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Is Pulmonary Vein Firing an Epiphenomenon? Introduction Rapid firing in pulmonary veins (PVs) is a leading cause of paroxysmal atrial fibrillation. We hypothesized that PV firing (PV-F) should continue after circumferential PV isolation (CPVI) because the PV tissue responsible for PV-F remains intact. Methods and Results In Group-1 (n = 92), isoproterenol (ISP) and adenosine triphosphate (ATP) were co-administered to provoke PV-F before and after CPVI. The site of rapid focal discharge that initiated atrial fibrillation (AF) defined PV-F versus non-PV-F. Additional 17 patients with PV-F induced by ISP+ATP before CPVI were enrolled into Group-2 and various pacing maneuvers were used in conjunction to ISP+ATP to provoke PV-F after CPVI. In Group-1, AF was induced in 47/81 (58.0%) and 16/88 (18.2%) patients before and after CPVI, respectively (P < 0.01). Before CPVI, 43/47 (91.5%) of the rapid firing originated from PV. After successful CPVI, 88/92 patients were in sinus rhythm and non-PV-F was induced in 14/88 patients. PV-F was induced in 2/88 patients, which was eliminated by ganglionated plexus ablation outside the CPVI line. In Group-2, various pacing maneuvers with ISP+ATP only induced PV-F in 1/17 patients after CPVI. Conclusion Marked suppression of PV-F after CPVI strongly suggests that the real source of PV-F is located in the atrium. PV-F may be an epiphenomenon. [ABSTRACT FROM AUTHOR]

Atrial fibrillation (AF) was initiated by rapid firing from left superior pulmonary vein (PV) by administration of isoproterenol (ISP) and adenosine triphosphate (ATP) before ablation. After successful isolation of all PVs, ISP and ATP were administered again. PVs were still isolated but an episode of rapid firing was observed inside the left PV isolation line during sinus rhythm. Radiofrequency energy was then delivered to the areas of superior left ganglionated plexus (GP) and inferior left GP. Then, PV firing could no longer be initiated. It suggests additional GP ablation may have additional benefit to circumferential PV isolation, to reduce the incidence of AF recurrence. (PACE 2012; 35:e316-e319) [ABSTRACT FROM AUTHOR]

Background: This study aims to describe significant left atrial appendage activation following ablation of persistent atrial fibrillation, and explore its relationship with aggressive septal ablation. Methods and Results: Significant left atrial appendage activation delay was found in 23 out of 201 patients undergoing persistent atrial fibrillation ablation. Of them, 14 were found in their index procedures, of whom septal line ablation was performed in nine (odds ratio 15.2, 95% confidence interval 4.6–50.8, P < 0.001). Another nine were found during their redo procedures (including two with biatrial activation dissociation), all of whom received extensive left septal complex fractionated electrograms ablation in their prior procedures (P = 0.002) . Electrocardiograph showed split P wave with the latter component merged into the QRS wave. Activation mapping demonstrated the earliest breakthrough of the left atrium changed to coronary sinus in 18 (85.7%) patients. After 1 month, the mitral A wave velocity was 18.2 ± 17.0 cm/s, and decreased significantly as compared with preablation (20.2 ± 19.1 vs 58.2 ± 17.9 cm/s, P = 0.037) in patients undergoing redo procedures. Fourteen (60.9%) remained arrhythmia-free during follow-up for 10.6 ± 6.2 months. Conclusion: Septal line ablation and extensive septal complex fractionated electrograms ablation are correlated with significant left atrial activation delay or even biatrial activation dissociation, and should be performed with prudent consideration. (PACE 2010; 33:652–660) [ABSTRACT FROM AUTHOR]

Noninducibility of atrial fibrillation (AF) by additional electrograms-guided ablation may benefit the clinical outcome. This report illustrates the effect of adenosine triphosphate (ATP) injection on AF inducibility after pulmonary vein (PV) isolation. AF was triggered twice by ATP without PV reconnection. Meanwhile, complex fractionated atrial electrograms (CFAEs) were observed, and ablation targets on these sites appeared to be essential to the AF elimination. It suggests that CFAEs may contribute to the initiation of some AF. ATP may be useful to induce AF after proven PV isolation, and further ablation might be necessary to ensure efficacy after circumferential PV isolation. (PACE 2010; 33:248–251) [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for paroxysmal AF (PAF) is limited by an unacceptable recurrence rate, mainly due to pulmonary vein (PV) reconnection. Strategies to minimize reconnection include adenosine infusion and also a waiting period of 30 minutes after PV isolation. The aim of the present study was to assess whether these two strategies revealed the same conduction gap. Methods and Results: In total, 88 consecutive patients (54 males, mean age of 60 years) with drug refractory PAF underwent circumferential PV isolation (CPVI). After isolation of ipsilateral PVs, with entry and exit block checked using a circular mapping catheter, 20 mg ATP was injected during isoproterenol infusion to reveal dormant conduction gap(s). Unless the reconnection revealed by ATP persisted, PVs were further remapped with the circular mapping catheter at 30 minutes postisolation. Totally, PV reconnection was observed in 56 (64%) patients. 24.3% veins (80/329) were found reconnected. Reassessment at 30 minutes postablation was more efficient as compared to ATP induction (19.8% vs 14.6% for ATP). The agreement between these 2 methods is moderate (kappa value = 0.50). In veins that transiently reconnected after ATP administration and later observed at 30 minutes postablation, 94% (17 of 19) of them were found being reconnected with the same gap. Conclusion: Acute PV reconnection is common, occurring in 64% of patients, as detected by adenosine infusion and waiting time. Each shows a unique quality as compared to one another. The combined use of these 2 methods may reduce the AF recurrence rate after CPVI. [ABSTRACT FROM AUTHOR]

Background: Left bundle branch block (LBBB) and atrial fibrillation (AF) are commonly coexisting conditions. The impact of LBBB on catheter ablation of AF has not been well determined. This study aims to explore the long‐term outcomes of patients with AF and LBBB after catheter ablation. Methods: Forty‐two patients with LBBB of 11,752 patients who underwent catheter ablation of AF from 2011 to 2020 were enrolled as LBBB group. After propensity score matching in a 1:4 ratio, 168 AF patients without LBBB were enrolled as non‐LBBB group. Late recurrence and a composite endpoint of stroke, all‐cause mortality, and cardiovascular hospitalization were compared between the two groups. Results: Late recurrence rate was significantly higher in the LBBB group than that in the non‐LBBB group (54.8% vs. 31.5%, p =.034). Multivariate analysis showed that LBBB was an independent risk factor for late recurrence after catheter ablation of AF (hazard ratio [HR] 2.19, 95% confidence interval [CI] 1.09–4.40, p =.031). LBBB group was also associated with a significantly higher incidence of the composite endpoint (21.4% vs. 6.5%, HR 3.98, 95% CI 1.64–9.64, p =.002). Conclusions: LBBB was associated with a higher risk for late recurrence and a higher incidence of composite endpoint in the patients underwent catheter ablation. [ABSTRACT FROM AUTHOR]

Background: Atrial esophageal fistula (AEF) is a lethal complication that can occur post atrial fibrillation (AF) ablation. Esophageal injury (EI) is likely to be the initial lesion leading to AEF. Endoscopic examination is the gold standard for a diagnosis of EI but extensive endoscopic screening is invasive and costly. This study was conducted to determine whether fecal calprotectin (Fcal), a marker of inflammation throughout the intestinal tract, may be associated with the existence of esophageal injury. Methods: This diagnostic study was conducted in a cohort of 166 patients with symptomatic AF undergoing radiofrequency catheter ablation from May 2020 to June 2021. Fcal tests were performed 1–7 days after ablation. All patients underwent endoscopic ultrasonography 1 or 2 days after ablation. Results: The levels of Fcal were significantly different between the EI and non‐EI groups (404.9 µg/g (IQR 129.6–723.6) vs. 40.4 µg/g (IQR 15.0–246.2), p <.001). Analysis of ROC curves revealed that a Fcal level of 125 µg/g might be the optimal cut‐off value for a diagnosis of EI, giving a 78.8% sensitivity and a 65.4% specificity. The negative predictive value of Fcal was 100% for ulcerated EI. Conclusions: The level of Fcal is associated with EI post AF catheter ablation. 125 µg/g might be the optimal cut‐off value for a diagnosis of EI. Negative Fcal could predict the absence of ulcerated EI, which could be considered a precursor to AEF. [ABSTRACT FROM AUTHOR]

Background and objective: Atrioesophageal fistula (AEF) is a rare but devastating complication with high mortality post atrial fibrillation (AF) ablation. The purpose of current study was to determine the epidemiology, clinical features, pathogenesis, and management of AEF after AF ablation. Methods and results: Patients with diagnosed AEF were included and retrospectively analyzed according to the registry of 11 centers in China from January 2010 to December 2019. A total of 16 AEF cases were identified from 44 794 patients who received a left atrial ablation procedure (0.035% per procedure). The interval from procedure to clinical onset of AEF averaged 18.3 days (3‐39 days). The fever ranked the most common symptom, occurred in 14 of the 16 cases, followed by neurological deficits (n = 11), chest pain (n = 5), and hematemesis (n = 4). Patients undergoing surgical repair had a better prognosis compared to those receiving nonsurgical management ([4 of 8] 50.0% vs [8 of 8] 100%, P <.05) with an overall mortality rate of 75.0%. Conclusion: AEF is highly characterized by varied manifestations. Early diagnosis and urgent surgical repair are vital to those patients and associated with improved survival rates. [ABSTRACT FROM AUTHOR]

Background: Data on management of maternal arrhythmia among Chinese were limited. Radiofrequency catheter ablation (RFCA) proved to be a reliable treatment choice for sustained tachyarrhythmia but it has rarely been performed during pregnancy due to radiation exposure. Objective: To investigate the incidence of idiopathic sustained maternal arrhythmia and the feasibility of RFCA in the pregnant patients without fluoroscopy. Methods: From January of 2015 to December of 2018, the medical records on pregnancy‐related admissions in Beijing Anzhen Hospital (Beijing, China) were retrospectively analyzed. Patients who had sustained tachyarrhythmia episodes without structural heart disease were identified. Catheter ablation was performed in those with drug resistant and severely frequent tachyarrhythmia under the guidance of electroanatomical mapping system and intracardiac echocardiography catheter (ICE), if appropriate. Results: During the study period, 12 584 consecutive pregnant women were admitted for pregnancy‐related reasons, 156 (1.2%) of them were identified as sustained maternal tachyarrhythmia. Twenty‐eight patients (age 21‐37 years) received catheter ablation because the arrhythmias were drug resistant and severely frequent. The RFCA was successfully performed in all patients with zero fluoroscopy after 72.4 ± 24.7 min. Transseptal puncture was performed in 11 patients under the guidance of ICE. In a median of 37 (interquartile range [IQR]: 34‐39) weeks' pregnancy, 28 healthy fetuses were delivered. No cardiac‐related adverse event occurred during delivery. During later follow‐up, all patients were free of arrhythmia, and all the infants were well developed. Conclusion: Sustained maternal tachyarrhythmia is not uncommon in the clinical practice. To those with drug resistant and severely frequent arrhythmia, RFCA with zero fluoroscopy could be safely performed with acceptable efficacy. [ABSTRACT FROM AUTHOR]

Background: Due to the anatomically adjacent relationship between the left atrium (LA) and esophagus, energy delivery on the posterior wall of LA is limited. The aim of this study was to evaluate the feasibility of a novel esophageal retractor (SAFER) with an inflatable C‐curve balloon during atrial fibrillation (AF) ablation. Method: Nine patients underwent AF ablation assisted with the SAFER. After inflation, the esophagus was deviated laterally away from the intended ablation site of the posterior wall under local anesthesia. The extent of mechanical esophageal deviation (MED) was evaluated under fluoroscopy, defined as the shortest distance from the trailing esophageal edge to the closest point of the ablation line. Gastroscopy was performed before and after ablation. The target ablation index used in all LA sites including the posterior wall was 400–450 after effective MED. All adverse events during the periprocedural period were recorded. Results: The mean deviation distance achieved 16.2 ± 9.6 mm away from the closest ablation point of the pulmonary vein lesion set. With respect to the individual left and right pulmonary vein lesion sets, the deviation distance was 19.7 ± 11.5 and 12.7 ± 6.8 mm, respectively. The extent of deviation was 0 to 5 mm, 5.1 to 10 mm, or >10 mm in 0(0%), 7(38.9%), and 11(61.1%), respectively. Procedural success was achieved in all patients without acute reconnection. There was only one esophageal complication which manifested as esophageal erosion and this patient experienced throat pain possibly related to the SAFER retractor with no clinical sequelae. Conclusion: Esophageal deviation with the novel eccentric balloon is a novel feasible choice during AF ablation, enabling adequate energy delivery to the posterior wall of LA. Additional prospective randomized controlled studies are required for further validation. [ABSTRACT FROM AUTHOR]

Background: Perimitral atrial tachycardia (PMAT) is the most frequent type of iatrogenic atrial tachycardia (AT) after atrial fibrillation (AF) ablation. Vein of Marshall ethanol infusion (EIVOM) is a promising technique in mitral isthmus (MI) ablation. Methods: A total of 165 patients with PMAT were divided into three groups according to ablation strategies, including RF only group (n = 89), RF‐EIVOM group (initial RF ablation with adjunctive EIVOM, n = 28), and EIVOM‐RF group (first‐step EIVOM with touch‐up RF ablation, n = 48). Acute and follow‐up procedure outcomes were evaluated. Results: PMAT terminated in 89.9%, 89.3%, and 93.7% of patients in RF only, RF‐EIVOM and EIVOM‐RF groups, respectively (p =.715), with complete MI block achieved in 80.9%, 89.3%, and 95.8% of patients (EIVOM‐RF vs. RF only, p =.012). First‐step utilization of EIVOM was associated with a significant shortening of RF ablation time at MI (EIVOM‐RF 2.1 ± 1.3 min, RF only 7.9 ± 5.9 min, RF‐EIVOM 6.8 ± 5.8 min; p <.001) and a decrease in the proportion of patients need ablation within coronary sinus (CS, EIVOM‐RF 14.6%, RF only 61.8%, RF‐EIVOM 64.3%; p <.001). After a mean follow‐up of 12.1 ± 6.2 months, AF/AT recurred in 39 (43.8%), 6 (21.4%), and 12 (25.0%) patients in RF only, RF‐EIVOM, and EIVOM‐RF group (RF‐EIVOM vs. RF only, p =.026; EIVOM‐RF vs. RF only, p =.022). Conclusions: EIVOM was associated with an enhanced acute MI block rate as well as reduced AF/AT recurrence. First‐step utilization of EIVOM promises to significantly simplify the RF ablation process. PMAT is the most common type of iatrogenic AT after AF ablation procedures. EIVOM contributed to a higher acute MI block rate and lower arrhythmia recurrence risk during follow‐up. First‐step utilization of EIVOM significantly reduced the need for radiofrequency ablation at MI and inside CS with the advantage of creating a homogenous, transmural lesion and eliminating epicardial connections. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) and stable coronary artery disease (SCAD) frequently coexist. This study aimed to assess the long‐term outcome of catheter ablation in patients with paroxysmal AF and SCAD. Methods: In total, 12,104 patients with paroxysmal AF underwent catheter ablation in the Chinese Atrial Fibrillation Registry between 2011 and 2019 were screened. A total of 441 patients with SCAD were matched with patients without SCAD in a 1:4 ratio. The primary endpoint was AF recurrence after single ablation. The composite secondary endpoints were thromboembolism, coronary events, major bleeding, all‐cause death. Results: Over a mean follow‐up of 46.0 ± 18.9 months, the recurrence rate in patients with SCAD was significantly higher after a single ablation (49.0% vs. 41.9%, p =.03). The very late recurrence rate of AF in the SCAD group was also significantly higher than that in the control group (38.9% vs. 31.2%;p =.04). In multivariate analysis, adjusted with the female, smoking, duration of AF, previous thromboembolism, COPD, and statins, SCAD was independently associated with AF recurrence (adjusted HR, 1.19 [1.02–1.40], p =.03). The composite secondary endpoints were significantly higher in the SCAD group (12.70% vs. 8.54%, p =.02), mainly due to thromboembolism events (8.16% vs. 4.41%, p <.01). Conclusions: SCAD significantly increased the risk of recurrence after catheter ablation of paroxysmal AF. The incidence of thromboembolic events after catheter ablation of paroxysmal AF in the patients with SCAD was significantly higher than that in those without SCAD. [ABSTRACT FROM AUTHOR]

Objective: To investigate theoptimal idarucizumab (dabigatran antagonist) usage strategy for patients with acute pericardial tamponade receiving uninterrupted dabigatran during catheter ablation for atrial fibrillation (AF). Methods: Ten patients presenting acute pericardial tamponade while receiving uninterrupted dabigatran during catheter ablation for AF in Beijing Anzhen Hospital from January 2019 to July 2020 were enrolled and retrospectively analyzed. A "wait and see" strategy of idarucizumab was carried out for all patients; in brief, idarucizumab was applied following pericardiocentesis, comprehensive evaluation of bleeding and hemostasis. Results: There were five males, five paroxysmal AF, and the average age of the patients was 64.0 ± 9.8 years. Among the 10 patients, four were treated with dabigatran 110 mg, six were treated with dabigatran 150 mg, and one was simultaneously given clopidogrel. The average time from pericardial tamponade to the last dose of dabigatran was 8.2 ± 3.4 h. All patients underwent pericardiocentesis successfully, and the average drainage volume was 322.5 ml (220.0 ± 935.0 ml). For reversal anticoagulation, six patients received protamine, and five patients received idarucizumab. Of the five patients who were treated with idarucizumab, four presented exact hemostasis, except for one patient who underwent continuous drainage and finally received surgery repair. The average time to restart anticoagulation was 1.1 ± 0.3 days after the procedure, and no rebleeding, embolism or deaths were observed. Conclusion: The "wait and see" strategy of idarucizumab for acute pericardial tamponade during the perioperative period of catheter ablation for AF may be safe and feasible. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for atrial fibrillation (AF‐CA) in patients with situs inversus dextrocardia (SID) can be challenging because of the contrary anatomy and associated anomalies. Cases and literature regarding AF‐CA in SID are rare and provide little information. Our study aims to present an improved procedure, ablation strategies, and evaluate the safety and outcomes of AF‐CA in patients with AF and SID. Methods: A total of 10 patients with AF‐SID (mean age, 60.4 ± 15.7 years; six paroxysmal AF, four persistent atrial fibrillation [PeAF]) were enrolled. For the improved procedure, images obtained by preacquired computed tomography and three‐dimensional electroanatomical mapping, integrating intracardiac echocardiography, and x‐ray imaging data are necessary to optimize the transseptal puncture and ablation procedure. Results: All patients successfully underwent 13 AF‐CA procedures without complications, including three patients received repeat procedures. However, two PeAF patients presented sick sinus syndrome (SSS) after the AF‐CA procedure, and one underwent permanent pacemaker implantation therapy during hospitalization. During the follow‐up period (6‐72 months), the outcomes were not favorable: three patients (30%) maintained sinus rhythm (SR) after the initial procedure; after repeated procedures, the overall SR rate was 40% (four patients). Conclusion: With the improved strategy, AF‐CA can be safely and effectively performed with low radiation exposure in patients with SID. However, the long‐term outcomes were not favorable, even when managed at a tertiary center by a team of specialists. Moreover, patients with PeAF might also have masked SSS, which should be carefully considered. [ABSTRACT FROM AUTHOR]

Background: Atrial fibrillation (AF) is common in abdominal solid organ transplant recipients and a cause of morbidity and mortality in this population. However, the outcomes of catheter ablation (CA) in transplant recipients with AF remain unclear. This study aimed to elucidate the outcomes of CA in renal and hepatic transplant recipients. Methods and Results: Between 2015 and 2019, 14 transplant recipients (nine with kidney transplantation and five with liver transplantation) were enrolled from among 10,741 AF patients and underwent CA at Anzhen Hospital. Another 56 patients matched by age, sex, and AF type were selected as the control group (four controls for each transplant recipient). During a mean follow‐up of 30.0 ± 13.3 months after the initial procedure, 10 (71.4%) of the transplant patients, compared to 41 (73.2%) of the control patients, remained free from AF recurrence (p = 1.000). A repeated procedure was performed in one transplant patient and in six control subjects. Consequently, 11 (78.6%) of the transplant patients, compared to 46 (82.1%) of controls, were in sinus rhythm after the repeated ablation (p =.715). Notably, Kaplan–Meier analysis did not demonstrate any significant differences in the atrial arrhythmia‐free rate after the initial and repeated procedure between the two groups. Vascular complications were identified in one transplant patient and two control subjects, while no life‐threatening complications were observed in either group. There was no transient allograft dysfunction in transplant recipients after CA. Conclusion: CA is safe and effective in abdominal solid transplant recipients, and maybe an optimal therapeutic strategy for this group. [ABSTRACT FROM AUTHOR]

Introduction: The best management strategy for patients with atrial fibrillation (AF) with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) is unknown. Methods and Results: This cohort study was conducted in Olmsted County, Minnesota, with resources of the Rochester Epidemiology Project. Patients with incident AF occurring between 2000 and 2014 with a prior or concurrent HF were included. Patients with LVEF ≥ 50% were designated as HF and preserved ejection fraction (HFpEF) and those with LVEF < 50% were designated as HF and reduced ejection fraction (HFrEF). Rhythm control in the first year after AF diagnosis was defined as prescriptions for an antiarrhythmic drug, catheter ablation, or maze procedure. The primary endpoint was all‐cause mortality. The secondary endpoints were cardiovascular death, cardiovascular hospitalization, and stroke or transient ischemic attack. Of 859 patients (age, 77.2 ± 12.1 years; 49.2%, female), 447 had HFpEF‐AF, and 412 had HFrEF‐AF. There was no difference in all‐cause mortality (10‐year mortality, 83% vs 79%; p =.54) or secondary endpoints between the HFpEF‐AF and HFrEF‐AF, respectively. Compared with the rate control strategy, rhythm control in HFpEF‐AF patients (n = 40, 15.9%) offered no survival benefits (adjusted HR, 0.70; 95% CI, 0.42–1.16; p =.16), whereas rhythm control in HFrEF‐AF patients (n = 52, 22.5%) decrease cardiovascular mortality (HR, 0.38; 95% CI, 0.17–0.86; p =.02). Conclusions: Patients with HFpEF‐AF and HFrEF‐AF had similar poor prognoses. Rhythm control strategy was seldom adopted in community care in patients with HF and AF. A rhythm control strategy may provide survival benefit for patients with HFrEF‐AF and the benefit of rhythm control in patients with HFpEF‐AF warrants further study. [ABSTRACT FROM AUTHOR]

Background: During ablation for atrial fibrillation (AF), energy delivery toward the left atrial posterior wall may cause esophageal injury (EI). Ablation index (AI) was introduced to estimate ablation lesion size, however, the impact of AI technology on the risk of EI has not been explored. Method: From March 2019 to December 2019, 60 patients with paroxysmal AF undergoing first‐time ablation were prospectively enrolled. The first 30 consecutive patients were ablated with the AI target value of 400 (AI‐400 group), and the later 30 consecutive patients were ablated with the AI target value of 350 at the posterior wall (AI‐350 group). Endoscopic ultrasonography was used to evaluate EI postablation. EI was classified as a category 1 (erythema or erosion) or a category 2 (hematoma or ulceration). Results: Compared with the AI‐400 group (59.9 ± 8.4 years; male, 60%), the AI‐350 group (59.1 ± 9.9 years; male, 50%) had a lower incidence of EI (3.3% vs 26.7%, P =.03). There was no significant difference in the percentage of first‐pass PVI between the AI‐400 group and the AI‐350 group (left PVI: 80% vs 73.4%, P =.54; right PVI: 80% vs 60%, P =.1). Neither ablation time nor fluoroscopy time was significantly different between the AI‐400 group and the AI‐350 group. Conclusions: AF ablation guide by AI target value of 350 may reduce esophageal thermal injury and has a similar efficiency on the acute success rate of first‐pass PVI compared with an AI target value of 400 at the posterior wall. [ABSTRACT FROM AUTHOR]

The close proximity of esophagus to the left atrial posterior wall predisposes esophagus to thermal injury during catheter ablation for atrial fibrillation (AF). In this retrospective study, we aimed to investigate risk factors of esophageal injury (EI) caused by catheter ablation for AF. Patients who underwent first-time AF ablation from July 2013 to June 2018 were included. The esophagus was visualized by oral soluble contrast during ablation for all patients and a subset of patients were selected to undergo endoscopic ultrasonography (EUS) to estimate EI post ablation. Degree of EI was categorized as Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial ulcers; 2b: deep ulcers); type 3: perforation (3a: perforation without communication with the atria; 3b: atrioesophageal fistula [AEF]). Of 3,852 patients, 236 patients (61.5 ± 9.7 years; male, 69%) received EUS (EUS group) and 3616 (63.2 ± 10.9 years; male, 61.1%) without EUS (No-EUS group). In EUS group, EI occurred in 63 patients (type 1 EI in 35 and type 2 EI in 28), and no type 3 EI was observed during follow up. In a multivariable logistic regression analysis, an overlap between the ablation lesion and esophagus was an independent predictor of EI (odds ratio, 21.2; 95% CI: 6.23–72.0; P < 0.001). In No-EUS group, esophagopericardial fistula (EPF; n = 3,0.08%) or AEF (n = 2,0.06%) was diagnosed 4–37 days after ablation. In 3 EPF patients, 2 completely recovered with conservative management and 1 died. Two AEF patients died. Ablation at the vicinity of the esophagus predicts risk of EI. EUS post ablation may prevent the progression of EI and should be considered in management of EI. It remains challenging to identify patients with high risk of EI. [ABSTRACT FROM AUTHOR]

Introduction: Repeat ablation strategy for atrial fibrillation (AF) recurrence after multiple ablation procedures is known to be challenging. This study evaluated the insights of adjunctive ablation for epicardial arrhythmogenic substrates in those patients via a percutaneous epicardial approach. Methods and Results: Thirty‐five consecutive patients with AF/atrial tachycardia (AT) recurrence, who had two or more prior ablation procedures, were enrolled from September 2016 to December 2018. In addition to a standard endocardial approach, epicardial mapping and ablation were performed via a percutaneous subxiphoid access in the electrophysiology lab. Adjunctive epicardial ablations for left lateral ridge (LLR) were performed in 31 of 35 patients (88.6%) for efficient transmural lesions with pacing capture loss. Marshall Bundle (MB) potentials were documented on epicardial LLR in three patients and abolished by direct epicardial ablation. Bachmann's bundle (BB) was ablated as an epicardial conduction gap in four patients with a refractory anterior wall line. Two epicardial AT/AF triggers were detected followed by successful termination with epicardial ablation. No periprocedural complications occurred. About 23 of 35 patients (65.7%) remained free from AF/AT after 23.2 ± 9 months of the procedure. Conclusions: Patients with multiple failed prior AF procedures refractory to antiarrhythmic therapy might warrant a percutaneous epicardial mapping and ablation strategy, with adjunctive therapy for targeting LLR/MB, BB, and underlying epicardial triggers in addition to a standard endocardial approach. [ABSTRACT FROM AUTHOR]

Introduction: The outcomes of atrial fibrillation (AF) ablation remain suboptimal. It is important to identify which AF patients will most likely benefit from ablation and who are more likely to show treatment failure, especially in those with structural heart disease such as hypertrophic cardiomyopathy (HCM). Methods and Results: We enrolled 120 HCM patients who underwent primary AF ablation (48 with persistent AF). Preprocedural QTc was measured and corrected using the Bazett's formula, and the distribution of fragmentation of the QRS complex (fQRS) was recorded. Arrhythmia recurrence was defined as any kind of documented atrial tachyarrhythmia of more than 30 seconds. Overall, arrhythmia recurrence occurred in 69 patients after 13.4 months' follow‐up. fQRS was present in 71 (59.17%) patients and was most commonly (81.69%) observed in the inferior leads. QTc more than 448 ms could predict arrhythmia recurrence with a sensitivity of 68.1% and specificity of 68.6%. Patients with QTc more than 448 ms (hazard ratio [HR]: 1.982; 95% confidence interval [CI]: 1.155‐3.402; P = .013) or those with fQRS+ (HR: 1.922; 95% CI: 1.151‐3.210; P = .012) were at an increased risk of recurrence. A combination of fQRS+ and QTc more than 448 ms was superior to fQRS or QTc alone in predicting arrhythmia recurrence. Conclusion: In patients with HCM undergoing AF ablation, QTc prolongation, specifically >448 ms, and presence of fQRS are independent risk factors for arrhythmia recurrence at follow‐up. The combination of these two parameters has greater predictive value and would help to identify patients who are at the highest risk of procedural failure. [ABSTRACT FROM AUTHOR]

We present the case of a 29‐year‐old man who developed ventricular tachycardia (VT) secondary to a cardiac lipoma located adjacent to the interventricular groove, which could not be fully resected. Antiarrhythmic drugs and endocardial and epicardial ablation failed to prevent VT recurrence. Finally, noninvasive stereotactic body radiation therapy (SBRT) targeting the lipoma was performed, with a total dose of 24 Gy delivered in three fractions. The number of VT episodes was reduced from 189/24 h before SBRT to 0 after the procedure. At 4‐month follow‐up, there were no signs of therapy‐related complications. Our experience suggests that SBRT could emerge as a viable treatment option for patients with cardiac tumors who develop refractory ventricular arrhythmias. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: To assess the long‐term outcome of catheter ablation in patients with hypertrophic cardiomyopathy (HCM), especially in patients with apical HCM (ApHCM). Methods and results: From 9,249 AF ablation cases, 97 patients (28 with ApHCM and 69 with non‐ApHCM) were enrolled. Another 97 patients matched by age, AF type, AF duration, and left atrial diameter were selected as the control group. After a mean follow‐up of (44.3 ± 29.6) months, success rate after a single procedure was 42.9% in the ApHCM patients (P  =  0.725), 36.2% in the non‐ApHCM patients (P  =  0.136) versus 50.5% in the control group. After multiple procedures, success rate both in the ApHCM group (50%, P  =  0.047) and in the non‐ApHCM group (50.4%, P  =  0.017) were lower than in the controls (68.0%). More patients in the ApHCM and in the non‐ApHCM group suffered very late recurrence beyond 1 year after the index procedure. Left atrial diameter (hazard ratio [HR] 1.04, 95% confidential interval [CI] 1.01–1.08, P  =  0.018) and AF duration (HR 1.01, 95% CI 1.00–1.01, P  =  0.005) were independent predictors of recurrence after the index ablation. There was no difference in thromboembolic events between the HCM group and the control group (8.2% vs. 3.1%, P  =  0.082). Conclusions: Patients with ApHCM or non‐ApHCM had similar success rate of AF ablation after single procedure and lower success rate after multiple procedure compared with the control group. [ABSTRACT FROM AUTHOR]

Background The mechanisms underlying atrial fibrillation (AF) initiation and pulmonary vein isolation (PVI) effectiveness remain unclear. Ganglionated plexus (GPs) have been implicated in AF initiation and maintenance. In this study, we evaluated the impact of GP ablation in patients with pulmonary vein (PV) firing after PVI. Methods Patients with drug-refractory paroxysmal AF undergoing radiofrequency catheter ablation therapy with PVI were screened. Among 840 cases over a 3.75-year period, 12 cases were identified with persistent PV firing (left = 4 and right = 8) after PVI was achieved and left atrial sinus rhythm restored. Adjacent GP ablation was performed anatomically and followed if necessary by additional PV ablation. Results In eight patients, PV firing was terminated during GP ablation outside of the circumferential ablation line. In one patient, additional PV ablation resulted in cessation of PV firing and in the remaining three patients, firing could not be terminated by GP ablation or additional PVI. Conclusion GP ablation outside of wide antral circumferential line frequently results in the cessation of rapid firing from electrically isolated PVs. These observations suggest that interactions between left atrium and PV beyond electrical conduction warrant consideration in AF mechanisms. [ABSTRACT FROM AUTHOR]

Ablation of Left-Sided Accessory Pathways with Atrial Insertion Away from the Mitral Annulus Background A left-sided accessory pathway (AP) with atrial insertion away from the mitral annulus (MA) may result in difficulty or failed ablation along the MA. We report our initial experience of ablating this rare form of AP by a 3-dimensional electroanatomical mapping system (CARTO). Methods From January 2007 to August 2011, 29 patients with left-sided APs who failed previous ablations in other centers were enrolled in this study. Left atrium (LA) was reconstructed during orthodromic atrioventricuar reentry tachycardias (AVRTs) or ventricle pacing by using a 3-dimensional electroanatomical mapping system. The AP atrial insertion was defined as the earliest retrograde atrial activation and successful ablation of the AP at the site. Results Among the 29 patients who had failed previous ablation, 7 patients were found to have atrial insertions away from the MA. Out of the 7 patients, atrial insertions were at the base of the LA appendage in 5 patients and at the anterior roof of LA in 2 patients. Ablation at the atrial insertion successfully abolished AP conduction. The mean distance between the atrial insertion sites and the MA was 24.9 ± 4.9 mm. No patients reported recovered AP conduction or recurrent tachycardias after at least 12-month follow-up. Conclusions Left-sided APs may have atrial insertions away from the MA. By using the CARTO system, atrial insertions can be reliably identified and ablated. [ABSTRACT FROM AUTHOR]

Atrial Remodeling and Lone Atrial Fibrillation. Background: We sought to investigate the role of anatomic remodeling of the atria and pulmonary veins (PVs) in the progression of lone atrial fibrillation (AF) using dual-source computed tomography (DSCT). Methods and Results: From 1,308 consecutive patients referred for an index ablation procedure for AF, we prospectively enrolled 29 consecutive patients with recently developed (<3 months) lone persistent AF (PsAF) and 23 consecutive patients with short-lasting (6-12 months) lone PsAF, all of whom had a history of paroxysmal AF (PAF). The control group consisted of 33 patients with lone PAF. On DSCT, the recently developed PsAF group showed more extensive atrial anatomic remodeling than the PAF group as shown by ∼40% higher spot biatrial volume, even though the mean duration of continuous AF was only 6 weeks. In contrast, the DSCT variables in the recently developed PsAF group and the short-lasting PsAF group were comparable, despite the fact that the mean duration of continuous AF in the latter group was 8 months. Series of cross-sectional areas of the ostial 1.5 cm of PV trunks were comparable in the PAF and PsAF groups in all but 3 ostial planes. A higher spot left atrial volume was the only independent factor associated with the progression of lone PAF to PsAF (OR: 1.06, 95% CI: 1.03-1.09, P<0.0001) on logistic regression. Conclusions: Prominent anatomic remodeling of the atria, rather than the PVs, underlies the mechanism of recent progression of lone paroxysmal AF to the persistent variety. (J Cardiovasc Electrophysiol, Vol. 23, pp. S29-S35, November 2012) [ABSTRACT FROM AUTHOR]

. Background: It is difficult to ablate a right-sided accessory pathway (AP) with atrial insertion far from the tricuspid annulus (TA). We report our initial experience of ablating this rare AP by a 3-dimensional electroanatomical mapping system (CARTO). Methods: From January of 2006 to April of 2008, 18 patients with right-sided APs who failed previous outside ablations were enrolled in this study. Retrograde AP conduction was mapped during pacing at the right ventricular apex by activation-mapping the right atrium (RA) using a 3-dimensional electroanatomical mapping system. AP atrial insertion was defined as the earliest retrograde atrial activations and successful ablation of the APs at this site. Results: Among the 18 patients who had failed previous ablation, 10 patients (7 patients with right manifest APs and 3 patients with right conceal APs) had atrial insertions far from the TA. Of the 10 patients, the atrial insertions were found at the base of the RA appendage in 3 patients, at the high lateral RA in 5 patients, at the low lateral RA in other 2 patients. Ablation at the atrial insertions successfully abolished the AP conduction. The mean distance between the atrial insertion sites and the TA was 20.2 ± 2.7 mm. No patients reported recovered AP conduction or recurrent tachycardias after 6-month follow-up. Conclusions: The right-sided APs may have atrial insertion far from the TA. These uncommon variation of APs can be reliably identified and ablated using CARTO system. (J Cardiovasc Electrophysiol, Vol. 22, pp. 499-505 May 2011) [ABSTRACT FROM AUTHOR]

The ectopic foci originating from superior vena cava (SVC) may act as triggers in the occurrence and perpetuation of atrial fibrillation (AF). Unfortunately, the SVC isolation may result in potential dysfunction of sinus node. Furthermore, little is known about the occurrence of sinus node injury complicated by the SVC isolation. Patients with AF or atypical atrial flutter experienced SVC isolation. The junctional rhythm or sinus arrest could be observed, if sinus node was injured. Atropin and dopamine administration ruled out the vagal irritation of sinus node, when junctional rhythm or sinus arrest occurred. One hundred and thirty-two patients who had no electrocardiogram signs of sinus node dysfunction before ablation experienced the SVC isolation . Six patients (three men, three women, mean age 62.5 ± 8.6 years) had sinus node injury (4.5%, 6/132): four patients had junctional rhythm and one male patient had junctional rhythm and sinus arrest simultaneously; another male patient required AAI mode permanent pacemaker implantation due to the persistent junctional rhythm after SVC isolation . The ablation sites of all six patients closed to the junction of right atrium and SVC during the ablation of anterolateral free wall of the SVC. Sinus node may be damaged due to the ablation sites closer to sinus node. The definition of the junction of right atrium and SVC is very important, the ablation sites of anterolateral free wall of the SVC should not be too close to the SVC orifice. (PACE 2011; 34:163-170) [ABSTRACT FROM AUTHOR]