bluuebunny/crossref_metadata_2025 huggingface dataset:
Achieving acute mitral isthmus block with catheter ablation with vein of marshall ethanol infusion
Authors: Andronache M , Pastorcici A , Massoulie G , Blendea D , Boudias A , Catalan PA , Jean F , Dauphin C , Eschalier R , Costea A , Rosu R , Cismaru G , Puiu M , Souteyrand G , Motreff P
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Achieving bidirectional mitral isthmus block during radiofrequency (RF) ablation for persistent atrial fibrillation (AF) is still challenging. The conventional ablation method involves RF applications on the endocardial aspect of the Mitral Isthmus (MI), and for a majority of patients, in the distal coronary sinus (CS). 

Purpose

We have evaluated the acute success of obtaining mitral isthmus block by adding another epicardial component using ethanol infusion in the vein of Marshall (EIVOM) in addition to endocardial MI and epicardial CS ablation. 

Methods 

We studied 121 patients (pts.) with a mean age of 65 years (range 40-83) 73% men; 119 with longstanding persistent AF (98%) and 2 with perimitral flutter (2%). The mean duration of AF was 53 months (12-244 months). In the majority of patients, additional endocardial (on the ventricular aspect of the MI) and/or epicardial (distal CS) (RF) ablation was performed in order to achieve MIB. The ablation procedure was performed under general anesthesia (GA) for 81 pts (67%). EIVOM was perform with a mean 6 ml ethanol (range 2-10ml) 

Results

 Bidirectional MIB was obtained in 114 pts. (94,2%). The 7 patients without MIB were scheduled for another ablation procedure (4 pts under GA during the first procedure). The average RF delivery time to block was 160 seconds (range 42-480 seconds) for the endocardial MI RF ablation (point-by-point application with a power of 50W and an Ablation Index of 450-500, contact force 10-20g) and 156 seconds (range 55-438) for the epicardial MI RF ablation (applications with a power of 20W). Bidirectional endocardial and epicardial MIB was confirmed by conventional pacing maneuvers performed in sinus rhythm. No major complications were observed. The parameters associated with failure for MIB were AF duration, Left Atrial dilatation >200 ml, MI thickness (epicardial endocardial distance on the CARTO maps >15mm).

Conclusion

Ethanol infusion in the vein of Marshall is a safe approach and is associated with a higher success rate of obtaining acute bidirectional endocardial and epicardial mitral isthmus block when compared with the conventional method. Abstract Figure. Bloc Mitral Endo; Bloc Mitral Epi;
Usefulness of the angiographic anatomy of the vein of marshall for ablation procedures for persistant atrial fibrillation
Authors: Pastorcici A , Andronache M , Blendea D , Massoulie G , Dauphin C , Boudias A , Catalan PA , Jean F , Costea A , Escalier R , Mihai PA , Rosu R , Cismaru G , Souteyrand G , Motreff PA
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Ethanol Infusion in the Vein of Marshall (EIVOM) was recently proposed as an efficient adjunctive technique for obtaining mitral isthmus block during catheter ablation for persistent atrial fibrillation. 

Purpose

Given these considerations the objective of this research was to delineate the angiographic anatomy of the Vein of Marshall (VOM). 

Methods

Fluoroscopy images were obtained retrospectively in 124 patients with persistent atrial fibrillation who underwent coronary sinus angiography for EIVOM (96 patients) or cardiac resynchronization implant (18 patients). The measurements were performed using Osirix DICOM reader using the known diameter of the angiographic catheter for calibration. The distance between the ostium of the coronary sinus (CS) and the ostium of the VOM was measured in the anteroposterior view. Additionally, the angle at which the ostium of VOM opens in the CS was obtained. 

Results

The diameter of the VOM ostium was 1.8 ± 0.6mm. The length of the VOM was 18.6 ± 9.1mm. The distancebetween the CS ostium and VOM ostium was as follows: less than 10mm for 1 patient (1%), between 11-20mm for 10 patients (10.41%), between 21-30mm for 38 patients (39.58%), 31-40mm for 31 patients (32.29%), between 41-50mm for 15 patients (15.62%) and >50mm for 1 patients (1%) (53mm). 

The average takeoff angleof the VOM from the CS between the main branch of the VOM and the CS was measured at 140 degrees (range 90-175 degrees). No correlation could be made between the takeoff angle and the distance between CS ostium and VOM ostium. 

In the group of patients undergoing cardiac resynchronization the takeoff angle from the CS was 153°±17° and it correlated significantly with the left ventricular systolic diameter and the left ventricular ejection fraction determined by echocardiography(r = 0.52; p = 0.008 and respectively r = 0.50; p = 0.009).

Conclusions

Understanding the anatomy of the Vein of Marshall (VOM) is crucial in helping operators efficiently exploit the therapeutic potential of ethanol injection after accurate localization of such an important branch of the left atrial venous system. Abstract Figure. 1 Fig 1 Angle CS-VOM
Catheter ablation with ethanol infusion in the vein of marshall for persistent atrial fibrillation: safety and procedure duration
Authors: Massoulie G , Andronache M , Pastorcici A , Dauphin C , Costea A , Blendea D , Catalan PA , Lizet T , Jean F , Eschallier R , Puiu M , Rosu R , Cismaru G , Souteyrand G , Motreff PA
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Ethanol Infusion in the Vein of Marshall (EIVOM) has been recently introduced as an efficient technique that helps achieving mitral isthmus block during ablation procedures for persistent atrial fibrillation (PAF) or peri-mitral atrial flutter.

Purpose

We have evaluated the safety of EIVOM and the duration required to perform this procedure. 

Methods 

We performed EIVOM in 121 patients for PAF (mean age of 65 years (range 40-83, 73% men; Mean EF 50%. The main steps of the EIVOM were as follows: the procedure commenced with catheterization of the coronary sinus, followed by the subsequent introduction of an angiography catheter that allowed for iodine contrast injection and vein of Marshall (VOM) localization, 1.5-2.5 mm angioplasty balloon over 0.014" guidewire placement and finally the ethanol injection up to 10 ml. 

Results

No major complications were observed during the ablation procedure or before hospital discharge.

In 62 patients in whom procedure duration data was available the mean EIVOM procedure time was 41 min (range from 13 to 105 min).

After the first 20 procedures, where the learning curve for the operators has to be taken into consideration, a reduction in the time required to achieve EIVOM was consistently noted, with an average of less than 30 min. and for the last 20 procedures less than 20 min. Factors which increase the time required for successful EIVOM include: difficulty in visualizing the ostium of the VOM, a VOM ostium located proximally, difficulty in advancing the angioplasty wire into the VOM and balloon displacement and repositioning.

Conclusions

Ethanol infusion in the Vein of Marshall is a safe and efficient technique that can be performed in an acceptable amount of time after an initial learning curve. Abstract Figure. Image 1 VOM
Digoxin and association with mortality in patients discharged from hospital with atrial fibrillation, with or without heart failure
Authors: Mpotis M , Kartas A , Samaras A , Akrivos E , Vrana E , Liampas E , Papazoglou A , Moysidis D , Papanastasiou A , Baroutidou A , Karvounis H , Tzikas A , Giannakoulas G
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

OnBehalf

MISOAC- AF study group

BACKGROUND

Digoxin is widely used in atrial fibrillation (AF) and heart failure (AF). However, established evidence is conflicting regarding its association with clinical outcomes.

AIM

To investigate the relation between digoxin and adverse outcomes in patients with AF, with or without HF, in a contemporary AF cohort.

METHODS

We performed a retrospective analysis of data from 698 patients, originating from the MISOAC- AF (Motivational Interviewing to Support Oral AntiCoagulation Adherence in patients with non-valvular Atrial Fibrillation) trial, and followed over a median of 2.5 years. HF was denoted at baseline. The primary outcome was all-cause mortality and the secondary outcome was all-cause hospitalization, in a time-to-event analysis. Propensity scores were used to derive matched populations, balanced on key baseline covariates. To limit potential confounding, we also implemented inverse probability of treatment weighting (IPTW) analysis.

RESULTS

Among patients with HF, 10.5% (n = 39) were administered digoxin at baseline, whereas 89.5% (n = 331) were not. Digoxin administration was not associated with an increased risk of death (hazard ratio (HR) in the digoxin group, 1.21; 95% Confidence Interval (CI), 0.69 to 2.13, p = 0.5) or hospitalization of any cause (HR 1.15; 95% CI, 0.67 to 1.96; p = 0.6). Among patients without HF, 3.5% (n = 11) were administered digoxin, with neutral effects on all-cause mortality (HR: 3.25; 95% CI, 0.98 to 10.70), p = 0.06) and all-cause hospitalization (HR, 1.15; 95% CI, 0.67 to 1.96, p = 0.60). Consistent qualitatively results were observed using IPTW.

CONCLUSIONS

Among patients with AF, digoxin administration was not associated with an increased risk of death and hospitalization of any cause, irrespective of HF status. Abstract Figure.
Antiarrhythmic drug responders among patients with recurrent atrial fibrillation after catheter ablation
Authors: Park Y , Yu H , Kim TH , Uhm JS , Joung B , Lee MH , Pak HN
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): The Ministry of Health and Welfare The National Research Foundation of Korea (NRF)

Backgroud

Sinus rhythm (SR) can be maintained with antiarrhythmic drugs (AADs) in a considerable number of patients with recurrent atrial fibrillation (AF) after AF catheter ablation (AFCA).

Purpose

We explored the characteristics and long-term outcomes of patients who maintained clinically acceptable rhythm control with AADs for 2 years.

Methods

Among 2,935 consecutive AAD-resistant patients who underwent a de novo AFCA, we included 512 recurrent patients (73.0% men, 59.2 ± 10.5 years old, 56.4% paroxysmal AF) who were followed up for over 2 years under AAD medications.

Results

In total, 218 patients remained in SR (AAD-responders[2-yrs], 42.6%) and 294 had recurrent AF among whom, 162 underwent repeat procedures (redo-AFCA[AAD failure-2-yrs]). We also compared the AAD-responders[2-yrs] with 40 patients who underwent AFCA before AADs (redo-AFCA[Before AAD]). AAD-responders[2-yrs] were independently associated with an old age (odds ratio [OR] 1.02 [1.00-1.04] p = 0.037), paroxysmal AF (OR 1.51 [1.04-2.19] p = 0.003), and a delayed recurrence timing of > 18 months (OR 1.52 [1.04-2.22] p = 0.032). When comparing the AAD-responder[2-yrs] and redo-AFCA[AAD failure-2-yrs] groups, the recurrence pattern showed a convergence after 7 years. The overall rhythm outcome was better in the redo-AFCA[Before AAD] group than AAD group (log rank p = 0.013).

Conclusion

Among the patients with recurrent AF after AFCA, over 40% remained in SR with AADs for 2 years, especially those who were old, those with a paroxysmal type, and those who had a delayed recurrence timing of >18 months after the de novo procedure. UnivariateMultivariateOdds Ratio(95% CI)p valueOdds Ratio(95% CI)p valueAge1.02 (1.00-1.04)0.0231.02 (1.00-1.04)0.037Female1.64 (1.11-2.42)0.0141.29 (0.85-1.95)0.236PAF1.58 (1.11-2.26)0.0121.51 (1.04-2.19)0.030Time to recurrence after the initial AFCA >18mo*1.59 (1.11-2.30)0.0131.52 (1.04-2.22)0.032LA dimension, mm0.99 (0.96-1.02)0.360LV ejection fraction, %1.03 (1.01-1.06)0.0111.02 (0.997-1.046)0.081Heart failure0.65 (0.34-1.24)0.192Hypertension1.18 (0.83-1.67)0.358Diabetes1.01 (0.65-1.71)0.844Stroke or TIA0.96 (0.56-1.66)0.879Vascular disease1.43 (0.88-2.31)0.151Logistic regression analysis for AAD responders Abstract Figure. K-M analysis of AF-free survival rate
Polypharmacy and major adverse events in atrial fibrillation
Authors: Tsagkaris C , Kartas A , Samaras A , Papazoglou A , Moysidis D , Vrana E , Vouloagkas I , Papanastasiou A , Kotzampasis G , Baroutidou A , Karagiannidis E , Louka A-M , Matiashova L , Tzikas A , Giannakoulas G
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Polypharmacy has been defined as the daily use of more than 4 drugs, by an individual, regardless of the condition(s) they have been prescribed for and their efficacy. The burden of polypharmacy pertains to adverse drug reactions, disability, frequent and longtime hospitalization and long-term mortality. The prevalence of polypharmacy exceeds 10% in most adult age groups and particularly in the elderly. At the same time, atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia, afflicting more than 8% of the elderly and those with multiple comorbidities.

Purpose

The purpose of this study was to examine the association between the presence of polypharmacy and outcomes among AF patients.

Methods

This is a retrospective analysis among 1140 patients enrolled in the MISOAC-AF trial. All cause- and cardiovascular- mortality have been defined as primary endpoints. Independent clinical predictors of polypharmacy and of major adverse outcomes were identified via bootstrapped multivariate logistic and Cox regression analysis, respectively.

Results

The mean number of prescribed medications at patients’ discharge was 3.9 ± 1.6 and polypharmacy (use of more than 4 medications daily) was found in 36.9% of the patients. Smoking (p = 0.036), dyslipidemia (p < 0.001), coronary artery disease (p < 0.001), heart failure (HF; p = 0.003) and chronic kidney disease (p < 0.001) were independent predictors of polypharmacy among AF paients. Kaplan–Meier survival analysis showed that AF patients with polypharmacy have significantly greater risk of CV death (p = 0.040), while Cox regression analysis indicated polypharmacy as an independent predictor for all-cause and CV- mortality [adjusted hazard ratios: 1.31(1.03 - 1.67) and 1.39(1.05 - 1.84), respectively] and for the composite outcome of AF- or HF- related hospitalization or CV death [adjusted hazard ratio: 1.31 (1.05 - 1.63)].

Conclusion

This study highlights the implications of polypharmacy in the context of AF, a prevalent, chronic, life-threatening condition. Investigating polypharmacy is quite relevant in the era of pharmacovigilance, contributing to rational pharmacotherapy with regard to cardiovascular conditions and beyond. Abstract Figure. Mortality rates by polypharmacy presence
The magnitude and the course of local impedance drop to guide successful AF ablation: insight from an Italian registry
Authors: Schillaci V , Zucchelli G , Solimene F , De Simone A , Pandozi C , Stabile G , Di Cori A , Arestia A , Narducci ML , Battaglia A , Cauti F , La Greca C , Terzaghi C , Malacrida M , Segreti L
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

It has been demonstrated that an ablation strategy based on local impedance (LI) algorithm is helpful in guiding successful ablation of atrial fibrillation (AF) cases. How the magnitude and the course of LI drop could impact the effectiveness of ablation has to be proved.

Purpose

We aimed to evaluate LI drop characteristics in predicting effective radiofrequency (RF) ablation of consecutive AF cases.

Methods

Consecutive patients undergoing AF ablation at 8 Italian centers were included in the CHARISMA registry. A RF ablation catheter equipped with mini-electrodes technology and a dedicated algorithm was used to measure LI and to guide ablation. For our purpose, we defined the time to drop (τ) as the time for the first deflection of LI drop to the plateau. RF applications were targeted to a LI drop of 10 Ω and were stopped when a maximum cut-off LI drop of <40 Ω was observed. Successful single RF ablation was defined according with a reduction of signal voltage by at least 50% and inability to capture local tissue on pacing. The ablation endpoint was PVI as assessed by entrance and exit block. Follow-up were scheduled at 3, 6 and 12 months post-ablation.

Results

153 consecutive patients (61% paroxysmal AF, 39% persistent AF) were enrolled in the study. 3556 point-by-point first-pass RF applications of >10 s duration were performed around PVs. The mean LI drop was 13 ± 8Ω, the mean τ was 18.7 ± 13s and the median LI drop/τ was 0.67 [QI-QIII, 0.37 – 1.17] Ω/s. Both absolute drops in LI and LI drop/τ were greater at successful ablation sites (n = 3122, 88%) than at ineffective ablation sites (n = 434, 12%) (14 ± 8Ω vs 6 ± 4Ω, p < 0.0001 for LI; 0.73[0.41–1.25]Ω/s vs 0.35[0.22–0.59]Ω/s for LI drop/τ, p < 0.0001). Every 5-point increment in LI drop was associated with successful ablation, with an OR of 3.13 (95%CI: 2.7 to 3.6, p < 0.0001), reaching the highest point when a value larger than 15 Ω was observed (99.9% of acute success). A significant trend was observed from lower to higher LI drop/τ values and a value greater than 0.65 Ω/s (best cut-off value on the basis of the ROC analysis) was significantly associated with successful RF delivery with an OR of 5.54 (95%CI: 4.31 to 7.11, p < 0.0001). No complications occurred during and after procedures. At 1-year follow-up, the AF recurrence rate was 12% after the 90-day blanking period.

Conclusions

The magnitude and time-course of the LI drop during RF delivery were associated with effective lesion formation. This ablation strategy for PVI guided by LI technology proved safe and effective, and resulted in a very low rate of AF recurrence over 1-year follow-up.
Electrical cardioversion during cryoballoon pulmonary vein isolation predicts long-term ablation success in persistent atrial fibrillation
Authors: Boehmer A , Rothe M , Soether CM , Dobre BC , Abboud J , Kaess B , Ehrlich JR
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Cryoballoon pulmonary vein isolation (cryoPVI) is an established option for treatment of atrial fibrillation (AF) but many periprocedural events influencing long-term outcome and procedural safety of ablation remain unclear. In radiofrequency ablation studies, failure to convert to sinus rhythm and electrical cardioversion (ECV) have been associated with increased recurrence rates. In this context, the influence of ECV during cryoPVI on long-term ablation efficacy is unclear.

Objective

A prospective comparison of AF recurrence after cryoballoon ablation in patients who were in AF or atrial tachycardia at the beginning of cryoPVI requiring ECV during procedure with patients who underwent ablation therapy without ECV.

Methods

We analyzed consecutive patients who underwent cryoPVI in a single-center cohort between 2018 and 2020. Follow-up was performed at 3, 6, 12, 18 and 24 months after ablation. Primary endpoints were: symptomatic AF recurrence for efficacy and bleeding, phrenic nerve injury, stroke or death for safety.

Results

472 consecutive patients who underwent ablation in a single-center cohort were analysed. Mean follow-up time was 15 months. In 195 patients (74 paroxysmal AF vs. 121 persistent AF, age 69 ± 10 years, 57% male, CHA2DS2-VASc 2.6 ± 1.4) at least one ECV was performed following ablation, while no cardioversion was necessary in 277 patients (214 paroxysmal AF vs. 63 persistent AF, age 69 ± 10 years, 55% male, CHA2DS2-VASc 2.7 ± 1.5). After 24 months, primary efficacy endpoint occurrence was significantly higher in persistent AF requiring cardioversion during procedure than for persistent AF without cardioversion and paroxysmal AF with/ without cardioversion (56.1 % vs. 31.2%, 33.6%, 32.9%, log-rank p = 0.009, figure). Primary safety endpoint occurred in form of pericardial effusion or transient phrenic nerve injury in two patients in cardioversion group (1.0%) and three patients without cardioversion (1.1%). No deaths or strokes were observed in either group. Total procedure duration (55.6 ± 17min vs. 57.7 ± 15.9min, P = 0.17) and left-atrial dwell time (39.7 ± 14.9min vs. 42 ± 15.6min, P = 0.11) were similar.

Conclusion

In patients with persistent AF, the need for ECV during cryoPVI predicts a poorer long-term outcome during 2-year follow-up. Future studies should focus on this specific patient population. Abstract Figure.
Anticoagulant treatment status and outcomes of elderly non-valvular atrial fibrillation patients with a history of catheter ablation in Japan: subanalysis of the ANAFIE registry
Authors: Okumura K
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private company. Main funding source(s): Daiichi Sankyo Co., Ltd.

OnBehalf

ANAFIE Registry Group

Backgrounds

Benefits of catheter ablation (CA) have been shown for patients with atrial fibrillation (AF). However, data in elderly patients aged ≥75 years who have undergone CA for non-valvular AF (NVAF) are insufficient.

Purpose

The All Nippon Atrial Fibrillation In the Elderly (ANAFIE) Registry is a prospective, multicenter, observational study, which was designed to collect the real-world data on the clinical status and prognosis in 30,000 over Japanese patients (aged ≥75 years) with NVAF. This cross-sectional subanalysis of the ANAFIE registry assessed the 2-year outcomes and anticoagulant treatment in elderly NVAF patients with a history of CA.

Methods

A total of the 32,275 patients from the ANAFIE registry were divided into two groups by a history of CA: the CA and No-CA groups. Kaplan-Meier analysis was used to evaluate the annualized incidences of stroke/systemic embolic event (SEE), major bleeding, intracranial hemorrhage (ICH), heart failure requiring hospitalization (HF), and all-cause mortality. Hazard ratio (HR) for each event was analyzed using the Cox proportional-hazards model.

Results

Of all patients, 2,970 patients (9.2%) were included in the CA group and 29,305 (90.8%) were included in the No-CA group. The CA group had lower age (mean 78.9 vs 81.7 years), higher prevalence of paroxysmal AF (73.0 vs 39.0%), higher creatinine clearance (mean 53.1 vs 47.9 mL/min) and lower CHA2DS2-VASc (mean 4.2 vs 4.5) and HAS-BLED scores (mean 1.8 vs 1.9) than the No-CA group. Oral anticoagulants (OACs) were administered in 87.3% of the CA group (warfarin, 16.8%; direct OAC, 70.5%) and 92.9% of the No-CA group (warfarin, 26.4%; direct OAC, 66.5%). Compared with the No-CA group, the CA group had lower the annualized incidences (/100 patient-year [95%confidence intervals]) of stroke/SEE (0.74 [0.52, 0.96] vs 1.72 [1.61, 1.83]), major bleeding (0.63 [0.43, 0.84] vs 1.12 [1.03, 1.21]), ICH (0.49 [0.31, 0.67] vs 0.78 [0.71, 0.86]), HF (2.54 [2.12, 2.96] vs 4.44 [4.26, 4.62]), and all-cause mortality (1.45 [1.14, 1.77] vs 3.95 [3.78, 4.11]).

Conclusions

Elderly NVAF patients with a history of CA had lower adverse incidences compared with patients without a history of CA. A more optimal OAC therapy for elderly NVAF patients with a history of CA should be examined in the future.
Personalized atrial fibrillation ablation by tailoring ablation index to the left atrial wall thickness. the ablate by-law single center study
Authors: Teres C , Penela D , Soto-Iglesias D , Jauregui B , Ordonez A , Chauca A , Carreno-Lineros JM , Scherer C , Huguet M , Ramirez-Paesano C , Oller G , Panaro A , Carballo J , Ortiz-Perez JT , Berruezo A
Published: May 2021

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Dr Teres is funded by the research fellowship grant from the Swiss Heart Rhythm Foundation, Dr Carreno was funded was funded by a Scholarship from Sociedad Española de Cardiología (SEC).

Introduction

Left atrial wall thickness (LAWT) is a determinant of transmural lesion formation during atrial fibrillation (AF) ablation. The utility of ablation index (AI) to dose radiofrequency (RF) delivery for the reduction of AF recurrences has already been proven with a target AI ≥ 400 at the posterior wall and ≥550 at the anterior wall.

Objective

To determine if adapting AI to atrial wall thickness (AWT) is feasible, effective and safe during AF ablation.

Methods

Consecutive patients referred for a first PAF ablation. LAWT 3D-maps were obtained from multidetector computed tomography (MDCT) and integrated into the CARTO navigation system. LAWT maps were semi-automatically computed from the MDCT as the local distance between the LA endo and epicardium and categorized into 1mm-layers and AI was titrated to the LAWT, as follows: Thickness < 1 mm (red): 300; 1-2 mm (yellow): 350; 2-3 mm (green): 400; 3-4 mm (blue): 450; > 4 mm (purple): 450 (Figure). The ablation line was designed in a personalized fashion to avoid thicker regions. All ablation procedures were performed under general anesthesia with a high frequency low-volume ventilation. Primary endpoints were acute efficacy and safety, and freedom from AF recurrences. Follow-up (FU) was scheduled at 1, 3, 6, and every 6 months thereafter.

Results

90 patients [60 (67 %) male, age 58 ± 13 years] were included. Mean LAWT was 1.25 ± 0.62 mm. Mean AI was 366 ± 26 on the right pulmonary veins (RPVs) with a first-pass isolation in 84 (93%) patients and 380 ± 42 on the left pulmonary veins (LPVs) with first-pass in 87 (97%). Procedure time was 59 min [49-66]; RF time 14 min [12,5-16]; fluoroscopy time 0.7 min [0.5-1.4]. No major complication occurred. Eighty-six out of 90 (95.5%) patients were free of recurrence after a mean FU of 11 ± 4 months.

Conclusions

 Personalized AF ablation, adapting the AI to LAWT allowed decreasing RF delivery, fluoroscopy and procedure time while obtaining a high rate of first-pass isolation. Lesion durability as estimated by freedom from AF recurrences was as high as in more demanding ablation protocols. Abstract Figure. Personalized protocol and results
Sex differences in mapping and rhythm outcomes of a repeat atrial fibrillation ablation
Authors: Pak HN , Park JW , Yang SY , Kim M , Yu HT , Kim TH , Uhm JS , Joung BY , Lee MH
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

The risk of procedure-related complications and rhythm outcomes differ between men and women after atrial fibrillation catheter ablation (AFCA). We evaluated whether consistent sex differences existed in mapping and rhythm outcomes in repeat ablation procedures.

Methods

Among 3,282 patients in the registry, we analysed 443 consecutive patients (24.6% female, 58.5 ± 10.3 years old, 61.5% paroxysmal AF) who underwent a second AFCA. We compared the clinical factors, mapping, left atrial (LA) pressure, complications, and long-term clinical recurrences after propensity score matching.

Results

The LA volume index (43.1 ± 18.6 vs. 35.8 ± 11.6 ml/m2, p < 0.001) was higher, but LA dimension (40.0 ± 6.8 vs. 41.6 ± 6.3mm, p = 0.018), LA voltage (0.94 ± 0.55 vs. 1.20 ± 0.68 mV, p = 0.002), and pericardial fat volume (89.5 ± 43.1 vs. 122.1 ± 53.9 cm3, p < 0.001) lower in women with a repeat ablation than in their male counterparts. The pulmonary vein (PV) reconnections were lower (58.7% vs. 74.9%, p = 0.001), but the proportion of extra-PV triggers (27.5% vs. 17.0%, p = 0.026) and elevated LA pulse pressures (79.7% vs. 63.7%, p = 0.019) was significantly higher in women than men. There was no significant sex difference in the procedure-related complication rate (4.6% vs. 4.2%, p = 0.791). During a 31(8∼60) month median follow-up, clinical recurrences were significantly higher in women after both the de novo procedure (log rank p = 0.039, antiarrhythmic drug [AAD]-free log rank p < 0.001) and second procedure (log rank p = 0.006, AAD-free log rank p = 0.093). A female sex (HR 1.51 [1.06-2.15], p = 0.023), non-paroxysmal AF (HR 1.78 [1.30-2.34], p < 0.010), and extra-PV triggers (HR 1.88 [1.28-2.75], p = 0.001) were independently associated with clinical recurrences after repeat procedures.

Conclusions

During the repeat AFCA procedures, PV reconnections were lower in women than men, and the existence of extra-PV triggers and an LA pressure elevation was more significant, which resulted in poor rhythm outcomes.
Catheter ablation versus antiarrhythmic drugs as first-line therapy for symptomatic atrial fibrillation: a systematic review and meta-analysis
Authors: Casula M , Pignalosa L , Fortuni F , Baldi E , Sanzo A , Savastano S , Petracci B , Vicentini A , Rordorf R
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

In patients with symptomatic atrial fibrillation (AF), current international guidelines favor the use of antiarrhythmic drugs (AAD) as initial therapy for the maintenance of sinus rhythm. Previous studies have compared catheter ablation for pulmonary vein isolation versus AAD in this clinical scenario but the best first-line therapeutic option in patients with symptomatic AF candidates for rhythm control strategy remains an open issue.

Aim

To compare efficacy and safety of catheter ablation versus AAD as first-line therapy in patients with symptomatic AF.

Methods

We searched electronic databases for randomized controlled trials (RCTs) comparing catheter ablation versus AAD as first-line therapy for symptomatic AF. The primary efficacy outcome was any recurrence of atrial tachyarrhythmias. The secondary efficacy outcomes were symptomatic arrhythmic recurrences. The safety outcomes were serious adverse events related to the therapeutic regimen. Outcome events were defined according to the definition used in each original study. The effect size was estimated using a random-effect model as risk ratio (RR) and relative 95% confidence interval (CI) with the statistical software Review Manager 5.3.

Results

Five RCTs counting 997 patients (503 treated with catheter ablation and 494 with AAD) were included in the analysis. Mean age was 57 ± 3 years, 30% were female. Mean left ventricle ejection fraction was 60%±4% and mean left atrial diameter was 40 mm ± 1 mm. At baseline 52% of patients were treated with a beta-blocker and 11% with a calcium channel blocker. In the catheter ablation group 258 patients (51%) underwent cryoablation and 245 (49%) radiofrequency ablation. Median follow-up was 12 months (IQR 12-24 months). Patients treated with catheter ablation had statistically significant lower risk of atrial tachyarrhythmias recurrences (RR 0.59; 95%CI 0.45-0.76; p < 0.0001 – Figure A) and of symptomatic arrhythmia recurrences (RR 0.45; 95%CI 0.25-0.80; p = 0.007 – Figure B) compared with those treated with AAD. The risk of serious adverse events related to the therapeutic regimen did not differ significantly between patients undergoing catheter ablations and those treated with AAD (RR 0.85; 95%CI 0.45-1.59 – Figure C).

Conclusions

In patients with symptomatic AF, catheter ablation as first-line therapy is associated with a reduced risk of atrial tachyarrhythmias recurrences compared with AAD, without statistically significant differences in the risk of serious adverse events related to the treatment. Abstract Figure.
Artificial intelligence-predicted poor responders to catheter ablation for atrial fibrillation
Authors: Park JW , Kwon OS , Shim JM , Yu HT , Kim TH , Uhm JS , Kim JY , Choi JI , Joung BY , Lee MH , Kim YH , Pak HN
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Although atrial fibrillation (AF) catheter ablation is effective for rhythm control, in some patients it is hard to maintain sinus rhythm in spite of repeated AF catheter ablation (AFCA) procedures and anti-arrhythmic drugs (AADs). We explored the pre-procedural predictors for poor responders to AFCA and tested whether artificial intelligence (AI) assists the prediction of poor responders in the independent cohort by determining the invasive parameters.

Methods

Among 1,214 patients who underwent AFCA and regular rhythm follow-up for 56.2 ± 33.8 months (59 ± 11 years, 73.5% male, 68.6% paroxysmal AF), we differentiated 92 poor responders defined as those with sustained AF despite repeat AFCAs, AADs, or electrical cardioversion. Using the Youden index, we identified advanced LA remodeling with lower LA voltage under 1.109mV. AI model, which was derived from development cohort using medical record, was applied to predict LA voltage <1.109mV in the independent cohort (n = 634, poor responders = 24) using a grad-cam score.

Results

The patients with lower LA voltage under 1.109mV showed significantly poorer rhythm outcomes (Log-rank p < 0.001). We determined invasive parameter LA voltage by using the multiple variables (age, female sex, AF type, CHA2DS2VASc score, LA dimension, E/em, hemoglobin, PR interval) and achieved relatively good prediction power of AI for LA voltage <1.109mV (AUC = 0.734, sensitivity 0.729, specificity 0.643) in the test cohort. In the independent cohort, the AI model showed good discrimination power for poor responders (AUC 0.751, p < 0.001) by estimating LA voltage, which is an invasive variable. The patients with predicted lower LA voltage (grad-cam score <0) showed poorer rhythm outcome after active rhythm control (Log-rank p < 0.001)

Conclusions

The patients with advanced atrial remodeling with low LA voltage, which can be predicted by an AI, showed significantly higher recurrence of AF after AFCA with AADs or cardioversion. AI may assist to select these poor responder patients before the AFCA procedure. Abstract Figure.
General anaesthesia during radiofrequency ablation of atrial fibrillation is associated with improved procedural characteristics but with similar long-term outcomes: a single center study
Authors: Traykov V , Marchov D , Marinov M , Boychev D , Gelev V
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

General anaesthesia (GA) or conscious sedation can be used during radiofrequency catheter ablation (RFCA) of atrial fibrillation (AF) based on physician’s and patient’s preference. Increasing number of centers include GA in their institutional protocols for RFCA of AF. 

Purpose

The current study aims to compare real-world data on procedural characteristics, complication rate and procedural outcomes in patients undergoing RFCA of AF under GA or sedation at a single center.

Methods

A total of 167 patients (116 males, age 57.53 ± 9.78 years) with paroxysmal or persistent AF undergoing RFCA were studied retrospectively. Patients underwent RFCA under GA (108 patients, Group 1) provided by the anaesthesia team at our institution or under conscious sedation (59 patients, Group 2) guided by the operator using bolus doses of midazolam and fentanyl. We compared procedural time, fluoroscopy time, dose-area product (DAP), number of lesions and cumulative RF time between the two groups. We also analysed the complication rates and the long-term outcome in the two groups. Results are presented as mean ± SD or median (25th – 75th percentile).

Results

  Groups 1 and 2 were comparable in terms of baseline clinical characteristics. Group 1 patients demonstrated significantly shorter procedural time as compared to Group 2: 149.52 ± 41.31 min vs. 208.23 ± 77.10 min, P < 0.0005. Fluoroscopy time was also shorter in Group 1 24 (20-31.75) min compared to 36 (22.5-46.5) min in Group 2, P < 0.0001. This corresponded to lower radiation dose expressed by DAP which was also significantly lower in Group 1 patients: 3230 (1660-6793.2) cGy/cm2 vs. 13880 (4215-21324) cGy/cm2 for Group 2, P < 0.0001. Administration of GA during the procedure was associated with lower number of RF applications: 52.49 ± 19.36 in Group 1 vs. 68.33 ± 30.74 in Group 2, P = 0.0001. This corresponded with the lower cumulative RF time noted in the patients from Group 1: 2499.2 ± 824.17 sec vs. 3220 ± 1357.26 sec in Group 2, P < 0.0001. Procedural complications occurred in 5 patients from Group 1 (4.6%) and in 8 patients (13.6%) in Group 2, P = 0.066. There was a single case of atrioesophageal fistula in a patient from Group 1. After a median follow-up of 20 (8-41) months 75% of the patients from both Group 1 and Group 2 were arrhythmia-free following 1.5 ± 0.68 procedures (P = 1.0). 

Conclusion

Performing RFCA of AF under GA is associated with shorter procedural time, lower radiation dose and with the need for less energy application. This does not result in significantly lower complication rates. Long-term procedural outcomes do not seem to be affected by the use of GA.
Fluoroless ablation of atrial fibrillation using intracardiac ultrasound integrated with 3D electroanatomical mapping system
Authors: Antolic B , Jan M , Vrbajnscak M , Zizek D , Kajdic N
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Intracardiac echocardiography (ICE) is gaining increasingly wider adoption in interventional electrophysiology (EP) and represents an all-round tool for ablation of atrial fibrillation (AF). The key upgrade to the usefulness of ICE is its integration into three-dimensional (3D) electroanatomic mapping (EAM) system (ICE/EAM automatic integration system).

Purpose

The aim of this single-centre retrospective study was to evaluate feasibility, safety and acute efficacy of ICE/EAM automatic integration system guided fluoroless ablation of AF. 

Methods

Patients with symptomatic paroxysmal or persistent AF referred for first pulmonary vein isolation (PVI) radiofrequency catheter ablation (RFCA) from September 2017 to August 2020 were included in the study. Those who underwent additional ablations for concomitant arrhythmias were excluded from statistical analysis. All procedures were performed without the use of fluoroscopy. A detailed 3D virtual anatomy of the left atrium (LA) and structures relevant to AF ablation was constructed from ultrasound contours obtained with ICE probe inside the LA. Pulmonary veins (PVs) and antral regions were additionally mapped with fast anatomical mapping. PVI was performed with contact force (CF) sensing catheter. Procedural endpoint was successful PVI. 

Results

A total of 56 patients underwent RFCA (35.7% females, median age 62.7 years, 53.6% paroxysmal AF). Acute PVI was achieved in all patients (100%). Adverse events were detected in two patients (3.6%). The median procedure duration was 110.5 min (IQR 100.0-133.8). First-pass isolation was achieved in 50/56 LPVs (89.3%) and in 44/56 RPVs (78.6%). In patients where first-pass isolation was no achieved, intravenous carina had to be ablated in 3/6 (50%) of LPVs and 9/12 (75%) of RPVs. 

Conclusions

Flouroless PVI using ICE/EAM automatic integration system is feasible, safe and acutely effective. We achieved high rate of first-pass isolation.
Obesity paradox in catheter ablation of atrial fibrillation: analysis of national inpatient sample 2016-2018
Authors: Thyagaturu H , Shah K , Li S , Thangjui S , Shrestha B , Naik R
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Introduction

Obesity is a common cardiovascular risk factor and have been associated with favorable outcomes in congestive heart failure, coronary artery disease and atrial fibrillation (Afib), the so-called obesity paradox.

Purpose

 To study the phenomenon of obesity paradox for in-hospital and procedural outcomes in catheter ablation of Afib hospitalizations. 

Methods

We queried January 2016 to December 2018 National Inpatient Sample (NIS) to identify adult (≥18 yrs) hospitalizations with a primary diagnosis of Afib. Patients with appropriate ICD-10 PCS codes for catheter ablation were identified. Obese patients were compared with non-obese patients. We used the Chi-square tests to evaluate the differences between binary or categorical variables, and Student’s t-tests for continuous variables. Multivariate logistic regression was used in outcomes analysis to adjust for potential hospital and patient-level confounders.

Results

 We identified 53,524 weighted catheter ablation of Afib procedural hospitalizations across three years. Of which, 13,335 (25%) of them were associated with obesity. The obese hospitalizations were associated with younger age (mean age 64.0 vs 69.3 yrs; P < 0.01), higher persistent Afib (46.6% vs 37.5%; P < 0.01), higher comorbidity burden (% of >3 Elixhauser comorbidity score 96.8% vs 72.6%; P < 0.01) and had more OSA (43.6% vs 14.7%; P < 0.01). After adjusting for patient and hospital-level characteristics, we observed statistically significant decrease in odds of in-hospital mortality in obese Afib patients undergoing catheter ablation compared to non-obese [Odds Ratio (OR): 0.000004; P < 0.01]. We also observed the obese group had statistically significant association with longer LOS [4.1 vs 3.8 days; P < 0.01], lower total hospitalization charges [US$ 144,882 vs 157,412; P < 0.01] and increased odds of post-operative respiratory failure [OR: 1.97 (1.03 – 3.7); P = 0.04] compared to non-obese group.

Conclusion

In this large retrospective study of catheter ablation of Afib hospitalizations, higher BMI and obesity was associated with decreased in-hospital mortality consistent with the obesity paradox phenomenon. However, it was associated with longer LOS. The vascular complications and other procedural outcomes except respiratory failure were comparable between both groups. Further prospective studies are necessary to verify our study findings.
Catheter ablation of atrial fibrillation without pulmonary vein isolation
Authors: Futyma P , Zarebski L , Wrzos A , Futyma M , Kulakowski P
Published: May 2021

Funding Acknowledgements

Type of funding sources: None.

Background

Pulmonary vein isolation (PVI) is a cornerstone for catheter ablation (CA) of atrial fibrillation (AF), however, long-term efficacy of PVI is frequently below expectations. PVI is invasive, expensive and may be associated with devastating complications. It has been postulated that vagally-mediated AF can be treated by attenuation of parasympathetic drive to the heart using cardioneuroablation by means of radiofrequency CA (RFCA) of the right anterior ganglionated plexus (RAGP), however, data in literature and guidelines are lacking.

Purpose

To examine the efficacy of RFCA targeting RAGP without PVI in management of vagal AF.

Methods

We included consecutive 9 male patients with vagal AF who underwent RFCA of RAGP without PVI. RAGP was targeted anatomically from the right atrium (RA) at the postero-septal area below superior vena cava (SVC) and from the left atrium (LA) if needed. The aim was to achieve >30% increase in heart rate (HR) . The follow up consisted of regular visits and Holter ECG conducted every 3 months.

Results

A total number of 9 patients (age 52 ± 13) with vagally-mediated AF underwent RFCA of RAGP (mean RAGP RF time 147 ± 85, max power 34 ± 8W). The mean procedure time was 60 ± 29min. HR increase >30% was achieved in 8 (89%) patients (pre-RF vs post-RF: 58 ± 8bpm vs 87 ± 12bpm, p = 0.00002) . Transseptal  to reach RAGP also from the LA was needed in 2 (22%) patients. There were no major complications during the procedures. The follow up lasted 6 ± 2 months. Antiarrhythmic drugs were discontinued in 8 (89%) patients. There was 1 (11%) AF recurrence in the patient in whom targeted HR acceleration during RFCA was not achieved. B-blockers were administered in  6 (67%) patients due to increased HR and such treatment was well tolerated by all.

Conclusions

Catheter ablation of RAGP without performing PVI is feasible and can be effective in majority of patients with vagally-mediated AF. Increased HR after such cardioneuroablation can be well controlled using b-blockers and is usually associated with mild symptoms. The role of cardioneuroablation for treatment of vagally-mediated AF needs to be determined in prospective trials. Abstract Figure. Cardioneuroablation in vagal AF
Extent of atrium with 1:1 electrogram activation predicts response to ablation of atrial fibrillation
Authors: Ganesan P , Bhatia N , Rogers AJ , Krummen D , Wang P , Clopton P , Rappel WJ , Narayan S
Published: May 2021

Funding Acknowledgements

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Institutes of Health

Background

Mechanisms associated with successful termination of persistent atrial fibrillation (AF) are still under debate. We sought to study the association between spatial extent of atrium with organized conduction and AF ablation success. We hypothesized that patients with large areas of atrium having 1:1 electrogram activation akin to ‘atrial tachycardia’ may have a higher likelihood of AF termination by ablation.

Methods

In n = 40 AF patients, n = 20 had termination by ablation ("Term"), and the remaining did not have AF termination by ablation ("Non-term"). Basket catheters (64 poles) were used to record unipolar electrograms (EGMs) in one or both atrium. Ablation targeted localized rotational/focal regions, after which pulmonary vein isolation was performed. Unipolar EGMs of 4sec duration at each 2x2 electrode neighborhood within 8x8 catheter grid were processed using a statistical correlation technique to identify the duration of 1:1 activations. Any EGM activation cycle that had a correlation above 80% was considered to be 1:1. Duration of contiguous 1:1 cycles was determined as percentage of total duration (4 sec).

Results

Spatial area of atrium (percentage of mapping field) and the corresponding 1:1 durations were assessed for patients in Term and Non-term groups. Fig A shows spatial 1:1 maps of a Term and a Non-term patient. Fig B shows examples of 1:1 and non-1:1 EGMs. Patients in Term group had higher average 1:1 atrial area than non-term group for any 1:1 duration (Fig C, 15 ± 22% vs 2 ± 4% with ≥70% 1:1 duration, p = 0.03). Positive and negative predictive values of duration≥70% for AF termination were 64.7%, and 75%, with specificity 60% and sensitivity 78.6%, exceeding clinical risk scores.

Conclusion

Persistent AF atrium shows areas of organized 1:1 conduction. Larger 1:1 atrial areas were identified in patients in whom AF terminated by ablation. Future studies should investigate mechanistic bases of organized conduction in AF. Abstract Figure.