bluuebunny/crossref_metadata_2025_split huggingface dataset:
An international two-centre experience with the third generation laser balloon system: safety, efficiency, and efficacy
Authors: Martignani C , Bartoli L , Spadotto A , Massaro G , Piemontese G P , Angeletti A , Ziacchi M , Phan H L , Keelani A , Eitel C , Vogler J , Biffi M , Kuck K H , Tilz R R , Heeger C H 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Endoscopic laser balloon systems (ELBS) are a new tool for pulmonary vein isolation (PVI). The third generation ELBS underwent significant structural improvements compared to its predecessors. These include a novel feature (RAPID mode), potentially allowing an automized and high-speed circumferential energy delivery for PVI. However, there is a lack of data on its use.

Objective
We analyzed the safety, efficiency, and efficacy of the third-generation ELBS in a cohort of patients who underwent ablation of atrial fibrillation in a German and an Italian centre.

Methods
We prospectively enrolled all consecutive patients who underwent PVI using the third-generation ELBS between June 2019 and November 2022. All the procedures were performed by four operators. For each pulmonary vein (PV), we always attempted to obtain a complete circumferential lesion using only the RAPID mode. When this was not feasible, the operator treated the remaining gaps with point-by-point laser delivery.

Results
We included 163 patients in our study (mean age 61.9 ± 11.4, persistent atrial fibrillation 30.6%, female patients 30.6%). The operators identified and successfully isolated 655 pulmonary veins. There was an anatomical variation of the PVs in 41 (25.1%) patients, of whom 19 had either a left or a right common trunk, and 23 had a supernumerary right PV. 424 PVs (64%) were isolated for at least 80% of their circumference using the RAPID mode, 389 (59.4%) were treated using it for a minimum of 90% of their circumference, and finally, 289 (44%) were isolated using only RAPID. The operators could perform the procedure using only the RAPID mode in 35 (21.5%) patients. We observed a mean total procedural and fluoroscopic times of 95.7 ± 44.5 min and 13.9 ± 8.4, respectively. 5 (3%) periprocedural complications occurred. There were three episodes of transient phrenic nerve palsy (the most extended episode resolved two months after discharge). One episode of pericardial tamponade occurred, with a subsequent need for pericardiocentesis. Finally, there was one periprocedural transient ischaemic attack (TIA). During energy delivery, eight pinhole balloon ruptures occurred.
Eighty-five patients were followed up for at least six months (mean follow-up 12.2 ± 4.4 months). Among these, 26 (30.5%) presented a recurrence after the blanking period. Among baseline features, persistent AF was not a predictor of recurrence.

Conclusion
This is one of the largest cohorts of patients treated with third-generation ELBS. In our two-centre experience, the system proved efficient, safe, and effective and the RAPID mode showed good applicability.
Pulmonary vein isolation and additional selective ablation of low voltage areas and atrial late potentials for persistent atrial fibrillation (SOLVE-AF-Study)
Authors: Jadidi A , Mueller-Edenborn B , Eichenlaub M , Lehrmann H , Allgeier J , Trenk D , Neumann F , Westermann D , Arentz T 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Private company. Main funding source(s): Abbott

Introduction
Novel catheter ablation technologies (e.g. RF with contiguous lesions) for pulmonary vein isolation (PVI) achieve high (80-85%) arrhythmia freedom rates at 12 months in both paroxysmal and persistent AF. However, success rates are importantly reduced (45-50%) in persistent AF patients presenting atrial cardiomyopathy with additional low voltage areas in the left atrial body.

Aim
SOLVE-AF study is a prospective randomized multicenter study, in which the standard approach "circumferential PVI" is compared to "additional ablation of low voltage areas and ablation of slow conducting "atrial late potentials (ALPs)" during sinus rhythm (SR)".

Methods
320 patients with persistent AF will be included. Patients undergo left atrial high definition voltage mapping in SR. 160 patients with low voltage areas (&lt;0.5mV at &gt;5cm2) within the LA body will be randomized to "circumferential-PVI" vs. "additional low-voltage-guided ablation". The remaining 160 without low voltage substrate (registry group) will undergo "circumferential-PVI". Arrhythmia recurrences (defined as AF/AT &gt;30 sec) will be assessed at 6 and 12 months (7-day-Holter and event-recorder) following ablation therapy (top panel).

Results
Currently, 120 patients have been included into the registry group and 120 patients with low voltage substrate have been randomized. Results of the SOLVE-AF-pilot study including a total of 210 patients (110 registry patients without LA-LVS and 100 patients with LA-LVS who were assigned to PVI-only versus additional substrate-based ablation) at the University-Heart-Center-FR-BK favor "PVI plus substrate-based ablation" in those patients who do present significant low voltage areas (see KM-curve bottom panel).

Conclusions
Results from the pilot trial suggests improved arrhythmia freedom rate with PVI plus additional substrate-based ablation during sinus rhythm. Final results of the prospective randomized multi-center trial SOLVE-AF are expected in June 2024.
Identification of atrial complex electrograms by short-coupled extrastimuli in paroxysmal and persistent atrial fibrillation
Authors: Silva E , Lobo Torres I , Fernandez Garcia M , Gomez Lopez A , Fernandez Rivero R , Cano Calabria L , Fernandez-Armenta Pastor J 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Public hospital(s). Main funding source(s): - Health Council of the Andalusian Regional Government through the project "PI-0057-2017".
- European Regional Development Fund/European Social Fund.

Introduction
Electrogram fractionation during atrial fibrillation (AF) and sinus rhythm have been studied as marker of atrial remodeling and potential target for ablation.

Objective
The aim of our study was to analyze the response to closely coupled atrial extrastimuli and try to identify areas of hidden slow conduction (HSC) that can promote reentry and AF maintenance in paroxysmal and persistent AF.

Methods
Twenty consecutive patients with paroxysmal AF and persistent AF (10:10) underwent first PVI procedure. During sinus rhythm triple short coupled extrastimuli was delivered. Locations showing double or highly fragmented electrograms in response to triple extrastimuli were defined as positive electrogram (HSC-EGM) (Figure 1). Increase in duration (delta) of the bipolar EGM was recorded. Two consecutive high-density maps were acquired using a multipolar catheter during AF, sinus and paced rhythms. Spatial correlation of HSC-EGM and complex atrial fractionation (CFAEs) during AF were evaluated.

Results
Patients with persistent AF showed a higher number and percentage of HSC-EGM than paroxysmal AF (13,9% vs 3,3%, p&lt;0.001) (Figure 2). Delta of EGM duration was 53 ± 22 ms compared to 16 ± 14 ms in sites with a negative response (p&lt;0.001). The number of HSC-EGM distinguished with extrastimuli was lower than that of CFAEs during AF (19 vs 56 per map, p&lt;0.01). The reproducibility of the extension and distribution of HSC-EGM in the repeated maps was superior to that of the CFAEs. The distribution of the HSC-EGM was comparable with those found in the initial map (p=0,32), however, there were significant differences in the distribution of CFAEs between the first map and the remap (p=0.003).

Conclusion
HSC-EGM in response to triple extrastimuli are more frequent in persistent AF. This type of evoked response could reveal the presence of slow conduction areas and could be considered a potential target for ablation of persistent atrial fibrillation. More studies are needed to confirm this hypothesis.
Heterogeneity in voltage and activation time in the left atrium of atrial fibrillation patients undergoing pulmonary vein isolation
Authors: Meijer I , Keshtkar S , Kong X , Jiang C , Ma C , Camara O , Marquering H , Arrarte Terreros N , De Groot J 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Public grant(s) – EU funding. Main funding source(s): ITEA 3 Symphony project

Introduction
Electro-anatomical maps are standardly used to visualize anatomy and electrophysiological properties of the left atrium during pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients. We sought to describe heterogeneity in atrial voltage and activation time, as a proof-of-principle, to study its association with treatment outcome. Therefore, we projected all data-points from electro-anatomical maps to the CT scan meshes of the left atrium and calculated median voltage and activation time in patients with paroxysmal or persistent AF undergoing first PVI ablation. We hypothesize that the variation and heterogeneity in these parameters throughout the left atrium carry important prognostic and diagnostic information and can be used to discern different subtypes of AF.

Methods
We included AF patients who underwent PVI for the first (cohort I) and second time (cohort II) during 2021-2022. Electro-anatomical maps during sinus rhythm were acquired before and after the ablation procedure and were projected on the patient-specific CT-scan-derived mesh of the left atrium. Patients underwent 6 to 12-month follow-up and were classified as persistent (AF lasting longer than 7 days and usually requiring electrical cardioversion) and paroxysmal (self-terminating AF episodes, lasting shorter than 7 days, mostly shorter than 24 hours). We determined bipolar voltages and activation times for persistent and paroxysmal AF patients in each cohort. In addition, we compared global left atrial voltage and activation times pre- and post-PVI.

Results
Our study population consisted of 24 patients: 14 patients in cohort I and 10 patients in cohort II. Summary of baseline and voltage and activation times can be found in Figure 1. In both cohorts, patients with persistent AF showed a trend towards a lower median LA voltage (Figure 1), but not a longer median atrial activation time. Paroxysmal patients showed more heterogeneity (wider IQR) in both voltage and activation times compared to persistent AF patients. Figure 2 displays a typical example of an electro-anatomical reconstruction of a paroxysmal AF patient pre- and post-second-PVI where the local heterogeneity can be observed - after the ablation, higher voltages and shorter activation times were observed.

Conclusion
We provide a proof-of-principle demonstrating that with the use of conventional electro-anatomical maps, important information on heterogeneity and variance in local voltage and activation time can be quantified. This quantification can help discern different AF subtypes and might contribute to understanding different arrhythmogenic substrates and treatment outcome differences.
Atrial myocardial substrate has a significant influence on local impedance data - clinical experience from high power short duration and standard radio frequency ablations
Authors: Herold V , Reents T , Maurer S , Bahlke F , Kottmaier M , Krafft H , Lengauer S , Tutarel O , Hessling G , Deisenhofer I , Bourier F 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
Local impedance is a new clinically used RF ablation parameter used to predict RF lesion creation. By now, data about the influence of atrial substrate on local impedance is still scarce. The aim of this study was to investigate local impedance data of different atrial tissues (healthy myocardium vs. Low Voltage areas) and the importance of local impedance drops during HPSD and standard RF ablation in atrial tissue.

Methods
A total of n=1319 clinical RF applications in n=51 clinical left atrial ablation procedures were analyzed regarding underlying RF ablation parameters (RF power, duration, contact force, global and local impedance data). 3D mapping data were used to differentiate RF ablations in low voltage areas (&lt;=1.0mv) from those in healthy atrial myocardium (&gt;1.0mV). Local and global impedance baseline values and drops, RF electrogram amplitude attenuation, as well as RF data were calculated and registered for statistical analysis.

Results
Local impedance drops were significantly higher during RF application in healthy myocardium when compared to low voltage areas (18,6 vs. 16,6 Ohm, p&lt;0.01). Baseline local impedance was significantly higher in healthy atrial myocardium when compared to low voltage areas (105,4 vs. 99,1 Ohm, p&lt;0.01). There was no significant difference in global impedance values between low voltage areas and healthy atrial myocardium (p=0.34). These findings were confirmed in HPSD (60W, 10s) as well as in standard (30-40W, 30-60s) RF applications. Impedance drops were significantly larger in HPSD when comapred to standard RF ablation (p&lt;0.01). Detailed boxplot results are presented in the Figure.

Conclusions
Local impedance drop is a good predictor of RF lesion creation in HPSD as well standard RF ablations. Interestingly, different local impedance but not global impedance values were observed in healthy and low voltage areas. In clinical practice, local impedance may be a useful parameter to identify atrial substrate.
Initial experience and early outcomes of posterior wall ablation using pulsed-field ablation
Authors: Kueffer T , Madaffari A , Muehl A , Seiler J , Thalmann G , Servatius H , Tanner H , Haeberlin A , Baldinger S H , Kozhuharov N A , Noti F , Reichlin T , Roten L 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background
The success rate of pulmonary vein isolation (PVI) is lower in patients with persistent compared to paroxysmal atrial fibrillation (AF). In patients with persistent AF, additional isolation of the posterior wall is under investigation to improve ablation success. Pulsed field ablation (PFA) might be superior to conventional methods for posterior wall isolation due to its safety profile and might allow for posterior wall ablation (PWA) rather than posterior wall isolation (PWI) based on its efficiency.

Purpose
To report our initial experience with PWA using a multipolar PFA catheter.

Methods
Consecutive patients with PWA during their first PFA procedure for AF between May 2021 and October 2022 at our institution were included. For PWA, the multipolar PFA ablation catheter was used in flower configuration only. With the wire in each of the pulmonary veins and the sheath angulated posteriorly, we first performed 2 x 2 sets of anchor lesions with the catheter rotated by ~30° between sets. Next, with the wire retracted back into the device, single sets of two applications were delivered in an overlapping fashion and without catheter rotation between lesion sets to cover the entire posterior wall between the superior and inferior pulmonary veins. Finally, completeness of PWA was verified by 3D electro-anatomical mapping.

Results
PWA using PFA was performed in 163 patients (mean age 67 years, 71% male). In 55 patients (34%), PWA was added to PVI during the first AF ablation procedure and the remaining 108 patients (66%) had undergone a median of two (interquartile range 1-3) previous AF ablation procedures using either cryoablation and/or radiofrequency ablation. Of all patients, 45 (28%) had paroxysmal, 93 (57%) persistent AF, and 22 patients (15%) left atrial reentry tachycardia. Median procedure duration and fluoroscopy time were 120 (70-190) min, and 18 (9-36) min, respectively. 3D-EAM showed no residual electrical signal (&gt;0.05 mV) on the posterior wall at the end of the procedure in any patient. No cardiac tamponade, stroke, phrenic nerve injuries, atrio-esophageal fistula, or clinically manifest coronary spasm occurred.
A repeat ablation was performed in seven patients (4%) and 3D-EAM showed persisting posterior wall isolation in six (86%) and recurrent roof dependent atrial flutter in one patient. Despite PWA, low-voltage signals were found in four (67%) cases on the superior aspect of the posterior wall.

Conclusions
Left atrial PWA can be performed safely and efficiently using PFA. Early data on the durability of PWA are promising. The impact of PWA on arrhythmia-free outcome needs to be evaluated in larger, prospective randomized trials.
Role of diagnosis-to-ablation time in paroxysmal atrial fibrillation: preliminary results of the MULTI AF trial
Authors: Rossi L , Biagi A , Genovese D , Pelargonio G , Devecchi C , Pentimalli F , Bertini M , Bottoni N , Bricoli S , Bolognesi M G , Aschieri D 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Introduction
Diagnosis-to-ablation time (DAT) has been already defined as a predictor of atrial fibrillation (AF) ablation outcome. AF promotes pathological atrial remodelling at electrical, cellular, and structural levels. The aims of this study were to determine the role of DAT in atrial electrical remodelling and its impact on AF recurrencies.

Methods
Between January 2020 and February 2022, 122 patients (62% male, age 63.5±10.8 y) underwent pulmonary veins isolation (PVI) for paroxysmal atrial fibrillation in 7 Italian centres.
For each patient, a high-density bipolar voltage map (BVM) of the left atrium (LA) was acquired by sequential multielectrode mapping in sinus rhythm through the Pentaray™ Catheter and the CARTO3® mapping system. More than 200 voltage points per map were acquired in different segments of the LA (posterior, anterior, lateral, superior, septal and inferior ). The procedural endpoint was PVI by circumferential ablation around the pulmonary vein antra. On top of PVI no "adjunctive" ablations, were performed. All patients were monitored as outpatients for AF recurrence.

Results
For the 122 patients enrolled the mean DAT was 37.6±35.2 months. Two groups were identified according to DAT: 51 patients in Group A with DAT ≤ 12 months and 71 patients in Group B with DAT &gt; 12 months. The two groups have similar clinical, electrocardiographic and echocardiographic characteristics. Intraprocedural pulmonary vein isolation was achieved in all patients.
At the high-density left atrial BVM a concealed electrical remodelling was detected in group B in each LA segment (Fig.1), with the mean global LA voltage amplitude significantly lower in patients with DAT&gt;12 months (group A 2.32±0.81 mV vs group B 1.47±0.74 mV, p&lt;0.01).
After a median follow-up of 11.9±9.4 months, 14 patients (11.4%) had AF recurrencies following the first ablation procedure. A significant lower rate of AF recurrence was found among patients with DAT &lt; 12 months (Fig. 2): 2 patients in group A vs 12 patients in group B (4% vs 18.2%, p&lt;0.01).

Conclusion
Patients with paroxysmal atrial fibrillation with DAT&gt;12 months have significantly lower bipolar LA voltages, revealing a concealed atrial remodelling. Furthermore, DAT&gt;12 months is associated with poor AF ablation outcome.
Insights into level of pulmonary vein isolation using pulsed-field ablation for atrial fibrillation and unexpected effects in the posterior wall
Authors: Osca Asensi J , Izquierdo M T , Navarro J , Cano O , Pimenta P , Ayala H , Jover P , Martinez-Dolz L 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: None.

Background/Introduction
Pulse field ablation (PFA) has emerged as an effective, safe and efficient tool for pulmonary vein isolation (PVI).

Purpose
We studied the extent of PVI, specifically the isolation of PV antrum, carina and left atria’s posterior wall after PFA with an ultrahigh density mapping (UHD).

Methods
We involved the first patients referred for atrial fibrillation (AF) ablation treated with a PFA multispline catheter. PFA-lesion extension was assessed with a voltage-map UHD mapping performed before and immediately after PVI.

Results
Sixty-one consecutive patients underwent PVI with PFA (62±10 year old, 23 women, 39 paroxysmal AF). Four out of 61 patients were excluded because their posterior wall was isolated with extra aplications on purpose. Acute results involved a 100% success of PVI and the only safety issue was a pericardial effusion in one patient managed conservatively. Mean procedure and fluoroscopy times were 59±39 min and 16±5 min, respectively. UHD immediately after PVI revealed early reconnection just in one vein (1/228 veins). PFA created wide antral circumferential lesions without electrical activity registered by UHD mapping inside the isolation area. There were no notch-like normal voltage areas at the anterior or posterior side of carinas. As a result of the PVI with this technology, it was observed the existence of a narrow corridor in the posterior wall in 8 patients (14%) and in another 8 cases right and left antral ablation converged at the posterior wall creating an unexpected isolation area. There was a significant relationship between LA posterior inter-carina distance and posterior wall´s level of isolation (77,1±7mm, no affectation; 68,8±7mm narrow corridor; 60,3±1mm posterior wall isolation (fig 1); p=0.036). Finally, it was a significant linear correlation between posterior inter-carina distance and the distance between the ipsilateral, antral levels of isolation at the posterior wall (fig 2, r=0.79, p=0.001)

Conclusion(s)
PFA creates wide antral circumferential PVI lesions involving the ipsilateral veins carina. Nevertheless, in small left atria it can create an undesired isolation or a narrow corridor in the posterior wall.
Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: results from the FAST AFA trial
Authors: Koenig S , Wohlrab L , Leiner J , Pellissier V , Nitsche A , Hindricks G , Bollmann A 
Published: May 2023

Abstract

Funding Acknowledgements
Type of funding sources: Other. Main funding source(s): This study was financially supported by Biosense Webster.

Introduction
Same-day discharge (SDD) protocols following catheter ablation (CA) of atrial fibrillation (AF) were already introduced in selected facilities in Europe but a widespread implementation has not yet succeeded. Data on patients’ perspectives to support early discharge regimens is lacking. Therefore, we conducted a survey to address patients’ beliefs towards SDD and identify variables that are associated with their evaluation.

Methods
As a part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing a left atrial CA for AF or atrial flutter were asked to participate in the survey consisting of a study-specific SDD-questionnaire, the AF knowledge scale and pre-defined patient reported outcome measures. The study cohort was stratified based on SDD willingness and a logistic regression analysis was used to identify predictors for patients’ valuation.

Results
Between 07/26/2021-07/01/2022, 256 of 376 screened patients consented to study participation of whom 248 (median age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%) and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, 52.2% of patients saw no advantages in SDD and expressed concerns including uncertainties with occurring complaints (50.6%), as well as the insufficient recognition (47.8%) and treatment (48.9%) of complications. Symptoms at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not.

Conclusion
We provide a detailed survey expressing patients’ beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.