated electrograms was also performed . RESULTS Successful PV electrical isolation did not differ between the two groups . A significant reduction in fluoroscopy times was demonstrated in the CT group ( 49 + /- 27 minutes vs 3DM group 62 + /- 26 minutes , P = 0.03 ) . Arrhythmia recurrence was reduced in the CT group ( 32 % vs 51 % in the 3DM group , P < 0.01 ) . In 30 symptomatic patients ( 12 CT and 18 3DM ) , repeat procedures for AF ( 13 in 3DM and 5 CT , P < or = 0.10 ) and AT ( 5 in 3DM and 7 CT , P = NS ) were performed . Overall success on 7-day monitor off antiarrhythmic drugs was achieved in 60 % in the 3DM group when compared with 83 % in the CT group ( P < 0.05 ) at a follow-up of 25 + /- 5 weeks . CONCLUSION CA for AF guided by CT integration was associated with reduced fluoroscopy times , arrhythmia recurrence , and increased restoration of sinus rhythm . Improved visualization of complex LA geometries might improve the safety and success of CA for AF OBJECTIVES This r and omized study compared uninterrupted rivaroxaban therapy with warfarin therapy as prophylaxis against catheter ablation (CA)-induced asymptomatic cerebral infa rct ion ( ACI ) and identified the risk factors of rivaroxaban . BACKGROUND The reported incidence of ACI during CA for atrial fibrillation ( AF ) remains at 10 % to 30 % , and periprocedural oral anticoagulation could affect this incidence . METHODS Patients with nonvalvular AF undergoing radiofrequency CA were r and omly assigned to receive either uninterrupted rivaroxaban or warfarin as periprocedural anticoagulation therapy . CA was performed after at least 1 month of adequate anticoagulation . Cerebral magnetic resonance imaging ( MRI ) was performed within 2 weeks before and 1 day after CA to detect ACI . RESULTS A total 132 patients were enrolled ; 127 ( median : 60.0 years of age ; 83.5 % males ; 64.6 % incidence of paroxysmal AF ) complied with the study protocol and were analyzed ; 64 patients received  rivaroxaban  , and 63 patients received warfarin . The rates of CA-induced ACI in the rivaroxaban group ( 15.6 % [ 10 of 64 patients ] ) were similar to those in the warfarin group ( 15.9 % [ 10 of 63 patients ] ; p = 1.000 ) . No thromboembolic events developed ; no differences in major or nonmajor bleeding rates were observed between the 2 drug groups ( 3.1 % vs. 1.6 % , respectively , or 18.8 % vs. 19.0 % , respectively ) . Multiple regression analysis indicated that the presence of deep and subcortical white matter hyperintensity ( p = 0.002 ; odds ratio [ OR ] : 5.323 ) and the frequency of cardioversions ( p = 0.016 ; OR : 1.250 ) were associated with the incidence of ACI . CONCLUSIONS No notable differences were found between the incidence of CA-induced ACI in the rivaroxaban group and that in the warfarin group in this r and omized study BACKGROUND Although atrial fibrillation ( AF ) is a risk factor for endothelial dysfunction ( ED ) , the effect of catheter ablation ( CA ) on AF-associated ED has not been evaluated . The aims of this study are to determine if the degree of ED predicts the outcome of AF ablation and to evaluate whether ED can be improved through restoring sinus rhythm ( SR ) by successful CA . METHODS This study prospect ively enrolled 80 subjects who underwent CA for AF ( paroxysmal AF = 61 , persistent AF = 19 ) . Eighty subjects with no history of AF were enrolled as controls , all of whom were matched by age , gender , body mass index , and atherosclerotic risk factor distribution . Brachial artery flow-mediated dilatation ( FMD ) was measured at baseline , and at 1 month and 6 months post CA in AF subjects who remained in SR . Among controls , FMD was measured at baseline and at 6 months . We used high sensitivity C-reactive protein ( hs-CRP ) , interleukin-6 , soluble E- or P-selectin , and endothelin-1 as biomarker indices for inflammation and /or ED . RESULTS Compared with controls , AF subjects had lower FMD at baseline ( FMD(baseline ) , P < 0.001 ) . After successful CA , FMD was significantly improved at 1 month and 6 months , nearly approaching control levels . A multivariate analysis revealed that FMD(baseline ) , hs-CRP , and left atrial volume ( LAV ) were independent predictors for arrhythmia recurrence after CA . Other biomarkers were not related to rhythm outcome . CONCLUSION AF subjects have significantly impaired FMD , which can be reversed through maintenance of SR by successful CA . FMD(baseline ) , hs-CRP , and LAV are important predictors for AF recurrence after CA INTRODUCTION Atrial fibrillation ( AF ) and diabetes mellitus type 2 ( DM2 ) often coexist ; however , a small number of patients with DM2 undergoing catheter ablation ( CA ) of AF  have been included in previous studies . The aim of this study was to evaluate safety and efficacy of ablation therapy in DM2 patients with drug refractory AF . METHODS AND RESULTS From January 2005 to September 2006 , 70 patients with a diagnosis of DM2 and paroxysmal ( n = 29 ) or persistent ( n = 41 ) AF were r and omized to receive either pulmonary vein isolation or a new antiarrhythmic drug treatment ( ADT ) with a 1-year follow-up . The primary endpoint was the time to first AF recurrence . By Kaplan-Meier analysis , at the end of follow-up , 42.9 % of patients in the ADT group and 80 % of patients who received a single ablation procedure and were without medications were free of AF ( P = 0.001 ) . In the ablation group , a significant improvement in quality -of-life ( QoL ) scores as compared with ADT group was observed . Six patients in the ADT group ( 17.1 % ) developed significant adverse drug effects . Hospitalization rate during follow-up was higher in the ADT group ( P = 0.01 ) . The only complication attributable to ablation was one significant access-site hematoma . CONCLUSION In patients with DM2 , CA of AF provides significant clinical benefits over the ADT and appears to be a reasonable approach regarding feasibility , effectiveness , and low procedural risk BACKGROUND Given the potential complications of atrial fibrillation ( AF ) recurrence after ablation , better predictors of the effectiveness of the procedure are necessary to guide patient selection . AIM This prospect i ve study was conducted to evaluate the clinical relevance of global left atrial longitudinal strain ( GLAS ) and AF recurrence after catheter ablation . METHODS In 115 consecutive patients with AF ( persistent , n=62 ; paroxysmal , n=53 ) ,  transthoracic echocardiography was performed before catheter ablation to assess baseline left atrial mechanical function using speckle tracking echocardiography ( STE ) . RESULTS After 12 months of follow-up , 22 ( 35.5 % ) patients in the persistent AF group and 15 ( 28.3 % ) in the paroxysmal AF group exhibited AF recurrence . In both the paroxysmal and persistent AF population s , patients with recurrence presented with significantly impaired GLAS compared with patients without recurrence . Patients with recurrence also had a significantly higher pro-B-type natriuretic peptide concentration . A receiver operator curve analysis yielded area under the curve values of 0.94 and 0.86 for paroxysmal and persistent AF , respectively . In a multivariable Cox proportional-hazards analysis , GLAS was an independent predictor of AF recurrence after catheter ablation in both the paroxysmal AF group ( hazard ratio : 0.79 , 95 % confidence interval : 0.67 - 0.96 ; P=0.01 ) and the persistent AF group ( hazard ratio : 0.81 , 95 % confidence interval : 0.71 - 0.93 ; P=0.004 ) . CONCLUSIONS In both paroxysmal and persistent AF , decreased baseline left atrial deformation capabilities assessed by two-dimensional STE can help to identify patients at high risk of AF recurrence after catheter ablation . This variable may help to guide c and i date selection and improve therapeutic strategies Background — Information on comparative outcome between radiofrequency catheter ablation ( RFA ) and antiarrhythmic drugs ( AADs ) > 1 year after r and omization is important for clinical decision-making . Methods and Results — A total of 198 patients ( age , 56±10 years ) with paroxysmal atrial fibrillation were r and omly assigned to RFA ( 99 patients ) or to AADs ( 99 patients ) . We evaluated efficacy of RFA or AADs in a comparable 48-month follow-up period according to intention-to-treat analysis . Cardiac rhythm was assessed with daily transtelephonic transmissions . Quality of life was also analyzed . At 4 years , among the 99 patients first assigned to RFA , the procedure was repeated because of recurrent atrial fibrillation/atrial tachycardia in 27 patients ( 27.3 % ) . Among the 99 patients r and omly assigned to AADs , 87 ( 87.9 % ) crossed over to undergo RFA and 4 years after r and om assignment only 12 ( 12.1 % ) were in sinus rhythm with AAD alone without ablation . Despite the high level of crossovers , at 4 years the intention-to-treat analysis showed that 72.7 % of patients in the ablation arm and 56.5 % of those initially r and omly assigned to AADs were free of recurrent atrial fibrillation/atrial tachycardia ( P=0.017 ) . During the follow-up , 19.2 % of AAD patients progressed to persistent atrial fibrillation before switching to RFA . RFA significantly improved quality of life ( P<0.001 ) , whereas before crossing over to RFA , patients receiving AADs showed poorer quality of life . Except for new left atrial tachycardia , there were no serious complications caused by RFA . Conclusions — With follow-up extended to 4 years after r and omly assigned , ablation remains superior to antiarrhythmic drug in these patients with paroxysmal atrial fibrillation . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00340314 BACKGROUND Different catheter ablation ( CA ) strategies have been established in the treatment of persistent atrial fibrillation ( persAF ) .  Pulmonary vein isolation ( PVI ) only might be an option for the initial ablation procedure . There is a paucity of outcome data on second-generation cryoballoon ( CBG2 ) PVI in persAF . METHODS Patients with symptomatic drug-refractory persAF who underwent initial CA of AF  were prospect ively enrolled and PVI was performed with CBG2 . The primary composite endpoint was freedom from AF , atrial tachycardia , or related symptoms after a 3-month blanking period . The secondary endpoint referred to periprocedural complications . RESULTS One hundred seventy-three consecutive patients ( 64±10 years , 29 % female ) with symptomatic drug-refractory persAF were identified . Acute PVI was achieved in 100 % of pulmonary veins with the CB technique . The left atrial procedure time was 112±30min . Major complications occurred in 1.7 % ( 3 of 173 patients ) including two phrenic nerve palsies ( 1 % ) , which resolved until discharge , and one pericardial effusion ( 0.6 % ) . Follow-up ≥12 months was completed for 157 of 173 patients ( 91 % ) . Median follow-up was 14 months . At 12 months , the primary composite endpoint was achieved in 129 of 157 patients ( 82 % ) . However , 22 of 129 patients at risk ( 17 % ) were still on antiarrhythmic drugs . A relapse during the blanking period was identified as the only independent predictor for AF recurrence . CONCLUSION PVI using the second-generation cryoballoon is a reasonable treatment option for patients with symptomatic drug-refractory persAF with a favorable rate of freedom from AF and a low complication rate Catheter ablation ( CA ) is a procedure commonly used to restore sinus rhythm in patients with atrial fibrillation ( AF ) . However , AF recurrence after CA remains a relevant clinical issue . We tested the effects of an oral antioxidant treatment ( alpha lipoic acid [ ALA ] ) on AF recurrence post-CA . Patients with paroxysmal AF have been enrolled in a r and omized , prospect i ve , double-blind , controlled placebo trial . After CA , patients have been r and omly assigned to receive ALA oral supplementation ( ALA group ) or placebo ( control group ) and evaluated at baseline and after a 12-month follow-up : 73 patients completed the 12-month follow-up  ( ALA : 33 and control : 40 ) . No significant difference has been detected between the 2 groups at baseline . Strikingly , 1 year after CA , ALA therapy significantly reduced serum markers of inflammation . However , there was no significant difference in AF recurrence events at follow-up comparing ALA with placebo group . Multivariate analysis revealed that the only independent prognostic risk factor for AF recurrence after CA is age . In conclusion , ALA therapy reduces serum levels of common markers of inflammation in ablated patients . Nevertheless , ALA does not prevent AF recurrence after an ablative treatment AIMS  Atrial fibrillation ( AF ) ablation  is increasingly being performed in electrophysiology laboratories . Pericardial effusion ( PE ) is certainly one of the most frequently observed complications during AF ablation . The aim of our study was to investigate the incidence and outcome of PE following cryothermal energy balloon ablation ( CBA ) in comparison with conventional circumferential pulmonary vein isolation with a focal radiofrequency ( RF ) catheter . METHODS AND RESULTS A total of 133 consecutive patients ( 105 males ) with paroxysmal AF were included in this study . Forty-six patients ( 36 males ) underwent CBA  ( A rct ic Front , Medtronic , USA ) and 87 ( 69 males ) point-by-point RF ablation guided by electroanatomical mapping ( Carto , Biosense Webster , Diamond Bar , CA , USA ) . Ablation was performed under general anaesthesia with both techniques . All patients underwent a 2D transthoracic echocardiogram within 24 h before and after the procedure as routinely performed in our centre . Pericardial effusion was detected in 19 ( 14.2 % ) of 133 patients . Sixteen patients presented mild effusion , one moderate effusion , and two pericardial tamponades . There was no significant difference in the incidence of PE between the cryoballoon and the RF group ( 11 vs. 16 % ) . A longer procedural time , coronary artery disease , and arterial hypertension were found to be independent predictors of PE during AF ablation . CONCLUSION Pericardial effusion occurred in a similar proportion following CBA and RF ablation for AF .  Pericardial effusion was mostly mild and asymptomatic , with benign clinical outcome not requiring additional hospitalization days Aims VENTURE-AF is the first prospect i ve r and omized trial of uninterrupted rivaroxaban and vitamin K antagonists ( VKAs ) in patients with non-valvular atrial fibrillation ( NVAF ) undergoing catheter ablation ( CA ) . Methods and results Trial size was administratively set at 250 , the protocol -specified target . Events were independently and blindly adjudicated . We r and omly assigned 248 NVAF patients  to uninterrupted rivaroxaban ( 20 mg once-daily ) or to an uninterrupted VKA prior to CA and for 4 weeks afterwards . The primary endpoint was major bleeding events after CA . Secondary endpoints included thromboembolic events ( composite of stroke , systemic embolism , myocardial infa rct ion , and vascular death ) and other bleeding or procedure-attributable events . Patients were 59.5 ± 10 years of age , 71 % male , 74 % paroxysmal AF , and had a CHA2DS2-VASc score of 1.6 .  The average total heparin dose used to manage activated clotting time ( ACT ) was slightly higher ( 13 871 vs. 10 964 units ; P < 0.001 ) and the mean ACT level attained slightly lower ( 302 vs. 332 s ; P < 0.001 ) in rivaroxaban and VKA arms , respectively . The incidence of major bleeding was low ( 0.4 % ; 1 major bleeding event ) . Similarly , thromboembolic events were low ( 0.8 % ; 1 ischemic stroke and 1 vascular death ) . All events occurred in the VKA arm and all after CA . The number of any adjudicated events ( 26 vs. 25 ) , any bleeding events ( 21 vs. 18 ) , and any other procedure-attributable events ( 5 vs. 5 ) were similar . Conclusion In patients undergoing CA for AF , the use of uninterrupted oral rivaroxaban was feasible and event rates were similar to those for uninterrupted VKA therapy . Name of the Trial Registry Clinical trials.gov trial registration number is NCT01729871 Background — MRI-detected brain lesions are common after  left atrial catheter ablation for symptomatic atrial fibrillation . The clinical relevance of these acute ischemic lesions is not fully understood , but ablation-related cerebral injury could contribute to cognitive dysfunction . Methods and Results — In the prospect i ve Mesh Ablator versus Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation ( MACPAF ) study , serial 3-T brain MRIs and neuropsychological assessment were performed to analyze the rate of ablation-related brain lesions and their effect on cognitive function .  Thirty-seven patients with paroxysmal atrial fibrillation ( median age , 63.0 [ interquartile range , 57–68 ] years ; 41 % female ; median CHA2DS2VASc score 2 [ interquartile range , 1–3 ] ) underwent 41 ablation procedures according to study criteria . None of these patients had overt neurological deficits after ablation . High-resolution diffusion-weighted imaging , performed within 48 hours after ablation , showed that new brain lesions ( range , 1–17 ) were present in 16 ( 43.2 % ) patients after 18 ( 43.9 % ) left atrial catheter ablation procedures . Follow-up MRI at 6 months ( median , 6.5 ; interquartile range , 6–7 ) revealed that 7 ( 12.5 % ) of the 56 total acute brain lesions after ablation formed a persistent glial scar in 5 ( 31.3 % ) patients . Large diffusion-weighted imaging lesions and a corresponding fluid-attenuated inversion recovery lesion 48 hours after ablation predicted lesion persistence on 6-month follow-up . Neither persistent brain lesions nor the ablation procedure itself had a significant effect on attention or executive functions , short-term memory , or verbal and nonverbal learning after 6 months . Conclusions — Ablation-related acute ischemic brain lesions persist to some extent but do not cause cognitive impairment 6 months after the ablation procedure . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01061931 AIMS Catheter ablation of the pulmonary veins ( PVs ) is a promising therapeutic approach for symptomatic atrial fibrillation ( AF ) . The prospect i ve r and omized single-centre study ' Mesh Ablator versus Cryoballoon Pulmonary Vein Ablation of Symptomatic Paroxysmal Atrial Fibrillation ' ( MACPAF ; clinical trials.gov NCT01061931 ) compared the efficacy and safety of two balloon-based PV ablation systems . METHODS AND RESULTS Thirty-two patients underwent PV ablation for symptomatic paroxysmal AF using the A rct ic Front ® or the HD Mesh Ablator ® catheter  according to study protocol . The primary endpoint was complete PV isolation ( PVI ) at the end of the ablation procedure , determined by exit block after achieving entrance block . Long-term follow-up data are not included in this publication . Patients ' mean age was 61.7 ± 8.9 years , 43.2 % were female , and median CHA₂DS₂-VASc score was 2.0 . In the intention-to-treat analysis , the rate of the primary endpoint was 56.5 % in patients r and omized to the A rct ic Front ® and 9.5 % in patients r and omized to the HD Mesh Ablator ® catheter ( P = 0.001 ) . In the per- protocol analysis , complete PVI was achieved in 13 ( 76.5 % ) of 17 A rct ic Front ® patients but in none of the 15 HD Mesh Ablator ® patients ( P < 0.0001 ) . There were one major and two minor complications in each study arm but no clinical ly evident stroke . Post-procedural AF recurrence was detected within hospital stay in two ( 11.8 % ) A rct ic Front ® patients and in seven ( 46.7 % ) HD Mesh Ablator ® patients ( P = 0.049 ) . CONCLUSION The MACPAF study revealed a superiority of the A rct ic Front ® catheter concerning complete PVI . Owing to the insufficient efficacy of the HD Mesh Ablator ® catheter , the safety board decided to stop MACPAF prematurely BACKGROUND Catheter ablation ( CA ) is a common treatment for atrial fibrillation ( AF ) . Although rivaroxaban is increasingly used as a substitute for warfarin , its safety and efficacy during CA have not been established in Japanese patients . In the present study we explored the efficacy/safety of rivaroxaban during the CA perioperative period . Methods and Results : We prospect ively enrolled Japanese AF patients scheduled for CA who had received either rivaroxaban ( rivaroxaban cohort , JACRE-R ) or warfarin ( warfarin cohort , JACRE-W ) during the perioperative period . Primary outcome was a composite of thromboembolism and major bleeding within 30 days after CA . In JACRE-R and JACRE-W , 1,118 ( median age , 65 years ) and 204 patients ( median , 69 years ) were enrolled from 42 and 22 institutions , respectively . In JACRE-R , the primary outcome occurred in 7 patients ( 0.6 % ) , comprising thromboembolism in 2 and major bleeding in 5 . Non-major bleeding occurred in 27 patients ( 2.4 % ) , and the incidence was significantly lower in patients without heparin bridging ( n=572 ) than in those with heparin bridging ( n=546 ) . In JACRE-W , the primary outcome occurred in 3 patients ( 1.5 % ) , all of which were major bleeding . After adjustment for patients ' characteristics , no signiﬁcant difference was observed between the JACRE-R and JACRE-W cohorts for the primary outcome . CONCLUSIONS The rates of thromboembolism and major bleeding events during the AF ablation perioperative period in Japanese patients treated with rivaroxaban  was as low as in those treated with warfarin . ( Circ J 2016 ; 80 : 2295 - 2301 ) OBJECTIVES The aim of this study was to compare -- in patients with persistent and permanent atrial fibrillation (AF)--the  efficacy and safety of left atrial ablation with that of a biatrial approach . BACKGROUND Left atrium-based catheter ablation of AF , although very effective in the paroxysmal form of the arrhythmia , has an insufficient efficacy in patients with persistent and permanent AF . METHODS Eighty highly symptomatic patients ( age , 58.6 + /- 8.9 years ) with persistent ( n = 43 ) and permanent AF ( n = 37 ) , refractory to antiarrhythmic drugs , were r and omized to two different ablation approaches guided by electroanatomical mapping . A procedure including circumferential pulmonary vein , mitral isthmus , and cavotricuspid isthmus ablation was performed in 41 cases ( left atrial ablation group ) . In the remaining 39 patients ( biatrial ablation group ) , the aforementioned approach was integrated by the following lesions in the right atrium : intercaval posterior line , intercaval septal line , and electrical disconnection of the superior vena cava . RESULTS During follow-up ( mean duration 14 + /- 5 months ) , AF recurred in 39 % of patients in the left atrial ablation group and in 15 % of patients in the biatrial ablation group ( p = 0.022 ) . Multivariable Cox regression analysis showed that ablation technique was an independent predictor of AF recurrence during follow-up . CONCLUSIONS In patients with persistent and permanent AF , circumferential pulmonary vein ablation , combined with linear lesions in the right atrium , is feasible , safe , and has a significantly higher success rate than left atrial and cavotricuspid ablation alone Background — Several approaches have been developed for radiofrequency catheter ablation of atrial fibrillation , but the correct intraprocedural end point is still under debate , and few data exist about the destiny of ablation lesions over time . The aim of the present study was to evaluate the long-term maintenance of intraprocedural end points of ablation procedures . Methods and Results — Inclusion criteria were ( 1 ) a previous ablation procedure of pulmonary vein ( PV ) encircling performed for drug-refractory persistent atrial fibrillation ; ( 2 ) a “ complete ” intraprocedural end point , which consisted of voltage abatement inside the lesions , PV disconnection , and exit-block pacing from inside the lesions , attained in all PVs ; and ( 3 ) stable sinus rhythm documented during a minimum follow-up of 2.5 years after the procedure . Twenty volunteers were selected ( 12 males , mean age 59±7 years ) and underwent a repeat electrophysiological study . After a follow-up of 36.4±4.7 months , complete voltage abatement was maintained around 32 PVs ( 40.0 % ) , PV disconnection persisted in 12 ( 37.5 % ) of the previously isolated PVs , and exit block was present in 39 PVs ( 48.7 % ) . Ten patients who underwent a redo ablation procedure because of recurrences of atrial fibrillation were used as the control group . Differences in intraprocedural end-point maintenance between the 2 groups were not statistically significant . Conclusions — Common intraprocedural end points such as voltage abatement , PV disconnection , and exit block persist only in a limited number of patients , even when the outcome is favorable during follow-up . Further investigation will be required to determine whether such data will have implication s for ablation strategies Background — Periprocedural thromboembolic and hemorrhagic events are worrisome complications of catheter ablation for atrial fibrillation ( AF ) . The periprocedural anticoagulation management could play a role in the incidence of these complications . Although ablation procedures performed without warfarin discontinuation seem to be associated with lower thromboembolic risk , no r and omized study exists . Methods and Results — This was a prospect i ve , open-label , r and omized , parallel-group , multicenter study assessing the role of continuous warfarin therapy in preventing periprocedural thromboembolic and hemorrhagic events after radiofrequency catheter ablation . Patients with CHADS2 score ≥1 were included . Patients were r and omly assigned in a 1:1 ratio to the off-warfarin or on-warfarin arm . The incidence of thromboembolic events in the 48 hours after ablation was the primary end point of the study . The study enrolled 1584 patients : 790 assigned to discontinue warfarin ( group 1 ) and 794 assigned to continuous warfarin ( group 2 ) . No statistical difference in baseline characteristics was observed . There were 39 thromboembolic events ( 3.7 % strokes [ n=29 ] and 1.3 % transient ischemic attacks [ n=10 ] ) in group 1 : two events ( 0.87 % ) in patients with paroxysmal AF , 4 ( 2.3 % ) in patients with persistent AF , and 33 ( 8.5 % ) in patients with long-st and ing persistent AF . Only 2 strokes ( 0.25 % ) in patients with long-st and ing persistent AF were observed in group 2 ( P<0.001 ) . Warfarin discontinuation emerged as a strong predictor of periprocedural thromboembolism ( odds ratio , 13 ; 95 % confidence interval , 3.1–55.6 ; P<0.001 ) . Conclusion — This is the first r and omized study showing that performing catheter ablation of AF without warfarin discontinuation reduces the occurrence of periprocedural stroke and minor bleeding complications compared with bridging with low-molecular-weight heparin . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT01006876
Where data were available , the relative benefits seen held true both after a single or multiple procedure(s ) .
For patients with persistent atrial fibrillation , CA achieves significantly greater freedom from recurrent atrial fibrillation compared with medical therapy .
BACKGROUND Catheter ablation ( CA ) is commonly performed for persistent atrial fibrillation , but few high- quality r and omized controlled trials ( RCTs ) exist , leading to funding restrictions being proposed in several countries .
We performed a r and om-effects meta- analysis of RCTs and non- RCTs to assess the efficacy of CA for persistent atrial fibrillation .