bluuebunny/crossref_metadata_2025_split huggingface dataset:
High-density, high-resolution mapping in patients with recurrent atrial fibrillation after cryoballoon pulmonary vein isolation: findings and outcome after repeat ablation
Authors: Musat D , Milstein N S , Shaw R , Bhatt A , Habibi M , Preminger M , Sichrovsky T , Mittal S 
Published: November 2023

Abstract

Background
Some patients have recurrent atrial fibrillation (AF) after cryoballoon (CB) pulmonary vein isolation (PVI). When these patients undergo repeat ablation, radiofrequency (RF) energy is used. However, there are scarce data from high-density, high-resolution mapping in these patients and the outcome after repeat ablation.

Objectives
We sought to determine the rate of PV reconnections in these patients and the impact of repeat ablation on long-term freedom from recurrent AF or atrial tachycardia (AT).

Methods
Following CB PVI, 70 (27%) out of 264 patients required repeat ablation. This cohort evaluated the 43 (61%) patients in whom high-density, high-resolution three-dimensional mapping and subsequent ablation were performed with the Boston Scientific RHYTHMIA system. All patients had an implantable loop recorder (ILR) capable of daily remote data transmission; all recurrences of AF/AT were adjudicated.

Results
The mean age of the 43 patients was 68 ± 9 years; 28 (65%) patients were male and the CHA2DS2-VASc score was 2.8 ± 1.8. The median AF burden (AFB) in the cohort was 2.23% (IQR: 0.40, 11.0); recurrences were paroxysmal in 27 (63%) patients. Recurrent PV connection was seen in 32 (74%) patients; these were limited to 1 or 2 veins in 26 (81%) patients. PVI alone was performed in 15 (35%) patients; the other 28 (65%) patients underwent PVI, if needed, and additional lesions. During the next year, 23 (53%) patients continued to have recurrent AT/AF with an overall median AFB of 0.36% (IQR: 0, 7.19). Outcome was similar in patients who had PVI alone and those who had additional lesions with/without PVI (Figure).

Conclusions
Following CB PVI, persistent PVI was observed in only a quarter of patients when assessed by high density, high-resolution mapping. A targeted ablation strategy based on mapping data resulted in continued AF in half the cohort, though the AFB was reduced by 84%. There is a need to identify optimal mapping and ablation strategies in patients who continue to have AF after CB PVI as well as the optimal endpoint after repeat ablation.
Left atrial posterior wall isolation using pulsed-field ablation: procedural characteristics, safety, myocardial injury and short-term outcomes
Authors: Weidlich S , Schweigler A , Serban T , Krisai P , Voellmin G , Knecht S , Sticherling C , Kuehne M , Badertscher P 
Published: November 2023

Abstract

Background
Pulsed-field ablation (PFA) has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). Among targets beyond pulmonary vein isolation (PVI), ablation of the left atrial posterior wall (LAPW) has gained increased interest in patients with persistent AF. PFA offers a novel ablation technology possibly able to overcome the obstacles of incomplete isolation and concerns of damage to adjacent structures.

Purpose
To assess procedural characteristics, safety, myocardial injury and short-term outcomes of patients undergoing LAPW ablation in a clinical setting.

Methods
Consecutive patients undergoing PFA PVI with LAPW isolation were included. Using a multi-spline PFA catheter in a flower configuration, two anchor lesions per vein extending to the LAPW were deployed. Then, the wire was pulled back into the lumen, the PFA catheter and sheath were rotated along the entire LAPW in a flower configuration thereby creating overlapping lesions as assessed by a 3D-electro-anatomical mapping system. First-pass isolation was controlled using a multipolar mapping catheter. Complications were checked with an echocardiogram, high sensitivity cardiac troponin T was measured the next day and for recurrence detection a Holter ECG was performed during follow up.

Results
25 patients with persistent AF undergoing PVI were included (age 69 ± 12 years, left atrial volume index 37 ml/m2). 17 patients underwent redo-PVI with LAPW and 8 patients first time PVI with LAPW ablation. The median number of applications to perform LAPW isolation using PFA was 24 (IQR 14-28). The median procedure time was 69 min (IQR 56-81). The median LA dwell time was 59 min (IQR 49-72). The median fluoroscopy time was 10 min (IQR 8-14). First-pass isolation was achieved in 24/25 cases (95%). There were no complications. High sensitivity cardiac troponin T level post-procedurally was 951 ng/L (IQR 717-1189). Median duration of follow-up were 95 days, (IQR 84-184), AF recurrence was observed in 2 patients (8%).

Conclusion
LAPW ablation with PFA appears safe and results in high acute isolation rates. The optimal technique to perform LAPW ablation using PFA needs to be defined. Data on long-term outcomes are missing.
Pulmonary vein isolation with posterior wall isolation versus pulmonary vein isolation alone for patients with persistent atrial fibrillation: a systematic review and meta-analysis
Authors: Rivera A , Nascimento B N S R , Miyawaki I A , Menezes Junior A 
Published: November 2023

Abstract

Background
Pulmonary vein isolation (PVI) is considered the cornerstone of atrial fibrillation (AF) ablation, with a better success rate in paroxysmal AF vs. persistent AF. Although recent evidence suggests that additional ablation targets such as the left atrial posterior wall (LAPW) may play a role in improving the efficacy of AF ablation, the effectiveness of PVI combined with posterior wall isolation (PWI) remains unclear in patients with persistent AF.

Purpose
We aimed to perform a systematic review and meta-analysis of PVI with vs. without PWI in patients with persistent AF.

Methods
We systematically searched PubMed, EMBASE, Cochrane and ClinicalTrials databases for randomised controlled trials (RCTs) comparing PVI alone and PVI with PWI. The systematic review and meta-analysis followed Cochrane and PRISMA recommendations. Review Manager 5.1 was used for statistical analysis. Heterogeneity was examined with I2 statistics. Random-effect models were used if I² &gt; 25%.

Results
We included 10 RCTs with a total of 1,415 patients, of whom 702 (49.6%) were assigned to the PVI alone group. Freedom from AF recurrence did not differ significantly between groups (OR 1.40; 95% CI 0.95-2.05; p=0.09; Figure 1A), nor did freedom from all recurrence of any atrial arrhythmia (OR 1.33; 95% CI 0.80-2.21; p=0.28; Figure 1B). No significant differences were found between the two groups in terms of left ventricular ejection fraction (p=0.24) or left atrial diameter (p=0.71). There was also no significant difference found in adverse events, including phrenic nerve injury (p=0.73), pericarditis (p=0.71), and cardiac tamponade (p=0.59). Total procedure time (MD 22.7 minutes; 95% CI 15.6-29.9; p&lt;0.01; Figure 2A) and ablation time (MD 13.56 minutes; 95% CI 8;06-19.07; p&lt;0.01; Figure 2B) were significantly lower in the PVI group.

Conclusion
Our findings suggest that freedom from recurrence of AF, freedom from recurrence of atrial arrhythmias, and adverse events is not significantly different between patients who undergo PVI for persistent AF with or without PWI. As expected, adding PWI to PVI was associated with a longer procedure and ablation time.Figure 1Figure 2
Left atrial fibrosis-guided ablation in patients with atrial fibrillation: a systematic review and meta-analysis of randomized trials
Authors: Ahn H J , Lee S R , Lee K Y , Choi J M , Kwon S , Choi E K , Oh S 
Published: November 2023

Abstract

Background
Left atrial fibrosis is related to atrial fibrillation (AF) recurrence after AF ablation. However, the benefit of patient-specific substrate modification guided by fibrosis delineated on voltage mapping or magnetic resonance imaging (MRI) is conflicting.

Objective
To compare the efficacy and safety of additional modification of left atrial fibrosis [identified by low-voltage area (LVA) or late gadolinium-enhancement on MRI] vs. circumferential pulmonary vein isolation (PVI) with or without stepwise ablation not targeting fibrosis in AF.

Methods
A systematic search of PubMed, EMBASE, and Cochrane Central Register of Controlled Trials was performed from inception to November 2022. Only randomized studies investigating the utility of fibrosis-guided substrate modification beyond conventional PVI were included. The primary outcome was a recurrence of any atrial arrhythmia. Major adverse events and procedural, fluoroscopic, and total ablation time were defined as secondary outcomes. We calculated pooled estimates of the outcomes by a random-effect model and reported them as risk ratio (RRs) and 95% confidence interval (CI).

Results
A total of 9 studies (8 randomized controlled clinical trials and 1 randomized design within a prospective study) and 2135 patients with AF were included. The atrial arrhythmia recurrence was lower in the additional fibrosis-guided ablation group (RR 0.82; 95% CI 0.71-0.94; p=0.006) (Figure 1A). No differences were found between fibrosis-guided substrate modification and conventional PVI group in major adverse events [RR 1.25 (0.55-2.81), p=0.598)] and mean differences of procedural time [-2.88 (-40.34 to 34.57) min], fluoroscopic time [1.82 (-1.86 to 5.49) min], and total ablation time [-14.28 (-48.70 to 20.14) min]. In the stratified analyses, there were no interactions of the lower atrial arrhythmia recurrences within the modality of fibrosis identification (LVA vs. delayed enhancement on MRI), type of AF (paroxysmal vs. persistent), the burden of LVA (no or low vs. high), and strategy of the control group (PVI only vs. PVI plus stepwise ablation) (Figure 1B).

Conclusion
By incorporating two modalities of left atrial substrate evaluation – voltage mapping and MRI – we conclude that the individually tailored fibrosis-guided ablation in AF is associated with a lower recurrence after catheter ablation.
An international multicentre experience with the third-generation laser balloon system: safety, efficiency, and efficacy
Authors: Martignani C , Bartoli L , Spadotto A , Tilz R R , Heeger C H , Giaccardi M , Miracapillo G , Forleo G B , Schiavone M , Giomi A , Arena G , Ciconte G , Pappone C , Montemerlo E , Rovaris G 
Published: November 2023

Abstract

Background
Pulmonary vein isolation (PVI) with endoscopic laser balloon systems (ELBS) is an innovative option for catheter ablation of atrial fibrillation (AF). The third-generation ELBS has several structural improvements, including a novel feature (RAPID mode), potentially allowing a high-speed and precise circumferential PVI. Nevertheless, there is a need for large, multicentre studies on its use.

Objective
To assess the safety, efficiency, and efficacy of the third-generation ELBS in a multicentric, international cohort of patients.

Methods
We analyzed the data of all consecutive patients who underwent PVI using the third-generation ELBS between June 2019 and December 2022 in eight Italian and one German Hospital. For each pulmonary vein (PV), the maximum amount of laser delivery with the RAPID mode was attempted. When RAPID mode was not feasible, the operator used point-by-point laser delivery.

Results
We enrolled 429 patients (mean age 61.1±10.7 years, persistent atrial fibrillation 27.7%, female patients 27.7%). The operators isolated 1654 pulmonary veins. 93 (21.7%) patients had an anatomical variation of the left atrium, 60 of them had either a left or a right common trunk, and 33 had a middle PV. Mean total procedural and fluoroscopic times were 115.4±58.2 min and 19.3±12.8 min, respectively. Information on the use of RAPID mode was available for 336 patients: mean use of this feature was possible for 86±18.2 % of the PVs circumference. The operators could use the RAPID mode for at least 90% of all PVs circumference in 148 of 336 patients (44%), and ablation using only RAPID mode was possible in 79 of them (23%). 12 (2.8%) periprocedural complications occurred. There were 6 (1.4%) episodes of phrenic nerve palsy, of which only 1 (0.2%) did not completely resolve during follow up. 3 (0.7%) pericardial tamponades occurred, with a subsequent need for pericardiocentesis. Finally, there were 3 (0.7%) periprocedural transient ischaemic attacks (TIA), which resolved without sequelae. 219 patients were followed up for at least six months (mean follow-up 12.3 ± 6 months). Among these, 63 (28.8%) presented a clinical and/or subclinical recurrence after the blanking period.

Conclusion
This is the largest multicentre cohort of patients treated with the third-generation ELBS. In this multicentric international experience, the system proved to be safe, efficient and effective and the RAPID mode showed optimal applicability.
Novel technique for significant reduction of phrenic nerve injury in cryoballoon pulmonary vein isolation
Authors: Phkhaladze K , Omran H , Thale J , Sciacca V , Fink T , Isgandarova K , Braun M , Khalaph M , Guckel D , El Hamriti M , Sohns C , Vogt J , Sommer P , Imnadze G 
Published: November 2023

Abstract

Background/Introduction
Pulmonary vein isolation (PVI) in cryoballoon (CB) technique is a golden standard for AF treatment. However, collateral damage of non-cardiac structures, such as phrenic nerve injury (PNI) remains an Achille’s heel of CB technology.

Purpose
The purpose of this study was to develop a therapeutic concept while establishing a new technique with three consecutive steps during the procedure in order to significantly decrease the occurrence of PNI in the intervention group in comparison with control group.

Methods
We conducted a retrospective, multicenter, observational review involving 1000 patients with symptomatic, treatment-resistant atrial fibrillation (AF) within last 8 years evaluating incidence and clinical characteristics of PNI during cryoballoon PVI. Patients were divided into the control (n=750) and intervention (n=250) groups. Patients in the intervention group were treated according to the new technique with three additional consecutive steps:
A-Phrenic nerve stimulation close to the stimulation threshold (double output) instead of 10V stimulation.
B-Advance approach for right superior pulmonary vein (PV) using the pre-freezing technique.
C-Pull away after vein isolation and/or after achieving -40°C for both right-sided PVs.

Results
A total of 1000 patients with a mean age of 63 (±11) years (62.3 % male) were investigated. 59.5% (n=595) of patients were admitted with paroxysmal AF, while 40.3% (n=403) suffered from persistent and 0.2% (n=2) from permanent AF. In 95.8% (958) it was the first PVI procedure. Two subtypes of PNI including permanent (without recovery until discharge) and transient (recovery until discharge) PNI were investigated. Transient PNI occurred in 8 patients (3.2%) in the intervention group compared to 46 patients (6.1%) in the control group, p=0.07. Persistent PNI occurred in one patient (0.4%) in the intervention group compared to 23 (3.1%) in the control group, p=0.017. Any PNI occurred in 9 patients in the intervention group (3.6%) compared to 69 patients (9.2%) in the control group, p=0.004.

Conclusion
This retrospective study provides insights into the use and effectiveness of our novel technique for PVI, which could markedly reduce the incidence of PNI, especially persistent PNI.
Anticoagulation therapy in patients with atrial fibrillation and active cancer
Authors: Jaakkola J , Teppo K , Halminen O , Linna M , Haukka J , Putaala J , Mustonen P , Kinnunen J , Hartikainen J , Airaksinen K E J , Lehto M 
Published: November 2023

Abstract

Background
Atrial fibrillation (AF) is common among cancer patients. Oral anticoagulation therapy (OAT) is important to prevent stroke in AF patients, but active cancer may also predispose to bleeding. Current knowledge on the use of OAT among AF patients with active cancer is scarce.

Purpose
To assess the influence of active cancer on the initiation of OAT in patients with AF and to explore cancer features predicting withholding OAT.

Methods
The nationwide FinACAF registry linked data from several registries covering all levels of care as well as drug purchases and included all 123 618 patients diagnosed with incident AF in Finland during 2011- 2018 with an indication for OAT (≥1 non-sex CHA2DS2-VASc point). Patients were considered to have active cancer if they had received a new cancer diagnosis or treatment for cancer during the preceding year from AF diagnosis. The primary outcome was the initiation of OAT (including non-vitamin K oral anticoagulants (NOAC) and warfarin) and the secondary outcome the initiation of any anticoagulation therapy (AAT; including OAT and low molecular-weight heparin) during the first year from AF diagnosis.

Results
The mean age of the patients was 73.9 (standard deviation 11.5) years and 62 955 (50.9%) of them were women. Altogether, 7015 (5.7%) patients had active cancer at AF diagnosis. The median CHA2DS2-VASc (3 [interquartile range 2-4] for both groups) and HAS-BLED (2 [interquartile range 2-3] for both groups) scores were similar in patients with active cancer and those without cancer history. Patients with active cancer, compared to those without cancer history, less often initiated OAT (47.7% vs. 70.5 %) or AAT (61.8% vs. 71.8%) (Figure). In Fine-Gray regression analyses with all-cause mortality as a competing risk, after adjusting for confounding factors, active cancer remained associated with lower likelihood of OAT (adjusted subdistribution hazard ratio (aSHR 0.501) (95% confidence interval (CI): 0.485-0.518), p&lt;0.001) as well as AAT (aSHR 0.745 (95%-CI 0.723-0.769, p&lt;0.001) initiation. Among cancer patients, metastases, gastrointestinal cancer and radiotherapy were associated with lower likelihood of OAT initiation, while only metastases predicted lower likelihood of AAT initiation (Table). Among patients initiating OAT, active cancer was associated with lesser likelihood of choosing a NOAC over warfarin compared to those without cancer (36.0% vs. 39.2%; adjusted hazard ratio 0.712 (95%-CI: 0.640-0.792), p&lt;0.001).

Conclusion
AF patients with active cancer are less likely to initiate anticoagulation therapy, and those starting OAT are less likely to initiate with NOACs, compared to patients without cancer history. Metastases are the most important predictor of withholding anticoagulation therapy among AF patients with cancer.
Individual risk prediction of anticoagulation in atrial fibrillation patients with cirrhosis
Authors: Kim I , Lee H W , Kim B K , Seo J W , Min P K , Choi E Y , Yoon Y W , Lee B K , Hong B K , Rim S J , Kwon H M , Kim J Y 
Published: November 2023

Abstract

Background
We aimed to assess absolute risk and benefit from OAC therapies in individual AF patients with liver cirrhosis (LC), and to develop the optimal dose selecting risk calculator for each patient.

Methods
We derived and validated a prediction model for major bleeding (MB) and stroke/systemic thromboembolism (SSTE) in AF patients with LC from two-center observational cohort (n=420 in derivation cohort, n=180 in validation cohort) with 4 treatment options (standard-, low-dose NOACs, warfarin, and no OACs). Readily available clinical variables were included in machine learning-based ensembled risk calculation models.

Results
Model calibration and discrimination was adequate with c-statistics of 0.77[0.66-0.87] for MB and 0.74[0.74-0.84] for SSTE. Three-year absolute risk increases (ARIs) for MB with standard-dose NOACs ranged from &lt;10% in 37% of patients to &gt;30% in 18% of patients, with low-dose NOACs ranged from &lt;10% in 47% of patients to &gt;30% in 12% of patients compared without OACs. Three-year absolute risk reductions (ARRs) for SSTE with standard-dose NOACs ranged from &lt;7% in 48% of patients to &gt;15% in 22% of patients, with low-dose NOACs ranged from &lt;7% in 57% of patients to &gt;15% in 17% of patients compared without OACs. The ARI cutoff for MB and ARR cutoff for SSTE with OAC were shown as &gt;2.4%/year and &gt;1.2%/year (c-statistics 0.81[0.78-0.83], 0.75[0.72-0.79]).

Conclusions
Artificial intelligence combining clinical variables was found to predict individual patient’s bleeding and stroke/systemic embolism risks well and it can also guide each patient’s appropriate OAC dose in AF patients with LC (web-calculator can be accessed as: https://riskcalc.shinyapps.io/AFLC/).
Predicting incident atrial fibrillation in patients with embolic stroke of undetermined source
Authors: Chousou P A , Chattopadhyay R , Ring L , Khadjooi K , Warburton E , Mukherjee T , Bhalraam U , Tsampasian V , Potter J , Perperoglou A , Pugh P , Vassiliou V 
Published: November 2023

Abstract

Introduction
Atrial fibrillation (AF) is an important potential embolic source in patients who have suffered an embolic stroke of undetermined source (ESUS). AF has been detected in over 40% of patients when monitored with an implantable loop recorder (ILR). Recent clinical trials, however, have suggested that empirical anticoagulation of all patients with an ESUS is not an effective approach to reduce stroke risk. Thus predicting which patients are most likely to develop AF is of increased importance. Risk models for predicting incident AF exist but they do not incorporate modern techniques such as advanced echocardiographic parameters to create a comprehensive risk model.

Purpose
We sought to create a multi-parametric risk score for the prediction of incident AF in patients with ESUS.

Methods
This was a single-centre retrospective study. Consecutive adult patients referred for ILR implantation following ESUS, between March 2009 and November 2019, without prevalent AF or atrial flutter, were included.
Patients’ notes were reviewed for clinical and anthropometric data. Each patients’ echo was re-reviewed both for conventional measures, and advanced parameters including left atrial strain using speckle-tracking (figure 1) and atrial electromechanical delay utilising the time from onset of the electrocardiographic P-wave to the lateral tissue Doppler A’ wave- "lateral PA".
Univariate and multivariable analyses were performed, and a subsequent Lasso regression analysis used to develop a risk prediction model. Bootstrapping was used to perform internal validation.

Results
A total of 323 patients with ESUS who underwent a loop recorder implantation were included. Incident AF was detected in 142 patients (47.1%). Increased duration of the time between the electrocardiographic P-wave and the lateral tissue Doppler A’ wave (greater lateral PA), older age, higher diastolic blood pressure, abnormal left atrial reservoir strain were most strongly associated with increased AF risk. These were combined to form the PADS score below. Model discrimination was good, with an area under the curve of 0.72.

Conclusion(s)
The PADS score is a novel risk score for the prediction of incident AF in patients who have suffered an ESUS, based on the duration of the P-wave to the lateral tissue Doppler A’ wave, Age, Diastolic blood pressure and left atrial strain reservoir . Further work is required to assess whether the PADS score can be used to risk stratify patients into a high risk group which would derive benefit from immediate anticoagulation, an intermediate risk group who require prolonged continuous monitoring and a low risk group who can continue on conventional management for their stroke.PADS formulaLA strain using speckle strain analysis