bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical and instrumental factors associated with sinus rhythm maintenance following direct current cardioversion of late persistent non-valvular atrial fibrillation at 6-months follow-up
Authors: Mikhaliev K , Zharinov O , Skybchyk Y
Published: May 2024

Purpose

To study the clinical and instrumental factors, associated with sinus rhythm (SR) maintenance following direct current cardioversion (DCCV) in patients with late persistent non-valvular atrial fibrillation (AF) at 6-months follow-up.

Methods

The cohort single-center study analyzed clinical and instrumental data from 59 late persistent AF patients (with duration of its episode ≥90 days [up to 12 months]), who underwent an elective DCCV. At 6-months follow-up, 32 (54 %%) patients succeeded to maintain SR, in contrast to 27 (46 %) patients with a failure to its maintenance.

Results

The univariate logistic regression analysis revealed, that the absence of heart failure (HF) stage C (i.e., the presence of its stage B), the higher left ventricular ejection fraction (LVEF) (by transthoracic echocardiography [TTE]), left atrial appendage flow velocity (LAAFV) >40 cm/s and the freedom from left atrial spontaneous echo contrast (LASEC) (by transesophageal echocardiography), ‒ all were associated with the higher chance to maintain SR at 6-months follow-up (Figure). At the same time, the higher baseline left atrial dimension (LAD) and more advanced pulmonary hypertension (PH) (by TTE) were associated with the failure of its maintenance to be more probable (Figure). At multivariate analysis, the following predictors of SR maintenance after DCCV at 6-months follow-up were identified: higher LVEF (OR 1,07 (95 % CI 1,01-1,13); р=0,021); LAAFV >40 cm/s (OR 4,33 (95 % CI 1,06-17,78); р=0,042), and less advanced PH (OR 0,24 (95% CI 0,06-0,93); р=0,038).

Conclusion

Better LV systolic function, LAAFV >40 cm/s and less advanced PH were the predictors of SR maintenance following DCCV in patients with late persistent (with duration of its episode ≥90 days) non-valvular AF at 6-months follow-up.
Atrial fibrillation recurrence in oncocardiological patients treated with catheter ablation. A retrospective cohort study
Authors: Albarran-Rincon R , Barragan Campos J , Ramos Ardanaz P , Garcia De Yebenes Castro M , Garcia-Bolao I
Published: May 2024

Background

The relationship between oncological events and cardiovascular pathologies is a subject still widely discussed. Certain chemotherapy drugs, including alkylating agents, anthracyclines, taxanes, and topoisomerase II inhibitors have proven to possess arrhythmic and cardiotoxic capabilities. There is enough evidence to suggest an association between oncological events and the appearance of newly onset AF, but there is little to no scientific literature about the management of these patients and the outcome of normal therapeutically procedures.

Purpose

This study assess if oncocardiological patients with AF should be considered a risk group when planning to undergo catheter ablation for the arrhythmia treatment.

Methods

The studied population was based on the data recollection from the electrophysiology department and consisted of patients with AF intervened by radiofrequency catheter ablation. All the procedures were conducted between January 1st 2019 and December 31st 2022. Among 138 participants enrolled for this study, 68 of them had either recent history of oncological events (maximum of 5 years cancer-free). The control group had no previous nor active history of cancer. The cohort with the desired exposure (cancer patients) was compared with a cancer-free group. Two primary outcomes were measured: procedure related complications, and first AF recurrence within the first 12 months. Complications were categorized according to two dichotomous variables: the existence of acute complications directly during the procedure or within the first 12 hours after the end of the procedure, and the occurrence of self-limited arrhythmic events during the blanking period.

Results

When compared as dichotomous variables (yes/no) with Fisher’s exact test, no statistical significance was observed between the studied cohort and control for complications and events during blanking. The proportion of patients free of sustained episodes of AF at 12 months was 52,9% in the oncologic group and 77,9% in the Control group (P = 0.003; RR of 3.14; 95% CI 1.5 - 6.6) for the oncologic group. When not adjusted by any other factor, association with Cancer was shown (HR 2.43; P =0.005; 95% CI 1.3 – 4.4) for recurrence of arrhythmic events. The regression model with Kaplan-Meier method shows the overall 12-month survival in two groups and the difference between the two survival curves was statistically significant (P=0.0016).

Conclusion

Oncocardiological patients have demonstrated a significantly higher incidence in post-ablational recurrence when compared with a similar cancer-free control group. Results found in acute and chronic procedural complications were similar in both cohorts.
Impact of wall thickness on tissue cooling effect of cryoballoon ablation: Investigation using an experimental heart model
Authors: Masuda M , Matsuda Y M , Uematsu U H , Mano T
Published: May 2024

Background

Understanding of the tissue cooling properties of cryoballoon ablation during pulmonary vein isolation is lacking.

Purpose

To delineate the depth of the tissue cooling effect during cryoballoon freezing at the pulmonary venous ostium.

Methods

A left atrial-pulmonary vein model, produced by a 3-dimensional printer using CT data from a patient, was constructed so that porcine thigh muscles of various thicknesses could be fixed and thermocouples could be fixed at locations corresponding to the epicardial side of the pulmonary vein ostium. The model was placed in a 37-degree water bath with a pulmonary vein water flow at a rate that mimicked biological blood flow, and the cryoballoon was advanced into the left superior vein until the vein was completely occluded. Cryofreezing was performed 5 times each for a porcine thigh muscle of 2-, 4-, and 6-mm thickness, and epicardial tissue cooling was monitored as assessed by the mean temperature of 12 evenly distributed thermocouples covering the roof region of the left superior vein.

Results

Epicardial tissue cooling effects were more in the order of 2-mm, 4-mm, and 6-mm thickness (Figure) with a mean temperature of -41.4 ± 4.2 for 2 mm, -33.0 ± 4.0 for 4 mm, and 8.0 ± 8.7 °C for 6 mm at 180 sec (p for trend < 0.0001). In addition, tissue temperature drops were steeper in thin muscle (maximum temperature drop per 5 s: 5.2 ± 0.9, 3.9 ± 0.7, 1.3 ± 0.7 °C, p for trend < 0.0001).

Conclusion

The cooling effect is weaker in the deeper layers during cryobaloon freezing, and longer freezing duration would be recommended in case of thick myocardium.
The efficacy and safety of additional pulmonary vein antrum substrate ablation after cryo-ablation in patients with persistent atrial fibrillation
Authors: Yoshida A , Akita T , Takami K , Tagashira T , Tsuda S , Terashita D , Takahashi Y , Suzuki M , Takata K , Nishijo K , Matsuura T , Kim Y , Yamada S
Published: May 2024

Background

Cryo-ablation for persistent atrial fibrillation (PeAF) has been reported to be safe and comparable to radiofrequency (RF) ablation, but the outcome was not satisfactory. AF drivers mapping after pulmonary vein isolation (PVI) was reported to be widely identified in left atrium (LA). On the other hand, extensive drivers ablation is considered to have limited durability of PVI compared to cryo-ablation.

Purpose

This study sought to investigate the efficacy and safety of additional PV antrum substrate ablation after PVI by cryo-ablation in patients with PeAF.

Methods

A total of 122 consecutive patients (90 men, 32 women) who underwent ablation between January 2021 and July 2023 for PeAF, except for patients with long standing ≥10years AF, or large LA diameter ≥55mm, or low left ventricular ejection fraction (LVEF) ≤35% with organic heart disease, were divided into three groups; cryo-ablation alone (Cryo group; 30 patients), RF ablation alone guided by AF drivers mapping (RF group; 52 patients), or cryo-ablation plus RF for AF drivers (Cryo+RF group; 40 patients). AF drivers mapping was performed by real-time phase mapping system or complex fractionated electrograms (Figure1). The outcome of freedom from atrial tachy-arrhythmia lasting longer than 30 seconds without anti-arrhythmic drugs after three months blanking period of a single procedure was compared among groups.

Results

Baseline characteristics of patients (68±9.2 years old, LVEF 57±9.9 %, LA diameter 43±5.4 mm, persistent AF duration 9.4±18 months, long standing ≥1year AF 17 patients) were similar in three groups. The incident of recurrence of atrial tachy-arrhythmia in Cryo+RF group was significantly lower compared with Cryo group (15% vs. 37%; p=0.014) and RF group (15% vs. 25%; p=0.28) (Figure2). There was no serious complication in three groups.

Conclusion

Additional drivers RF ablation after cryo-ablation for PeAF is safe and associated with a significant reduction in atrial tachy-arrhythmia recurrence.Figure 1Figure 2
Effects of diagnosis-to-ablation time and antiarrhythmic drug responsiveness on the rhythm outcomes of atrial fibrillation catheter ablation
Authors: Kim H J , Kim D H , Kim K P , Choi S H , Kim M H , Park J W , Yu H T , Kim T H , Uhm J S , Joung B Y , Lee M H , Pak H N
Published: May 2024

Background

Atrial fibrillation (AF) is a progressive disease. Additionally, delaying AF catheter ablation (AFCA) for a year, during antiarrhythmic drug (AAD) therapy does not reduce the efficacy of this ablation. This study explored AFCA rhythm outcomes based on the diagnosis-to-ablation time (DAT) and AAD responsiveness in participants with either paroxysmal AF (PAF) or persistent AF (PeAF).

Methods

We included the data of 1,038 participants with AAD-resistant PeAF, all of whom had a clear time point for the diagnosis of PeAF and had undergone an AFCA for the first time. Participants who experienced recurrences of the paroxysmal type, while on AAD therapy, were analyzed as a cohort of AAD-partial-responders; whereas those who consistently maintained a PeAF, while on AAD therapy were analyzed as a cohort of AAD-non-responders. We calculated the DAT cutoff to determine long-term rhythm outcomes, using a maximum log-likelihood approach, based on the Cox proportional hazards regression model.

Results

Of the participants, 79.8% were male, and the median age was 61 years. The cohort of AAD-non-responders had a higher body mass index and larger left atrial diameter than that of the cohort of AAD-partial-responders. Furthermore, the cohort of AAD-non-responders showed a significantly higher incidence of AF recurrence subsequent to AFCA (adjusted hazard ratio= 1.75, 95% confidence interval: 1.33–2.30; log-rank test: p< 0.001) than that of the cohort of AAD-partial-responders. The log-likelihood graphs of the Cox proportional hazards regression models showed bimodal morphology for the cutoff values of 22 and 40 months. The cutoff value of DAT that most optimally discriminated between rhythm outcomes was 22 months.

Conclusions

Thus, both the DAT and AAD responsiveness affected the rhythm outcomes of AFCA. Delaying AFCA to a DAT of longer than 22 months was inadvisable, particularly in the participants in whom PeAF progressed to PAF during AAD therapy.
Procedural safety and outcome of additional left atrial posterior wall ablation using pulse field ablation for atrial fibrillation
Authors: Tay Cheong Kiat J , Lim E , Pung X M , Chong D , Lim P , Chua K , Ho K L , Tan V H , Yeo C , Teo W S , Ching C K
Published: May 2024

Introduction

Pulsed field ablation (PFA) has recently been shown to be comparable to radiofrequency ablation and cryoablation in terms of acute safety and outcome for pulmonary vein isolation (PVI) for atrial fibrillation (AF). Efficacy and safety of additional left atrial posterior wall ablation (LAPWA) is unknown. We hereby report safety profile and short-term success at 6 months.

Methods

Consecutive patients with paroxysmal or persistent atrial fibrillation who underwent PFA were included. Procedures were performed under conscious sedation or general anaesthesia, with or without intracardiac echocardiography/ pre- or post-ablation electroanatomic mapping at the operators’ discretion. Safety endpoints included all-cause death within 30 days, cardiac tamponade, stroke/ TIA, MI, diaphragmatic paralysis, AE fistula. Primary efficacy endpoint was arrhythmia recurrence after 90 days blanking period at 6 months.

LAPWA was performed using 2.0 kV biphasic waveforms, 2 deliveries for each application site. The lesion set depended on the patient’s AF ablation history, LA size, and anatomy. After LA mapping post PVI (index or re-do), 2 anchor lesions per vein extending to the LAPW were deployed. A lesion set was then performed between the anchor lesions on the LAPW (upper and lower row) with the catheter in a flower configuration and the intention of 50% overlap for the neighbouring application sites at 3D EAM.

Results

Seventy-two (76% males) patients underwent PFA for AF, 55 (76.4%) were paroxysmal and 4 (5.6%) were redo cases. 19 (72%) underwent additional LAPWA. LAPWA was more likely performed in patients with persistent AF (57.9% vs 11.3%, p<0.001), require GA (p=0.043), with 100% EAM use (p=0.026). While total PFA applications was expectedly higher in the LAPWA group (65.7 ± 12.4 vs 42.9 ± 9.0, p<0.001), there were no significant differences in PFA dwell time in LA (44.2 ± 14.8 vs 42.3 ± 15.5min, p=0.628), procedural time (121.3 ± 43.8 vs 119.2 ± 49.4min, p=0.866) and fluoroscopic dose, AK (130 ± 107 vs 139 ± 102mGy, p=0.748). Average number of applications required for LAPW was 18 applications. LAPW isolation was acutely successful in all 19 patients on EAM. There were 6 inpatient complications of which all happened in the non-LAPWA group and unrelated to PFA. Arrhythmia recurrence was comparable at 6 months (11.1% vs 8.9%, p=1.00).

Conclusion

Additional LAPWA on top of PVI using PFA is safe with excellent acute isolation of posterior wall and does not increase procedural nor fluoroscopic duration. Short term outcome appears comparable and LAPWA may be useful especially in patients with persistent AF who may not be able to tolerate long procedures but will benefit from durable rhythm control.
Intra-procedural three-dimensional rotational angiography in cryoballoon ablation of atrial fibrillation - results from a randomised clinical trial
Authors: Prepolec I , Pasara V , Pezo Nikolic B , Puljevic M , Puljevic D , Milicic D , Velagic V
Published: May 2024

Introduction

There are a variety of approaches for pre-procedural imaging to facilitate atrial fibrillation (AF) ablation. Intra-procedural three-dimensional rotational angiography (3DRA) is the least employed method and it can be advantageous regarding efficiency and procedural logistics (1). There is an open question whether LA imaging could improve safety and outcomes of cryoballoon (CB) ablation.

Purpose

The aim of this study is to evaluate possible benefits of 3DRA for procedural success, safety and long-term outcomes of CB ablation.

Methods

We designed a single-centre unblinded randomised clinical trial and recruited 134 patients (64.2% male, 59.0±11.6 years) with paroxysmal (93.3%) and early-persistent AF. Patients were randomised to no imaging or 3DRA which was performed intra-procedurally after trans-septal puncture. Angiographic images were segmented and overlaid to the fluoroscopy screen to guide the ablation procedure. Patients were scheduled for follow-up visits and twenty-four hour ECG recordings at 3, 6 and 12 months, and every 6 months thereafter.

Results

Of all the patients recruited, 66 (49.3%) were randomised to 3DRA and angiography was successfully performed in all but one patient (1.5%). Procedure time was significantly longer when 3DRA was performed (86.7±27.8 min compared to 67.2±22.1 in non-3DRA group, p<0.001). Total radiation dose (447.4±485.0 vs. 133.9±166.2 mGy, p<0.001) and contrast administration (131.8±28.3 vs. 40.8±26.5 ml, p<0.001) were significantly higher in the 3DRA group (Table 1). In patients who received no imaging one pulmonary vein (PV) couldn’t be isolated in 2 patients while this occurred in 3 patients in the 3DRA group (OR 1.57, 95% CI 0.25-9.72). Only minor complications were reported in both groups. Five patients developed large haematoma (4 in the 3DRA group vs. 1 in the control group). In each group there were 3 incidents of impending or transient phrenic nerve palsy. During 12 months of follow-up, 88.2% of patients in the control group and 81.8% in the 3DRA group were free of atrial fibrillation (OR 1.67, 95% CI 0.63-4.38). Two patients from the control group developed atrial flutter and were treated by ablation. In total, 10 patients underwent redo procedures (7 in the control and 3 in the 3DRA group respectively) and PV reconnections were detected in 9 cases.

Conclusion

3DRA is a safe and efficient intra-procedural imaging method to guide CB ablation of AF. However, it significantly increases procedure duration, total radiation dose and contrast expenditure. In our trial it did not have any impact on the acute success rate of PV isolation or freedom from atrial fibrillation during 12-month follow-up.
Gastric hypomotility after adjunctive pulmonary vein and posterior wall isolation using cryoballoon in patients with atrial fibrillation: case control study
Authors: Esato M , Kikuchi S , Kaneshiro M , Mori T , Tominaga S , Kametani R , Yoshioka S
Published: May 2024

Background

Pulmonary vein isolation (PVI) and concomitant electrical isolation of left atrial (LA) posterior wall (posterior wall box isolation [POBI]) using cryoballoon have mentioned as alternative ablation method for atrial fibrillation (AF). Gastric hypomotility (GH) is a possible complication of cryoballoon ablation (CBA); however, it remains unclear which factors are associated with GH during PVI plus POBI using cryoballoon.

Objective

We sought to investigate the clinical characteristics and intra-procedural parameters in AF patients with GH after PVI plus POBI using cryoballoon.

Methods

Forty-seven patients who underwent first-time CBA procedure for drug-refractory AF were enrolled. After the completion of ipsilateral superior and inferior PVI, cryoballoon was subsequently used to perform POBI; ablating in a segmental fashion for both superior and inferior portions of LA posterior wall. Intra-procedural luminal esophageal temperature (LET) monitoring, and postprocedural esophagogastroscopy within 72 hours were performed in all patients. In addition, intra-procedural parameters of CBA were comparatively evaluated between the patients with or without GH.

Results

Of overall enrolled patients (69.6 ± 9.6 years, 62% paroxysmal AF, CHA2DS2-VASc score 3.2 ± 1.7), GH were observed in 4 (8.6%) patients. Clinical characteristics were similar between the patients with and without GH, while the diameter of left inferior pulmonary vein ostium was significantly smaller in patients with GH compared with those without (15.0 ± 1.5mm vs. 18.8 ± 0.5mm; p=0.018). With regard to the intra-procedural parameters, minimum balloon temperatures at 30 seconds after CBA initiation during inferior portions of LA posterior wall, and minimum LET during POBI were significantly lower in patients with GH compared with those without (-43.3 ± 4.9°C vs. -37.2 ± 5.0°C; p=0.024, and 15.8 ± 1.0°C vs. 23.0 ± 6.0°C; p=0.022, respectively). The optimal cut-off values for prediction were -45°C (sensitivity 75%; specificity 92.5%), and 16.8°C (sensitivity 100%; specificity 85.4%), respectively.

Conclusion

Specific anatomical information and intra-procedural parameters aid identifying high-risk populations of GH after PVI plus POBI using cryoballoon.
Acute safety and efficacy of ablation for atrial fibrillation in elderly patients by means of pulsed field ablation
Authors: Dello Russo A , Solimene F , Iacopino S , Bianchi S , Riva S , Casella M , Maggio R , Rossillo A , Cipolletta L , Tundo F , Arestia A , Artale P , Valeri Y , Malacrida M , Tondo C
Published: May 2024

Background

It is well known that age affects the efficacy of pharmacological treatment for atrial fibrillation (AF). Thermal ablation (radiofrequency or cryoballoon) is an established strategy for AF. However, there is no evidence evaluating efficiency, effectiveness, and safety outcomes in elderly patients in the context of the novel pulsed-field ablation (PFA) technology.

Purpose

We aimed to analyze the efficacy and safety of PFA in elderly (age≥75 years) patients with AF compared to non-elderly (age<75 years) patients with AF.

Methods

All consecutive patients undergoing AF ablation with the Farapulse system at 10 centers were included. Protocol-directed PVI was delivered using 2000 V with eight applications per vein, that is, four applications each in the basket and flower poses. Additional lesions were performed at the operator’s discretion.

Results

A total of 851 consecutive patients were included: 83 (9.8%) had ≥75 years (median of 77[75-78] years) whereas 768 (90.2%) had <75 years (median of 62[56-68] years, p<0.0001). Older patients had more comorbidities compared to younger patients (kidney disease: 9.6% vs 1.2%, p<0.0001; chronic obstructive pulmonary disease: 8.4% vs 3%, p=0.021; cancer history: 18.1% vs 6.1%, p=0.0004; hypertension: 61.4% vs 43.8%, p=0.002), whereas they exhibited a higher LVEF (60±6% vs 57±8%, p=0.0243). No differences between older and younger patients were found in terms of underlying AF type (paroxysmal AF: 66.3% vs 68.9%, p=0.62), procedure type (repeat ablation: 8.4% vs 13.4%, p=0.29), more extensive lesion set than PVI only (28.9% vs 22.5%, p=0.22) and the use of 3D mapping system (22.9% vs 21.1%, p=0.67). By looking at procedural metrics, no differences were also found between groups: 73±28 min vs 72±32 min for skin-to-skin time, p=0.41; 93±41 min vs 88±43 min for preparation plus skin-to-skin time, p=0.11; 18±9 min vs 17±9 min for fluoroscopy time, p=0.61 and 32[32-40] vs 32[32-38] PFA spots to achieve PVI, p=0.29. PVI was achieved in all patients. No major procedure-related adverse events were reported.

Conclusion

In our experience, the use of Farapulse PFA system for AF ablation in elderly patients was rapid, safe and effective, with no differences compared to the younger population.
Pulsed-field ablation of atrial fibrillation in patients with multiple cardiovascular comorbidities: acute safety and efficacy from a large nationwide multicenter experience
Authors: Casella M , Bianchi S , Solimene F , Tondo C , Dello Russo A , Schillaci V , Tundo F , Valeri Y , Colella J , Compagnucci P , Volpicelli M , Polselli M , Fassini G , Malacrida M , Iacopino S
Published: May 2024

Background

Patients with multiple cardiovascular (CV) comorbidities are increasing users of health care globally. The decision to perform ablation of atrial fibrillation (AF) may be challenging in this population, due to the difficulty in evaluating their life expectancy and the associated procedural risk. In addition, no data have been reported on the efficiency, effectiveness, and safety outcomes for non-thermal ablation, such as electroporation with pulsed-field ablation (PFA).

Purpose

To evaluate procedural workflow and safety for AF ablation in these patients through a novel PFA technology (Farapulse) in a large, nationwide clinical practice.

Methods

Consecutive patients who had undergone PFA of AF from 10 Italian centers were included. Patients were stratified according to the numbers of several comorbidities, assigning 1 point each, including: advanced age (≥80 years), LVEF≤35%, structural heart disease, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, previous stroke/TIA, hyperthyroidism, cancer history, cancer ongoing, severe sleep apnea, diabetes, hypertension, dyslipidemia.

Results

We included 634 patients (age 62±9 years, 73% male, 67% paroxysmal AF, 88% de novo ablation procedure, LVEF 57±8%). Two-hundred-nine (33%) patients had no risk-factors, 179 (28.2%) patients had at least 1, 137 (21.6%) two, 63 (9.9%) patients 3 risk-factors and 46 (7.3%) patients more than 4 comorbidities. Patients with accumulated risk factors (≥4) had a higher percentage of long-standing AF (17.4% vs 5.4%, p=0.005) and more often underwent de novo ablation procedure (93.5% vs 81.3%, p=0.04). In these cases, operators decided to adopt more frequently, albeit not significantly, advanced diagnostic such as 3D mapping system (30.4% vs 21.9%, p=0.20) or intracardiac echocardiography (41.3% vs 29.8%, p=0.13), a general anesthesia sedation strategy (41.3% vs 32.1%, p=0.88) and a more extensive lesion set beyond PVI (i.e. left atrial posterior wall area, 32.6% vs 23.1%, p=0.15). Procedures in which patients with accumulated risk factors are involved required longer support (preparation plus skin-to-skin) time (90[65-120] min vs 72[60-100] min, p=0.02) and skin-to-skin time (70[60-100] min vs 60[55-85] min, p=0.03) compared to patients with <4 risk factors, whereas time to PVI (19[14-25] min vs 20[14-25] min, p=0.81) and total number of PFA deliveries to achieve PVI (32[32-38] vs 32[32-36], p=0.55) were similar. PVI was achieved in all patients. No major procedure-related adverse events were reported.

Conclusion

In this preliminary experience, the use of Farapulse PFA system for AF ablation in patients with accumulated risk factors was safe and effective and resulted in similar and fast time to PVI.
Percutaneous left atrial appendage occlusion can impair pulmonary vein isolation with pulse field ablation
Authors: Molitor N , Berger F , Breitenstein A , Chen S , Chun J , Galuszka M , Reichlin T , Roten L , Kueffer T , Lemoine M , Ouyang F , Wolber T , Brunckhorst C , Duru F , Saguner A
Published: May 2024

Background

Pulsed-field ablation (PFA) is a promising new ablation modality for pulmonary vein isolation (PVI). However, the feasibility in the presence of a percutaneous left atrial appendage occluder (LAAO) has not yet been investigated. We observed that PFA applications in the left pulmonary veins after LAAO can be interrupted. The aim of this analysis was to investigate the feasibility of PFA with a single-shot device for PVI after LAAO.

Methods / Results:

Retrospective multicenter analysis. A total of 16 patients (male 81.3%, mean age 71.6 +/-7.4) underwent PVI with PFA after LAAO at 5 different centers in Switzerland and Germany, from August 2021 until July 2023. In 5 patients PFA application at the left-sided PVs was aborted due to interference with the LAAO (Figure). In one patient, the left superior PV could be isolated by repositioning the PFA catheter, in 2 cases successful PVI was achieved after switching to radiofrequency ablation, and in 2 cases the respective left sided PV was not isolated. In all 5 patients the LAAO was an Amplatzer Amulet device (Amplatzer Amulet vs. other LAAO, p=0.069). Mean LAAO size was not significantly different among both groups.

Conclusions

LAAO can interfere with PFA applications around the left superior pulmonary vein. This effect may be associated with the design of the LAAO.
Predicting atrial fibrillation recurrence after catheter ablation using an artificial intelligence-enabled electrocardiogram algorithm
Authors: Gruwez H , Barthels M , Dhont S , Meekers E , Wouters F , Pierlet N , Nuyens D , Rivero-Ayerza M , Van Herendael H , Pison L , Haemers P , Vandervoort P
Published: May 2024

Introduction

Predicting atrial fibrillation (AF) recurrence post catheter ablation may help to assess procedural eligibility and determine AF management. While several predictors of AF recurrence post ablation have been established and numerous clinical risk scores have been proposed, their performance remained underwhelming and clinical utility was limited. Hence, new predictors are needed. Artificial intelligence (AI) algorithms using deep neural networks (DNN) to analyze biometrical data might generate such predictors. DNN algorithms have been developed to identify patients with AF based on a 12-lead electrocardiogram (ECG) in sinus rhythm. Whether these algorithms can function as a predictor of AF recurrence after AF ablation remains unknown.

Purpose

To evaluate the prediction of AF recurrence after ablation using an AI-enabled ECG algorithm trained to predict AF on an ECG in sinus rhythm.

Methods

This study retrospectively analyzed observational data from the DIGITOTAL study, that monitored AF recurrence with a PPG-based smartphone application in 96 subjects after AF ablation. Patients with a 12-lead ECG in SR available within a timeframe of 3 months before the ablation procedure were included in the analysis. Although all patients had a history of AF, an AF-risk score was calculated by the DNN described elsewhere.1

Results

An ECG in sinus rhythm was available in 53 patients (14 women [26.4%]; mean [SD] age, 62.0 [9.7] years) out of the 96 patients followed-up in the DIGITOTAL study. Testing the DNN on the last ECG before the ablation procedure resulted in an area under the receiver operating curve (AUC) of 0.65 (95% CI, 0.49 - 0.80), and an area under the precision recall curve (AUPRC) of 0.56 (95% CI, 0.34 - 0.78). The optimal cutoff score resulted in a sensitivity of 60.0% (95% CI, 36.1% - 80.9%), specificity of 66.7% 66.7% (95% CI, 48.2% - 82.0%), accuracy of 0.64 (95% CI, 0.50 - 0.77), F1-score of 55.8% (95% CI, 38.5% - 74.4%), positive predictive value 52.2% (95% CI, 30.6% - 73.2%) and negative predictive value 73.3% (95% CI, 54.1% - 87.7%). Patients classified in the high-risk group versus low-risk group were more likely to exhibit AF recurrence up to one year after AF ablation (hazard ratio, 2.6; 95% CI, 1.1 - 6.5; P-value = 0.037).

Conclusions

The AI-enabled ECG algorithm, trained to predict AF on a sinus rhythm ECG, was able to predict AF recurrence after ablation with an accuracy comparable to the existing clinical risk scores. Further studies are needed to determine whether the DNN score can be used as an independent predictor and improve existing risk scores.
Prevalence of non pulmonary vein triggers and pulmonary pressure change in atrial fibrillation ablation for cardiac amyloidosis patients
Authors: La Fazia V , Pierucci N , Gianni C , Torlapati P G , Mohanty S , Della Rocca D G , Gigante C , Bode W , Bassiouny M , Burkhardt J D , Gallinghouse G , Horton R , Al-Ahmad A , Di Biase L , Natale A
Published: May 2024

Background

Cardiac amyloidosis (CA) has been associated with an increased risk of atrial arrhythmias and high risk to develop pulmonary hypertension due to infiltration of the amyloid protein in the atrial wall. Though non-PV triggers are commonly seen in left atrium, they are also seen in the right side of the heart, so identifying them at the time of ablation is essential.

Objective

The study evaluates the prevalence of non-PV triggers during catheter ablation in atrial fibrillation (AF) patients affected by cardiac amyloidosis and how restoration of sinus rhythm affects pulmonary pressures.

Methods

This is a study including 74 consecutive patients with an established diagnosis of amyloidosis ATTR diagnosed with cardiac MRI or myocardial biopsy that underwent their first AF catheter ablation. All have a transthoracic echocardiogram before ablation. They underwent pulmonary vein (PV) isolation + isolation of left atrial posterior wall and superior vena cava. Additionally, extrapulmonary triggers, which are defined as ectopic triggers originating from sites other than PVs including left atrial appendage (LAA), coronary sinus (CS), interatrial septum, crista terminalis, mitral valve anulus were identified. Post procedure, patients were followed up routinely with ECG during office visits, echocardiogram, 7-day Holter monitor and event recorders during the first year followed by biannual checkups during the remaining part of the follow-up period. Student’s t-test was used to compare pulmonary pressure between the groups.

Results

Isoproterenol-challenge revealed non-PV triggers in 51 (68.9%) patients. These triggers were mostly mapped to LAA (39, 52.7%), CS (30, 40,5%), and crista terminalis (35, 47.3%). Besides, ectopic beats were seen originating from inter-atrial septum (19, 25.6%), mitral valve annulus (10, 13.5%). More than one trigger was found in (68%) patients. At 1-year after the ablation, 65 (87.8%) were arrhythmia-free off antiarrhythmic drugs.

Moreover, in patients who maintained sinus rhythm post-ablation, there was either a non progression or a reduction in pulmonary pressures (PAPm before ablation: 44.8 ± 8.9 mmHg vs PAPm after ablation 45.1 ± 11.1 mmHg, P value =0.87). Conversely, those experiencing arrhythmic recurrences demonstrated an increase in pulmonary pressures (PAPm before ablation: 41.9 ± 7.7 mmHg vs PAPm after ablation 47.8 ± 10.2 mmHg, P value =0.019). Fig.1

Conclusion

Our findings suggest that non-PV triggers are highly prevalent in cardiac amyloidosis AF patients including a high rate crista terminalis firing. Notably, restoration of sinus rhythm post-ablation was linked to stable or reduced pulmonary arterial pressures, whereas patients with arrhythmic recurrences experienced a significant increase.
Treatmen of atrial fibrillation with cryoballoon pulmonary vein isolation - results of a 5-year follow-up
Authors: Pasara V , Nekic A , Prepolec I , Bogdanic J E , Putric Posavec J , Pezo-Nikolic B , Puljevic M , Puljevic D , Milicic D , Velagic V
Published: May 2024

Background

Atrial fibrillation is the most common arrhythmia in the general population and cryoballoon ablation is gradually becoming a first-line treatment. However, data regarding long-term outcomes after this procedure are still lacking.

Aim

The goal was to show the results of a long-term follow-up following the cryoballoon pulmonary vein isolation in patients with atrial fibrillation (AF).

Methods

A total of 126 patients were included in the study of which 77.0% had paroxysmal atrial fibrillation (PAF). Successful treatment outcome was defined as AF recurrence-free survival with stabile sinus rhythm during 5 years after the procedure. A treatment failure was defined as symptomatic AF recurrence with ECG verification (12 lead ECG or AF lasting >30s by Holter EKG). The patients on antiarrhythmic therapy and those who underwent a redo pulmonary vein isolation procedure were also included.

Results

Following cryoballoon pulmonary vein isolation in a 5-year period 52.4% of patients were in stable sinus rhythm without AF recurrence. With redo pulmonary vein procedures a total of 61.9% of patients were without AF recurrence. Together with antiarrhythmic drugs 57.9% of patients were in sinus rhythm without AF recurrence in a 5-year period. With redo pulmonary vein isolation and antiarrhythmic drugs a total of 73.8% of patients were without AF recurrence. There was a statistically significant difference regarding AF recurrence between patients who underwent redo pulmonary vein isolation and those who did not (p=0.006). In patients with PAF, 62.9% remained without AF recurrence, and 79.4% underwent a redo procedure. In patients with persistent atrial fibrillation (PersAF), 41.4% were without AF recurrence, and 55.1% underwent a redo procedure. The difference between PAF and PersAF was statistically significant (p=0.009).

Conclusion

Data from our center show good long-term results of cryoballoon pulmonary vein isolation in patients with atrial fibrillation. The procedure is especially successful in patients with PAF.1 The use of redo procedures is justified as it increases the long-term success rate.
A propensity score matched comparison of pulsed field versus hybrid ablation in patients with long standing persistent atrial fibrillation
Authors: Doundoulakis I , Della Rocca D G , Mene R , Mouram S , Pannone L , Sorgente A , Sousonis V , Stroker E , Sieira J , Almorad A , Boveda S , Sarkozy A , Chierchia G B , La Meir M , De Asmundis C
Published: May 2024

Introduction

On one hand pulsed-field ablation (PFA) has shown favourable data in terms of safety and efficiency for pulmonary veins isolation (PVI). One the other hand, hybrid ablation results in better outcomes in patients with persistent atrial fibrillation (AF), as it combines a thoracoscopic epicardial and transvenous endocardial approach in a single procedure.

Purpose

Aim of this study was to to compare 1-year follow-up data of patients with long standing persistent AF undergoing PVI and posterior wall isolation using PFA, and hybrid AF ablation.

Methods

Consecutive patients with long standing persistent AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with long standing persistent AF undergoing a first PVI with hybrid ablation were selected using a 1:1 nearest neighbor propensity score matching. Hybrid AF ablation was performed in a one-step procedure: (i) thoracoscopic ablation followed by (ii) endocardial mapping and eventual ablation. All patients received PVI and posterior wall isolation in both group. Additional lesions were performed based on clinical indication and physician judgement. The primary endpoint was recurrence of atrial tachyarrhythmia after 12 months of follow-up (with a blanking period of 3 months).

Results

A total of 130 patients with persistent AF underwent hybrid ablation and 72 patients underwent PFA. 85 patients (age:67.5±9.7 years, 68.2% males, CHA2DS2-VASc: 2.5±1.3) with long standing persistent AF underwent their first AF ablation (PFA N= 39; Hybrid N = 46). After a 1-year follow-up, freedom from atrial tachyarrhythmia recurrence was 74.4% with PFA and 71.7% with hybrid ablation (p = 0.786). After propensity score matching, a total of 39 matched pairs of PFA and hybrid first AF ablation remained. The result remained unchanged and no significant difference was observed between treatment cohorts after matching (Figure 1, p=0.039).

Conclusion

In a propensity score matched analysis of patients with long standing persistent AF, freedom from any atrial tachyarrhythmia 1 year after AF ablation using PFA was favourable and at least as good as with hybrid ablation.
Associations of fat and muscle mass indices with incident atrial fibrillation: data of PREVEND
Authors: Suthahar N , Zwartkruis V , Middeldorp M E , Van Veldhuisen D J , Bakker S J L , Gansevoort R T , Kardys I , Rienstra M , De Boer R A
Published: May 2024

Background

Whether the association between body mass and atrial fibrillation (AF) risk is driven by fat mass or muscle mass remains unclear.

Objective

To examine the association of relative fat mass (RFM, a novel marker of whole-body fat percentage) and 24-hour urinary creatinine excretion (a marker of total muscle mass) with incident AF.

Participants: We included 8120 community-dwelling adults from the PREVEND cohort without prevalent AF.

Results

The mean age of the population was 49.8±12.6 years and 50.0% (n=4060) were women. The mean RFM was 30.2±7.4 % and the mean creatinine excretion was 12.3±3.5 mmol/24h. During a mean follow-up period of 9.7±2.4 years, 261 AF events (3.2%) occurred. We included RFM, creatinine excretion, age, sex, height, heart rate, hypertension and cardiovascular disease history in a multivariable Cox regression model. The association between RFM and AF risk was linear, and the hazard ratio per 1 SD increase in RFM was 1.40; 95%CI: 1.17-1.66 (P<0.001). The association between creatinine excretion and AF risk was non-linear (P-value quadratic trend=0.006): compared with individuals in tertile 2 of creatinine excretion, those in tertile 1 had a HR of 1.70; 95%CI: 1.21-2.29 (P=0.002) and those in tertile 3 also had a HR of 1.74; 95%CI: 1.22-2.47 (P=0.002).

Conclusion

In the general population, both fat mass and muscle mass are associated with incident AF. While obesity should be considered as a major risk factor for AF, increased AF risk in individuals with low and high muscle mass warrants further investigation.
Peak frequency mapping usefulness and utilization for typical AVNRT ablation
Authors: Handayani A , Merino D , Merino J L , Sanroman-Junquera M , Moreno J , Castrejon-Castrejon S , Cossiani M M , Franco E , Granero C L , Alarcpn J J D V , Relan J , Kim S
Published: May 2024

Background

Accurate identification of slow pathway for the AVNRT ablation is important to achieve successful result and avoid complications mainly AV nodal block. There were some developments to produce precise image to locate this such as identify low voltage bridge (LVB) using electro-anatomical mapping and visualization of direct slow pathway capture (DCSP). The peak frequency (PF) associated with bipolar EGMs is a novel parameter which may serve to distinguish near filed (NF) from far field (FF) electrocardiogram (EGM) components. This technique can be used to differentiate sub-components derived from high density mapping. Previous study suggested this mapping appears to assist in substrate differentiation, pathway localization, and contact assessment. However, this approach has been never evaluated clinically in AVNRT ablation

Objective

This study conducted to evaluate the usefulness and utilization of the peak frequency mapping to identify the slow pathway location.

Method

The study conducted in November to December 2023 where twenty consecutive patients with common AVNRT were included in the study. Regular bipolar voltage and activation maps were generated with a regular 4 mm tip catheter. Following this, peak frequency maps (PF) were computed online prior ablation and displayed on the activation map with shadowed areas where PF was <200 Hz (figure, left panel). Focal radiofrequency application (RFa) was directed to the areas of late activation (figure, left panel) and low frequency (figure, right panel) (LA-LF). Successful ablation reached if junctional rhythm was recorded during RFa and AVNRT was no longer inducible afterwards.

Results

Twenty patients (48 ±15 years, 75% female) were enrolled in the study. A late activation low frequency area of 0.92±0.48 cm2 was found in 18 of them. This study revealed that there was a difference between PF in the slow pathway area compared to the adjacent area where the mean PF at the slow pathway area was 175.5 ± 37.1 Hz (analysis per patient) and 170.1 ± 48.10 Hz (analysis per recording site) which was lower and differed significantly than the PF recorded at the adjacent atrial area (279.71 ± 28.11 Hz per patient, 279.91 ± 69.47 Hz per recording site) (P<0.0001). Following the mapping, RFa were successfully applied at these late activation low-frequency (LA-LF) area induced junctional rhythm in 17 patients. AVNRT was no longer inducible after the ablation in all 17 patients. Additional RFa were often given to reinforce the result (11 ± 9 RFa, 4.03 ± 3.35 min RFa time).

Conclusion

The peak frequency mapping could be performed to map the slow nodal pathway which is often located in an area of late activation and low frequency.
HV interval cutoff should be different in women and men with syncope and bundle branch block
Authors: Francisco Pascual J , Medina Maguina J M , Santos Ortega A , Perez Rodon J , Adelino R , Seder E , Benito B , Jordan P , Lal-Trehan Estrada N , Mallofre N , Ferreira Gonzalez I , Rivas Gandara N
Published: May 2024

Background

Determining the optimal HV interval cutoff for predicting the need for pacemaker (PM) implantation has been a recent focus of research. Current ESC guidelines recommend HV > 70 msec based on initial studies; however, new data suggest that a cutoff of >60 msec could appropriately identify patients at high risk for requiring PM implantation. While previous studies have indicated that women with bundle branch block (BBB) have a lower risk of AV block (AVB), gender differences in the optimal cutoff for considering a positive EPS have not been thoroughly investigated.

Methods

This cohort study included consecutive patients with unexplained syncope and BBB, enrolled from January 2010 to October 2021, with a median follow-up time of 3 years. Patients underwent a stepwise workup protocol involving an electrophysiological study (EPS) and long-term follow-up with an implantable cardiac monitor (ICM).

Results

Of the 503 patients in the study, 185 (38%) were women. The median age was 78 years (IQR 71-83), the median LVEF was 58% (IQR 50-62), and 110 (22%) had ischemic heart disease. The ECG showed LBBB in 194 (39%) patients and RBBB in 287 (57%). Among these, 177 (35%) also had left anterior hemiblock. The median HV interval was 60 msec (IQR 52-73), and EPS was diagnostic in 252 (50%) patients, with the majority (221, 44%) for AVB. In 91 patients with initially negative EPS, a diagnosis was made during follow-up with an ICM, and in 35, AVB was documented. In patients with negative EPS, an HV interval >60 msec was associated with an increased risk of AVB during follow-up (HR 2.5, 95% CI 1.6-4). However, significant gender differences were found. The risk of AVB was 2.5 times higher in men (95% CI 1-6) (Figure 1). Furthermore, sensitivity, specificity, PPV, and NPV for the cutoff of 60 msec were 47%/84%/51%/82% in men and 21%/78%/21%/78% in women. The AUC to predict AVB was 0.72 (95% CI 0.6-0.8) in men and 0.51 (95% CI 0.4-0.6) in women (Figure 2).

Conclusions

In patients with initially negative EPS, an HV interval >60 msec was associated with a higher risk of AVB during follow-up; however, significant gender differences were observed in diagnostic accuracy. In women, a cutoff of HV interval >60 msec presented poor diagnostic accuracy compared to men. Moreover, the HV interval did not adequately predict the development of AVB in women with a basal HV interval <70 msec, suggesting it may not be suitable for considering PM implantation in female patients.FIGURE 1FIGURE 2
Cardioneuroablation for vasovagal syncope. Results from an EHRA Survey
Authors: Penela D , Berruezo A , Roten L , Futyma P , Richter S , Chun J
Published: May 2024

Background

Cardioneuroablation (CNA) is a recently introduced catheter-based therapy for vasovagal syncope (VVS), involving the modulation of the cardiac autonomic nervous system. Over the past decade, the body of evidence supporting CNA has consistently grown, sparking increased interest, and leading to broader adoption of this novel therapy for VVS treatment. However, several knowledge gaps persist, particularly concerning clinical indications, methodology, and long-term outcomes.

Purpose

The aim of this survey is to provide a comprehensive overview of the daily utilization of CNA in Europe.

Methods and Results

Among 204 participants, half reported that they are already performing CNA in their centres. The survey indicated CNA as an emerging therapy, with most centres initiating this treatment within the last two years. A significant majority of those who responded (71%) adopted a systematic approach by targeting ganglionated plexuses (GPs) in both the right atrium (RA) and left atrium (LA) as their first-line approach. The second most common approach (16%) involved performing ablation LA GPs only in the cases where there is no response following RA ablation. Figure 1 shows the GPs usually targeted for ablation. The most frequent procedural endpoint was the increase in the heart rate. Ninety percent of respondents relied on an anatomical approach for GP localization, while 59% also guided the procedure using electrogram analysis. Less frequently used approaches included pre-procedural imaging (20%), high-frequency stimulation (17%), and spectral analysis (10%). Only 11% of physicians discharged patients who underwent CNA without anticoagulation or antiplatelet therapy. In most cases (58%), respondents discharged their patients with anticoagulation, while 28% on single antiplatelet therapy. Overall, CNA is considered an effective procedure (80% of responders rating its effectiveness at or above 70%) and a safe procedure (with an estimated 1% rate of procedure-related complications, with symptomatic sinus tachycardia being the most frequently reported).

Conclusions

This survey confirmed high expectations for the future of this therapy, as most responders anticipate that CNA will be indicated as a first-line therapy for patients with recurrent cardioinhibitory VVS. Future efforts are necessary to standardize the procedural flow and peri-procedural patient management.