Mechanisms of recurrent atrial fibrillation: comparisons between segmental ostial versus circumferential pulmonary vein isolation. A randomized prospective comparison of CartoMerge and CartoXP to guide circumferential pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation. Atrial Electroanatomic Remodeling After Circumferential Radiofrequency Pulmonary Vein Ablation: Efficacy of an Anatomic Approach in a Large Cohort of Patients With Atrial Fibrillation Recurrence of pulmonary vein conduction and atrial fibrillation after pulmonary vein isolation for atrial fibrillation: a randomized trial of the ostial versus the extraostial ablation strategy. Is Pulmonary Vein Isolation Necessary for Curing Atrial Fibrillation? Randomized comparison of encircling and nonencircling left atrial ablation for chronic atrial fibrillation. Role of residual potentials inside circumferential pulmonary veins ablation lines in the recurrence of paroxysmal atrial fibrillation. Comparison of lesion formation between contact force-guided and non-guided circumferential pulmonary vein isolation: a prospective, randomized study. Is circumferential pulmonary vein isolation preferable to stepwise segmental pulmonary vein isolation for patients with paroxysmal atrial fibrillation? Pulmonary venous isolation versus additional substrate modification as treatment for paroxysmal atrial fibrillation Pulmonary vein isolation combined with superior vena cava isolation for atrial fibrillation ablation: a prospective randomized study. Myeloperoxidase and Risk of Recurrence of Atrial Fibrillation After Catheter Ablation Left atrial ablation versus biatrial ablation for persistent and permanent atrial fibrillation: a prospective and randomized study. Left atrial strain as predictor of successful outcomes in catheter ablation for atrial fibrillation: a two-dimensional myocardial imaging study Circumferential Radiofrequency Ablation of Pulmonary Vein Ostia: A New Anatomic Approach for Curing Atrial Fibrillation Efficacy of additional ablation of complex fractionated atrial electrograms for catheter ablation of nonparoxysmal atrial fibrillation. Early identification and treatment of PV re-connections: role of observation time and impact on clinical results of atrial fibrillation ablation. Left atrial mechanics predict the success of pulmonary vein isolation in patients with atrial fibrillation Detection and Quantification of Left Atrial Structural Remodeling With Delayed-Enhancement Magnetic Resonance Imaging in Patients With Atrial Fibrillation Clinical predictors of noninducibility of sustained atrial fibrillation after pulmonary vein isolation. Left Atrial Posterior Wall Isolation Does Not Improve the Outcome of Circumferential Pulmonary Vein Ablation for Atrial Fibrillation: A Prospective Randomized Study Additional left atrial septal line does not improve outcome of patients undergoing ablation for long-standing persistent atrial fibrillation Catheter ablation of atrial fibrillation in patients with atrial septal defect: long-term follow-up results
BACKGROUND Electrical isolation of pulmonary veins ( PVs ) is an effective therapy for atrial fibrillation ( AF ) . Both segmental ostial PV ablation and circumferential ablation with PV-left atrial ( LA ) block have been implicated to eliminate AF . However , the mechanism of the recurrent AF after undergoing either strategy remains unclear . METHODS AND RESULTS Of the 73 consecutive patients with symptomatic AF that underwent PV isolation and had recurrences of AF , Group 1 consisted of 46 patients ( age 56 + /- 13 years old , 35 males ) who underwent PV isolation by segmental ostial PV ablation and Group 2 consisted of 27 patients ( age 51 + /- 11 years old , 24 males ) who underwent circumferential ablation with PV-LA block .  In Group 1 , the earliest ectopic beat or ostial PV potentials were targeted . In Group 2 , circumferential ablation with PV-LA block was performed by encircling the extraostial regions around the left and right PVs . During the first procedure , all patients had PV-AF . There was no difference in the non-PV ectopy between Group 1 and Group 2 . During the second procedure , the incidence of an LA posterior wall ectopy initiating AF was significantly lower ( 20 % vs. 0 % , P = 0.01 ) in Group 2 . There was no difference in the PV ectopy initiating AF during the second procedure . CONCLUSION Circumferential ablation of AF with PV-LA block may eliminate the LA posterior wall ectopy and decrease the incidence of LA posterior wall ectopy initiating AF during the second procedure BACKGROUND CartoXP and CartoMerge have been used to treat atrial fibrillation ( AF ) for several years . Our r and omized prospect i ve study compared clinical outcomes of these two versions of three dimensional electroanatomic mapping system in guiding catheter ablation for paroxysmal atrial fibrillation ( PAF ) . METHODS Eighty-one patients with symptomatic , drug refractory PAF were r and omly assigned to  CartoMerge group ( n=42 , mean age ( 54.5+/-13.1 ) years , history of AF=3.2 years ) or CartoXP group ( n=39 , mean age ( 59.8+/-15.6 ) years , history of AF = 2.9 years ) . All patients underwent 64-slice computed tomography ( MSCT ) 1 to 3 days prior to ablation procedure . Using CartoMerge(TM ) Image Integration Module , 3D anatomical images of the left atrium ( LA ) and pulmonary veins ( PVs ) derived from MSCT of CartoMerge group were established and merged with the electroanatomical map . The integrated images were used to guide the procedure of circumferential pulmonary vein isolation ( CPVI ) . In the other group , CPVI was guided just by CartoXP . The endpoint of CPVI in both groups was abolition or dissociation of pulmonary vein potentials ( PVPs ) . RESULTS Mapping points to establish the electroanatomical model of the LA/PVs were 48.7+/-13.4 in CartoMerge group and 62.5+/-15.7 in CartoXP group ( P<0.001 ) . Mean distance between mapping points and the MSCT surfaces in CartoMerge group was ( 1.59+/-0.33 ) mm . Accomplishment of abolition or dissociation of PVPs was achieved 95.2 % in CartoMerge group and 92.3 % in CartoXP group . Duration s of procedure and exposure to X-ray were ( 156+/-25 ) minutes , ( 179+/-21 ) minutes ( P<0.001 ) and ( 19.6+/-7.5 ) minutes , ( 28.5+/-12.8 ) minutes ( P<0.001 ) , respectively . After a follow-up with duration of ( 11.9+/-3.1 ) months vs ( 12.4+/-3.6 ) months post the first ablation procedure , patients free of AF were 33 ( 78.6 % ) in CartoMerge group and 29 ( 74.4 % ) in CartoXP group ( P>0.50 ) . No patient suffered pulmonary vein stenosis , atrioesophageal fistula , stroke or death . CONCLUSION Compared to CartoXP , CartoMerge shortened the catheter ablation procedure and exposure to X-ray , without affecting the clinical outcomes of circumferential pulmonary vein isolation for the treatment of paroxysmal atrial fibrillation in experienced centres Background —Circumferential radiofrequency ablation around pulmonary vein ( PV ) ostia has recently been described as a new anatomic approach for atrial fibrillation ( AF ) . Methods and Results —We treated 251 consecutive patients with paroxysmal ( n=179 ) or permanent ( n=72 ) AF .  Circular PV lesions were deployed transseptally during sinus rhythm ( n=124 ) or AF ( n=127 ) using 3D electroanatomic guidance . Procedures lasted 148±26 minutes . Among 980 lesions surrounding individual PVs ( n=956 ) or 2 ipsilateral veins with close openings or common ostium ( n=24 ) , 75 % were defined as complete by a bipolar electrogram amplitude < 0.1 mV inside the lesion and a delay > 30 ms across the line . The amount of low-voltage encircled area was 3594±449 mm2 , which accounted for 23±9 % of the total left atrial ( LA ) map surface . Major complications ( cardiac tamponade ) occurred in 2 patients ( 0.8 % ) . No PV stenoses were detected by transesophageal echocardiography . After 10.4±4.5 months , 152 patients with paroxysmal AF ( 85 % ) and 49 with permanent AF ( 68 % ) were AF-free . Patients with and without AF recurrence did not differ in age , AF duration , prevalence of heart disease , or ejection fraction , but the LA diameter was significantly higher ( P < 0.001 ) in permanent AF patients with recurrence . The proportion of PVs with complete lesions was similar between patients with and without recurrence , but the latter had larger low-voltage encircled areas after radiofrequency ( expressed as percent of LA surface area;P < 0.001 ) . Conclusions —Circumferential PV ablation is a safe and effective treatment for AF . Its success is likely due to both PV trigger isolation and electroanatomic remodeling of the area encompassing the PV ostia BACKGROUND Both segmental ostial and circumferential extraostial pulmonary vein ( PV ) isolation have been proven effective in the treatment of atrial fibrillation ( AF ) . However , the recurrence of AF and PV conduction after the 2 ablation strategies has never been compared in a r and omized study . METHODS A total of 100 consecutive patients ( age 56 + /- 10 ; 71 men ) with symptomatic AF ( paroxysmal , 51 ; persistent , 49 ) were r and omized to segmental ostial ( n = 54 ) or circumferential extraostial ( n = 46 ) PV isolation . A circular catheter positioned at the ostium of each target PV guided the ostial PV isolation . Extraostial PV isolation was performed by encircling the paired left and right PVs , respectively , guided by an electroanatomic mapping system . RESULTS A total of 84 % of the patients had recurrent AF after the first PV isolation procedure , showing 72 % with AF and 12 % with organized left atrial tachycardia . In patients undergoing reablation , all but 2 patients had recurrence of left atrium PV conduction ( > 95 % ) . During a mean follow-up of 12 months without antiarrhythmic medication , 57 % of patients who underwent extraostial PV isolation were free of arrhythmia symptoms compared with 31 % of patients who underwent ostial PV isolation ( P < .05 ) . This difference in success rate between the 2 ablation strategies was mainly seen in patients known with persistent AF ( 52 % and 15 % , respectively ; P = .02 ) as opposed to patients with paroxysmal AF ( 65 % and 46 % , respectively ; P = .26 ) . CONCLUSIONS Overall , the more proximal , extraostial PV isolation was found to be superior to ostial PV isolation , especially in patients known with persistent AF . A high recurrence rate of 84 % after a single complete PV isolation procedure was seen . At reablation , more than 95 % had recurrence of left atrium PV conduction regardless of the procedure used , supporting the idea that complete PV isolation seems essential to prevent arrhythmia recurrences Background —Pulmonary veins ( PVs ) play a pivotal role in initiating and perpetuating  atrial fibrillation ( AF ) . We investigated if PV electrical isolation from the left atrium is required for curing AF . Methods and Result —Fifty-one patients with paroxysmal or persistent AF underwent circumferential radiofrequency ablation of PV ostia performed with an anatomic approach . The end point of the ablation procedure was the recording of low peak-to-peak bipolar potentials ( < 0.1 mV ) inside the lesions . Left atrium pacing was used to assess the conduction between the PVs and the left atrium . During a mean follow-up period of 16.6±3.9 months , 41 patients ( 80.4 % ) were free of atrial arrhythmias . When patients with and without AF recurrence were analyzed , no significant difference was observed in the mean number of PVs in which the ablation end point was reached ( 3.4±1.2 versus 3.7±0.87 ) and PVs isolated ( 1.5±1.4 versus 1.6±1 ) . We noted that , although in 29 of 41 patients ( 71 % ) without AF recurrence , the ablation end point was reached in all PVs mapped , it was only possible to demonstrate the isolation of all PVs mapped in 2 patients . On the other h and , in 7 of 10 patients ( 70 % ) with AF recurrence , the ablation end point was reached in all PVs mapped , whereas one patient had all PVs isolated . Conclusions —Our findings show that with the use of a pure anatomic approach , it is possible to prevent AF in > 80 % of patients undergoing catheter ablation . Moreover , the isolation of PVs is not crucial for curing AF BACKGROUND Left atrial ( LA ) circumferential ablation has been reported to eliminate atrial fibrillation ( AF ) . Whether an ablation without encirclement of the pulmonary veins ( PVs ) is as effective as LA circumferential ablation is not clear . OBJECTIVES The purpose of this study was to compare the efficacy of LA circumferential ablation and nonencircling linear ablation in patients with chronic AF . METHODS Eighty patients with chronic AF were r and omized to undergo LA circumferential ablation ( n = 40 ) or nonencircling linear ablation ( n = 40 ) . In LA circumferential ablation , the PVs were encircled , with additional lines made in the mitral isthmus and posterior wall or roof . In nonencircling linear ablation , 4 + /- 1 ablation lines were created through areas of complex electrograms , with lines in the roof ( 38 ) , anterior wall ( 36 ) , septum ( 40 ) , mitral isthmus ( 32 ) , and posterior annulus ( 6 ) . The endpoint of LA circumferential ablation and nonencircling linear ablation was voltage abatement . RESULTS LA flutter occurred in 15 % after LA circumferential ablation and in 18 % after nonencircling linear ablation ( P = .8 ) . A repeat ablation procedure was performed for recurrent AF in 7 and 11 patients or for atrial flutter in 6 and 4 patients after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .8 ) . At 9 + /- 4 months , the prevalence of AF was 28 % in the LA circumferential ablation and 25 % in the nonencircling linear ablation group ( P = .8 ) . Sixty-eight percent and 60 % of patients were in sinus rhythm and free of AF and atrial flutter in the absence of antiarrhythmic drug therapy after LA circumferential ablation and nonencircling linear ablation , respectively ( P = .5 ) . There were no complications . CONCLUSION Nonencircling linear ablation and LA circumferential ablation are equally efficacious in eliminating chronic AF . However , the advantage of nonencircling linear ablation is that it eliminates the need for ablation along the posterior wall of the LA . Therefore , nonencircling linear ablation may avoid the small but real risk of atrioesophageal fistula formation associated with LA circumferential ablation BACKGROUND Residual gaps due to incomplete ablation lines are known to be the most common cause of recurrent atrial fibrillation ( AF ) after catheter ablation . We hypothesized that any residual potentials at the junction of the left atrium and pulmonary vein ( PV ) , inside the circumferential PV ablation ( CPVA ) lines , would contribute to the recurrence of AF or post-AF ablation atrial flutter ( AFL ) ; therefore , the elimination of these potentials increases AF-/AFL-free survival rates . METHODS AND RESULTS One hundred and two patients with paroxysmal AF ( PAF ) were enrolled and prospect ively r and omized to a group with  ablation of residual potentials  as add-on therapy to  CPVA + PV electrical isolation ( PVI ) ( group 1 , n = 49 ) , or a group without ablation of the residual potentials ( group 2 , n = 53 ) . Post-CPVA residual potentials , inside the ablation lines , were identified by contact bipolar electrode mapping catheter and a detailed 3-dimensional voltage map . Twenty-three patients in group 1 and 18 patients in group 2 had post-CPVA residual potentials ( 46.9 % vs 34.0 % , P = 0.182 ) . The AF-/AFL-free survival rate during follow-up of 23.3 ± 7.9 months was not different in comparisons between the 2 groups ( P = 0.818 ) , and 79.6 % and 81.1 % of the patients in groups 1 and 2 maintained a sinus rhythm ( P = 0.845 ) , respectively . CONCLUSIONS Residual potentials inside CPVA were commonly found in the patients with PAF after CPVA + PVI . Further ablation of residual potentials did not increase the efficacy of catheter ablation in patients with PAF BACKGROUND Contact force ( CF ) monitoring could be useful in accomplishing circumferential pulmonary vein ( PV ) isolation ( CPVI ) for atrial fibrillation ( AF ) . OBJECTIVE The purpose of this study was to compare procedure parameters and outcomes between CF-guided and non-guided CPVI . METHODS Thirty-eight consecutive AF patients ( mean age 60 ± 11 years , 28 paroxysmal AF ) undergoing CPVI were r and omized to non-CF-guided ( n = 19 ) and CF-guided ( n = 19 ) groups .  CPVI was performed with the ThermoCool SmartTouch catheter in both groups . The end-point was bidirectional block between the left atrium ( LA ) and PV . In the CF group , CF was kept between 10 and 20 g during CPVI , whereas in the non-CF group , all CF information was blanked . Radiofrequency energy at 30 W in the anterior and 25 W in the posterior LA wall was applied for 20 - 25 seconds at each point . RESULTS CPVI was successfully accomplished without any major complications in both groups . Mean CF in the non-CF and CF groups were 5.9 ± 4.5 g and 11.1 ± 4.3 g , respectively , for left-side CPVI , and 9.8 ± 6.6 g and 12.1 ± 4.8 g , respectively , for right-side CPVI ( both P < .001 ) . The procedure and fluoroscopy times  for CPVI in the non-CF and CF groups were 96 ± 39 minutes and 59 ± 16 minutes , respectively ( P < .001 ) , and 22 ± 63 seconds and 9 ± 20 seconds ( P = NS ) , respectively . Total number of residual conduction gaps was 6.3 ± 3.0 in the non-CF group and 2.8 ± 1.9 in the CF group ( P < .001 ) . During 6-month follow-up , 84.2 % of patients in the non-CF group and 94.7 % in the CF group were free from any atrial tachyarrhythmias ( P = .34 ) . CONCLUSION CF-guided CPVI  is effective in reducing procedure time and additional touch-up ablation and may improve long-term outcome BACKGROUND Stepwise segmental pulmonary vein isolation ( SPVI ) and circumferential pulmonary vein isolation ( CPVI ) have been developed to treat patients with atrial fibrillation ( AF ) , but the preferable approach for paroxysmal AF ( PAF ) has not been established . METHODS AND RESULTS One hundred and ten patients with symptomatic PAF were r and omized into a stepwise SPVI group ( n=55 ) or CPVI group ( n=55 ) . Systemic SPVI combined with left atrial linear ablation tailored by inducibility of AF was performed in the stepwise SPVI group . Circumferential linear ablation around the left and right-sided pulmonary veins ( PVs ) guided by 3-dimensional electroanatomic mapping was performed in the CPVI group . The endpoints of ablation are non-induciblity of AF in the stepwise SPVI group and continuity of circular lesions combined with PV isolation in the CPVI group . After the initial procedures , atrial tachyarrhythmis ( ATa ) recurred within the first 3 months in 23 of the 55 patients ( 41.8 % ) who underwent stepwise SPVI and in 20 of the 55 patients ( 36.4 % ) who had CPVI ( p=0.69 ) . Repeat procedures were performed in 7 patients from the stepwise SPVI group and 5 from the CPVI group ( p=0.76 ) . During the 3 - 9 months after the last procedure , 46 patients ( 83.6 % ) from the CPVI group and 43 ( 78.2 % ) from the stepwise SPVI group did not have symptomatic ATa while not taking anti-arrhythmic drugs ( p=0.63 ) . Severe subcutaneous hematoma or PV stenosis occurred in 3 patients . CONCLUSIONS The efficacy of stepwise SPVI is comparable to that of CPVI for patients with PAF Background Pulmonary vein isolation alone is ineffective in maintaining sinus rhythm in up to one third of patients with paroxysmal atrial fibrillation ( AF ) . We compared pulmonary vein antral isolation plus additional limited ablation along the inferoposterior left atrium and epicardially within the adjacent coronary sinus ( PVAI + CS ) to pulmonary vein antral isolation ( PVAI ) alone in patients with paroxysmal AF . Methods Forty-two consecutive patients with paroxysmal AF were prospect ively r and omized to PVAI vs. PVAI + CS . All patients were seen 3 , 6 , 12 , and 18 months after ablation and underwent 24-h ambulatory Holter monitoring . Results Following a single procedure , 17 out of 22 patients ( 77 % ) remained arrhythmia free off antiarrhythmic medication after PVAI at 18 months vs. 10 out of 20 ( 50 % ) after PVAI + CS ( p < 0.01 ) . After PVAI , three patients had recurrent paroxysmal AF , and two had atrial tachycardia , whereas after PVAI + CS , three patients had recurrent paroxysmal AF , and seven had atrial tachycardia . All patients in the PVAI + CS group with atrial tachycardia who underwent a second procedure were found to have peri-mitral macro-reentry as the underlying mechanism . Eighty-one percent of patients remained arrhythmia free off medication after 1.09 procedures in the PVAI group vs. 80 % after 1.35 procedures in the PVAI + CS group ( p < 0.01 ) . Conclusion The addition of limited ablation along the inferoposterior left atrium and within the adjacent coronary sinus to PVAI alone did not reduce the recurrence rate of paroxysmal atrial fibrillation and was associated with an increased rate of peri-mitral macro-reentrant atrial tachycardia AIMS Circumferential pulmonary vein isolation ( CPVI ) is an established strategy for atrial fibrillation ( AF ) ablation . Superior vena cava ( SVC ) , by harbouring the majority of non-pulmonary vein ( PV ) foci , is the most common non-PV origin for AF . However , it is unknown whether CPVI combined with SVC isolation ( SVCI ) could improve clinical results and whether SVCI is technically safe and feasible . METHODS AND RESULTS A total of 106 cases ( 58 males , average age 66.0 + /- 8.8 years ) with paroxysmal AF were included for ablation . They were allocated r and omly to two groups : CPVI group ( n = 54 ) and CPVI + SVCI group ( n = 52 ) . All cases underwent the procedure successfully . Pulmonary vein isolation was achieved in all cases . The procedural time and fluoroscopic time were comparable between the two groups . The mean ablation time for SVC was 7.8 + /- 2.7 min . Superior vena cava isolation was obtained in 50/52 cases . In the remaining two cases , SVCI was not achieved because of obviating diaphragmatic nerve injury . During a mean follow-up of 4 + /- 2 months , 12 ( 22.2 % ) cases in the CPVI group and 10 ( 19.2 % ) cases in the CPVI + SVCI group had atrial tachyarrhythmias ( ATa ) recurrence ( P = 0.70 ) . Nine of 12 cases in the CPVI group and 8/10 cases in the CPVI + SVCI group underwent reablation ( P = 0.86 ) , and PV reconnection occurred in 7/9 cases in the CPVI group and in 8/8 cases in the CPVI + SVCI group . All PV reconnection was reisolated by gaps ablation . There was no SVC reconnection in the CPVI + SVCI group . In two cases without PV reconnection from the CPVI group , SVC-originated short run of atrial tachycardia was identified and eliminated by the SVCI . At the end of 12 months of follow-up , 50 cases ( 92.6 % ) in the CPVI group and 49 ( 94.2 % ) in the CPVI + SVC group were free of ATa recurrence ( P = 0.73 ) . CONCLUSION In our series of paroxysmal AF patients , empirically adding SVCI to CPVI did not significantly reduce the AF recurrence after ablation . Superior vena cava isolation may be useful , however , in selected patients in whom the SVC is identified as a trigger for AF . However , because of the preliminary property of the study and its relatively small sample size , the impact of SVCI on clinical results should be evaluated in a large series of patients Background Myeloperoxidase ( MPO ) has been associated with the development of atrial fibrillation ( AF ) , but its impact on the recurrence of AF after catheter ablation has not been explored . This study investigated the effect of plasma MPO on recurrence after catheter ablation of paroxysmal AF . Methods and Results Two hundred eighty-eight consecutive patients with paroxysmal AF and who underwent circumferential pulmonary vein isolation were prospect ively enrolled . After a mean ± SD follow-up of 516 ± 204 ( 91–910 ) days , the recurrence rates were 16.9 % , 25.7 % , 29.7 % , and 38.0 % from the lowest MPO quartile to the highest MPO quartile , respectively ( P = 0.023 ) . After adjustment for age , sex , left atrial diameter , high-sensitivity C-reactive protein , and pulmonary vein isolation , there was an increased risk of recurrence in the subjects with the highest MPO quartile compared with those with the lowest quartile ( hazard ratio , 3.18 ; 95 % confidence interval , 2.12–5.23 ; P = 0.024 ) . As a continuous variable , MPO was also an independent predictor of recurrence ( hazard ratio , 2.12 ; 95 % confidence interval , 1.71–3.27 ; P = 0.032 ) . Conclusions Patients with high MPO levels were at an increased risk of AF recurrence after catheter ablation 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 The objective of this study was to investigate atrial myocardial properties through two-dimensional ( 2D ) myocardial imaging in patients with atrial fibrillation ( AF ) and its predictive role for recurrence after catheter ablation . Methods and results Echocardiographic examinations were performed in 40 patients with paroxysmal AF before catheter ablation and 40 age- and gender-matched healthy control subjects . Using a software package , bidimensional acquisitions were analyzed to measure longitudinal strain and strain rate for the left atrium ( LA ) . Systolic strain and strain rate in all eight segments , and its average values , were significantly reduced in AF patients compared to controls . During 9 months of follow-up after catheter ablation for AF , 11 of 40 AF patients had AF recurrence . AF recurrence was associated with gender , LA volume index , and average values of systolic strain and strain rate . By multivariate analysis , only average strain was an independent predictor of AF recurrence ( OR = 0.88 , 95 % CI 0.79 - 0.98 , p = 0.018 ) . Conclusions Lower systolic strain of LA was strongly associated with recurrence after catheter ablation . Thus , diverse adjunctive ablation strategies should be considered to reduce recurrence in patients with lower systolic strain Background —The pulmonary veins ( PVs ) and surrounding ostial areas frequently house focal triggers or reentrant circuits critical to the genesis of atrial fibrillation ( AF ) . We developed an anatomic approach aim ed at isolating each PV from the left atrium ( LA ) by circumferential radiofrequency ( RF ) lesions around their ostia . Methods and Results —We selected 26 patients with resistant AF , either paroxysmal ( n=14 ) or permanent ( n=12 ) . A nonfluoroscopic mapping system was used to generate 3D electroanatomic LA maps and deliver RF energy . Two maps were acquired during coronary sinus and right atrial pacing to vali date the lateral and septal PV lesions , respectively . Patients were followed up closely for ≥6 months . Procedures lasted 290±58 minutes , including 80±22 minutes for acquisition of all maps , and 118±16 RF pulses were deployed . Among 14 patients in AF at the beginning of the procedure , 64 % had sinus rhythm restoration during ablation . PV isolation was demonstrated in 76 % of 104 PVs treated by low peak-to-peak electrogram amplitude ( 0.08±0.02 mV ) inside the circular line and by disparity in activation times ( 58±11 ms ) across the lesion . After 9±3 months , 22 patients ( 85 % ) were AF-free , including 62 % not taking and 23 % taking antiarrhythmic drugs , with no difference ( P = NS ) between paroxysmal and permanent AF . No thromboembolic events or PV stenoses were observed by transesophageal echocardiography . Conclusions —Radiofrequency PV isolation with electroanatomic guidance is safe and effective in either paroxysmal or permanent AF BACKGROUND The efficacy of ablation of complex fractionated atrial electrograms ( CFEs ) in the single ablation procedure for nonparoxysmal atrial fibrillation ( AF ) patients is not well demonstrated . The aim of this study was to compare the ablation strategies of pulmonary vein isolation ( PVI ) plus linear ablation with and without additional ablation ofCFEs in these patients . METHODS Consecutive 60 patients ( 49 + /- 11 years old , 50 male , 10 female ) with nonparoxysmal AF underwent catheter ablation guided by a NavX mapping system .  A stepwise approach included a circumferential PVI and left atrial ( LA ) linear ablation followed by either the additional ablation of continuous CFEs in the LA/coronary sinus ( the first 30 patients ) or not ( the second 30 patients ) , detected by an automatic algorithm . RESULTS There was no difference in the baseline characteristics between the two groups . Complete PVI eliminated some continuous CFEs and altered the distribution of CFEs . Following PVI and linear ablation , the remaining continuous CFEs were identified in 7.9 + /-10 % mapping sites of the LA and CS , and were ablated successfully with a procedural AF termination rate of 53 % . With a follow-up of 19 + /-11 months , a Kaplan-Meier analysis showed that the patients with additional ablation of the CFEs had a higher rate of sinus rhythm maintenance . Multivariate analysis showed the single procedure success could be predicted by the procedural AF termination and the additional ablation of continuous CFEs in the LA/CS . CONCLUSIONS Ablation of continuous CFEs after PVI and LA linear ablation had a better long-term efficacy based on the results of single-ablation procedure AIMS Circumferential pulmonary vein isolation ( CPVI ) has been reported to account for 30 % of atrial fibrillation ( AF ) recurrence after initial ablation , and pulmonary vein ( PV ) re-connection accounts for about 80 % of AF recurrence . There is no information in the literature whether early identification and treatment of acute PV conduction recovery during initial ablation has an impact on subsequent clinical results . The objective is to investigate the prevalence of acute PV conduction recovery during the observation time after PV isolation for paroxysmal AF , and to evaluate the impact of re-isolation treatment on clinical results . METHODS AND RESULTS Ninety cases with paroxysmal AF ( 51 males , mean age of 56.4 + /- 12.3 years ) were r and omized to 3 groups to undergo CPVI .  In Group A , there was no observation time post-ablation . In Group B , there was 30 min of observation time post-ablation . In Group C , there was 60 min of observation time post-ablation . All PV re-conduction was re-isolated at the end of the observation time . ECG and Holter monitors were used to evaluate the clinical effectiveness of ablation . All cases underwent the procedure successfully . The mean procedural time in Group A was significantly shorter than in Group B and Group C , but there was no significant difference on fluoroscopic time and PV isolation time among the three groups . In Group B , PV re-conduction occurred in 8 cases ( 25 % ) at 30 min post-isolation , in 10 cases ( 31.2 % ) at 60 min post-isolation for left PVs , and in 6 cases ( 18.8 % ) at 30 min post-isolation for right PVs . In Group C , PV re-conduction for left PVs occurred in 9 cases ( 30 % ) at 30 min post-isolation and in 11 cases ( 36.7 % ) at 60 min post-isolation ; for right PVs this occurred in 7 cases ( 23.3 % ) at 30 min post-isolation and in 8 cases ( 26.7 % ) at 60 min post-isolation . During a mean follow-up of 6.7 + /- 2.3 months , 17 cases ( 60.7 % ) in Group A , 27 cases ( 84.3 % ) in Group B , and 26 cases ( 86.7 % ) in Group C had no recurrence of atrial tachyarrhythmias , P = 0.04 . CONCLUSION The prevalence of acute PV conduction recovery was about 30 % after PV isolation , which mostly occurred within 30 min after initial isolation . Re-isolation of recovered PV conduction contributed to the improvement in the success rate of ablation for paroxysmal AF Background Atrial fibrillation ( AF ) is a common arrhythmia with relevant impact on mortality and morbidity .  Pulmonary vein isolation ( PVI ) is an established therapy in patients who remain symptomatic under optimal medical therapy . However , up to 70 % of patients present with recurrence of AF after PVI . Therefore , identifying ideal c and i date s is an unmet clinical need . Left atrial ( LA ) fibrosis is associated with reduced LA function . Analysis of LA mechanics using 2D speckle tracking echocardiography ( STE ) might give more insight into LA substrates and be therefore of predictive value . Methods This prospect i ve single-center pilot study included 31 patients ( mean age , 62.3 ± 9.1 years ; 19 males ) with AF who underwent PVI and 20 matched healthy controls ( mean age , 60.6 ± 6.6 years ; 10 males ) .  2D STE strain indices of LA reservoir ( RLA ) , conduit , and , if feasible , contractile function , were analyzed before and 6 months after PVI . Assessment of the LV diastolic function was based on st and ard indices . Responders to PVI were defined as being asymptomatic and free of AF in a 7-day Holter-ECG after 6 months . Results At baseline , all patients with AF had significantly lower reservoir and contractile function compared with controls . After 6 months , 17 patients ( 54.8 % ) were identified as responders . At baseline , the reservoir function was significantly higher in responders compared with nonresponders ( 32.7 ± 11.1 vs. 22.9 ± 10.9 % ; P = 0.019 ) . Only in responders , RLA and contractile LA function improved and reached normal values whereas LA function remained unchanged in nonresponders . In a ROC analysis , a RLA value of ≥19.5 % discriminated responders and nonresponders in patients with persistent AF with a sensitivity of 86 % and a specificity of 100 % ( P = 0.012 ; area under the curve 0.943 ; CI , 0.81–1.0 ) . Conclusions LA reservoir function helps to predict efficacy of PVI after 6 months . Only in responders , reservoir , and contractile function normalized within 6 months after PVI indicating a lower level of atrial remodeling at baseline . No deleterious effects of ablation were detected in nonresponders Background — Atrial fibrillation ( AF ) is associated with diffuse left atrial fibrosis and a reduction in endocardial voltage . These changes are indicators of AF severity and appear to be predictors of treatment outcome . In this study , we report the utility of delayed-enhancement magnetic resonance imaging ( DE-MRI ) in detecting abnormal atrial tissue before radiofrequency ablation and in predicting procedural outcome . Methods and Results — Eighty-one patients presenting for pulmonary vein antrum isolation for treatment of AF underwent  3-dimensional DE-MRI of the left atrium before the ablation .  Six healthy volunteers also were scanned . DE-MRI images were manually segmented to isolate the left atrium , and custom software was implemented to quantify the spatial extent of delayed enhancement , which was then compared with the regions of low voltage from electroanatomic maps from the pulmonary vein antrum isolation procedure . Patients were assessed for AF recurrence at least 6 months after pulmonary vein antrum isolation , with an average follow-up of 9.6±3.7 months ( range , 6 to 19 months ) . On the basis of the extent of preablation enhancement , 43 patients were classified as having minimal enhancement ( average enhancement , 8.0±4.2 % ) , 30 as having moderate enhancement ( 21.3±5.8 % ) , and 8 as having extensive enhancement ( 50.1±15.4 % ) . The rate of AF recurrence was 6 patients ( 14.0 % ) with minimal enhancement , 13 ( 43.3 % ) with moderate enhancement , and 6 ( 75 % ) with extensive enhancement ( P<0.001 ) . Conclusions — DE-MRI provides a noninvasive means of assessing left atrial myocardial tissue in patients suffering from AF and might provide insight into the progress of the disease . Preablation DE-MRI holds promise for predicting responders to AF ablation and may provide a metric of overall disease progression BACKGROUND Noninducibility of  sustained atrial fibrillation ( AF ) after pulmonary vein isolation ( PVI )  has been shown to be associated with a better clinical outcome . We evaluated the role of clinical variables that could predict noninducibility of sustained AF after PVI . METHODS AND RESULTS Data were collected prospect ively from 181 patients ( 153 male ; age 54 + /- 9 years ) referred for ablation of drug-refractory symptomatic paroxysmal AF ( duration < or = 7 days ) . Clinical variables were evaluated with regard to their ability of predicting noninducibility of sustained AF  ( < or = 10 minutes ) after PVI . Univariate analysis was performed on all collected variables followed by multivariate analysis for variables showing a P value < 0.1 . After PVI , sustained AF was noninducible in 97 ( 54 % ) patients . The following clinical variables showed a significant difference between the groups : body weight , longest AF episode , duration of AF history , presence or absence of structural heart disease , left ventricular ( LV ) hypertrophy , prior cardioversion , left atrial ( LA ) parasternal , and longitudinal diameters and LV diameters . On multivariate analysis , three independent predictors of noninducibility were identified : a shorter duration of AF episodes ( AF < 12 hours : RR 0.01 ( 0.002 - 0.06 ) , P < 0.001 ; AF 12 - 48 hours : RR 0.07 ( 0.01 - 0.37 ) , P = 0.001 ) ; LA longitudinal diameter < 57 mm ( RR 0.33 ( 0.13 - 0.82 ) , P = 0.016 ) ; and absence of LV hypertrophy ( RR 0.15 ( 0.04 - 0.63 ) , P = 0.01 ) . CONCLUSIONS Shorter AF episodes , smaller LA longitudinal diameter , and absence of LV hypertrophy are independent predictors of noninducibility of sustained AF after PVI Background —Ablation of the pulmonary veins ( PVs ) for atrial fibrillation treatment is often combined with linear radiofrequency lesions along the left atrium ( LA ) to improve the success rate . The study was design ed to assess the contribution of LA posterior wall isolation to the outcome of circumferential pulmonary vein ablation ( CPVA ) . Methods and Results —CPVA consisted of continuous radiofrequency lesions encircling both ipsilateral PVs plus an ablation line along the mitral isthmus . Patients were then r and omized into 2 groups . In the first group , superior PVs were connected by linear lesions along the LA roof ( CPVA-1 group ) . In the second group , the LA posterior wall was isolated by adding a second line connecting the inferior aspect of the 2 inferior PVs ( CPVA-2 group ) . The study included 120 patients ( 53±11 years , 77 % male , 60 % paroxysmal atrial fibrillation , LA of 41.3±5.4 mm , 46 % with hypertension , and 22 % with structural heart disease ) . After a single ablation procedure and a mean follow-up of 10±4 months , 24 ( 40 % ) patients of the CPVA-1 group had atrial fibrillation recurrences and 3 ( 5 % ) had new-onset LA flutter . In the CPVA-2  group , recurrences were due to atrial fibrillation episodes in 23 patients ( 38 % ) and LA flutter in 4 ( 7 % ) . Freedom from arrhythmia recurrences was not statistically different in the CPVA-1 group as compared with the CPVA-2 group ( log rank P=0.943 ) . Conclusion —Isolation of the LA posterior wall did not increase the success rate of CPVA Objective — Additional septal linear ablation in patients undergoing ablation of long-st and ing persistent atrial fibrillation ( AF ) could be beneficial due to additional extensive atrial tissue ablation and incidental ablation of sites with complex fractionated electrograms . We assessed the long-term outcome of patients after ablation of long-st and ing persistent AF with an additional left atrial ( LA ) septal line . Methods — Thirty-four patients were included . The patients were r and omized into two groups and underwent pulmonary vein ( PV ) isolation with roof line , mitral isthmus line and coronary sinus ablation . In group 1 an additional LA septal line was created . Results — AF converted into atrial tachycardia in 2 patients during septal ablation in group 1 . In group 2 AF terminated via atrial tachycardia in 3 patients ( P = ns ) . During a mean follow-up of 620 ± 119 days , 7 ( 41 % ) and 8 ( 47 % ) patients from group 1 and group 2 were free from recurrences ( P = ns ) . Redo procedures were performed in 5 patients of group 1 and in 5 patients of group 2 . For a follow-up of 349 ± 273 days after the last ablation , Cox ’s F-test showed a trend of more recurrences in group 1 ( P = 0.07 ) . Conclusions — In patients with long-st and ing AF , an additional LA septal linear ablation is not associated with a significantly higher AF termination rate . A septal linear lesion might increase the risk of septal reentrant tachycardias , and is associated with a trend towards a worse outcome Introduction Atrial fibrillation ( AF ) is commonly found in patients with structural heart disease ( SHD ) , including atrial septal defect ( ASD ) . The feasibility and safety of ablation for AF in patients with unrepaired ASD is seldom reported . Objectives This study aims to evaluate and compare the long-term efficacy of  AF ablation  in patients with and without ASD . Methods From January 2008 to December 2012 , 18 consecutive patients were identified with medically refractory AF and an unrepaired ASD under catheter ablation .  For each ASD patient , four control subjects were matched from our data base . Results There were no significant differences between groups in terms of age , sex , type of AF , LA diameter , LVIDD , and EF . The mean procedural and fluoroscopy times were not different between the groups ( p = NS ) . After a median follow-up of 20 months , the patients in the ASD group had 44.4 % AF recurrence after a single procedure compared with 34.7 % in the control group ( p = 0.11 ) . The mean LA diameter in non-recurrent patients was smaller than in recurrent patients ( p = 0.03 ) . In univariate Cox proportional hazards analyses , the factor found to have a significant association with arrhythmia recurrences was left atrial diameter ( hazard ratio 1.059 , 95 % confidence interval 1.002 to 1.120 , p = 0.03 ) . Conclusions These results indicate that in patients with AF and an ASD amenable to percutaneous closure , a staged approach with radiofrequency ablation of AF preceding closure is a rational strategy
Dilated LA significantly increases the risk of AF recurrence after  single CPVI .
This is especially applicable to the patients with long-term follow-up
AIMS Left atrial ( LA ) enlargement is associated with atrial fibrillation ( AF ) .
However , it is controversial whether dilated atrium can predict post-ablation AF recurrence .
We undertook a systematic review and meta- analysis to analyse the association between LA diameter and  AF recurrence after single circumferential pulmonary vein isolation ( CPVI )  and explore the potential mechanism .