Pulmonary venous isolation by antral ablation with a large cryoballoon for treatment of paroxysmal and persistent atrial fibrillation: medium-term outcomes and non-randomised comparison with pulmonary venous isolation by radiofrequency ablation The usefulness of global left atrial strain for predicting atrial fibrillation recurrence after catheter ablation in patients with persistent and paroxysmal atrial fibrillation. Randomized Evaluation of Right Atrial Ablation After Left Atrial Ablation of Complex Fractionated Atrial Electrograms for Long-Lasting Persistent Atrial Fibrillation Radiofrequency catheter ablation maintains its efficacy better than antiarrhythmic medication in patients with paroxysmal atrial fibrillation: On-treatment analysis of the randomized controlled MANTRA-PAF trial. Left atrial strain as predictor of successful outcomes in catheter ablation for atrial fibrillation: a two-dimensional myocardial imaging study Cost-Effectiveness of Radiofrequency Catheter Ablation Compared With Antiarrhythmic Drug Therapy for Paroxysmal Atrial Fibrillation Cryoballoon versus radiofrequency catheter ablation for paroxysmal atrial fibrillation. Cardiac rate normalization in chronic atrial fibrillation: comparison of long-term efficacy of treatment with amiodarone versus AV node ablation and permanent His-bundle pacing. Left atrial deformation imaging with ultrasound based two-dimensional speckle-tracking predicts the rate of recurrence of paroxysmal and persistent atrial fibrillation after successful ablation procedures. Predictive value of early recurrence and delayed cure after catheter ablation for patients with chronic atrial fibrillation. Perception of Atrial Fibrillation Before and After Radiofrequency Catheter Ablation: Relevance of Asymptomatic Arrhythmia Recurrence Radiofrequency Catheter Ablation and Antiarrhythmic Drug Therapy: A Prospective, Randomized, 4-Year Follow-Up Trial: The APAF Study Is Pulmonary Vein Isolation Necessary for Curing Atrial Fibrillation? Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of paroxysmal atrial fibrillation (RAAFT-2): a randomized trial. Concomitant obstructive sleep apnea increases the recurrence of atrial fibrillation following radiofrequency catheter ablation of atrial fibrillation: clinical impact of continuous positive airway pressure therapy. Long-Term Improvement in Left Ventricular Strain After Successful Catheter Ablation for Atrial Fibrillation in Patients With Preserved Left Ventricular Systolic Function Ablation of atypical atrial flutter guided by the use of concealed entrainment in patients without prior cardiac surgery. Prospective randomized comparison of left atrial and biatrial radiofrequency ablation in the treatment of atrial fibrillation. Catheter ablation of atrial fibrillation in patients with atrial septal defect: long-term follow-up results Second‐generation cryoballoon ablation for treatment of persistent atrial fibrillation: Three‐year outcome and predictors of recurrence after a single procedure Prevention of atrial fibrillation recurrence with corticosteroids after radiofrequency catheter ablation: a randomized controlled trial. Cryoballoon versus radiofrequency for pulmonary vein re-isolation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation. Prolonged PR Interval Predicts Clinical Recurrence of Atrial Fibrillation After Catheter Ablation
Background To prevent  atrial fibrillation ( AF ) recurrence after catheter ablation , pulmonary venous isolation ( PVI ) at an antral level is more effective than segmental ostial ablation . Cryoablation around the pulmonary venous ( PV ) ostia for AF therapy is potentially safer compared to radiofrequency ablation ( RFA ) . The aim of this study was to investigate the efficacy of a strategy using a large cryoablation balloon to perform antral cryoablation with ‘ touch-up ’ ostial cryoablation for PVI in patients with paroxysmal and persistent AF . Methods Paroxysmal and persistent AF patients undergoing their first left atrial ablation were recruited . After cryoballoon therapy , each PV was assessed for isolation and if necessary , treated with focal ostial cryoablation until PVI was achieved . Follow-up with Holter monitoring was performed . Clinical outcomes of the cryoablation protocol were compared , with consecutive patients undergoing PVI by RFA . Results 124 consecutive patients underwent cryoablation . 77 % of paroxysmal and 48 % of persistent AF subjects were free from AF at 12 months after a single procedure . Over the same time period , 53 consecutive paroxysmal AF subjects underwent PVI with RFA and at 12 months , 72 % were free from AF at 12 months ( p = NS ) . There were too few persistent AF subjects ( n=8 ) undergoing solely PVI by RFA as a comparison group . Procedural and fluoroscopic times during cryoablation were significantly shorter than RFA . Conclusions PV isolation can be achieved in less than 2 h by a simple cryoablation protocol with excellent results after a single intervention , particularly for paroxysmal AF 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 —With electrogram-guided radiofrequency ablation ( RFA ) of long-lasting persistent atrial fibrillation ( AF ) , the best results have been reported when complex fractionated electrograms ( CFAEs ) in both the left ( LA ) and right ( RA ) atria were targeted . However , many studies have reported excellent outcomes from RFA of long-lasting persistent AF with the use of other ablation strategies that were limited to the LA . The incremental value of RFA of RA CFAEs is yet to be defined . Methods and Results —In 85 patients with long-lasting persistent AF ( age=59±10 years ) , RFA was directed at CFAEs in the LA and coronary sinus until AF terminated ( 19 ) or all identified LA CFAEs were eliminated . Sixty-six patients who remained in AF were r and omly assigned to cardioversion and no further RFA ( n=33 ) or to RFA of RA CFAEs ( n=33 ) . RA sites consisted of the crista terminalis ( 69 % ) , septum ( 38 % ) , superior vena cava ( 28 % ) , coronary sinus ostium ( 22 % ) , and the base of the appendage ( 31 % ) . AF terminated in 1 ( 3 % ) of 33 patients during RA RFA . At 17±6 months after a single ablation procedure , 74 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Rates of freedom from AF were similar in the patients r and omized to no RFA in the RA ( 24 % ) and those r and omized to RFA of RA CFAEs ( 30 % , P=0.8 ) . The ablation procedure was repeated in 26 patients ( 31 % ) for AF ( n=22 ) or atrial flutter ( n=4 ) . At 16±7 months after the final procedure , 89 % of the patients in whom AF terminated during LA RFA were in sinus rhythm . Among the r and omized patients , the proportion of patients who remained in sinus rhythm was similar in patients who did not undergo RFA of RA CFAEs ( 52 % ) and those who did ( 58 % , P=0.6 ) . Conclusion —After RFA of CFAEs in the LA and coronary sinus , ablation of CFAEs in the RA provides little or no increment in efficacy among patients with long-lasting persistent AF BACKGROUND The Medical ANtiarrhythmic Treatment or Radiofrequency Ablation in Paroxysmal Atrial Fibrillation ( MANTRA-PAF ) is a r and omized trial comparing radiofrequency catheter ablation ( RFA ) to antiarrhythmic drugs ( AADs ) as first-line treatment of paroxysmal atrial fibrillation ( PAF ) . In order to eliminate the clouding effect of crossover we performed an on-treatment analysis of the data . METHODS AND RESULTS Patients ( n=294 ) were divided into three groups : those receiving only the assigned therapy ( RFA and AAD groups ) and those receiving both therapies ( crossover group ) . The primary end points were AF burden in 7-day Holter recordings at 3 , 6 , 12 , 18 , and 24 months and cumulative AF burden in all recordings . At 24 months , AF burden was significantly lower in the RFA ( n=110 ) than in the AAD ( n=92 ) and the crossover ( n=84 ) groups ( 90th percentile 1 % vs. 10 % vs. 16 % , P=0.007 ) , and more patients were free from any AF ( 89 % vs. 73 % vs. 74 % , P=0.006 ) . In the RFA , AAD and the crossover groups 63 % , 59 % and 21 % ( P<0.001 ) of the patients had no AF episodes in any Holter recording , respectively . Quality of life improved significantly in all groups . There were no differences in serious adverse events between the RFA , AAD and crossover groups ( 19 % vs. 8 % vs. 23 % ) ( P=0.10 ) . CONCLUSIONS In the treatment of antiarrhythmic therapy naïve patients with PAF long-term efficacy of RFA was superior to AAD therapy . Thus , it is reasonable to offer RFA as first-line treatment for highly symptomatic patients who accept the risks of the procedure and are aware of frequent need for reablation(s ) 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 —Radiofrequency catheter ablation ( RFA ) has emerged as an important treatment strategy for atrial fibrillation ( AF ) . The potential cost-effectiveness of RFA for AF , relative to antiarrhythmic drug ( AAD ) therapy , has not been fully explored from a US perspective . Methods and Results —We constructed a Markov disease simulation model for a hypothetical cohort of patients with drug-refractory paroxysmal AF , treated either with RFA with/without AAD or AAD alone .  Costs and quality -adjusted life-years were projected over 5 years . Model inputs were drawn from published clinical trial and registry data , from new registry and trial data analysis , and from data prospect ively collected from patients with AF treated with RFA at our institution . We assumed no benefit from ablation on stroke , heart failure or death , but did estimate changes in quality -adjusted life expectancy using data from several AF cohorts . In the base case scenario , cumulative costs with the RFA and AAD strategies were $ 26 584 and $ 19 898 , respectively . Over 5 years , quality -adjusted life expectancy was 3.51 quality -adjusted life-years with RFA versus 3.38 for the AAD group . The incremental cost-effectiveness ratio for RFA versus AAD was thus $ 51 431 per quality -adjusted life-year . Model results were most sensitive to time horizon , the relative utility weights of successful ablation versus unsuccessful drug therapy , and to the cost of an ablation procedure . Conclusions —RFA with/without AAD for symptomatic , drug-refractory paroxysmal AF appears to be reasonably cost-effective compared with AAD therapy alone from the perspective of the US health care system , based on improved quality of life and avoidance of future health care costs BACKGROUND Catheter ablation is an established treatment for atrial fibrillation ( AF ) .  Cryoballoon ablation ( CBA ) has emerged as an alternative to radiofrequency ablation ( RFA ) . However , there are few data comparing these modalities for treatment of paroxysmal AF ( pAF ) in the U.S. POPULATION The purpose of this study was to compare procedural times , safety , and efficacy of CBA against RFA . METHODS A single-center prospect i ve cohort study evaluated patients who underwent catheter ablation for pAF using CBA or RFA between January 1 , 2010 and October 31 , 2013 . Patients with prior ablation and those without rhythm follow-up for at least 3 months were excluded . The primary end point was freedom from AF , atrial flutter , and atrial tachycardia ( FFAF ) > 30 seconds after a 3-month blanking period without requirement for antiarrhythmic drugs . We also compared rates of successful pulmonary vein isolation ( PVI ) , fluoroscopy and procedure times , and major complication rates . RESULTS A total of 201 patients were included ( CBA = 101 , RFA = 100 ) . The rate of successful PVI was 99.3 % in CBA versus 97.4 % in RFA ( P = 0.08 ) . Procedure times were shorter with CBA ( 192.9 ± 44.0 minutes vs 283.7 ± 78.0 minutes , P < 0.001 ) as well as total fluoroscopy times ( 46.0 ± 22.4 minutes vs 73.0 ± 30.1 minutes , P < 0.001 ) . Overall complication rates were equivalent ; however , fewer cardiac perforations occurred with CBA ( 0 % vs 4 % , P = 0.042 ) . The 1-year FFAF rates were 60.3 % for CBA and 61.1 % for RFA ( log rank P = 0.93 ) . CONCLUSION CBA was associated with equivalent 1-year FFAF rate as RFA for pAF . Procedure and fluoroscopy times were shorter for CBA and fewer cardiac perforations occurred Chronic atrial fibrillation ( AF ) is a common arrhythmia with significant morbidity and mortality . AF has been the subject of considerable attention and intensive clinical research in recent years . Current opinion on the management of AF favors the restoration and maintenance of normal ventricular rhythm . This has several potential benefits , including the alleviation of arrhythmia-associated symptoms and hemodynamic improvements . Maintenance of frequents normalization of ventricular rhythm ( NVR ) can be achieved with antiarrhythmic drug therapy or with AV node radiofrequency ablation ( RFA ) and permanent ventricular pacing . Recent interest has focused on the use of class III antiarrhythmic agents , such as amiodarone hydrochloride . This investigation compared amiodarone to AV node RFA and permanent pacing of the His-bundle area in maintaining NVR in patients with resistant chronic AF . After 12 months of treatment with amiodarone ( 200 to 400 mg/d ) 30 % of patients remained in NVR , 30 % were in transitional phase of improvement , and 40 % showed negative effect . Only a few patients in this group developed ocular or hepatic side effects . On one year follow-up was achieved in 100 % of cases without any clinical ly significant side effects being seen . In conclusion , analysis of the results of this study suggests that low-dose amiodarone is well tolerated in the management of chronic AF in a selected patient population . The more aggressive interventional radiofrequency ablation technique is significantly more effective and more reliable in the long-term clinical treatment of drug-resistant AF OBJECTIVE Since predictors of recurrence of atrial fibrillation ( AF ) after ablation procedures are poorly defined , this prospect i ve study was conducted to assess the value of left atrial ( LA ) deformation imaging with two-dimensional speckle-tracking ( 2D-ST ) to predict AF recurrences after successful ablation procedures . METHODS AND RESULTS One hundred and three consecutive patients ( age 58.1 ± 16.6 years , 72.8 % male ) with AF ( 76 paroxysmal , 27 persistent ) and 30 matched controls underwent transthoracic echocardiography and 2D-ST-LA-deformation analysis with assessment of LA-radial and LA-longitudinal strain ( Sr , Sl ) , and velocities derived from the apical 4- and 2-chamber views ( 4CV , 2CV ) . AF recurrence was assessed during 6 months of follow-up . For determination of AF-related LA changes , AF patients were compared to controls and patients with AF recurrences after ablation procedures ( n = 30 , 29.1 % ) were compared with patients who maintained sinus rhythm ( n = 73 , 70.9 % ) . Atrial deformation capabilities were significantly reduced ( P < 0.0005 ) in patients with AF ( 4CVSl 17.8 ± 13.5 % ; 4CVSr 22.3 ± 14.9 % ; 4CV-velocities 2.53 ± 0.97 seconds ) when compared with controls ( 4CVSl 31.3 ± 12.4 % ; 4CVSr 30.3 ± 9.1 % ; 4CV-velocities 3.48 ± 1.01 cm/s ) . Independent predictors for AF recurrence after ablation procedures were 2CV-LA-global-strain ( Sr , P = 0.03 ; Sl , P = 0.003 ) , 4CV-LA-gobal-strain ( Sr , P = 0.03 ; Sl , P = 0.02 ) , and regional LA-septal wall-Sl ( P = 0.008 ) . LA-global-strain parameters were superior to regional LA function analysis for the prediction of AF recurrences , with cutoff values ( cov ) , hazard ratios ( HR ) , positive and negative predictive values ( PPV , NPV ) were : 4CVSl cov , 10.79 % ( HR 27.8 , P < 0.0005 ; PPV 78.8 % , NPV 93.9 % ) , 4CVSr cov , -16.65 % ( HR 24.8 , P < 0.0005 ; PPV 69.4 % , NPV 96.6 % ) , 2CVSl cov , 12.31 % ( HR 22.7 , P < 0.0005 ; PPV 75.8 % , NPV 95.3 % ) , and 2CVSr cov , -14.9 % ( HR 12.9 , P < 0.0005 ; PPV 64.3 % , NPV 93.2 % ) . CONCLUSION Compared with controls , AF itself seems to decrease LA deformation capabilities . The assessment of global LA strain with 2D-ST identifies patients with high risk for AF recurrence after ablation procedures . This imaging technique may help to improve therapeutic guiding for patients with AF BACKGROUND Radiofrequency catheter ablation ( RFCA ) for curing atrial fibrillation ( AF ) is often followed by early recurrence and delayed cure , so the present study investigate the predictive factors this in patients with chronic AF . METHODS AND RESULTS Ninety-two consecutive patients ( 70 males ; mean age , 58.7+/-6.4 years ) with chronic AF who underwent RFCA for treatment of symptomatic AF were enrolled .  Early recurrence of AF ( ERAF ) occurred in 45 patients after ablation . Not achieving AF termination could predict ERAF ( odds ratio ( OR ) 0.95 ; 95 % confidence interval ( CI ) 0.84 - 1.13 ; p=0.02 ) in multivariate analysis . During a follow-up of 12+/-11 ( range , 5 - 25 ) months , delayed cure occurred in 35.6 % ( 16/45 ) of the patients with ERAF . Left atrial size and AF termination during ablation were related to delayed cure . AF termination was the only independent predictive factor for delayed cure ( OR 1.47 ; 95 % CI 1.05 - 1.87 ; p=0.02 ) . CONCLUSION Not achieving AF termination is the only independent predictor of ERAF . Among patients with ERAF , those with a smaller left atrium and AF termination have a higher probability of delayed cure . AF termination can independently predict delayed cure . These results emphasize the importance of AF termination during ablation for patients with chronic AF Background —The objective of this study was to assess the incidence and impact of asymptomatic arrhythmia in patients with highly symptomatic atrial fibrillation ( AF ) who qualified for radiofrequency ( RF ) catheter ablation .  Methods and Results —In this prospect i ve study , 114 patients with at least 3 documented AF episodes together with corresponding symptoms and an ineffective trial of at least 1 antiarrhythmic drug were selected for  RF ablation .  With the use of CARTO , circumferential lesions around the pulmonary veins and linear lesions at the roof of the left atrium and along the left atrial isthmus were placed . A continuous , 7-day , Holter session was recorded before ablation , right after ablation , and after 3 , 6 , and 12 months of follow-up . During each 7-day Holter monitoring , the patients recorded quality and duration of any complaints by using a detailed symptom log . More than 70 000 hours of ECG recording were analyzed . In the 7-day Holter records before ablation , 92 of 114 patients ( 81 % ) had documented AF episodes . All episodes were symptomatic in 35 patients ( 38 % ) . In 52 patients ( 57 % ) , both symptomatic and asymptomatic episodes were recorded , whereas in 5 patients ( 5 % ) , all documented AF episodes were asymptomatic . After ablation , the percentage of patients with only asymptomatic AF recurrences increased to 37 % ( P<0.05 ) at the 6-month follow-up . An analysis of patient characteristics and arrhythmia patterns failed to identify a specific subset who were at high risk for the development of asymptomatic AF . Conclusions —Even in patients presenting with highly symptomatic AF , asymptomatic episodes may occur and significantly increase after catheter ablation . A symptom-only – based follow-up would substantially overestimate the success rate . Objective measures such as long-term Holter monitoring are needed to identify asymptomatic AF recurrences after ablation 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 —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 IMPORTANCE Atrial fibrillation ( AF ) is the most common rhythm disorder seen in clinical practice . Antiarrhythmic drugs are effective for reduction of recurrence in patients with symptomatic paroxysmal AF .  Radiofrequency ablation is an accepted therapy in patients for whom antiarrhythmic drugs have failed ; however , its role as a first-line therapy needs further investigation . OBJECTIVE To compare radiofrequency ablation with antiarrhythmic drugs ( st and ard therapy ) in treating patients with paroxysmal AF as a first-line therapy . DESIGN , SETTING , AND PATIENTS A r and omized clinical trial involving 127 treatment-naive patients with paroxysmal AF were r and omized at 16 centers in Europe and North America to received either antiarrhythmic therapy or ablation .  The first patient was enrolled July 27 , 2006 ; the last patient , January 29 , 2010 . The last follow-up was February 16 , 2012 . INTERVENTIONS Sixty-one patients in the antiarrhythmic drug group and 66 in the radiofrequency ablation group were followed up for 24 months . MAIN OUTCOMES AND MEASURES The time to the first documented atrial tachyarrhythmia of more than 30 seconds ( symptomatic or asymptomatic AF , atrial flutter , or atrial tachycardia ) , detected by either scheduled or unscheduled electrocardiogram , Holter , transtelephonic monitor , or rhythm strip , was the primary outcome . Secondary outcomes included symptomatic recurrences of atrial tachyarrhythmias and quality of life measures assessed by the EQ-5D tool . RESULTS Forty-four patients ( 72.1 % ) in the antiarrhythmic group and in 36 patients ( 54.5 % ) in the ablation group experienced the primary efficacy outcome ( hazard ratio [ HR ] , 0.56 [ 95 % CI , 0.35 - 0.90 ] ; P = .02 ) . For the secondary outcomes , 59 % in the drug group and 47 % in the ablation group experienced the first recurrence of symptomatic AF , atrial flutter , atrial tachycardia ( HR , 0.56 [ 95 % CI , 0.33 - 0.95 ] ; P = .03 ) . No deaths or strokes were reported in either group ; 4 cases of cardiac tamponade were reported in the ablation group . In the st and ard treatment group , 26 patients ( 43 % ) underwent ablation after 1-year . Quality of life was moderately impaired at baseline in both groups and improved at the 1 year follow-up . However , improvement was not significantly different among groups . CONCLUSIONS AND RELEVANCE Among patients with paroxysmal AF without previous antiarrhythmic drug treatment , radiofrequency ablation compared with antiarrhythmic drugs result ed in a lower rate of recurrent atrial tachyarrhythmias at 2 years . However , recurrence was frequent in both groups . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00392054 BACKGROUND Recent studies have suggested an emerging link between obstructive sleep apnea ( OSA ) and  atrial fibrillation ( AF ) . Patients with OSA are less likely to remain in sinus rhythm after radiofrequency catheter ablation of AF . OBJECTIVE To evaluate the efficacy of appropriate treatment with continuous positive airway pressure ( CPAP ) on recurrences of AF after ablation . METHODS This study prospect ively included 153 patients ( 128 men ; 60 ± 9 years ) who underwent extensive encircling pulmonary vein isolation for drug refractory AF .  The st and ard overnight polysomnographic evaluation  was performed 1 week after ablation , and the total duration and the number of central or obstructive sleep apnea or hypopnea episodes were examined . RESULTS Of 153 patients , 116 patients were identified as having OSA . Data regarding the use of CPAP and recurrences of AF were obtained in 82 patients . The remaining 34 patients with OSA were defined as the no-CPAP group . Polysomnography revealed no sleep-disordered breathing in 37 patients . During a mean follow-up period of 18.8 ± 10.3 months , 51 ( 33 % ) patients experienced AF recurrences after ablation . A Cox regression analysis revealed that the left atrial volume ( hazard ratio [ HR ] 1.11 ; 95 % confidence interval [ CI ] 1.01 - 1.23 ; P<.05 ) , concomitant OSA ( HR 2.61 ; 95 % CI 1.12 - 6.09 ; P<.05 ) , and usage of CPAP therapy ( HR 0.41 ; 95 % CI 0.22 - 0.76 ; P<.01 ) were associated with AF recurrences during the follow-up period . CONCLUSIONS Patients with untreated OSA  have a higher recurrence of AF after ablation . Appropriate treatment with CPAP in patients with OSA is associated with a lower recurrence of AF Background —The effect of successful catheter ablation on left ventricular ( LV ) strain in patients with preserved LV systolic function is unknown . The aim of the present study was to assess the long-term effects of catheter ablation for atrial fibrillation ( AF )  on LV strain and strain rate in patients with preserved LV ejection fraction . Methods and Results —In 78 patients undergoing catheter ablation for AF  , speckle tracking strain imaging was performed to assess LV strain in 3 directions ( radial , circumferential , and longitudinal ) at baseline and after 12-month follow-up . The study population was divided into 2 groups , according to the maintenance of sinus rhythm ( SR ) during follow-up . After 13.8±4.7 months of follow-up , 54 patients ( 69 % ) were in SR ( SR group ) , whereas 24 patients ( 31 % ) had recurrence of AF ( AF group ) . No significant changes in LV ejection fraction from baseline to follow-up were noted ( 60±7 % versus 59±7 % , P = NS ) . Circumferential strain improved significantly in the SR group ( −18.3±3.2 % versus −20.4±3.8 % , P<0.001 ) , whereas it remained unchanged in the AF group ( −18.9±3.5 % versus −17.9±3.1 % , P = NS ) . In the SR group , significant improvements in LV longitudinal strain and strain rate were noted , whereas in the AF group , LV longitudinal strain and strain rate deteriorated significantly at long-term follow-up . Conclusions —After successful catheter ablation , LV circumferential and longitudinal strain and strain rate improve significantly in patients who maintain SR . In contrast , a decrease in LV longitudinal strain and strain rate is observed in patients with recurrence of AF INTRODUCTION Mapping techniques have not been systematic ally evaluated with respect to atypical atrial flutter ( AF ) not involving the inferior vena cava isthmus . The purpose of this study was to assess prospect ively the use of concealed entrainment ( CE ) in mapping of AF and to assess the clinical benefit of ablation of clinical ly relevant atypical AF . METHODS AND RESULTS In seven consecutive patients without prior cardiac surgery presenting with atypical AF , mapping was performed in the right and , if necessary , left atrium . At sites with CE , radiofrequency energy was delivered . In a posthoc analysis , the endocardial activation time , stimulus-flutter wave ( F ) interval , presence of split potentials and diastolic potentials , and postpacing interval were assessed , and effective sites were compared to ineffective sites . A total of 22 forms of atypical AF either could be induced or were present at the time of the study . Eleven of the 13 targeted atypical AFs ( 85 % ) were successfully ablated . The positive predictive value of CE increased from 45 % to 75 % in the presence of matching electrogram-F and stimulus-F intervals or if flutter terminated during entrainment pacing , and to 88 % in the presence of split atrial electrograms or diastolic potentials . During short-term clinical follow-up , none of the patients had recurrence of the ablated AF . However , the majority of patients required either medication for atrial fibrillation or repeated interventions for new forms of AF . CONCLUSION Mapping and ablation of atypical AF is feasible if sites with CE can be identified . However , the clinical benefit of successful ablations in patients with atypical flutter appears to be limited OBJECTIVE The aim of this study was to compare , in patients with permanent atrial fibrillation ( AF ) , the efficacy and safety of left atrial ablation with that of a biatrial procedure and to assess the risk factors for late failure of sinus rhythm restoration . METHODS Between January 2004 and January 2007 , 299 consecutive patients underwent the radiofrequency ablation procedure for AF associated with concomitant cardiac surgery .  According to a prospect i ve , open , and r and omized trial , 149 patients underwent left atrial plus cavotricuspid isthmus ablation  ( left atrial group ) , while 150 patients underwent biatrial ablation  ( biatrial group ) . The postoperative and mid-term follow-up results were compared between the two groups . Both univariate and multivariate analyses were used to assess the risk factors for late recurrence of AF . RESULTS There were seven in-hospital deaths ( 2.3 % ) , including two in the left atrial group ( 1.3 % ) and five in the biatrial group ( 3.3 % ) , and there were no differences in the incidence of the mortality and complications during the postoperative and follow-up periods between the groups . At discharge , sinus rhythm was maintained in 77.1 % of the patients , including 78.2 % of those in the left atrial group and 75.9 % in the biatrial group ( p=0.68 ) . Follow-up was completed in 97 % of the patients , with a mean time of 28+/-5 months . At the latest follow-up , two deaths occurred in the biatrial group . Sinus rhythm was documented in 237 ( 85.0 % ) out of all the patients , including 85.2 % ( 121/142 ) in the left atrial group and 84.1 % ( 116/138 ) in the biatrial group patients ( p=0.87 ) . Using a multivariate analysis , a left atrial diameter of > /=80 mm ( p=0.02 ) was an independent predictor for a late recurrence of AF . CONCLUSIONS Both the left atrial combined with cavotricuspid isthmus ablation and biatrial maze procedure is safe and effective in treating patients with AF , with an acceptable sinus conversion rate , mortality and morbidity . A left atrial dimension of > /=80 mm was a significant predictor for a late recurrence of AF 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 INTRODUCTION Data on long-term outcomes of cryoballoon ( CB ) ablation for treatment of persistent atrial fibrillation ( AF ) are sparse . Here , we report the first 3-year follow-up results and predictors of success for catheter ablation using the second-generation CB in patients with persistent AF . METHODS AND RESULTS For this prospect i ve observational study , we enrolled 101 patients ablated with the second-generation CB at our institution . The endpoint was the first documented recurrence ( > 30 seconds ) of AF , atrial flutter , or atrial tachycardia after a 3-month blanking period . Follow-up data were collected during outpatient clinic visits and included Holter-ECG recordings . The impact of several variables on recurrence was evaluated by means of univariate and multivariate analyses and Cox proportional hazards regression models . After a median follow-up of 37 ( 31 of 42 ) months , recurrence was documented in 30 patients ( 29.7 % ) . The median procedure and fluoroscopy times were 120 ( 102 of 147 ) and 20 ( 16 of 27 ) minutes , respectively . Phrenic nerve palsy occurred in 2.0 % of the patients . Among the 30 patients who experienced recurrence , 16 underwent repeat ablation in radiofrequency technique . Cox regression analysis showed that left atrial area > 21 cm2 and AF history duration > 2 years independently predicted recurrence . CONCLUSIONS Sinus rhythm was maintained in a substantial proportion of patients even 3 years after CB ablation . Patients with a nonenlarged left atrium and short AF history had the best outcome OBJECTIVES We sought to clarify the efficacy of corticosteroid therapy for preventing atrial fibrillation ( AF ) recurrence after pulmonary vein isolation ( PVI ) . BACKGROUND The inflammatory process may cause acute AF recurrence after PVI . However , no studies have examined the relationship between corticosteroid administration and AF recurrence after PVI . METHODS A total of 125 patients with paroxysmal AF were r and omized to receive either corticosteroids ( corticosteroid group ) or a placebo ( placebo group ) . In the corticosteroid group , intravenous hydrocortisone ( 2 mg/kg ) was given the day of the procedure , and oral prednisolone ( 0.5 mg/kg/day ) was administered for 3 days after the PVI . The body temperature and high-sensitivity C-reactive protein level were measured before and on each of the first 3 days after ablation . RESULTS The prevalence of immediate AF recurrence ( ≤3 days after the PVI ) was significantly lower in the corticosteroid group ( 7 % ) than in the placebo group ( 31 % ) . The maximum body temperature and C-reactive protein during the initial 3 days after ablation and the increase in the body temperature and C-reactive protein level from baseline were significantly lower in the corticosteroid group than in the placebo group . Corticosteroid treatment did not decrease AF recurrences between 4 and 30 days after ablation . The AF-free rate at 14 months post-ablation was greater in the corticosteroid group ( 85 % ) than in the placebo group ( 71 % , p=0.032 by the log-rank test ) . CONCLUSIONS Transient use of small amounts of corticosteroids shortly after AF ablation may be effective and safe for preventing not only immediate AF recurrences but also AF recurrences during the mid-term follow-up period after PVI AIM Catheter ablation of paroxysmal atrial fibrillation ( PAF ) is associated with an important risk of early and late recurrence , necessitating repeat ablation procedures . The aim of this prospect i ve r and omized patient-blind study was to compare the efficacy and safety of cryoballoon ( Cryo ) versus radiofrequency ( RF ) ablation of PAF after failed initial RF ablation procedure . METHODS Patients with a history of symptomatic PAF after a previous failed first RF ablation procedure were eligible for this study . Patients were r and omized to Cryo or RF redo ablation . The primary endpoint of the study was recurrence of atrial tachyarrhythmia , including AF and left atrial flutter/tachycardia , after a second ablation procedure at 1 year of follow-up . All patients were implanted with a cardiac monitor ( Reveal XT , Medtronic ) to continuously track the cardiac rhythm . Patients with an AF burden ( AF% ) ≤ 0.5 % were considered AF-free ( Responders ) , while those with an AF% > 0.5 % were classified as patients with AF recurrences ( non-Responders ) . RESULTS Eighty patients with AF recurrences after a first RF pulmonary vein isolation ( PVI ) were r and omized to Cryo ( N = 40 ) or to RF ( N = 40 ) . Electrical potentials were recorded in 77 mapped PVs ( 1.9 ± 0.8 per patient ) in Cryo Group and 72 PVs ( 1.7 ± 0.8 per patient ) in RF Group ( P = 0.62 ) , all of which were targeted . In Cryo group , 68 ( 88 % ) of the 77 PVs were re-isolated using only Cryo technique ; the remaining 9 PVs were re-isolated using RF . In RF group , all 72 PVs were successfully re-isolated ( P = 0.003 vs Cryo ) . By intention-to-treat , 23 ( 58 % ) RF patients were AF-free vs 17 ( 43 % ) Cryo patients on no antiarrhythmic drugs at 1 year ( P = 0.06 ) . Three patients had temporary phrenic nerve paralysis in the Cryo group ; the RF group had no complications . Of the 29 patients who had only Cryo PVI without any RF ablation , 11 ( 38 % ) were AF-free vs 20 ( 59 % ) of the 34 patients who had RF only ( P = 0.021 ) . CONCLUSION When patients require a redo pulmonary vein isolation ablation procedure for recurrent PAF , RF appears to be the preferred energy source relative to Cryo Background A prolonged PR interval is known to be a poor prognostic factor in cardiovascular disease . The aim of this study was to investigate the association between PR interval and clinical outcome in patients undergoing radiofrequency catheter ablation ( RFCA ) of atrial fibrillation ( AF ) . Methods and Results We prospect ively included 576 patients with AF ( 75.5 % male , 57.8±11.6 years old , 68.8 % paroxysmal AF ) who underwent RFCA .  We analyzed preprocedural sinus rhythm ECGs obtained in the absence of antiarrhythmic drug , and all enrolled patients were categorized into 4 groups based on the quartile values of the PR interval ( 166 , 182 , and 202 ms ) , and were analyzed according to the left atrium ( LA ) volume ( CT ; Computed tomography ) , LA voltage ( NavX ) , and clinical outcome of AF ablation . Based on quartile value of PR interval , the highest quartile of PR interval ( Q4 ; PR ≥202 ms ) was oldest ( P<0.001 ) , and most likely to have persistent AF ( P<0.001 ) and hypertension ( P=0.013 ) compared with the other groups . However , there was no significant difference in LA conduction velocity and atrial effective refractory period . Q4 had the greatest LA dimension ( P<0.001 ) and volume index ( P<0.001 ) , and lowest LA appendage‐emptying velocity ( P<0.032 ) and LA voltage ( P<0.001 ) compared with the others . For 13.1±7.5 months , the classification based on the PR interval was a significant predictor of AF recurrence after RFCA of AF ( HR=1.969 , 95 % CI 1.343 to 2.886 , P=0.001 ) . Conclusions The PR interval was closely associated with advanced LA remodeling due to AF , and had a noninvasive significant predictive value of clinical recurrence of AF after RFCA
Lower values of PALS are associated with an increased risk of AF recurrence after RFA .
PALS provides prognostic value in clinical practice
The usefulness of peak atrial longitudinal strain ( PALS ) in identifying patients at high risk of atrial fibrillation ( AF ) recurrence after radiofrequency ablation ( RFA )  has been investigated in several small AF population s. The aim of this systematic review and meta- analysis was to investigate whether PALS predicts recurrence of AF after RFA treatment .