bluuebunny/crossref_metadata_2025 huggingface dataset:
CHA2DS2-VASc score and the risk of death in atrial fibrillation
Authors: Aro A , Haukka J , Halminen O , Putaala J , Linna M , Mustonen P , Hartikainen J , Airaksinen J , Lehto M
Published: May 2022

Funding Acknowledgements

Type of funding sources: Foundation. Main funding source(s): Sigrid Juselius Foundation

Background

Atrial fibrillation (AF) is recognized as a major public health problem due to increased mortality, morbidity and risk of stroke. Advanced age and burden of other comorbidities are potential contributors to AF development and adverse outcomes. Clinical risk factor based CHA2DS2-VASc score is widely used to assess thromboembolic risk in AF, but mortality risk associated with different CHA2DS2-VASc scores is not established.

Purpose

Using data from a nationwide AF registry study including comorbidities and outcomes of unselected AF patients, we wanted to study whether CHA2DS2-VASc score could be useful in estimating prognosis in newly diagnosed AF patients.

Methods

New-onset AF patients in Finland 2007-2017 were identified from comprehensive national registries. Comorbidities were gathered from individualized registry data on drug reimbursements and from ICD-10 diagnoses during hospitalizations and outpatient visits in primary and specialist care. These were used to create CHA2DS2-VASc risk score for each AF patient at cohort entry, including data on heart failure, hypertension, age, diabetes, stroke, vascular disease and sex. Patients were followed until the end of 2018 from the causes of death registry, which records every death in the country. All-cause mortality in each CHA2DS2-VASc category per 1000 person-years was determined, and relative risk (RR) of death according to the CHA2DS2-VASc category was calculated.

Results

A total of 229 357 patients with new-onset AF (mean age 73.2 ± 13.2 years, 50.0% female) were identified. Distribution of CHA2DS2-VASc score among these individuals is shown in Table. Mortality increased significantly with rising CHA2DS2-VASc risk score points, as demonstrated in Table. Compared to CHA2DS2-VASc 0, those with 2 points had a RR 2.9 (95%CI 2.7-3.1), 3 points RR 5.0 (4.7-5.3), 4 points RR 8.0 (7.5-8.4), 5 points RR 11.0 (10.4-11.7) and >5 points RR 14.8 (14.0-15.7) for all-cause mortality.

Conclusions

In new-onset AF, mortality increased drastically with increasing age and comorbidities as depicted in the CHA2DS2-VASc score. Besides assessing thromboembolic risk, CHA2DS2-VASc score seems to be useful in estimating survival of AF patients.
Impaired heart rate variability triangular index predicts stroke and systemic embolism in patients with atrial fibrillation
Authors: Haemmerle P , Hennings E , Eken C , Aeschbacher S , Coslovsky M , Schlageter V , Osswald S , Kuehne M , Zuern CS
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Introduction

Despite the broad use of oral anticoagulants, stroke remains one of the most serious complications in atrial fibrillation (AF) patients. Stroke has been linked to disturbances of the autonomic nervous system as both share similar risk factors. Therefore, impaired cardiac autonomic function may indicate an enhanced stroke risk.

Purpose

We hypothesized that impaired cardiac autonomic function, quantified by means of heart rate variability (HRV), might be useful in predicting stroke in patients with AF.

Methods

We enrolled 1,933 patients with a documented history of AF from the multicenter Swiss-AF cohort study who were either in sinus rhythm (SR-group, n=1130) or AF (AF-group, n=803) on a 5-minute resting ECG recording. HRV triangular index (HRVI), standard deviation of normal-to-normal intervals, root mean square root of successive differences of normal-to-normal intervals, mean heart rate, 5-min total power and power in the high frequency, low frequency and very low frequency range were calculated. We constructed cox regression models to analyze the predictive power of HRV parameters for the composite endpoint stroke or systemic embolism.

Results

Mean age was 71±8 years in the SR group and 75±8 in the AF group, 28% of the total study cohort were female. 36 patients in the SR group (3.2%) and 58 patients in the AF group (6.5%) experienced a stroke or systemic embolism during a follow-up time of 4.0±1.3 years. In patients with sinus rhythm, HRVI <15 was the only HRV parameter independently associated with stroke or systemic embolism (hazard ratio 2.94; 95% confidence interval 1.3-6.8; p=0.011) after adjustment for multiple clinical confounders (age, sex, AF type, history of hypertension, history of diabetes, history of chronic kidney disease, prior stroke or transient ischemic attack, intake of oral anticoagulation, antiarrhythmics or betablockers). In the AF group, no HRV parameter was associated with the composite endpoint.

Conclusions

HRVI measured during SR on a single 5-minute ECG recording is an independent predictor of stroke or systemic embolism in AF patients. HRV analysis may help to improve risk stratification in AF patients.
BMP10 level helps to stratify risk of atrial fibrillation recurrence within one year after catheter ablation
Authors: Zink MD , Hermans B , Gramlich M , Philippens SAM , Vernooy K , Van Hunnik A , Linz DK , Zeemering S , Schotten U
Published: May 2022

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): DGK Electrophysiology grant

Background

Freedom of atrial fibrillation (AF) is the main purpose of catheter ablation. However, AF recurrence is commonly seen after catheter ablation. Cardiovascular biomarkers may help to identify patients at risk for AF recurrence.

Purpose

We investigated the association of preprocedural known and novel cardiovascular biomarker level with AF recurrence within one year after catheter ablation.

Methods

In 187 patients of the AFAB registry (University Maastricht, the Netherlands) clinical recurrence of AF after catheter ablation was investigated using Holter ECGs at 3- and 12-months follow-up. Blood samples taken before AF catheter ablation were analyzed for prediction of AF recurrence by known or novel cardiovascular biomarkers (FGF23, BMP10, Ang2, IGFBP7, CA125, NT-proBNP, TNT_hs, sFlt_1, ESM1_7F89A5, DKK3). Recurrence of AF was defined as any symptomatic, or ECG documented episode of AF within one year after catheter ablation. A logistic regression model adjusted for typical risk factors of AF recurrence (Sex, age, type of AF (paroxysmal or persistent), ongoing rhythm, LA diameter, heart failure, body mass index and hypertension) was calculated and receiver-operating analysis was performed for prediction of AF recurrence.

Results

AF recurrence was found in 86 patients within one year after catheter ablation. Elevated biomarker level in patients with AF recurrence were found for BMP10, Ang2, and NT-proBNP in univariate analysis (table 1). In the logistic regression BMP10 (Odds ratio 2.94, 95%CI 1.089-7.939, P=0.033) indicated a high probability of AF recurrence within one year. A model including factors of AF recurrence showed a predictability for AF recurrence of an area under the curve (AUC) of 0.68 (sensitivity 60%, specificity 64%). By adding each of the univariate significant biomarker the predictability of the model increases further Ang2 (AUC 0.69, sensitivity 69%, specificity 60%), NT-proBNP (AUC 0.69, sensitivity 65%, specificity 60%), and BMP10 (AUC 0.71, sensitivity 60%, specificity 73%).

Conclusions

Based on our data, Ang2, BMP10, NT-proBNP showed elevated values for patients with recurrence of AF within one year before catheter ablation. BMP10, which is likely associated with trabeculation of the heart, outperformed the other investigated known and novel biomarker indicating a higher probability of AF recurrence within one year after ablation.
A new prediction model for left ventricular systolic function recovery after catheter ablation of atrial fibrillation in patients with heart failure and reduced ejection fraction, The ANTWOORD Study
Authors: Bergonti M , Spera F , Tijskens M , Bonomi A , Saenen J , Huybrechts W , Miljoen H , Wittock A , Casella M , Tondo C , Heidbuchel H , Sarkozy A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with heart failure with reduced ejection fraction (HFrEF) and atrial fibrillation (AF), pulmonary vein isolation (PVI) improves left ventricular ejection fraction (LVEF), along with prognosis, in a variable percentage of patients.

Aim

To investigate the predictors of LVEF recovery after PVI and to develop a prediction model for individualized assessment.

Methods

We conducted an observational, retrospective, single-center study on 111 consecutive patients with AF and HFrEF undergoing PVI. Patients were divided into Responder vs. Non-Responder according to the "Universal definition of HF". Clinical predictors were evaluated by multivariate logistic regression analysis and cross-validation technique. Independent predictors were used to build an internally validated prediction model.

Results Responders (54%) had significantly shorter QRS duration and less dilated left atria. Persistent AF and absence of a known etiology more frequent among Responders. AF recurrence was non-significantly different between the two groups (p=0.2), although clinical AF burden was lower in Responders, after PVI (p<0.001). Absence of known etiology, presence of persistent AF, left atrial volume index<50ml/m2, and QRS<120msec were independent predictors of LVEF recovery and composed the "Antwerp Score". Patients with Antwerp Score ≤1 had 90% likelihood of LVEF recovery, compared to 5% in patients with 3-6.

Conclusions Patients with wide QRS complex, known HF etiology, dilated left atria, and paroxysmal AF were less likely to recover LVEF after PVI. A new score system based on the above-mentioned parameters adequately predict LV function recovery after PVI. These results warrant confirmation and prospective validation.
Radiofrequency ablation impact on the morpho-functional state of the heart in patients with atrial fibrillation and chronic heart failure
Authors: Zolotarova T , Brynza M , Bilchenko O , Lopin D , Volkov D
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Heart failure with preserved left ventricular ejection fraction (HFpLVEF) has become the dominant form of heart failure worldwide, along with an aging population and an increasing prevalence of obesity, diabetes and hypertension. Drug rhythm control has limited efficacy in HFpLVEF and a fairly high risk of side effects.

The aim of the study was to evaluate the radiofrequency ablation impact on the morpho-functional state of the heart in patients with atrial fibrillation and HFpLVEF based on 2-year follow-up.

Materials and methods

The study included 194 patients with an average age of 59.3±8.5 years with atrial fibrillation and concomitant HFpLVEF of I-III functional class of New York Heart Association. Patients were divided into 2 groups: 136 patients who underwent radiofrequency catheter ablation and 58 patients in the control group who did not undergo intervention and continued antiarrhythmic pharmacotherapy. Patients were comparable in terms of basic clinical and demographic indicators. In order to assess the morpho-functional state of the heart, transthoracic echocardiography was performed at the stage of inclusion in the study and 2 years after.

Results and discussion. According to the results of the analysis in the radiofrequency catheter ablation group 2 years after the intervention revealed: a statistically significant decrease in the mean end-systolic diameter of the left ventricle (3.3±0.48 cm versus 3.2±0.41cm, p<0.001); decreased size of the left atrium (4.3±0.71 cm versus 4.2±0.30 cm, p<0.001); LVEF increased significantly (61.9±7.14% versus 63.9±5.65%, p<0.001); the E/e’ ratio decreased statistically significantly (11.9±1.65 versus 9.4±1.48; p<0.001) and the left ventricular myocardial mass index (118.3±25.04 g/m2 versus 116.4±18.04 g/m2; p=0.045). In the pharmacotherapy group there were: a statistically significant increase in the average end-systolic size of the left ventricle (3.61±0.45 cm versus 3.63±0.41, p=0.007); statistically significant increased left atrium (4.3±0.61 cm versus 4.4±0.36; p <0.001) and the right atrium (4.1±0.52 cm versus 4.2±0.26; p<0.001); decreased left ventricular ejection fraction (58.1±6.12% versus 56.6±6.11; p<0.001); increased values of the ratio E/e’ (12.1±1.63 versus 12.7±1.27; p=0.002) and decreased level of the left ventricular myocardial mass index (120.5±24.05 g/m2 versus 118.3±20.13 g/m2; p=0.044).

Conclusion

Radiofrequency ablation of atrial fibrillation in patients with HFpLVEF to control sinus rhythm is associated with improved morpho-functional state of the heart at the 2-year follow-up compared with antiarrhythmic pharmacotherapy strategy: the left ventricular ejection fraction increases, the left ventricular diastolic function improves according to the E/e’ value, the size of the left atrium decreases.
Non-invasive continuous arterial pressure monitoring during transcatheter atrial fibrillation ablation: a feasibility prospective study
Authors: Di Cori A , Fiorentini F , Parollo M , Della Volpe S , Mazzocchetti L , Barletta V , Segreti L , Viani S , De Lucia R , Sarti M , Bozzoli D , Giannotti M , Soldati E , Zucchelli G , Bongiorni MG
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Introduction

Transcatheter atrial fibrillation (AF) ablation is still carried out with continuous invasive radial arterial blood pressure (BP) monitoring in many centers. Continuous noninvasive blood pressure (CNBP) measurement using the volume-clamp method is a non invasive alternative method used in ICU. No data on CNBP reliability are available in the electrophysiology lab during AF ablation, where rhythm variations are common.

Purpose

The objective of the present study was to compare continuous noninvasive arterial pressure measured with the ClearSight device with invasive radial artery pressure, used as the reference method during AF ablation.

Methods

We prospectively enrolled 55 consecutive patients (age 62±11 years, 79% male) undergoing transcatheter AF ablation (62% paroxysmal, 38% persistent) at our center. Standard of care invasive BP monitoring via a radial cannula and a contro-lateral non-invasive finger volume-clamp continuous BP measurement device were positioned simultaneously in all patients for the entire procedure. Bland-Altman analysis was used to analyze agreement between the two techniques.

Results

A total of 1219 paired measurements for systolic, diastolic, and mean arterial pressure were obtained in 55 subjects, with a mean (SD) of 22 (9) measurements per patient. Mean bias (SD) was -12,97 (13,89) mmHg for systolic pressure (level of agreement -14,24–40,20; correlation coefficient 0,84), -1,85 (8,52) mmHg for diastolic pressure (level of agreement -18,54–14,84; correlation coefficient 0,77) and 2,31 (8,75) mmHg for mean pressure (level of agreement -14,84–19,46; correlation coefficient 0,85).

Conclusion

In patients undergoing AF ablation, non-invasive finger volume-clamp continuous BP monitoring with the ClearSight device showed acceptable agreement with standard of care invasive BP monitoring. Larger studies are needed to confirm potential clinical implications of a continuous non-invasive BP monitoring during AF ablation.
Global preferences in mapping technology and its impact on fluoroscopy and procedure times during catheter ablation of atrial fibrillation
Authors: Shah S , Shim J , Martel J , Addo K , Delurgio D , Demo H , Hamdan F , Bonavita G , Li J , Bailey C , Kim Y
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Choice in mapping technology may play a critical role in reducing fluoroscopy and procedure times during atrial fibrillation (AF) ablation, however this relationship is not well studied.

Purpose

To assess the impact of mapping technology on trends in fluoroscopy use and procedure times in AF ablation procedures.

Methods

Acute procedure data from 525 AF cases was prospectively collected from 68 centers in nine countries. Choice of technology and ablation strategy, including PVI and substrate modification, were left to physician discretion. Procedure data such as total procedure and fluoroscopy times from cases using a grid-style mapping catheter (HD Grid) were compared to those using a circular mapping catheter (CMC).

Results

Of the 525 cases, HD Grid was used in 230 (44%), and CMC was used in 295 (56%). HD Grid was routinely used for both de novo and redo procedures while CMC was used predominantly for de novo procedures (Table 1). Similar procedure times were noted in redo PAF and redo PersAF procedures, while significantly shorter procedure times were observed for the HD Grid group in both de novo PAF and PersAF (113.9±48.8 vs. 125.9±56.3 minutes, p=0.04; and 142.8±53.2 vs. 169.8±52.2 minutes, p=0.001).

Overall fluoroscopy times were significantly shorter using HD Grid compared to a CMC (9.0±19.6 minutes vs. 19.8±16.4 minutes, p<0.001), including significantly shorter fluoroscopy times in de novo PAF, de novo PersAF, and redo PAF (Table 1). There were 155 cases completed without fluoroscopy use; zero fluoroscopy cases accounted for 50% (114/230) and 14% (41/295) of total cases completed with HD Grid and a CMC, respectively (p<0.001).

Conclusion(s)

Use of HD Grid was observed in a significantly higher portion of zero fluoroscopy cases and resulted in significantly shorter procedure and fluoroscopy times in both de novo PAF and de novo PersAF and significantly shorter fluoroscopy times in redo PAF. These observations suggest that use of HD Grid may better enable faster and safer procedures in these specific AF types compared to CMCs, although further analysis in a larger, randomized cohort may be warranted.
Visualization of pulmonary vein reconnections using dynamic mapping in redo procedures for patients with atrial fibrillation
Authors: Parreira L , Rossillo A , Del Greco M , Mantovan R , Fantinel M , Bottoni N , Bianco E , Bacchiega E , Tao C , Rossi P
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background/Introduction

Pulmonary vein (PV) reconnection is commonly associated with recurrence of atrial fibrillation (AF) after the initial catheter ablation procedure. Visualization and identification of PV reconnections are critical during repeat procedures.

Purpose

To examine the use of dynamic mapping (LiveView) in combination with a high-density mapping catheter (HD Grid) in the recognition of PV reconnections in redo AF ablation procedures.

Methods

Acute procedure data from 81 patients were prospectively collected. Mapping catheter selection and the use of LiveView was determined at the physician’s discretion. For cases where LiveView was used, the location and number of gaps from the previous procedure were identified using both standard mapping and dynamic mapping separately.

Results

Most of the patients included in the analysis were treated for paroxysmal AF (PAF: n=63/81, 77.8%). Dynamic mapping data was incorporated in 50 PAF cases and 15 persistent AF cases. Within these 65 cases, standard mapping identified a total of 120 PV gaps whereas LiveView identified a total of 138 PV gaps; gaps were most frequently identified on the right PVs, especially in the anterior region (Table1). A contact force-sensing ablation catheter was commonly (n=64/81, 79%) used by the operators. The right anterior region was ablated with an average contact force of 13.8±3.1g and Lesion index (LSI) of 5.2±0.7 at a power of 35.8±8.4W. Non-PV ablation was performed in 38 (46.9%) patients; the most common lesion sets were roofline, cavotricuspid isthmus (CTI) line, and mitral isthmus line. Acute PV isolation was achieved in all patients at the end of the procedure.

Conclusion

Data from this analysis suggest the incorporation of dynamic mapping data may help reveal more PV reconnections compared to standard mapping. Additional study is needed to assess the long-term clinical outcomes when regional dynamic mapping data is used to identify PV reconnections in repeat procedures.
Six-month follow-up of first real-world experience with pulmonary vein isolation using pulsed field ablation for paroxysmal atrial fibrillation
Authors: Neven K , Fueting A , Hoewel D , Brokkaar L , Rahe G , Reinsch N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Catheter ablation for AF using thermal energy can cause collateral damage. Pulsed field ablation (PFA) is a novel nonthermal energy source. Only a few small clinical studies have been published.

Objective

We report on the first “real-world” experience with 6-month follow-up with PVI with PFA for paroxysmal AF.

Methods

Pre and post ablation, phrenic nerve function was assessed. A high-density LA bipolar voltage map was created. All PVs were individually isolated using a steerable sheath and a pentaspline over-the-wire PFA catheter. After ablation, mapping was repeated to assess lesion formation. Patients had a scheduled follow-up visit at days 30, 90 and 180 after ablation.

Results

In 30 patients (age 63 years, 47% male), uncomplicated PFA was performed, with all PVs acutely isolated. Skin-to-skin procedure time was 120±21 min. Total LA dwell time was 109±22 min. LA dwell time of the PFA catheter was 31±12 min. Fluoroscopy time was 23±7 min. Dose-area product was 4,96±3,54 Gy.cm2. Number of applications per patient until complete PVI was 32±1. In 1 patient with roof dependent flutter, a roof line was intentionally created with 8 additional applications. In 2 patients, unintentional bidirectional mitral isthmus block was created. In 10 patients, temporary pacing due to vagal bradycardia after LSPV ablation was needed. There was no phrenic nerve palsy. In 1 patient who had repeated, di!cult CS-catheter placement, 6 hours after the procedure a cardiac tamponade with uncomplicated pericardial drainage of 250 ml blood occurred. Further in-hospital stay was uneventful, on day 2 all patients were discharged in SR. On day 30, all patients were free of complaints and there were no groin complaints. 29 Patients were in SR, 1 patient had a cardioversion because of asymptomatic AT with 4:1 conduction. On day 90, 27 (90%) patients were in SR, 3 patients had AF/AT recurrence. During redo LA procedure, 2 patients with isolated PVs had inducable LA macro-reentrant tachycardia (1 roof and 1 mitral isthmus dependent) and 1 patient had LIPV reconduction. All 3 patients had uncomplicated RF ablation. On day 180, all 30 patients were o" anti-arrhythmic drugs and in SR.

Conclusion

PVI using PFA for paroxysmal AF in a “real-world” setting is safe and feasible. Post-ablation clinical course and 6-month follow-up are favorable.
Pulsed field ablation for paroxysmal atrial fibrillation is safe for the bronchial system
Authors: Neven K , Fueting A , Hoewel D , Brokkaar L , Essling A , Reinsch N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Thermal LA ablation, like cryo can cause bronchial damage, like hemorrhagic lesions, atrio-bronchial fistula and severe bleedings. Pulsed field ablation (PFA) is a novel, non-thermal ablation modality.

Objective

We report on possible bronchial injury after PVI using PFA for paroxysmal AF.

Methods

A LA bipolar voltage 3D map was created. All PVs were individually isolated using a 13F steerable sheath and a pentaspline over-the-wire PFA catheter. After ablation, mapping was repeated to assess lesion formation. One day after PVI, bronchoscopy without biopsies was performed. Serial hemoglobin levels were measured during 30-day follow-up.

Results

In 30 patients (mean 63 years; 47% male), uncomplicated PFA was performed, with all PVs acutely isolated. Post ablation, all voltage maps consistently showed extensive antral PV lesions. ACT was >325 seconds in all patients. Clinical course was uneventful, no patient had chest discomfort, coughing or hemoptysis. All patients underwent uncomplicated bronchoscopy, without thermal lesions or ulcers. In 12 patients (40%), small amounts of blood clots without active bleeding were seen in multiple segments. All hemoglobin levels remained stable. At 30-day follow-up, all patients were asymptomatic.

Conclusion

PVI using PFA for paroxysmal AF is safe for the bronchial system. PFA using a straight tip, extra-sti! wire can lead to asymptomatic blood oozing in the bronchial system without clinical relevance at 30-day follow-up.

Figures: Postero-anterior LA view before (above) and after (below) ablation with the trachea and main bronchi (dark grey) projected over the roof and posterior wall. The right bipolar voltage 3D map shows extensive, non-magenta antral ablation lesions.
Pulsed field ablation for paroxysmal atrial fibrillation is safe for the esophagus
Authors: Neven K , Fueting A , Hoewel D , Rahe G , Bell J , Reinsch N
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Thermal LA ablation, like RF, cryo and laser can cause esophageal damage, like ulcera and atrio-esophageal fistula. Pulsed field ablation (PFA) is a novel, non-thermal ablation modality. Pre-clinical evaluation of PFA showed absence of thermal injury to the esophagus due to the tissue specificity of PFA. Only limited data from very small clinical studies on absence of esophageal injury after PFA is available.

Objective

We report on possible esophageal injury after PVI using PFA for paroxysmal AF in a real-world, non-clinical study setting.

Methods

A LA bipolar voltage 3D map was created. All PVs were individually isolated using a 13F steerable sheath and a pentaspline over-the-wire PFA catheter. After ablation, mapping was repeated to assess lesion formation. No proton-pump inhibitors were started. One day after PVI, esophagoscopy without biopsies was performed. All patients had a 30-day follow-up.

Results

In 30 patients (mean 63 years; 47% male), uncomplicated PFA was performed, with all PVs acutely isolated. Post ablation, all voltage maps consistently showed extensive antral PV lesions. Clinical course was uneventful, no patient had chest discomfort, coughing or hematemesis. All patients underwent uncomplicated esophagoscopy, without thermal lesions or ulcers. At 30-day follow-up, all patients were asymptomatic.

Conclusion

In a real-world, non-clinical study setting, PVI using PFA for paroxysmal AF is safe for the esophagus.

Figures: Postero-anterior LA view before (above) and after (below) ablation with the esophaus (dark grey) projected over the posterior wall. The right bipolar voltage 3D map shows extensive, non-magenta antral ablation lesions.
The novel POLARx ablation system improves cryothermal single-shot guided pulmonary vein isolation: impact of individual pulmonary vein anatomy
Authors: Guckel D , Lucas P , Isgandarova K , El Hamriti M , Bergau L , Fink T , Sciacca V , Braun M , Khalaph M , Imnadze G , Noelker G , Sommer P , Sohns C
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon (CB)-guided pulmonary vein isolation (PVI) is an established treatment for atrial fibrillation (AF). Recently, a novel balloon-guided cryothermal single shot device (POLARx) was introduced.

Purpose

This observational study aimed to evaluate ablation efficacy and outcome using the novel POLARx CB system compared to the established one and to access the impact of individual PV characteristics on freedom from arrhythmia recurrence in paroxysmal (PAF) and persistent (PERS) AF.

Methods

666 patients undergoing CB-guided ablation for AF were included. 601 patients treated with the AFA ablation system (Arctic Front Advance Pro, AFA) were compared to 65 consecutive patients who underwent PVI using the POLARx. Individual anatomical characteristics of the left atrium and PVs were assessed using pre-procedural cardiac magnetic resonance imaging (MRI). For each PV, the cross-sectional orifice area (CSOA) was determined. Follow-up examinations were scheduled after 3 and 6 months.

Results

Acute PVI was achieved in all patients (100%). 6-months AF-free survival was significantly higher in the POLARx cohort (POLARx: n=45, 69%; AFA: n=359, 60%; Log-rank p=0.037*). This applies to PAF (n=42, 65%, p=0.033*), PERS (n=23, 35%, p<0.001*) and normal PV anatomy (2 left- and two right-sided PVs; n=57, 88%, p< 0.001*). MRI found a comparable percentage of patients with normal PV anatomy (POLARx: n=57, 88%; AFA: n=512, 85%, p=0.126). A higher amount of variant PV anatomy was revealed in patients with PERS AF (p=0.043*), but this factor was not predictive for AF-recurrence (PAF: p=0.610; PERS: p=0.096). PAF patients with AF-recurrence presented with significantly larger CSOA of the left sided PVs and the right superior PVs (LSPV: 224.8 ± 98.1 mm2 vs. 220.6 ± 64.8 mm2, p<0.001*; LIPV: 145.9 ± 63.2 mm2 vs. 140.4 ± 52.8 mm2, p<0.001*; RSPV 268.9 ± 79.3 mm2 vs. 262.3 ± 75.6 mm2, p<0.001*). In patients with PERS AF no association between CSOA and ablation outcome was observed. Multivariate Cox regression analyses identified the AFA ablation system (p=0.022*, hazard ratio (HR) 1.776, confidence interval (CI) 0.240-9.281) and PERS AF (p<0.001*, HR 6.608, CI 0.220-73.839) as independent predictors for AF-recurrence.

Conclusion

PVI using the POLARx system improves freedom from AF recurrence independent of individual anatomical considerations and PV occlusion rates. For PAF patients, a significant association between CSOA and the outcome after CB- guided PVI was demonstrated.
Impact of very wide antral pulmonary vein isolation on esophageal temperature changes during pulsed field ablation
Authors: Kirstein B , Heeger C , Vogler J , Eitel C , Phan L , Keelani A , Feher M , Traub A , Samara O , Kuck K , Tilz R
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Esophageal thermal injury (ETI) is a serious drawback of available energy sources for atrial fibrillation (AF) ablation, especially on the posterior left atrial (LA) wall. Pulsed field ablation (PFA) is a novel non-thermal energy source with promising safety advantages over existing methods due to its unique myocardial tissue specificity sparing the esophagus.

Objective

To evaluate esophageal temperature changes during very wide antral pulmonary vein isolation (PVI) using the PFA system.

Methods

Thirteen consecutive AF patients (62% with paroxysmal AF; age: 61 years; 70% male) underwent first-time PFA under deep sedation. Eight pulse trains (2kV/2.5 sec, bipolar, biphasic, 4x basket/flower configuration each) were delivered to each pulmonary vein (PV). Extra pulse trains in the flower configuration were added for very wide antral circumferential ablation (vWACA). Continuous intraluminal esophageal temperature (TESO) was monitored with an S-shaped esophageal temperature probe.

Results

A median of 32 (IQR 32;32) and 8 (IQR 8;9) pulse trains for PVI and vWACA with a procedural time and catheter dwell time of 67 min (IQR 61-69) and 17 min (IQR 16-18) were applied. PFA with vWACA resulted in consecutive posterior LA wall isolation in 11/13 patients. Fluoroscopically, the esophagus coursed near the right PVs in 2/13, left PVs in 8/13 and mid-posterior wall position in 3/13 patients. Maximum TESO increase from baseline was 0.8 ±0.9 °C. However, no clinically relevant TESO changes occurred (Table 1). On short-term, all patients remained asymptomatic for sore throat, cough, or other symptoms potentially related to ETI. No esophago-duodenoscopy was necessary.

Conclusion

PFA of the PVs and lesion extension to the posterior LA wall demonstrated clinically non-significant TESO changes and has the potential to eliminate the risk of a thermal damage to the esophagus.
The role of local impedance drop in the acute lesion efficacy during pulmonary vein isolation performed with a new contact force sensing catheter
Authors: Szegedi N , Perge P , Sallo Z , Piros K , Nagy VK , Osztheimer I , Merkely B , Geller L
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is the cornerstone treatment for paroxysmal atrial fibrillation (AF). The effective lesion creation during the PVI is essential to reach optimal long-term results.

Purpose

Our pilot study aimed to evaluate the role of local impedance drop in lesion formation during pulmonary vein isolation with a novel contact force sensing ablation catheter that records local impedance as well and to find a local impedance cut-off value that predicts successful lesion formation.

Materials and methods

After completing point-by-point radiofrequency pulmonary vein isolation, the success of the applications was evaluated by pacing along the ablation line at 10 mA, 2 ms pulse width. Lesions were considered successful if loss of local capture was achieved.

Results

Out of 645 applications, 561 were successful and 84 were unsuccessful. Compared to the unsuccessful ablation points, the successful applications were shorter (p=0.0429) and had a larger local impedance drop (p<0.0001). There was no difference between successful and unsuccessful applications in terms of mean contact force (p=0.8571), force-time integral (p=0.0699) and contact force range (p=0.0519). The optimal cut-point for the local impedance drop indicating successful lesion formation was 21.80 Ohms on the anterior wall [AUC=0.80 (0.75-0.86), p<0.0001], and 18.30 Ohms on the posterior wall [AUC=0.77 (0.72-0.83), p<0.0001]. A local impedance drop larger than 21.80 Ohms on the anterior wall and 18.30 Ohms on the posterior wall was associated with an increased probability of effective lesion creation [OR=11.21, 95%CI 4.22–29.81, p<0.0001; and OR=7.91, 95%CI 3.77–16.57, p<0.0001, respectively].

Conclusion

The measurement of the local impedance may predict optimal lesion formation. A local impedance drop > 21.80 Ohms on the anterior wall and > 18.30 Ohms on the posterior wall significantly increases the probability of creating a successful lesion.
Oesophageal protection during AF ablation: real world registry data and mechanisms behind the therapeutic effect of tissue cooling
Authors: Leung L , Akhtar Z , Bajpai A , Li A , Sohal M , Norman M , Kaba R , Al-Subaie N , Louis-Auguste J , Hayat J , Zuberi Z , Gallagher M
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Oesophageal protection using a dedicated device to provide controlled active thermal protection of the oesophagus during atrial fibrillation ablation has been shown to be effective at reducing endoscopically detected oesophageal lesions. Real world registry data of this device and established evidence on the effect of cooling on localized tissue after thermal injury have been under review.

Purpose

To determine the safety of an oesophageal temperature control device by a review of real-world registry data on its clinical use during catheter ablation procedures and to clarify basic mechanisms of its therapeutic action by a literature review of scientific studies on cooling in the context of thermal injury.

Methods

The United States Food and Drug Administration (FDA) Manufacturer and User Facility Device Experience (MAUDE), FDA Medical and Radiation Emitting Device Recalls, the Medicines and Healthcare products Regulatory Agency (MHRA) Medical Device Alerts and SwissMedic records of Field Safety Corrective Actions (FSCA) databases were reviewed for any device-related adverse events. A systematic literature review was conducted to clarify the findings from studies investigating the physiological processes behind the therapeutic effect of cooling after tissue thermal injury.

Results

Of over 20,000 oesophageal temperature control devices clinically used, 7976 were recorded as having been used for the purpose of oesophageal protection during left atrial catheter ablations. No adverse events occurred related to its use during left atrial catheter ablations. No case of clinically significant oesophageal injury was reported in a patient who had been protected by the oesophageal temperature control device. 208 research articles retrieved from PubMed and MEDLINE that met the search criteria were reviewed. The common finding in all the studies was that cooling had an anti-inflammatory and restorative effect via modulation of several immune-mediated pathways, local cellular function and genetic expression.

Conclusions

There have been no adverse events reported to date in real world clinical use of an oesophageal temperature control device during left atrial catheter ablations, for the purpose of active thermal protection. Literature review data suggests that there are complex biophysical and cellular effects from cooling that leads to its therapeutic effect but further work is required to define the mechanisms of action of thermal protection in this specific context.
Ultrasound-guided femoral venipuncture for catheter ablation of atrial fibrillation: clinical benefit
Authors: Haskova J , Wichterle D , Peichl P , Stojadinovic P , Aldhoon B , Stiavnicky P , Borisincova E , Cihak R , Kautzner J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The most frequent complications of catheter ablation for atrial fibrillation (AF) are related to vascular access.

Purpose

Vascular complication rates of ultrasound-guided venipuncture (USGV) were analyzed and compared to historical controls (CTRL) with an anatomical landmark-guided approach.

Methods

The study cohort included 4646 consecutive patients (2330 and 2316 patients in USGV and CTRL groups, respectively). Clinical characteristics were as follows: age of 61±10 years, 67% males, 66% paroxysmal AF, CHA2DS2-VASc score of 2.0±1.4, 27% reablation, and procedure time of 208±69 min. Both femoral veins were cannulated with 2 and 2 sheaths (7, 11, and 2x 8.5 French) in the majority (>95%) of procedures. Major complications were defined as those requiring intervention (surgery, thrombin injection, or transfusion), or hematoma/bleeding with hemoglobin drop >30g/l, or condition prolonging hospitalization and/or resulting in re-hospitalization. They were extracted from the institutional tracking system for complications of invasive procedures and by a review of medical reports within the first 3 months of follow-up.

Results

There were 32 (1.38%) vs. 62 (2.66%) major complications related to vascular access in USGV and CTRL groups, respectively (Yates corrected Chi-square P=0.003), i.e. relative reduction of -48% in the USGV group. Surgical intervention was needed in 6 (0.26%) vs. 18 (0.77%) patients, respectively (Fisher exact test P=0.02), i.e. relative reduction of -64% in the USGV group. The differences remained significant after adjustment for baseline clinical characteristics. Multivariate analysis revealed that USGV strategy (P=0.0005), male gender (P=0.003), and less advanced age (P=0.0002) were significantly associated with lower complication rates.

Conclusions

USGV was associated with a statistically significant reduction of major vascular complications after catheter ablation for AF. This strategy also decreased the need for surgical correction of vascular complications. Ultrasound guidance can be recommended to improve the safety of femoral venous access.
Acute change of cardiac autonomic regulations after thermal and non-thermal pulmonary vein ablation
Authors: Stojadinovic P , Wichterle D , Peichl P , Cihak R , Jansova H , Nejedlo V , Haskova J , Kautzner J
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) by thermal energy (radiofrequency energy or cryoenergy) results in collateral ganglionic plexi ablation. On the contrary, pulsed electric field (PEF) energy presumably spares neural tissue.

Purpose

We investigated and compared the effect of PVI on parasympathetic input into the sinus node (SAN) and AV node (AVN) when four different ablation strategies were used.

Methods

A study enrolled 49 patients who underwent PVI in general anesthesia (age: 57 ± 13 years, 71% males). In 17 patients, point-by-point radiofrequency energy delivery by the irritated-tip catheter was used for ablation while 7 patients were ablated using a second-generation cryoballoon catheter. In 7 patients, PEF energy was delivered using a single-shot Farawave catheter while 18 patients were ablated using Sphere9 lattice-tip catheter (Affera, Inc.); both subgroups with manufacturer-specific PEF settings. Before and after PVI, the responsiveness of the SAN and AVN was assessed by extracardiac vagal nerve stimulation (ECVS) via a diagnostic catheter in the right internal jugular vein. Five-second stimulation trains were delivered with a frequency of 50 Hz, pulse width of 0.05 ms, and output of 1 V/kg (<70V) both in sinus rhythm and during atrial pacing. Substantial reduction of response to ECVS was arbitrarily defined as a maximum induced pause of <1.5 seconds.

Results

At baseline, physiological response to ECVS (long sinus arrest and/or AV block) was demonstrated. After PVI, a substantial reduction of SAN response was observed in 21/24 (88%) patients after thermal PVI and 7/25 (25%) patients after non-thermal PVI (P = 0.0001). Similarly, a substantial reduction of AVN response was observed in 21/24 (88%) patients after thermal PVI and 9/25 (36%) patients after non-thermal PVI (P = 0.0003). The Figure shows on the continuous scale the post-PVI pauses in sinus rhythm (maximum P-P interval) and atrial pacing (maximum R-R interval) induced by ECVS.

Conclusion

Vagal responses of SAN and AVN are preserved in most AF patients after non-thermal PVI. This contrasts with the much stronger effect of thermal PVI. Whether this may influence the clinical outcome of AF ablation procedures remains to be investigated in future studies.
Pulsed field ablation as the first choice regarding oesophageal safety for atrial fibrillation ablation?
Authors: Katic J , Sikiric I , Lisica L , Zaja I , Puljiz Z , Jurisic Z , Breskovic T , Anic A
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

The occurrence of endoscopy-detected oesophageal lesions has been reported in patients with atrial fibrillation (AF) after thermal-based pulmonary vein isolation (PVI) with even higher risk in patients undergoing ablation of the left atrial posterior wall (LAPW) (1). The main mechanism of oesophageal injury is thermal, resulting in oesophageal dysmotility, ulceration, perforation, or left atrio-oesophageal fistula formation, which are rare but life-threatening sequelae. Pulsed-field ablation (PFA) is a non-thermal ablation technology that uses high amplitude pulsed electrical fields to ablate tissues through cell membrane disruption (2). Precommercial experience with PFA reported no injury to the oesophagus for both PVI and LAPW ablation (3).

Purpose

To assess oesophageal safety in AF patients treated with three different PFA platforms.

Methods

In this single-centre experience we retrospectively analysed a total of 72 upper gastrointestinal (GI) endoscopies performed by a certified gastroenterologist one day after left atrial PFA. GI analysis focused on detection of oesophageal lesions nearest the left atrium and evidence of gastric hypomotility. PVI was performed using focal or single shot PFA catheters. Focal PFA catheters achieved PVI using the wide antral circumferential ablation (WACA) technique. LAPW ablation was performed exclusively by using single shot PFA devices.

Results

The patient characteristics were summarized in Table 1. Focal PFA catheters were used in 78% of patients. Post-procedure endoscopies revealed no mucosal lesions in any patient. Gastroparesis and perioesophageal vagal nerve injury were not found (Table 2).

Conclusion

PFA, whether applied by single shot devices or focal catheters, seems to be a safe ablation option with respect to oesophageal injury resulting from PVI and LAPW ablation in paroxysmal and persistent AF patients. Irrespective of catheter design, PFA configuration (monopolar versus bipolar, maximum output), or LA lesion set, we found absolute GI safety of PFA as class effect.
Minimally invasive atrial fibrillation ablation and left anterior descending bypass grafting
Authors: Van Der Heijden CAJ , Segers P , Masud A , Weberndorfer V , Chaldoupi SM , Luermans JGLM , Van Kuijk S , Barenbrug PJC , Maessen JG , Bidar E , Maesen B
Published: May 2022

Funding Acknowledgements

Type of funding sources: None.

Background

Minimally invasive direct coronary artery bypass (MIDCAB) with robotic left internal mammary artery (LIMA) harvesting for a critical left anterior descending (LAD) stenosis and thoracoscopic ablation for atrial fibrillation (AF) may represent safe and effective alternatives to more invasive surgical approaches via sternotomy.

Purpose

To evaluate the feasibility, safety and efficacy of a MIDCAB procedure with concomitant thoracoscopic AF ablation.

Methods

We prospectively analysed all patients who underwent a minimally invasive, off-pump, MIDCAB through a left mini-thoracotomy with concomitant left-sided thoracoscopic AF ablation using a bipolar radio frequent clamp between 2017 and 2021.

Results

Twenty-three patients were included (age 69±8 years, BMI 29±4kg/m2, paroxysmal AF 61%, LAVI 42±11 ml/m2). All patients received an off-pump LIMA-LAD anastomosis. Ablation of the left (n=23) and right (n=22) pulmonary veins and box (n=21) was succeeded by epicardial validation of exit- and entrance block (n=22). No procedural complications were observed and complications during hospital admission and after discharge were: bleeding of the LIMA-LAD anastomosis n=1; myocardial infarction requiring percutaneous intervention of the LIMA-LAD n=1, respiratory insufficiency due to pleural effusion or atelectasis n=3, hospital readmission due to pleural- and pericardial effusion n=2. Duration of hospital stay was 6±2 days. After 12 months, 16/20 (80%) patients were in sinus rhythm when allowing anti-arrhythmic drugs and 18/20 (90%) patients were free from myocardial infarction.

Conclusion

Robot-assisted MIDCAB surgery for LIMA-LAD grafting concomitant with left-sided thoracoscopic AF ablation is a feasible, safe and efficacious minimally invasive treatment strategy for patients with a critical LAD stenosis and AF suitable for minimally invasive surgery.