bluuebunny/crossref_metadata_2025 huggingface dataset:
Single versus double transseptal puncture for pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation - insights from "Go for Zero Fluoroscopy" registry
Authors: Miskowiec D , Qawoq H D , Zycinski P , Kosiuk J , Chudzik M , Kasprzak J D
Published: May 2024

Background

Transseptal puncture is one of the most challenging steps in catheter ablation of atrial fibrillation (AF) because of the potential risk of complication. While single TSP reduces the puncture-related risk, double TSP simplifies the procedure (immediate signal visualization in pulmonary veins, avoidance of multiple changes of catheters through the single sheath). The purpose of this study was to analyze the impact of single versus double TSP during pulmonary vein isolation (PVI) with radiofrequency (RF) catheter ablation for AF on the fluoroscopy usage and procedure time.

Methods

Data reported from the international, multicenter prospective „Go For Zero Fluoroscopy Registry" performed in years 2018–2019 were analyzed. Overall 25 European electrophysiology centers from 14 countries and up to 5 operators from each center were enrolled. Only isolated PVI procedures were analyzed.

Results

A total data of 393 PVI RF procedures were collected from 25 centers. The median dose-area-product (DAP), fluoroscopy time and overall procedure time were: 810 (325 – 1839) cGy*cm2, 8 (4 – 14) minutes and 124 (92 – 168) minutes, respectively. Single TSP was associated with significantly higher DAP: 984 (459 – 1939) vs 667 (227 – 1469) cGy*cm2 (p=0.002), longer fluoroscopy time: 11 (6 – 19) vs 6 (3 – 11) minutes (p<0.001) and longer overall procedure time: 133 (103 – 168) vs 110 (90 – 168) minutes (p=0.003) as compared with double TSP. Single and double TSP group did not differ significantly in regards of general anesthesia usage, circular and multipolar mapping catheter use (p>0.05). However, single TSP was performed by operators with longer EP lab experience: 10 (4 – 15) vs 3 (0 – 10) years (p<0,001).

Conclusions

Double TSP is related with lower fluoroscopy usage and shorter overall procedure time of pulmonary vein isolation with radiofrequency catheter ablation for atrial fibrillation.
Acute clinical outcomes of patients with HFpEF undergoing atrial fibrillation ablation
Authors: Ismaili D , Kany S , Obergassel S , Varnhorn L , Venedey N , Pinnschmidt H , Rottner L , Moser F , Lemoine M , My I , Riess J , Reissmann B , Kirchhof P , Metzner M , Rillig A
Published: May 2024

Aim

Robust data show that atrial fibrillation (AF) ablation can improve left ventricular function and prevent cardiovascular complications in patients with heart failure and reduced ejection fraction. The effectiveness and safety of AF ablation in patients with heart failure and preserved ejection fraction (HFpEF) is less well characterized.

Methods

We retrospectively analyzed 785 consecutive patients with normal left ventricular function undergoing AF ablation in a high-volume center including 251 with AF and HFpEF. We compared baseline parameters, procedural details and procedural complications by heart failure status.

Results

Patients with HFpEF (n=251/785) were older (median age 70 years vs. 64 years; p < 0.05) and more frequently female (48.2% vs. 32.2%; p < 0.05) compared to patients without HF. Symptom severity was comparable with a median European Heart Rhythm Association score of 2 in both groups (p > 0.05). Arterial (71.7% vs. 59.7%, p < 0.05), diabetes (16.7% vs. 9.4%, p < 0.05) and dyslipidemia (41.4% vs. 27.2%, p < 0.05) were more common in patients with AF and HFpEF. Acute pulmonary vein isolation (PVI) was achieved in all patients using cryoballoon or radiofrequency energy with similar frequency in both groups (cryoballoon ablation: 37.8% vs. 41.6%; p > 0.05). A subgroup of patients in both groups additionally underwent cavotricuspid isthmus ablation for coexistent atrial flutter (26% vs. 20.7%; p > 0.05). Procedure times (119.4 ± 47.7 min vs. 120.2 ± 48.3 min; p > 0.05) and fluoroscopy times (15.8 ± 10.4 min vs. 15.5 ± 7.1 min; p > 0.05) were comparable. Overall complication rates did not differ (12.7% vs. 10.3%; p > 0.05). While the incidence of pericardial tamponades was slightly higher (2% vs. 0%), other severe and minor complications showed no significant differences, including stroke/transient ischemic attack (TIA; 0.4% vs. 0.6%), major life-threatening bleeding (0% vs. 0.2%), vascular complications (1.6% vs. 2.1%), phrenic nerve palsy (0.8% vs. 1.5%), and pulmonary vein stenosis (0.4 vs. 0%). The mean in-hospital stay for the procedure was 2 days in both groups (p > 0.05). In-hospital recurrence rates were similar (12.4% vs. 17%; p > 0.05), as was the need for electrical cardioversion before discharge (5.6% vs. 6.6%; p > 0.05).

Conclusion

Patients with HFpEF undergoing AF ablation were older, more frequently female, and have more comorbidities than patients without heart failure. Acute procedural success and acute complication rates appear low. These data encourage randomized evaluations of the safety and efficacy of ablation-based rhythm control therapy in patients with AF and HFpEF.
Severity of tricuspid regurgitation predicts risk of atrial fibrillation recurrence after pulmonary vein isolation
Authors: Bismpos D , Wintrich J , Teusch A , Pavlicek V , Fischer P , Mahfoud F , Boehm M , Ukena C
Published: May 2024

Background

Atrioventricular valve regurgitation (AVVR) results in atrial remodeling, thus promoting the formation of a substrate for atrial fibrillation (AF). On the other hand, AF may cause functional AVVR by annular dilatation of the atria. In this vicious circle, the identification of the leading pathomechanism and consequently the optimization of treatment can be challenging.

Purpose

Our aim was to investigate whether the presence of significant AVVR and especially of tricuspid regurgitation (TR) affects the efficacy of catheter-based pulmonary vein isolation (PVI) for AF. Furthermore, we evaluated whether rhythm control for AF through PVI could lead to an improvement of AVVR severity. Finally we examined the effect of concomitant right atrial flutter on the arrhythmic outcome in patients with significant TR .

Methods

We enrolled patients undergoing first-time PVI for symptomatic AF. We compared the severity of AVVR at the time of the procedure as well as after 6 months, using transthoracic echocardiography. Moderate to severe AVVR was defined as significant. Moreover, we evaluated whether the presence of significant AVVR, at baseline and 6 months after the procedure, could serve as an independent predictor for AF recurrence.

Results

Out of 320 consecutive patients (mean age 66.3 ± 10 years, 61.6% male, 60% paroxysmal AF) , significant TR at baseline was documented in 13.1%, while significant mitral regurgitation (MR) in 10.9%. Six months after PVI, the proportion of patients with moderate to severe TR (13.1% to 7.2%; p<0.001) and MR (10.9% to 6.6%; p<0.001) decreased significantly. Compared to patients with post-interventional improvement of significant TR, right atrial (RA) dilatation at baseline was more pronounced in patients with persistent significant TR (RA area 20.2 ± 4.4 vs. 26.6 ± 8.3 cm2; p=0.002). The presence of significant TR, particularly without improvement during the follow-up, independently increased the risk of atrial fibrillation recurrences. Even after propensity-score matching, TR at baseline remained an independent risk predictor regarding recurrent atrial fibrillation (HR 2.2 [95% CI, 1.1 - 4.9]; p=0.045). Among patients with significant TR, those with documented right atrial flutter were at high risk for recurrence of atrial arrhythmia (HR 2.69 [95% CI, 1.0 – 6.9]; p=0.039), despite the additional ablation of the cavo-tricuspid isthmus. Significant MR was not associated with increased risk of atrial arrhythmias.

Conclusion

In patients with symptomatic AF undergoing PVI, the presence of moderate to severe TR, particularly without improvement 6 months after the procedure, was associated with a worse arrhythmic outcome. Further investigations to enhance the understanding of the underlying electrophysiological substrate and the need for tailored ablation strategies are warranted.TR as predictor for AF(propensity score)AVVR improvement after PVI
Cryoballoon versus radiofrequency catheter ablation: 3-year follow-up data from the prolonged Norwegian randomized study of persistent atrial fibrillation (NO-PERSAF study)
Authors: Wollner K , Rossvoll O , Tande P , Solheim E , Schuster P , Chen J
Published: May 2024

Background

Pulmonary vein isolation (PVI) is still regarded as a cornerstone for treatment of persistent atrial fibrillation (AF). Both radiofrequency ablation (RFA) and cryoballoon ablation (CBA) are frequently employed to achieve PVI. Similar results of both techniques have been reported during short follow-up, but clinical outcomes for long-term follow-up from randomized trials are still missing.

Purpose

This study aimed to evaluate the effectiveness of PVI performed with CBA compared with RFA in patients with persistent AF over 3 years.

Methods

For the NO-PERSAF study, 101 patients (63.2±8.6 years old, 80 male, 21 female), with persistent AF (77 persistent AF, 24 long-standing persistent AF) referred to PVI were randomized (1:1) to CBA or RFA and followed for 12 months. All patients participating in the NO-PERSAF study were invited to an extended outpatient evaluation with 12-lead ECG and 7-day Holter. The primary endpoint was any documented recurrent atrial tachyarrhythmia (ATA) lasting longer than 30 s during 3 years after the index ablation procedure (following a 3-month blanking period). The ATA-free survival curves were estimated by Kaplan-Meier method and analyzed by log-rank test.

Results

One patient crossed over from CBA to RFA group because of equipment problem during index ablation procedure. 99 of the original 101 patients responded (1 died of non-cardiovascular diseases, 1 lost). Freedom from ATA was achieved in 51 (50.5%) of the 101 patients, 28 (54.9%) out of 51 patients in the CBA group and 23 (46.0%) out of 50 patients in the RFA group (Figure 1). No difference of ATA recurrence was found between the two groups (p=0.327). There was significantly (p=0.031) less atrial flutter in the CBA group (7.8%; 4 atypical) compared with the RFA group (22%; 10 atypical, 1 typical).

28 patients received repeat ablations with RFA during the follow-up period, 15 in the CBA group and 13 in the RFA group (1 twice). Freedom from ATA after multiple ablations was achieved in 74 (73.3%) of the 101 patients, 40 (78.4%) out of the 51 patients in the CBA group and 34 (68.0%) out of the 50 patients in the RFA group. No difference of ATA recurrence was found between the two groups (p=0.178, Figure 2) after multiple ablations with RFA for AF and atrial flutter. Noticeably, 2 patients in the CBA group and none in the RFA group received atrioventricular nodal ablation after permanent pacemaker implantation.

Conclusions

Compared to RFA, PVI performed with CBA showed similar outcome of freedom from ATA over a long-term follow-up of 3 years. However, the incidence of atrial flutter was significantly lower in the CBA group.Figure 1Figure 2
Left atrial low-voltage area is associated with poor rhythm outcome and poor efficacy of left atrial additional ablation in patients with long-standing persistent atrial fibrillation ablation
Authors: Matsuda Y , Masuda M , Uematsu H , Sugino A , Ooka H , Kudo S , Fujii S , Asai M , Okamoto S , Ishihara T , Nanto K , Tsujimura T , Hata Y , Higashino N , Mano T
Published: May 2024

Background

Although left atrial additional ablation other than pulmonary vein (PV) isolation is often performed in order to modify arrhythmogenic substrate, rhythm outcome in patients with long-standing persistent atrial fibrillation (LS-PerAF) is still challenging. Left atrial low-voltage areas (LVAs) is correlated with degeneration of atrial myocardium, and atrial fibrillation (AF) recurrence following catheter ablation. However, in patients with LS-PerAF, the association between the prevalence of LVAs and rhythm outcome has not been clarified. We hypothesized that AF recurrence after AF ablation more frequently occurred in patients with LVAs than in those without, and that the prevalence of LVAs was associated with the efficacy of left atrial additional ablation.

Purpose

The purpose of this study was to investigate the association between the prevalence of LVAs and rhythm outcome or efficacy of left atrial additional ablation in patients with LS-PerAF ablation.

Methods

In total, 123 (age, 66 ± 9 years; female, 28 [23%]) consecutive patients who underwent initial ablation for LS-PerAF were included. Left atrial additional ablation was defined as an ablation for left atrium other than PV isolation and ablation for non-PV foci. The definition of LVAs was sites with a bipolar voltage of <0.5 mV covering ≥5 cm² of left atrium. Rhythm outcome after the catheter ablation was followed for 24 months.

Results

LVAs was found in 31 (25%) patients, and left atrial additional ablation was performed for 31 (25%) patients. Freedom from AF recurrence was significantly lower in patients with LVAs than in those without (Figure 1A). In contrast, freedom from AF recurrence was similar between patients with left atrial additional ablation and those without (Figure 1B). In patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without (Figure 2A). On the contrary, in patients with LVAs, freedom from AF recurrence during was similar between patients with left atrial additional ablation and those without (Figure 2B).

Conclusions

In patients undergoing LS-PerAF ablation, AF recurrence more frequently occurred in patients with LVAs than in those without. Only in patients without LVAs, freedom from AF recurrence was significantly higher in patients with left atrial additional ablation than in those without.Figure 1Figure 2
Durability of pulmonary vein isolation after radiofrequency-balloon ablation
Authors: Plank K , Schaack D , Tohoku S , Bordignon S , Chen S , Urbanek L , Schmidt B , Chun K R J
Published: May 2024

Aims

Recently a multi-electrode radiofrequency balloon (RFB) for pulmonary vein isolation (PVI) was introduced. To the best of our knowledge no data on PVI durability has yet been published.

Objectives

The aim of this single-center study was to investigate the incidence of pulmonary vein (PV) reconnectionafter RFB-guided PVI.

Methods

Patients undergoing second ablation for recurrent atrial tachyarrhythmia (ATa) following the initial RFB-PVI were investigated. Left arial (LA) electroanatomic mapping was used. The rate of PV reconnection, the type of recurrent ATaand procedural data were analyzed.

Results

Among 178 patients treated with RFB, 21 patients underwent a second procedure 11 ± 6 months after the initial PVI. 67% of these patients presented with atrial fibrillation (AF), 33% with atrial tachycardia. Regarding baseline characteristics, 71% of these patients were male, mean age was 67±10, mean BMI was 28±5, 67% had hypertension and 33% had coronary artery disease.

Overall, 83 PVs including one left common PV (LCPV) were assessed. The rate of PV reconnection was 28% (23/83 PVs). 57% of patients (12/21) had at least one reconnected PV. Patient with PV-reconnection had more AF recurrence and less often atrial tachycardia (AT) (AF: 75%, AT: 25%) than patients with durably isolated PVs (AF: 56%, AT: 44%).

Most reconnections were detected in septal PVs. Reconnections were distributed as follows: RIPV: 8/21, RSPV: 7/21, LIPV: 5/20, LSVP: 3/20, LCPV: 0/1.

Precise localization of the gaps could be identified in 15/23 PVs. Most common gap locations were at the anterior carina (4/15) for septal PVs and anterior-inferior (3/15) at the LIPV. Ablation strategy was pure PV reisolation in 8/12 patients and PV reisolation with additional linear lesions in 4/12 patients. All patients with durably isolated PVs were treated with additional substrate modification. In total, following additional lesions were set: anterior line: 6, roof line: 11, cavotricuspid isthmus (CTI): 7, LAA-Isolation: 1, free wall of the right atrium: 1.

Regarding procedural data of the index procedure, the number of applications was not a statistically significant predictor of reconnection (p=0.77).

Conclusion

We provide the first insight into durability of PVI after radiofrequency-balloon ablation. 72% of all PVs were still isolated. Our data on gap localization might help to identify regions where optimal balloon contact is difficult to achieve. More data on this topic might reveal predictors for PV reconnections.
The impact of additional radiofrequency ablation for atrial fibrillation substrates using with ExTRa-Mapping analysis after Cryo-ablation in patients with persistent atrial fibrillation
Authors: Akita T , Yoshida A , Kim Y , Matsuura T , Nishijo K , Takada K , Suzuki M , Takahashi Y , Terashita D , Tsuda S , Tagashira T , Takami K , Yamada S
Published: May 2024

Background

Pulmonary vein isolation (PVI) for persistent atrial fibrillation (AF) is well established. Cryo-ablation for persistent AF has been reported to be safe and effective and comparable to radiofrequency (RF) ablation in long term arrhythmia-free survival, but the outcome is limited. Phase mapping using software of ExTRa-Mapping is a new tool to clarify the real-time imaging of the AF wave dynamics.

Purpose

We investigated the distribution of rotors of left atrium (LA) after PVI by Cryo-ablation, and the efficacy and safety of additional RF ablation for AF substrates (rotor modification) after Cryo-ablation.

Methods

A total of 50 patients who underwent persistent AF ablation in our hospital were enrolled. The Cryo-ablation alone group (Cryo group; n=25) and the Cryo-ablation + additional RF substrates ablation group (Cryo+RF group; n=25) were randomly divided. First, PVI with Cryo-ablation was performed. Second, if AF did not term after PVI, the rotor of LA were analyzed using the NAVX and ExTRa-Mapping system. In Cryo+RF group, the extensive RF ablation of the PV antrum to modify the rotor area were performed (Abstract Picture 1). The recurrence rate of any atrial tachy-arrhythmia without anti-arrhythmic drugs and safety were evaluated in both groups.

Results

The patient characteristics (69 ± 9.2 years old, body-mass index 24 ± 3.2 kg/m2, LA diameter 43 ± 5.1 mm, left ventricular ejection fraction 60 ± 7.8 %, persistent AF duration 4.2 ± 5.1 months) did not differ between the both groups. The distribution of rotors of LA were predominantly present in the anterior (n = 36) and inferior (n = 27) walls of the LA, with only a few in the posterior wall (n = 7) in the both groups. In Cryo+RF group, except for 4 cases in which AF was termed by PVI or a rotor was not detected, extensive RF modification in anterior antrum of right pulmonary vein was performed in 18 of 21 cases. In an average follow-up of 482 ± 273 days, the recurrence rate of any atrial tachy-arrhythmia was significantly lower in Cryo+RF group compared with Cryo group (p=0.029, Abstract Picture 2). No serious complications occurred in both groups.

Conclusion

Additional extensive RF ablation of the PV antrum to modify the Rotor area resulted in a lower recurrence rate in patients with persistent AF.Modify the rotor areaRecurrence rate
Predictive value of guideline-referred risk scores in estimating left atrial low voltage areas and recurrence of atrial fibrillation in repeat ablation procedures
Authors: Georgi C , Bannehr M , Lochmann M , Reiners D , Haase-Fielitz A , Seifert M , Butter C
Published: May 2024

Background

Despite advances in mapping and ablation techniques, atrial fibrillation (AF) recurrence remains a challenge after pulmonary vein isolation. Low voltage areas (LVA) in the left atrium are associated with higher recurrence rates after left atrial ablation. Risk scores for evaluating post-ablation recurrences are not well established, although a better patient selection for repeat procedures would be of great help in clinical practice.

Purpose

Risk scores for prediction of AF recurrence have not been tested in a cohort of repeat ablations.

Methods

This single-center study includes consecutive patients from the prospective Bernau ablation registry undergoing ultra-high-density (UHD) mapping and repeat ablation for AF/AT recurrence between 2016 and 2020. The potential of seven guideline mentioned risk scores (APPLE, DR-FLASH, MB-LATER, ATLAS, CAAP-AF, BASE-AF 2, ALARMEc) to predict (1) AF/AT recurrence beyond a three-months blanking period after repeat left atrial ablation (Re-PVI ± further LA ablation) and (2) the percentage of left atrial LVA in UHD mapping was investigated. LVA were defined as sites with a bipolar peak-to-peak voltage of <0.5 mV with an extent of >1cm². Optimal cutoff for sensitivity and specificity for LVA and AF/AT recurrence as endpoint was chosen using C statistics with receiver-operator characteristics (ROC). Further ROCs were performed to illustrate the predictive ability of the scores. Pearson correlation was used to test associations between variables.

Results

160 patients (mean age 67.9 ± 9.1 years, 60.6% persistent AF, mean AF duration 4.6 ± 3.8 years) with complete left atrial UHD mappings (mean EGMs 9754 ± 5808) were included. Overall recurrence rate over a mean follow-up time of 16 ± 11 months was 55.6%. The predictive value of the investigated risk scores on AF/AT recurrence in our cohort was low (Table 1), with the highest power for CAAP-AF (p = 0.015, AUC = 0.615) and DR-FLASH score (p = 0.040, AUC = 0.594), Figure 1. With respect to left atrial LVA we found a better predictive power for the CAAP-AF (p < 0.001, AUC 0.702), APPLE (p < 0.001, AUC 0.687), DR-FLASH (p < 0.001, AUC 0.688), ATLAS (p = 0.005, AUC 0.634) and ALARMEc (p = 0.007, AUC 0.608) score to predict low voltage based on a calculated cut-off of 22% of total left atrial surface (Figure 1).

Conclusion

The predictive value of guideline-referred risk scores in estimating AF/AT recurrence after repeat ablation is low and does not seem to be of relevant help in patient selection for further interventional treatment. Some scores demonstrate a fairly good prediction for the amount of left atrial LVA and therefore might help in choosing the right mapping and ablation regime beforehand.
Ultrasound-guided venipuncture of femoral veins vs standard palpation approach in patients undergoing pulmonary veins isolation
Authors: Addeo L , Valeriano C , Viscusi M M , Buytaert D , Abbate V , Geelen P , Peythcev P , De Schouwer K , De Potter T
Published: May 2024

Introduction

Complications related to vascular access frequently arise during transcatheter atrial fibrillation (AF) ablation. Vascular access related complications remain the main cause of procedure related adverse events. In the literature, there is no clear evidence supporting the benefit of ultrasound-guided (USG) vascular access.

Purpose

We hypothesized that USG venipuncture could reduce vascular complication rates and reduce the need for additional interventions due to complications related to vascular access.

Methods

We conducted a single-center retrospective study. The primary endpoint was the rate of major complications, defined as arteriovenous fistula, pseudoaneurysm, and groin hematoma with Bleeding Academic Research Consortium (BARC) classification ≥ 2 requiring interventions such as transfusions or surgical/percutaneous repair and/or resulting in hospital prolongation or readmission). The secondary endpoints were the rate of minor complications, defined as groin hematoma with BARC classification = 1 or bleeding without sequelae, and the composite rate of additional non-scheduled exams and procedures due to vascular complications. The study included all patients who underwent atrial fibrillation ablation with radiofrequency (RF) between January 2020 and December 2022 in our center, performed by two expert operators: one utilizing a classic palpation (BLIND) approach and the second one employing the USG approach. Identical materials were used for access in both groups, and the choice of protamine administration or closure method was decided by the operator on a case by case basis. In total, there were 946 patients, 352 in USG group and 594 in BLIND group. For patients in both groups who were on vitamin K antagonists (VKAs), uninterrupted administration with an international normalized ratio (INR) ratio between 2.0 and 3.0 was required.

Results

Major complications were significantly reduced in the USG group compared to the BLIND group (0 (0%) in USG vs. 9 (1.5%) in BLIND, P = 0.02). No significant difference was observed in minor complications between the two groups (3 (0.8%) in USG vs. 6 (1.0%) in BLIND, P = 0.809). During hospitalization or readmission, 3 additional non-scheduled exams/procedures were required (3 vascular echos) in the USG group, while 33 were needed in the BLIND group (23 vascular echos, 6 thrombin injections, 2 surgical procedures and 2 CT-Angio) with a significative reduction (P 0.034).

Conclusions

USG venipuncture was associated with a reduction in major complication rates and a decrease in additional exams required during hospitalization or readmission. However, it did not lead to a reduction in minor complications. These findings support the use of ultrasound in AF ablation procedures to avoid access related complications requiring intervention.Baseline CharacteristicsSummary
Intelligent filter to remove artifact during cryo freezing for pulmonary vein isolation increases the time window for observation of time of isolation
Authors: De Pooter J , Firth K , Paamand R , Valvik M
Published: May 2024

Introduction

Time to pulmonary vein isolation (PVI) during cryo balloon (CB) PVI is a critical data point in characterizing the pulmonary vein (PV) isolation status as it improves clinical outcomes. PV potentials on the circular mapping catheter may be obscured by power line artifact during the freeze process as ice forms near the electrode. This study assesses the ability of an intelligent digital filter to sample, predict and remove noise from PV electrograms during the freeze cycle to increase the time window available to observe the abolition of PV potentials.

Method

An intelligent filter that detects and removes power line related signal artifact was developed. The filter algorithm was then retrospectively applied to electrograms collected during delivery of cryo energy in the PVISION trial of the PVI Analyzer study previously described. The PV potential amplitude immediately before the delivery of cryo energy was recorded. During the freeze cycle, artifact amplitude was measured and the time required for the noise to exceed that of the original PV potential recorded. This operation was repeated with the application of the predictive filter. An example of an analysis of a single bipolar trace is shown in Fig 1.

Results

The PVISION trial included 47 patients who underwent a cryo PVI procedure (42% female, mean age 59 years, +/- 11 years). Of those, 24 cases and 68 vein cryo applications had sufficient information about when the cryo freeze cycle started and ended. Of these 68 veins treated, 33 exhibited power line noise on one or more bipolar traces during the freeze cycle (49%). The mean amplitude of PV potentials before application of energy was 0.49 mV (+/- 0.79 mV) and the mean time to artifact exceeding this level was 69 (+/-50 seconds), across all bipolar traces with freeze noise present. After application of the intelligent filter, the mean time to artifact exceeding the baseline PV amplitude increased to 82 seconds (+/- 57 seconds), across all bipolar traces with freeze noise present. In 44 veins noise amplitude never exceeded PV potential amplitude on any of the bipolar traces during the freeze after application of the intelligent filter. Paired analysis of the average time of noise exceeding the PV potential amplitude during the freeze was 116 s before application of the filter and 26 s with the filter applied. See Fig 2. for a summary of the results.

Conclusion

An intelligent digital filter designed to remove artifact from electrograms during cryo ablation procedures might increase the time window before noise saturates PV potentials and, in some cases, remove noise such that it never exceeds that of the PV potential.Fig 1 Example of noise and filteringFig 2. Summary of results
Procedural and outcome impact of body mass index on pulsed field ablation of atrial fibrillation: insights from the EU-PORIA Registry
Authors: Telesca A , Bordignon S , Neven K , Reichlin T , Blaauw Y , Hansen J , Boveda S , Ouss A , Mulder B A , Ruwald M H , Reinsch N , Kueffer T , Albrecht E M , Chun J K R , Schmidt B
Published: May 2024

Introduction

Pulsed field ablation (PFA) is a "single-shot" non thermal ablation modality for atrial fibrillation (AF). In general, obesity is associated with increased risk of AF recurrence after catheter ablation with thermal energy sources.

Purpose

We aimed to assess the impact of body mass index (BMI) on procedural characteristics, safety, acute efficacy and long-term outcomes of PFA for symptomatic AF.

Methods

Of 1233 subjects enrolled in the EU-PORIA registry, in our subanalysis we included 1055 patients undergoing de novo pulmonary vein isolation (PVI)-only ablation procedure for symptomatic AF using the pentaspline PFA catheter from March 2021 until May 2022 at seven high-volume European centers. Patients were divided into two groups based on BMI: normal weight (nW, < 25 kg/m2) and overweight (oW, ≥ 25 kg/m2). Overweight patients were further categorized into three subgroups: pre-obesity (pOb, 25-29.9 kg/m2), obesity (Ob, 30-34.9 kg/m2) and severe obesity (sOb, ≥ 35 kg/m2). Clinical and procedural characteristics, complications and follow up data were collected.

Results

A total of 1055 patients (39% female, mean age 65,7±10,9 years, 65% paroxysmal AF) were enrolled. 32% of patients were normal weight (nW) and 68% overweight (oW). Among oW group, 438 subjects (41%) were assigned to pOb group, 204 (19%) to Ob, and 71 (7%) to sOb. Acute PVI was achieved in 100% of cases. The median skin-to-skin procedure and the median fluoroscopy time were similar between nW and oW and in all investigational subgroups, but radiation exposure increased in line with BMI (p<0.001). Periprocedural complications were 5% in nW, 1.6% in pOb, 3.9% in Ob, and 2.8% in sOb (p=0.06). The Kaplan-Meier estimate of arrhythmia-free survival was 80.2% in nW and 71.9% in oW (p=0.017). Each unit increment in BMI was associated with 4.2% increase in risk of AF/AT recurrence. Severe obese patients presented the highest 1-year AT/AF recurrence rate (37.2%). In the sOb group the rate of recurrence was not influenced by the type of AF (PAF 65.7% vs. pers AF 59.4%; p=0.484).

Conclusion

Overweight patients seem to experience more AF recurrences even after PFA PVI, mainly driven by a higher recurrence rate for BMI ≥ 35 kg/m2. Weight reduction programs remain crucial, nevertheless, reduced procedural times, good safety profile and acceptable 1-year observed AF/AT freedom make PFA a feasible strategy for AF rhythm control in patients with BMI ≥ 25 kg/m2.Freedom from AF/AT recurrence
Role of BMI on radiation dose in patients undergoing pulmonary vein isolation by pulsed field, cryoballoon and high-power-short-duration radiofrequency ablation
Authors: Kupusovic J , Avranas K , Schmidt K , Falagkari A , Luik A , Leistner D , Furnkranz A , Wakili R
Published: May 2024

Background

Different ablation modalities for pulmonary vein isolation (PVI) have been established. Since recent data from a randomized trial showed non-inferiority for pulse field ablation (PFA) vs. cryoballoon (CBA) or radiofrequency ablation (RFA) it seems reasonable to evaluate procedural parameters of these modalities in specific subgroups.

Purpose

The aim of this study was to evaluate radiation dose and procedural parameters in patients with body mass index (BMI) >26 kg/m² vs. ≤26 kg/m² undergoing PVI with different modalities.

Methods

Data of n=409 patients (140 PFA, 125 CBA, 144 RFA) having undergone PVI in three German centers for either paroxysmal or persistent atrial fibrillation were analysed. The primary endpoint was total radiation dose (Dose Area Product, DAP). Patients were analyzed with respect to BMI> vs. ≤26 kg/m² in PFA, CBA and RFA (with high-power short duration applications) groups, respectively. Secondary endpoints were radiation time and procedure time.

Results

The study included predominantly male patients (63.1%) with a mean age of 67.8±10.5 years. Cardiovascular risk factors were comparable within the groups, while the overall CHA2DS2-VASc-score was higher in CBA patients, which was largely influenced by a higher proportion of women in the CBA group. BMI was well balanced between the modalities (PFA: 28.7±5.6 kg/m² vs CBA: 28.5±6.0 kg/m² vs HPSD-RFA: 28.3±4.8 kg/m², p=0.78) as well as the proportion of patients with extreme obesity (BMI >30 kg/m²). The overall DAP was the lowest in the PFA group (370.2±274.6 µGym2) followed by HPSD-RFA (471.4±385.3 µGym2) and the highest in the CBA (1260.9±1053.5 µGym2) group. The radiation time was longest in the CBA group (16.6±17.0min) while being comparatively lower in PFA and HPSD-RFA groups (9.4±6.8 vs. 9.4±5.8 min). Procedure time was the shortest in the PFA group (79.6±30.5min), while being longest in the HPSD-RFA group (111.9±55.3 min). When stratifying patients according to BMI> 26 kg/m², there was a significant increase in DAP in all modalities, with the lowest mean increase in DAP in the PFA group (Δ143.84 µGym2), followed by HPSD-RFA (Δ329.54 µGym2) and the highest increase in the CBA group (Δ691.17 µGym2) (Figure 1). No difference was observed in radiation or procedure time when stratifying patients to BMI. (Figure 2)

Conclusion

Our study analyzing differences of radiation exposure according to elevated BMI among various PVI techniques shows that while there is a significant increase of DAP in patients with BMI >26 kg/m² in all modalities, the lowest increase is registered in the PFA collective. These results suggest that PVI performed with PFA, if available, or HPSD-RFA should be the energy sources of choice in obese patients with respect to radiation exposure.
Left atrial wall thickness measured by a machine learning method predicts AF recurrence after pulmonary vein isolation
Authors: Gomes D , Bello A R , Freitas P , Matos D , Certo Pereira J , Rodrigues G , Carmo J , Moscoso Costa F , Galvao Santos P , Abecasis J , Carmo P , Bello Morgado F , Cavaco D , M. Ferreira A , Adragao P
Published: May 2024

Background

Left atrial (LA) remodeling plays a significant role in the progression of atrial fibrillation (AF). Although LA wall thickness (LAWT) has emerged as an indicator of structural remodeling, its impact on AF outcomes remains unclear. We aimed to determine the association between LAWT and AF recurrence after pulmonary vein isolation (PVI).

Methods

Single-center registry of patients enrolled for radiofrequency PVI from 2016 to 2018. In all cases, a pre-ablation CT scan was performed within less than 48 hours. Mean LAWT was retrospectively determined by a semi-automated machine learning method with minimal human intervention (ADAS 3D®). Additionally, regional tissue thickness was assessed in four locations: roof and inferior, posterior, and anterior walls. In a subgroup of patients, a pre-ablation cardiac magnetic resonance (CMR) was also performed within the same week. LA functional parameters and fibrosis, using 3D delayed gadolinium enhancement, were analyzed. The primary endpoint was AF recurrence after a 3-month blanking period.

Results

A total of 439 patients (mean age 61±12years, 62% male, 78% with paroxysmal AF) were included. The mean LAWT was 1.4±0.2mm (ranging from 0.9 to 1.9mm). Software processing duration was 8.2±0.4 min, and the mean human input time was 1.3±0.1 min. There was no correlation between LAWT and CT-derived LA-indexed volume (Spearman –0.01, p=0.845). During a median follow-up of 5.8 (IQR 4.9–6.6) years, 238 patients (54%) had an AF relapse. LAWT was an independent predictor of recurrence, after adjusting for known confounders including age, non-paroxysmal AF, LA-indexed volume, and chronic kidney disease (adjusted HR 6.49 [95% CI 2.70-15.49], p<0.001). AF recurrence rates were 11%, 15%, and 21%/year across terciles of increasing LAWT (log-rank p<0.001) – Figure. The posterior LAWT revealed the strongest association with the study endpoint (HR 1.93 [95% CI 1.24-3.02], p=0.004).

In the cohort of 62 patients with both CT and CMR, LAWT showed weak correlations with LA ejection fraction and LA coupling index (Spearman <0.25; p=0.054 and p=0.093, respectively), and a moderate correlation with LA fibrosis (Spearman 0.468; p<0.001).

Conclusions

Mean LAWT, easily assessed by commercially available machine learning software, is an independent predictor of AF recurrence after PVI in the long-term follow-up. This association is mainly driven by the posterior LAWT. Whether patients with increased LAWT should receive tailored therapy deserves further investigation.Figure
Pressure-guided evaluation of pulmonary vein occlusion during cryoballoon pulmonary vein isolation for atrial fibrillation compared to contrast-guided approach
Authors: Alothman O , Borisov G , Keelani A , Issa K , Fink A , Frommhold M , Raffa S , Geller C
Published: May 2024

Introduction

Single-shot ablation devices (e.g. cryoballoon [CB] technique) have simplified pulmonary vein isolation (PVI) for interventional treatment of atrial fibrillation (AF). Vein occlusion is mainly assessed utilizing contrast media (CM) during CB ablation. However, this approach entails possible risks, including renal impairment and adverse contrast-related allergic reactions. Furthermore, the assessment of pulmonary venography is often challenging and necessitates fluoroscopy exposure.

Purpose

The primary objective of this study is to compare procedural data and outcome of pressure-guided (PG) vs. conventional (CM) assessment of vein occlusion.

Methods and results

From 07/2018 to 12/2022, 915 patients with AF (59% paroxysmal) undergoing CB-PVI at our hospital were prospectively enrolled (single-center experience). 369 (40,3%) patients (age 64,5 ± 10 years; 154 females 41,7%) underwent PVI with the use of CM (CM group), while in 546 (59,7%) cases (age 65,3 ± 10 years; 222 females 40,6%) pressure curve assessment (PG group) was exclusively used to guide the procedure (and no contrast was given).

Compared with the CM approach, pressure-guided procedures had lower X-ray time (9,5±5min vs 6,4±3,5min, P<0,0001) and X-ray dose (586±546cGy/cm2 vs 96,7±93 cGy/cm2, P<0,0001). Procedure time (PG: 90,3±20,1min, CM: 92,7±22,7 min, p:0,1 ) and ablation time (PG: 1352 ± 365 min, CM: 1393 ± 651 min, p: 0,2) were not different between groups. There was no significant difference observed in the BMI between the two groups, with a mean value of ca. 28.2 ± 4 kg/m2.

In 79 redo-procedures, persistent isolation of all pulmonary veins was observed in 11/45 (25%) patients in the CM group and 21/34 (61%) patients in the PG group (p: 0.001).

Conclusion

Compared to current (CM) assessment of vein occlusion, pressure monitoring is associated with less X-ray exposure during the index procedure and more frequent durable isolation of all PVs during repeat study for recurrence.
One shot "fire & ice"
Authors: Manfrin M , Bertagnolli L , Torri F , Unterhuber M
Published: May 2024

Introduction

Pulmonary vein isolation (PVI) is the best and first strategies during ablation of atrial fibrillation (1-4). Short- and long-term effectivity as well as procedure time are important parameters during PVI-ablation. New efforts are made to find longer effectivity, low risk of the procedure and shorter procedure.

Purpose

The aim of our study is to compare the two "balloon - one shot" methods (radiofrequency balloon "RFB" and cryoballoon "CB") in terms of speed, efficacy and safety.

Methods

Prospective, randomized, pilot single-center trial including 74 consecutive patients with paroxysmal, persistent or long lasting persistent atrial fibrillation who undergo for the first time PVI-ablation between December 2022 and October 2023. Patient were randomized 1:1 according type of AF, Sex, Hypertension, left ventricular ejection fraction e left atrial volume in a multi-electrode radiofrequency balloon catheter Heliostar ablation or in cryoballoon system ablation. Both groups had comparable clinical characteristics.

Results

Median Age of the population was 64 year (iq range 57-70), 19 were female (25,7%), 31 patients (42%) had paroxysmal atrial fibrillation, median EF was 60% (iq range 55-65) and median left atrial volume 36 ml/mq (iq 28-40). 37 patients undergo cryoballoon PVI and 37 patients undergo RF balloon Ablation.

Compared with the RFB group, the CB group showed a shorter procedure time [65 minutes (55-75) vs. 75 minutes (65-90) (P < 0.008)]. The DAP (dose area product) was lower in RFB Group [7 Gy*cm2 ( 5-10) vs CB Group 11 ( 7-18), p<0,001]. First-pass isolation was comparable.

We had 5 complications in RFB group (1 pericardial effusion without pericardiocentesis, 3 transitory ST-elevation on ECG due to air embolism, 1 transient phrenic nerve palsy) and 3 complications in CB group (3 transient phrenic nerve palsy) P=ns. During the procedures in 3 cases of RF group and in 1 case of CB group (p=ns) we had to change the balloon due to technical issues.

Conclusion

The RFB appears to have a safety and efficacy profile similar to that of the CB for PVI. CB has shorter procedural times but with a higher X-Ray exposure.Figure 1Figure 2
Difference between cryoballoon and radiofrequency ablations for atrial fibrillation based on electroanatomical mechanisms
Authors: Kim M H , Kwon O S , Kim D , Kim K , Yu H T , Kim T H , Uhm J S , Joung B , Lee M H , Pak H N
Published: May 2024

Backgrounds

Cryoballoon pulmonary vein isolation (PVI; Cryo-PVI) has comparable results to conventional radiofrequency PVI (RF-PVI) in patients with atrial fibrillation (AF). However, Cryo-PVI using a 28-mm cryoballoon has limitations for wide circumferential PVI or extra-pulmonary vein (PV) trigger (ExPVT) ablations. We compared long-term outcomes of Cryo-PVI and RF-PVI in patients without ExPVT and explored the potential electroanatomical mechanisms.

Methods

We identified 2,160 patients who underwent de novo AF ablation. After propensity score matching for age, sex, AF type, and left atrial (LA) diameter for patients without ExPVT (female 24.6%, mean 61.8years old, paroxysmal AF 53.2%), we compared rhythm outcomes between 403 Cryo-PVI and 403 RF-PVI procedures, considering AF type and LA size. We determined the LA diameter cutoff which best differentiated rhythm outcomes between RF-PVI and Cryo-PVI using a maximum likelihood approach based on the Cox proportional hazard model and investigated the relationship between PVI level and LA mass reduction through computational modeling.

Results

During the 24 months of median follow-up, Cryo-PVI showed poorer rhythm outcomes to RF-PVI (Log-rank p=0.009) in overall patients. However, Cryo-PVI showed comparable overall rhythm outcomes to RF-PVI (Log-rank p=0.370) in patients with paroxysmal AF. Cryo-PVI showed higher AF recurrence in patients with larger LA size (LA diameter≥40mm; hazard ratio [HR] 1.55 [1.04-2.30]; log-rank p=0.030) or with persistent AF (log-rank p=0.001). In the computational modeling, PV antrum was likely to be covered by Cryo-PVI in patients with small LA, but not in those with large LA.

Conclusions

Cryo-PVI showed inferior rhythm outcomes than RF-PVI in patients with higher LA diameter or with persistent AF.
Atrial fibrillation cryoablation guided by pulmonary vein pressure: comparison with the standard strategy
Authors: Madero S , Herreros Guilarte B , Diez De Las Heras D , Munoz San Jose J C
Published: May 2024

Background

Pulmonary vein (PV) isolation is the cornerstone for the treatment of patients with atrial fibrillation (AF). Balloon cryoablation (BCA) is the preferred single-shot option for ablation of PVs using contrast guided occlusion as the standard approach (SA). We have made a simplified procedure, using a pressure-guided approach (PG) aimed to obtain a PV wedge curve. This technique has been described previously(1-3). To our knowledge, no comparison has been made in real life with a mixed patient setting in AF (paroxysmal and persistent) and non-selected anatomy with exclusive PG.

Purpose

To compare a prospective cohort of patients going into AF BCA, using SA versus PG.

Methods

Between January 2022 and October 2023, 50 consecutive patients underwent BCA. The first 25 patients were treated with SA protocol and the latter 25 with PG. In both techniques, the aim was to obtain PV isolation with a 240 seconds application and no bonus attempt. A computed tomography angiography or MRI of the left atrium (LA) was performed in all the patients. 28-mm Cryoballoon and Intracardiac echo were used in all the procedures. We compared patients and procedure characteristics between both techniques.

Results

Both groups (SA vs PG) showed similar baseline characteristics with not significant differences between them: mean age (58±10 vs 61±10 years), median LA diameter (40±8 vs 41±5mm), mean LVEF (60±9 VS 63±7%), Paroxysmal AF (60 vs 56%), average CHA2DS2-VASc score (1.3±1.3 vs 1.8±1.5), One patient is SA group had a previous radiofrequency (RF) ablation with 4/4 veins reconnected, and in the PG group two patients had RF ablation with 7/8 veins reconnected (Table 1). The procedural characteristics between SA and PG, also did not show significant differences: median procedural time (120±20 vs 130±38 min), fluoroscopic time (24±13 vs 30±19 min), and isolation was achieved in 98/99 veins (99%) in each group (Table 2). In the SA group, two patients had complications: one patient with a transient palsy of the phrenic nerve and because of this, only 3/4 veins were targeted, and the second patient had a post-procedure pericarditis. In the PG group, one patient had a pericardial effusion seen at the end of the procedure that did not require drainage.

Conclusion

In our initial experience, BCA for AF with both strategies proved to be safe and effective in this mixed group with non-selected anatomy. This result reassures the PG as a way to enhance CBA because of the advantage in avoiding the use of intraprocedural IV contrast. Impact in performance during follow-up is yet to be seen in our cohort.Table 2.Baseline characteristicsTable 2.Procedural characteristics