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Aims: Whether adjusting the duration of ablation based on left atrial wall thickness (LAWT) provides extra benefits for pulmonary vein (PV) isolation for atrial fibrillation (AF) is uncertain. We studied the safety and efficacy of tailored cryoballoon PV isolation (CB-PVI) based on LAWT for paroxysmal AF., Methods and Results: Two hundred seventy-seven patients with paroxysmal AF refractory to anti-arrhythmic drug were randomized 1:1 to either LAWT-guided CB-PVI (n = 135) and empirical CB-PVI (n = 142). Empirical CB-PVI was performed using a 28 mm cryoballoon with recommended application for 240 s per ablation. Cryoapplication in the LAWT-guided group was titrated (additional application for 120 s at PVs, where >25% of the circumference includes segments with LAWT > 2.5 mm and reduced baseline application to 180 s at PVs where >75% of the circumference includes segments with LAWT < 1.5 mm) according to the computed tomography LAWT colour map. The primary endpoint was freedom from any documented atrial arrhythmia of more than 30 s without antiarrhythmic medication, after a single ablation procedure. During a mean follow-up of 18.7 months, patients in the LAWT-guided CB-PVI group (70.8%) had a higher event-free rate from primary endpoint than those in the empirical CB-PVI group (54.4%; hazard ratio 0.64, 95% confidence interval 0.42-0.99; P = 0.043). No differences were observed between the groups in complication rates (3.0% in LAWT-guided vs. 4.9% in empirical CB-PVI). The total procedure time was extended in the LAWT group than in the empirical group (mean 70.2 vs. 65.2 min, respectively)., Conclusion: The LAWT-guided energy titration strategy improved freedom from atrial arrhythmia recurrence, compared with conventional strategy., Competing Interests: Conflict of interest: none declared., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background: Atrial fibrillation (AF) inducibility with burst pacing (BP) after radiofrequency ablation (RFA) has been reported to be associated with AF recurrence. In contrast, the relevance of inducibility and recurrence after cryoablation (CRA) is unclear., Methods: We investigated 367 patients undergoing initial ablation for paroxysmal AF (RFA: 174, CRA: 193). Propensity score matching was conducted, retaining 134 patients in each group. Following pulmonary vein isolation (PVI), the inducibility by BP was tested. Inductions at 250 ppm were defined as low-frequency burst pacing (LFBP) positive, and those at 300 ppm were classified as medium-frequency burst pacing (MFBP) positive. They were followed for 600 days., Results: Forty-eight patients (18%) had AF recurrence. There was no significant difference in the recurrence rate between RFA and CRA (17% vs. 19%, Log-rank p = 0.79). In RFA, significant differences were observed for both LFBP (Log-rank p < 0.001) and MFBP (Log-rank p < 0.001). In contrast, in CRA, there were no significant differences for either LFBP (Log-rank p = 0.39) or MFBP (Log-rank p = 0.19). Multivariable analysis revealed that LFBP-positive (hazards ratio [HR] = 5.75, 95% confidence interval [CI] 2.41-13.7, p < 0.001) was an independent predictor for recurrence with RFA. Acute reconnection (HR = 2.73, 95% CI 1.13-6.56, p = 0.025) was an independent predictor for recurrence with CRA., Conclusion: The inducibility by BP after RFA predicted recurrence at both low and medium frequencies. LFBP-positive was an independent predictor of recurrence in multivariable analysis. In contrast, the inducibility by BP after CRA was not a predictor of recurrence., Trail Registration: This study did not require clinical trial registration., (© 2024 Wiley Periodicals LLC.)

Background: Patent foramen ovale (PFO) affects 20%-34% of adults and is associated with strokes and other disorders. The conventional treatment of PFO-related strokes is a closure procedure. The metal device is associated with some adverse events., Objective: Our aim was to investigate the efficacy and safety of PFO closure using cryoablation without implantation in patients with atrial fibrillation (AF) who underwent pulmonary vein isolation (PVI)., Methods: We divided the 22 patients with both PFO and AF who underwent PVI via cryoablation into 2 groups: standard PVI + atrial septal (AS) cryoablation group (group 1, n = 11) and standard PVI group (group 2, n = 11). The guidewire accesses the left atrium through the PFO without AS puncture during the procedure. Standard PVI via cryoablation was performed. The cryoballoon was retracted to the right atrium and inflated against the AS post-PVI. Patients in group 1 had cryoablation for 120-150 seconds, whereas patients in group 2 received sham ablation. The co-primary end points were the PFO closure rate and a composite of AF recurrence and stroke/transient ischemic attack (TIA) events., Results: There were no differences in procedure-related adverse events between the 2 groups. Neither group had an ischemic stroke report at 1-year follow-up. The PFO closure rate at 6 months in group 1 was significantly higher than that in group 2 (7 [63.6%] vs 1 [9.1%]; P = .002). AF recurrence post ablation was comparable in both groups at 3 months (3 [27.3%] vs 1 [9.1%]; P = .269), 6 months (0 vs 0), and 12 months (2 [18.2%%] vs 1 [9.1%]; P = .534) of follow-up., Conclusion: Cryoablation is a safe and effective approach to close PFO in patients with AF undergoing PVI in a single procedure., Competing Interests: Disclosures No potential conflict of interest was reported by the authors., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Pulmonary vein isolation (PVI) by cryoballoon ablation (CBA) is considered an effective primary strategy for early persistent atrial fibrillation (AF). However, data regarding CBA for long-standing persistent AF (PeAF) are limited. We evaluated the efficacy and safety of CBA for long-standing PeAF compared to PeAF., Methods: The study included 1484 patients with non-paroxysmal AF from Korean CBA registry data with follow-up of > 12 months after de novo CBA. The primary outcome was recurrence of atrial tachyarrhythmias (ATs) of ≥ 30-s after a 3-month blanking period., Results: A total of 367 PeAF (25%) and 1117 long-standing PeAF (75.3%) patients (mean age 61.9 ± 9.6 years, 80% men) underwent de novo CBA. Compared to patients with PeAF, patients with long-standing PeAF had more heart failure, previous stroke or transient ischemic attack, chronic kidney disease, higher CHA 2 DS 2 -VASc score, and larger left atrium (LA). During a mean follow-up period of 15.1 ± 10.9 months, ATs recurrence occurred in 41.4% of PeAF and 40.1% of long-standing PeAF. Multivariate analysis showed that female gender (hazard ratio [HR]: 1.31, p = 0.01), larger LA ≥ 45 mm (HR: 1.53, p < .001) and LA volume index ≥ 51 mL/m 2 (HR: 1.77, p < 0.001), and longer AF duration ≥ 5 years (HR: 1. 33, p = .003) were associated with ATs recurrence. After propensity score matching, larger LA was an independent factor for ATs recurrence., Conclusions: During a long-term follow-up period after index CBA in patients with non-paroxysmal AF, ATs recurrence rate was similar between PeAF and long-standing PeAF. CBA might be an effective strategy as an initial rhythm control therapy regardless of AF type., (© 2024 Wiley Periodicals LLC.)

Background: Pulsed field ablation (PFA) is an innovative technology recently adopted for the treatment of atrial fibrillation (AF). Preclinical and clinical studies have reported a remarkable safety profile, as a result of its tissue specific effect targeting cardiomyocytes and sparing adjacent tissues. Single-shot pentaspline system was the first PFA device to receive regulatory approval., Objective: We performed a meta-analysis to compare the efficacy and safety of PFA with the single-shot pentaspline system versus currently available 2nd/3rd/4th generation Cryoballoon technologies (CRYO)., Methods: We systematically searched electronic databases for studies focusing on AF ablation employing the PFA single-shot pentaspline system or 2nd/3rd/4th generation CRYO technologies. The primary endpoints were acute procedural success assessed on a vein and patient basis. Safety endpoints included overall periprocedural complications and major periprocedural complications. We also compared procedural, fluoroscopy times, and freedom from atrial tachyarrhythmias (ATs) at follow-up (secondary endpoints)., Results: Twenty and 70 studies were included for PFA and CRYO, respectively. PFA demonstrated greater acute procedural success on a vein basis (99.9% vs 99.1%; p<0.001), as well as per patient (99.5% vs 98.4%; p<0.001). PFA yielded lower overall periprocedural complications (3.1% vs 5.6%; p<0.001), shorter procedural time (75.9 min vs 105.6 min; p<0.001) and fluoroscopy time (14.2 min vs 18.9 min; p<0.001) compared to CRYO. No differences were found for major periprocedural complications (1.2% vs 1.0%; p=0.46) and freedom from ATs at 1 year (82.3% vs 80.3%; Log-rank p= 0.61)., Conclusions: PFA contributed to higher acute procedural success, and safety compared to CRYO. No statistically significant differences in AT recurrence at 1-year follow-up were observed., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objective: The pan-immune inflammatory (PIV) index holds prognostic value for cardiovascular diseases. This study aimed to investigate the predictive value of the PIV index regarding recurrence of atrial fibrillation (AF) after cryoballoon ablation (CBA)., Methods: The study included 307 patients with AF. Four inflammatory markers, namely, the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), systemic immune inflammation (SII) index, and PIV index, were used as indicators. COX regression analysis was conducted to evaluate the predictive value of AF recurrence after CBA. A receiver operating characteristic (ROC) curve was plotted, and the area under the curve (AUC) was calculated to evaluate the discriminative power of the indicators., Result: The PIV index [94.9 (168.9,504.9) vs. 143.2 (98.2,210.6), P < 0.01] and SII index [366.3 (256.6,491.9) vs. 569.9 (658.1,438.4), P < 0.01] were significantly higher in the recurrence group. Univariable COX regression analysis showed that these four indices, persistent AF, and left atrial diameter (LAD) were all associated with AF recurrence. In multivariable regression analysis, the PIV index, persistent AF, and LAD (all P < 0.05) were independent predictors of postoperative AF recurrence. The ROC curve analysis showed that the PIV index had a higher predictive value for AF recurrence (AUC = 0.768, P < 0.01, 95% CI: 0.696-0.840) than the SII index and NLR. Kaplan-Meier analysis showed that patients with a PIV index > 260.7 had a higher recurrence rate at 1-year follow-up (P < 0.01). Subgroup analysis indicated that PIV had a predictive value in patients with different types of AF., Conclusion: PIV index may be a potential biomarker for predicting relapse in patients with AF after CBA., Competing Interests: Declarations. Ethics approval and consent to participate: All the procedures followed were in accordance with the ethical guidelines of the Helsinki Declaration. This retrospective study was approved by the Affiliated Hospital of Nantong University Institutional Review Board, and exception to the requirement of informed consent was approved (Affiliated Hospital of Nantong University Institutional Review Board No.2018-K020). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2024. The Author(s).)

Introduction: Atrial fibrillation (AF) is the most common sustained arrhythmia, and catheter ablation (CA) is a primary therapeutic option. However, the 30-day all-cause mortality risk associated with CA for AF may be underestimated due to selection bias. Our study aimed to assess 30-day mortality in an unselected cohort of patients., Methods: Data from the National Health Fund-Poland covered over 99% of nationwide radiofrequency ablation (RF) or cryoballoon ablation for AF, with 100% recorded deaths. The study included consecutive CA procedures in adult patients between 2012 and 2019. Thirty-day mortality rates were calculated for each age group., Results: A total of 31 214 CAs for AF were performed on 26 767 patients (34.8% female). Forty-four percent of patients had hypertension, 31.2% had coronary artery disease, 14.4% had heart failure, 11% had diabetes mellitus, 5.6% had malignant neoplasms, 2.7% had a previous myocardial infarction, 2.5% had a previous stroke, and 2.2% had kidney disease. Thirty-two deaths (0.1%) occurred within 30 days, with the highest mortality in the oldest age group (>80 years). Statistical analysis revealed higher incidences of kidney disease (p < 0.001) and heart failure (p = 0.001) in patients who died within 30 days. Mortality risk did not significantly differ between cryoballoon and RF ablation, as well as first and subsequent ablation for AF. The risk of death within 7 days postablation for AF was 1 in 2750 procedures, while the risk of death on the same day postablation was 1 in 6250 procedures., Conclusions: The 30-day mortality rate in a large, unselected AF ablation cohort, covering 99% of procedures in the country, is low except for the oldest patients. This factor should be taken into consideration when offering CA for AF., (© 2024 Wiley Periodicals LLC.)

Background: Pulmonary vein isolation (PVI) employing cryoballoon (CB) or contact force-guided radiofrequency (CF-RF) catheter ablation has been established as an effective strategy for managing atrial fibrillation (AF). However, its efficacy in hypertrophic cardiomyopathy (HCM) remains to be further explored., Methods: This retrospective study analyzed 60 consecutive AF patients with HCM (average age 67 ± 10 years; 41 men) who were consecutively admitted to our hospital from January 2014 to December 2022 and underwent initial PVI., Results: The patients were treated with CB (26 patients) or CF-RF (34 patients). Successful PVI was achieved in both groups without significant complications. In the CF-RF group, additional ablations were performed on the cavotricuspid isthmus (14.7% of patients) and the anterior line (2.9%). The CB group benefited from reduced procedural times (93 ± 31 vs. 165 ± 60 min, p < 0.05) and decreased saline irrigation requirements (77.5 ± 31.4 vs. 870 ± 281.9 mL, p < 0.0001). Using a contrast medium was exclusive to the CB group (33.8 ± 4.2 mL). In a 12-month follow-up, the atrial tachyarrhythmia recurrence-free rates in the CB and CF-RF groups were comparable (77% and 76%, respectively; p = 0.63 according to the log-rank test). Notably, pulmonary vein reconnection was prevalent in most (7 out of 8) patients requiring a secondary ablation procedure., Conclusion: PVI is feasible as a strategy for AF in patients with HCM employing either CB or CF-RF techniques. While the recurrence-free rates were comparable in both groups, differences were noted in procedure duration, saline usage, and the need for a contrast medium., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: We previously developed an early reconnection/dormant conduction (ERC) prediction model for cryoballoon ablation to avoid a 30-min waiting period with adenosine infusion. We now aimed to validate this model based on time to isolation, number of unsuccessful cryo-applications, and nadir balloon temperature., Methods: Consecutive atrial fibrillation patients who underwent their first cryoballoon ablation in 2018-2019 at the Leiden University Medical Center were included. Model performance at the previous and at a new optimal cutoff value was determined., Results: A total of 201 patients were included (85.57% paroxysmal AF, 139 male, median age 61 years (IQR 53-69)). ERC was found in 35 of 201 included patients (17.41%) and in 41 of 774 veins (5.30%). In the present study population, the previous cutoff value of - 6.7 provided a sensitivity of 37.84% (previously 70%) and a specificity of 89.07% (previously 86%). Shifting the cutoff value to - 7.2 in both study populations resulted in a sensitivity of 72.50% and 72.97% and a specificity of 78.22% and 78.63% in data from the previous and present study respectively. Negative predictive values were 96.55% and 98.11%. Applying the model on the 101 patients of the present study with all necessary data for all veins resulted in 43 out of 101 patients (43%) not requiring a 30-min waiting period with adenosine testing. Two patients (2%) with ERC would have been missed when applying the model., Conclusions: The previously established ERC prediction model performs well, recommending its use for centers routinely using adenosine testing following PVI., (© 2024. The Author(s).)

Background: Pulmonary vein (PV) occlusion is crucial for adequate lesion formation during cryoballoon-guided pulmonary vein isolation (CB-PVI). PV occlusion is usually confirmed by angiographies over the inflated balloon device. The aim of our study was to analyze the safety and efficacy of pressure waveform-based PV occlusion assessment during CB-PVI utilizing a novel fully integrated pressure analysis tool., Methods: Consecutive patients with symptomatic atrial fibrillation (AF) scheduled for CB-PVI were prospectively enrolled for pressure waveform-based PV occlusion assessment. A patient cohort receiving conventional angiographies served as control group. Patients with common PV ostia were excluded., Results: The study group consisted of 40 patients (16 females, mean age was 64.5 ± 9.7, 45% persistent AF). The control group consisted of 40 matched patients. All 160 PVs in the study group were successfully isolated without the use of additional venograms confirming PV occlusion. The mean procedure duration was 69 ± 12 min in the study group with a mean fluoroscopy duration of 11.5 ± 4.4 min. The mean contrast medium volume was 22 ± 9 ml in the study group and 36 ± 12 ml in the control group (p = 0.0001). Mean procedure duration, mean balloon temperatures, and mean ablation application durations did not differ significantly between the study and the control group. No periprocedural complications occurred., Conclusion: CB-PVI utilizing a fully integrated pressure waveform analysis tool to assess PV occlusion is feasible and safe and significantly reduces the amount of contrast medium without impact on procedural parameters and freedom from arrhythmia recurrence., (© 2024. The Author(s).)

Background: Epicardial adipose tissue (EAT) is closely associated with atrial fibrillation (AF), suggesting that it may be one of the causes of AF progression. However, it is unclear whether AF affects EAT., Objective: This study aimed to demonstrate that sinus rhythm restoration reduces EAT volume (EATV) through left atrial reverse remodeling (LARR)., Methods: We analyzed data from 247 patients who underwent cryoballoon ablation for AF. EATV was assessed by contrast-enhanced computed tomography with a 3-dimensional analysis workstation, evaluating EATV surrounding the entire heart (Total-EATV) and left atrium (LA-EATV) at baseline and 6 months after cryoballoon ablation., Results: At 6 months, all patients but one with persistent AF were in sinus rhythm. Total-EATV and LA-EATV were both significantly decreased in patients with persistent AF (n = 33; Total-EATV: 148.8 ± 53.3 mL to 142.9 ± 53.5 mL [P = .01]; LA-EATV: 26.8 ± 11.3 mL to 25.2 ± 10.7 mL [P = .01]). No changes were observed in patients with paroxysmal AF (n = 214). Persistent AF was more strongly associated with LARR than paroxysmal AF (odds ratio, 2.34; 95% confidence interval, 1.01-5.44; P = .05). LARR showed an independent correlation with both Total-EATV and LA-EATV reduction (odds ratio, 1.78 [P = .04] and 2.80 [P < .001], respectively)., Conclusion: These findings suggest a novel "AF begets EAT" theory, complementing the previously accepted role of EAT as a cause of AF and supporting the "AF begets AF" mechanism., Competing Interests: Disclosures The authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Atrial fibrillation (AF) and heart failure (HF) often coexist, leading to increased mortality. A cryoballoon-based approach is a potential treatment for patients with HF because of its safety and efficacy., Objectives: The authors sought to evaluate the optimal timing of cryoballoon ablation after the first clinical diagnosis of AF and its prognosis for patients with HF., Methods: This large-scale multicenter study retrospectively collected data of patients with HF who underwent cryoballoon ablation for AF from 17 Japanese institutions. Patients were divided into 2 groups depending on the duration between the first diagnosis and ablation using a median time of 0.5 year (IQR: 0.3-2.0 years). Clinical endpoints of recurrence, mortality, and HF hospitalization were compared between the 2 groups., Results: Among 3,655 patients, 543 with HF were included for analysis. During a median follow-up period of 21.3 months (IQR: 12.0-36.8 months), 151 of 520 patients (29%) had a recurrence. The AF recurrence rate was significantly lower in the early-ablation group (≤0.5 year) than in the delayed-ablation group (>0.5 year) (24% [65/266] vs 34% [86/254], respectively; P  = 0.018). In the multivariable analysis, early ablation ≤ 0.5 year was independently associated with an absence of recurrence (HR: 0.581; 95% CI: 0.401-0.842; P  = 0.004). Delayed time for cryoballoon ablation incrementally increased the risk of postablation recurrence. Antiarrhythmic drug use was independently associated with delayed ablation. No significant differences in mortality or HF hospitalization were observed between the 2 groups., Conclusions: Early cryoablation reduced the risk of recurrence in patients with HF, which may help improve clinical management., Competing Interests: Drs Yanagisawa and Shibata are affiliated with a department sponsored by Medtronic Japan. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Objective: Cryoballoon ablation for pulmonary vein isolation is a time-efficient procedure that can alleviate stress on electrophysiology lab resources. This analysis modeled the impact of cryoballoon ablation on electrophysiology lab operation using data from Latin America., Methods: Data from centers in Argentina, Mexico, Colombia, and Chile of the were used as inputs for an electrophysiology lab efficiency simulation model. The model used the assumption that either two (today's electrophysiology lab operations) or three (including electrophysiology lab operational changes) cryoballoon ablation procedures could be performed per day. The endpoints were the percentage of days that resulted in 1) overtime and 2) time left for an extra non-ablation electrophysiology procedure., Results: Data from a total of 232 procedures from six Latin American centers were included in the analysis. The average electrophysiology lab occupancy time for all procedures in Latin America was 132 ± 62 minutes. In the Current Scenario (two procedures per day), 7.4% of simulated days resulted in overtime, and 81.4% had enough time for an extra electrophysiology procedure. In the Enhanced Productivity Scenario (three procedures per day), 16.4% of days used overtime, while 67.4% allowed time for an extra non-ablation electrophysiology procedure., Conclusions: Using real-world, Latin American-specific data, we found that with operational changes, three ablation procedures could feasibly be performed daily, leaving time for an extra electrophysiology procedure on more than half of days. Thus, use of cryoballoon ablation is an effective tool to enhance electrophysiology lab efficiency in resource-constrained regions such as Latin America., Competing Interests: APS: Speaker fees from Boehringer Ingelheim and Abbott; proctoring, consultancy, and advisory board services for Johnson & Johnson – Biosense Webster and Boston Scientific outside the submitted work. RIP: Proctoring fees from Medtronic, outside the submitted work. JFA: Speaker fees from Medtronic and Bayer Andina; proctoring and consultancy for Medtronic, outside the submitted work. APB: Speaker fees and consulting Medtronic, Abbott, Biotronik, MedSafe. RH, DPF, KJ, JT, TRH, AS: Medtronic employee. NM: Proctoring fees from Medtronic, outside the submitted work., (This work is licensed under a Creative Commons Attribution 4.0 International License.)

Background: Despite advances in efficacy and safety of pulmonary vein isolation (PVI), atrial fibrillation (AF) recurrence after PVI remains common. PV-reconnection is the main finding during repeat PVI procedures performed to treat recurrent AF., Objective: To analyze pulmonary vein (PV) reconnection patterns during repeat ablation procedures in a large cohort of consecutive patients undergoing radio frequency or cryoballoon-based PVI., Methods: Retrospective analysis of PV-reconnection patterns and analysis of re-ablation strategies in consecutive index RF- and CB-based PVI and their respective re-ablation procedures during concomitant usage of both energy sources at a single high-volume center in Germany., Results: A total of 610 first (06/2015-10/2022) and 133 s (01/2016-11/2022) repeat ablation procedures after 363 (60%) RF- and 247 (40%) CB-based index PVIs between 01/2015 and 12/2021 were analyzed. PV-reconnection was found in 509/610 (83%) patients at first and 74/133 (56%) patients at second repeat procedure. 465 of 968 (48%) initially via CB isolated PVs were reconnected at first re-ablation but 796 of 1422 initially RF-isolated PV (56%) were reconnected (OR: 0.73 [95% CI: 0.62-0.86]; p < .001). This was driven by fewer reconnections of the left PVs (LSPV: OR: 0.60 [95% CI: 0.42-0.86]; p = .005 and LSPV: 0.67 [0.47-0.95]; p = .026). PV-reconnection was more likely after longer, RF-based index PVI and in older females. Repeat procedures were shorter after CB-compared to after RF-PVI., Conclusions: Reconnection remains the most common reason for repeat AF ablation procedures after PVI. Our data suggest to preferentially use of the cryoballoon during index PVI, especially in older women., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: No data have been reported on cooling characteristics and the impact of variant pulmonary vein (PV) anatomy on atrial fibrillation (AF) recurrences after POLARx cryoballoon (CB) ablation., Objective: The purpose of this study was to analyze the impact of PV anatomy variants and cooling characteristics after CB ablation from a large multicenter prospective registry., Methods: The primary end point was defined as 1-year absence of any atrial tachyarrhythmias (ATAs: AF/atrial flutter/atrial tachycardia). Correlation between ATA recurrences and anatomy variants/cooling characteristics were evaluated. The secondary outcome was the rate of major periprocedural complications., Results: A total of 429 consecutive patients diagnosed with paroxysmal AF (83.4%) or persistent AF (peAF; 16.6%) were enrolled. Twenty-eight patients (6.6%) exhibited an anatomical variant (common ostium: 4.0%; adjunctive PV: 2.6%). Nadir temperature, thaw time, and total deflation time were different between standard PVs and PV variants. After the blanking period, over a mean of 431 ± 99 days of follow-up, 63 patients (14.7%) suffered an ATA recurrence. Patients with recurrences had both a shorter thaw time (18.5 ± 7 seconds vs 19.8 ± 7 seconds; P = .0012) and a shorter total deflation time, whereas time to isolation was longer (57.4 ± 42 seconds vs 49.1 ± 33 seconds; P = .04). Patients with anatomy variants showed a similar ATA recurrence rate (5 of 28 [17.9%]) to the standard PV anatomy group (58 of 401 [14.5%]) (P = .584), with a hazard ratio (HR) of 1.43 (95% confidence interval [CI] 0.49-4.13; log-rank, P = .4384). After adjusting for confounders, heart failure (HR 4.12; 95% CI 1.75-9.73; P = .0013) and peAF (HR 1.81; 95% CI 1.03-3.18; P = .0433) remained associated with ATA recurrence during follow-up., Conclusion: The POLARx CB system demonstrated long-term efficacy, along with a safe profile, in both patients with paroxysmal AF and those with peAF, regardless of the presence PV variants. Time to isolation was longer in patients with ATA recurrences during follow-up., Clinical Trial Registration: Catheter Ablation of Arrhythmias with a High-Density Mapping System in Real-World Practice (CHARISMA)., Clinicaltrials: gov identifier: NCT03793998. Registration date: January 4, 2019., Competing Interests: Disclosures Mr Malacrida is a salaried employee of Boston Scientific. Dr Tondo is a member of the Boston Scientific advisory board. The other authors have no conflicts of interest to declare., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: The existing literature regarding the treatment strategy for high-power short-duration (HPSD) ablation in patients diagnosed with atrial fibrillation (AF) is currently insufficient. The objective of this study is to perform a comparative analysis evaluating the effectiveness, safety, and procedural efficiency of HPSD versus cryoballoon ablation (CBA) for AF., Methods: A comprehensive search was conducted in PubMed, EMBASE, Cochrane Library, Scopus, Web of Science, and ClinicalTrials.gov databases to identify trials comparing HPSD with CBA for AF from their inception until December 25, 2023. Treatment effect measures were expressed as odds ratio (OR), mean difference (MD), accompanied by a 95% confidence interval (CI)., Results: The analysis comprised six eligible trials involving a total enrollment of 2481 patients. No statistically significant disparities were observed in recurrent atrial arrhythmia (OR 0.90; 95% CI, 0.71-1.16) or total complications (OR 0.65; 95% CI, 0.38-1.12) between the two ablation techniques examined in this study. However, HPSD technique exhibited a significantly prolonged procedure time (MD 27.42; 95% CI, 19.03 to 35.81). Conversely, no significant differences were observed between the two modalities in terms of total fluoroscopy duration (MD -4.37; 95% CI -10.70 to 1.96) and ablation time (MD 7.95; 95% CI -3.97 to 19.88). Furthermore, HPSD demonstrated significantly higher odds of extrapulmonary vein (PV) trigger ablation compared to CBA (OR 18.86; 95% CI, 5.12-69.49). The subgroup analyses revealed that CBA continued to exhibit superior procedure time (except for the paroxysmal AF subgroup: [MD 29.52; 95% CI -4.25 to 63.60]), while no significant differences in safety and efficacy (except for the HPSD ≥ 70 W subgroup: [OR 0.44, 95% CI 0.20-0.97]) outcomes were still observed., Conclusion: Among patients undergoing ablation therapy for AF, both HPSD and CBA demonstrate comparable efficacy and safety profiles; however, HPSD is associated with longer procedural time and higher rates of extra-PV trigger ablation., (© 2024 Wiley Periodicals LLC.)

Introduction: The impact of early recurrence of atrial tachyarrhythmia (ERAT) within the 90-day blanking period on long-term outcomes in atrial fibrillation (AF) patients undergoing cryoballoon ablation (CBA) is controversial. This study aimed to assess the relationship between ERAT and late recurrence of atrial tachyarrhythmia (LRAT) post-CBA., Methods: Utilizing data from a multicenter registry in Korea (May 2018 to June 2022), we analyzed the presence and timing of ERAT (<30, 30-60, and 60-90 days) and its association with LRAT risk after CBA. LRAT was defined as any recurrence of AF, atrial flutter, or atrial tachycardia lasting more than 30 s beyond the 90 days., Results: Out of 2636 patients, 745 (28.2%) experienced ERAT post-CBA. Over an average follow-up period of 21.2 ± 10.3 months, LRAT was observed in 874 (33.1%) patients. Patients with ERAT had significantly lower 1-year LRAT freedom compared to those without ERAT (42.6% vs. 85.5%, p < .001). Multivariate analysis identified ERAT as a potential predictor of LRAT, with a hazard ratio (HR) of 3.98 (95% confidence interval [CI], 3.47-4.57). Significant associations were noted across all examined time frames (HR, 3.84; 95% CI, 3.32-4.45 in <30 days, HR, 5.53; 95% CI, 4.13-7.42 in 30-60 days, and HR, 4.29; 95% CI, 3.12-5.89 in 60-90 days). This finding was consistently observed across all types of AF., Conclusion: ERAT during the 90-day blanking period strongly predicts LRAT in AF patients undergoing CBA, indicating a need to reconsider the clinical significance of this period., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Introduction: A hybrid convergent approach (endocardial and epicardial ablation) demonstrated superior effectiveness in a recent randomized study for long-standing persistent atrial fibrillation (LSPAF). Yet, there is a lack of real-world, long-term evidence as to which patients are best candidates for a hybrid convergent approach compared to standard endocardial cryoballoon pulmonary vein isolation (CB PVI)., Methods and Results: This single-center, retrospective analysis spanning from 2010 to 2015 compared two distinctly different atrial fibrillation (AF) cohorts; one treated with stand-alone cryoablation and one treated with a hybrid convergent approach. Baseline characteristics described candidates for each approach. The following criteria were utilized to determine CB PVI candidacy: (1) paroxysmal AF (PAF) (stage 3A) with failed class I/III antiarrhythmic drug (AAD) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD unwilling to undergo hybrid procedure. Selection criteria for the hybrid procedure included: (1) PAF refractory to both class I/III AAD and prior CB PVI (stage 3D) or (2) persistent/LSPAF (stage 3B/3C/3D) with failed class I/III AAD agreeable to hybrid procedure. Prior sternotomy was excluded. Serial electrocardiograms and continuous monitoring evaluated primary efficacy outcome of time-to-first recurrence of atrial arrhythmia after a 90-day blanking period. Secondary outcomes were procedure-related complications and AAD use (at discharge, 12, and 36 months). Kaplan-Meier methods evaluated arrhythmia recurrence. Of 276 patients, 197 (64.2 ± 10.6 years old; 66.5% male; 74.1% 3A-PAF; 18.3% 3B/3D-persistent AF; 1.0% 3C-LSPAF; 6.6% undetermined) underwent CB PVI and 79 (61.4 ± 8.1 years old; 83.5% male; 41.8% 3D-PAF; 45.5% 3B/3D-persistent AF; 12.7% 3C/3D-LSPAF) underwent hybrid procedure. Arrhythmia freedom through 36 months was 55.2% for CB PVI and 50.4% for hybrid (p = .32). Class I AAD utilization at discharge occurred in 38 (19.3%) patients in the CB PVI group and 5 (6.3%) patients in the hybrid group (p = .01). CB PVI class I AAD utilization at 12 months occurred in 14 (9.0) patients versus 0 patients for hybrid convergent (p = .004). Patients with one or more adverse event were as follows: two (1.0%) in the CB PVI group (both transient phrenic nerve palsy) and three (3.7%) in the hybrid group (two with significant bleeding and one with wound infection) (p = .14)., Conclusion: This study demonstrated that patients with more complex forms of AF (3D-PAF or 3B/3C/3D-persistent/LSPAF) could be well managed with a convergent approach. In a real-world evaluation, outcomes match safety and efficacy thresholds achieved for patients with earlier, less complex AF etiologies treated by CB PVI alone., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Cryoballoon ablation has been established as an effective method for pulmonary vein isolation and has recently been investigated for its efficacy of substrate modification on the left atrial roof area in patients with persistent atrial fibrillation. We herein report the first successful case of left atrial posterior wall isolation including roof line ablation using cryoballoons in a patient with persistent atrial fibrillation, dextrocardia, and situs inversus. Cryoballoon ablation proved to be a safe and straightforward approach to create lasting lesions along the left atrial roof line and left atrial posterior wall, even under challenging anatomical conditions.

Background: Different energy sources of balloon-based ablation for pulmonary vein isolation cause different kinds of endothelial damage and coagulation responses associated with thromboembolic risk., Objectives: The study sought to compare the impact of different balloon-based ablation, cryoballoon ablation (CBA) and laser balloon ablation (LBA), on coagulation/fibrinolysis biomarkers and silent cerebral events (SCEs) in paroxysmal atrial fibrillation., Methods: Paroxysmal atrial fibrillation patients who underwent pulmonary vein isolation using either CBA (n = 52) or LBA (n = 53) without radiofrequency touch-up ablation were eligible. Time course (day 0 [before ablation], day 1, day 2, and day 28) of myocardial enzymes and inflammatory and coagulation/fibrinolysis biomarkers was evaluated during the perioperative period. Brain magnetic resonance imaging was performed within 2 days after the procedure to evaluate SCEs., Results: There was no difference in patient characteristics between CBA and LBA.CBA had greater myocardial injury (troponin I and creatine kinase-MB) and lower inflammatory reaction (white blood cell count and neutrophil/lymphocyte ratio) than LBA. The coagulation biomarkers maximally increased by day 2 and then decreased in both groups. In day 28, the serum prothrombin fragment 1+2 and D-dimer levels in LBA were significantly higher than the values in CBA. The fibrinolysis biomarker (plasmin-α2 plasmin inhibitor complex) did not increase after the procedure in either group. The incidence of SCEs was comparable between CBA and LBA (11% vs 15%; P = .591). No thromboembolic event was observed., Conclusion: CBA and LBA had different effects on myocardial injury, inflammatory reaction, and coagulation activity but did not affect the incidence of thromboembolic events. LBA had significantly higher coagulation activity in day 28 and may require more careful postprocedural anticoagulation than CBA., (© 2024 Heart Rhythm Society. Published by Elsevier Inc.)

Background: Single-shot devices are increasingly used for pulmonary vein isolation (PVI) in atrial fibrillation (AF). The Arctic Front cryoballoon is the most frequently used single-shot technology. A recently developed novel pulsed field ablation (PFA) device (FARAPULSE) has been introduced with the aim to improve procedural safety and efficacy., Objective: This study will compare the novel FARAPULSE PFA device and the Arctic Front cryoballoon for first PVI in patients with symptomatic paroxysmal AF., Methods: SINGLE SHOT CHAMPION is a multicenter, randomized controlled trial with blinded endpoint adjudication by an independent clinical events committee. Overall, 210 patients with paroxysmal AF undergoing their PVI are randomized 1:1 between PFA and cryoballoon ablation. Continuous rhythm monitoring with an implantable cardiac monitor is performed in all patients., Results: The primary endpoint is time to first recurrence of any atrial tachyarrhythmia (AF and/or organized atrial tachyarrhythmia) lasting ≥120 seconds and identified by the implantable cardiac monitor within 91 and 365 days postablation. The composite procedural safety endpoint includes cardiac tamponade requiring drainage, persistent phrenic nerve palsy, vascular complications requiring intervention, stroke/transient ischemic attack, atrioesophageal fistula, and death occurring during or up to 30 days after the procedure. Key secondary endpoints include (1) increase in high-sensitivity troponin on day 1 postablation, (2) analysis of postablation 3-dimensional electroanatomic mapping (first 25 patients per study group), (3) AF burden, and (4) quality-of-life changes., Conclusion: SINGLE SHOT CHAMPION will evaluate the efficacy and safety of PVI using the novel FARAPULSE PFA for patients with symptomatic paroxysmal AF., (© 2024 Heart Rhythm Society. Published by Elsevier Inc.)

Background and Aims: One third of patients with atrial fibrillation (AF) suffer from high levels of anxiety and depression, which may significantly impair quality of life (QoL). The purpose of this study was to assess whether depressive and anxiety symptoms before ablation affect the QoL in patients with AF one year after cryoballoon ablation (CBA)., Methods: This single-center retrospective study investigated whether the AF patients with a high Hospital Anxiety and Depression Scale (HADS) score (≥ 8) had worse outcomes than patients with a low pre-ablation HADS score (< 8). The primary outcome was the difference in post-ablation QoL, and the secondary outcome included the difference in pre-ablative QoL, QoL improvement, and self-reported AF., Results: Two hundred ninety-five patients were stratified according to their HADS scores (total, depression, and anxiety). Patients with an elevated HADS total, depression, or anxiety score (≥ 8), had a significantly lower QoL before and 12 months after CBA than patients with a HADS score < 8 (p-value < 0.001 for all groups). All groups improved significantly in QoL after CBA ablation and to a similar extent. Sixty-three percent of the patients reported AF symptoms after the procedure, which was comparable between the cohorts of patients., Conclusion: Patients with elevated HADS scores reported a lower QoL compared to participants with low HADS scores at baseline and 12 months after CBA. However, both groups improved in QoL after CBA, irrespective of their depressive and anxiety symptoms., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Aims: Pulmonary vein isolation (PVI) represents the gold standard in the treatment of atrial fibrillation (AF) and the use of single-shot techniques, such as cryoballoon ablation (CBA) and pulsed field ablation (PFA) using a pentaspline catheter, has gained prominence. Recent studies hypothesize that PFA might be superior to CBA, although procedural efficacy and safety data are inconsistent. A meta-analysis was conducted to compare both energy sources for the treatment of AF., Methods and Results: A structured systematic database search and meta-analysis were performed on studies investigating outcomes, periprocedural complications, and/or procedural parameters of AF patients treated by either CBA or PFA. Eleven studies reporting data from 3805 patients were included. Pulmonary vein isolation by PFA was associated with a significantly lower recurrence of atrial fibrillation/atrial tachycardia [odds ratio (OR) = 0.73, 95% confidence interval (CI) = 0.54-0.98, I 2 = 20%] and fewer periprocedural complications (OR = 0.62, 95% CI = 0.40-0.96, I 2 = 6%) compared to CBA. The lower complication rate following PFA was mainly driven by fewer phrenic nerve injuries (OR = 0.19, 95% CI = 0.08-0.43, I 2 = 0%). However, there were more cases of cardiac tamponades after PFA (OR = 2.56, 95% CI = 1.01-6.49, I 2 = 0%). Additionally, using PFA for PVI was associated with shorter total procedure times [mean difference (MD) = -9.68, 95% CI = -14.92 to -4.43 min, I 2 = 92%] and lower radiation exposure (MD = -148.07, 95% CI = -276.50 to -19.64 µGy·mI 2 = 7%)., Conclusion: Our results suggest that PFA for PVI, compared to CBA, enables shorter procedure times with lower arrhythmia recurrence and a reduced risk of periprocedural complications. Randomized controlled trials need to confirm our findings., Competing Interests: Conflict of interest: R.W. received honoraria for lectures and advisory board activities and research funding from Boston Scientific. Otherwise, there are no conflicts of interest., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Background : Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to increase further due to the aging population, increasing prevalence of risk factors, improving detection methods, and broadening of catheter ablation indications. Along with limited healthcare resources and bed availability, these reasons led to the development of a same-day discharge (SDD) protocol. The aim of this study was to evaluate the health and economic impact of a routine adoption of same-day discharge after cryoballoon AF ablation. Methods : Consecutive patients with symptomatic and drug-refractory AF scheduled for first-time AF ablation were screened, and if deemed suitable, the SDD protocol was proposed and, if accepted, enrolled in the protocol. Results : A total of 324 patients were screened, and 118 were considered eligible for the SDD pathway. Fifty-two patients accepted the SDD pathway and were included in this study. The analysis showed that the variation in resource consumption associated with cryoablation in SDD is equal to EUR 739.85/patient. The analysis showed that the main cost driver for ordinary hospitalization was represented by the hospital stay, which was calculated to be 36% of the total cost. In total, there was a cost reduction of EUR 38.472 thanks to optimized AF patient management from the standard recovery setting to SDD. Conclusions : SDD after cryoballoon ablation of AF is feasible in selected patients with a standardized protocol.

Background: Data are lacking on patient-reported outcomes (PRO) following cryoballoon ablation (CBA) versus radiofrequency ablation (RFA). We sought to evaluate QoL and clinical outcomes of cryoballoon pulmonary vein isolation only (CRYO-PVI-ONLY) versus RFA with PVI and posterior wall isolation (RF-PVI+PWI) in a large prospective PRO registry., Methods: Patients who underwent AF ablation (2013-2016) at our institution were enrolled in an automated, prospectively maintained PRO registry. CRYO-PVI-ONLY patients were matched (1:1) with RF-PVI+PWI patients based on age, gender, and type of AF (paroxysmal vs. persistent). QoL and clinical outcomes were assessed using PRO surveys at baseline and at 1-year. The atrial fibrillation symptom severity scale (AFSSS) was the measure for QoL. Additionally, we assessed patient-reported clinical improvement, arrhythmia recurrence, and AF burden (as indicated by AF frequency and duration scores)., Results: A total of 296 patients were included (148 in each group, 72% paroxysmal). By PRO, a significant improvement in QoL was observed in the overall study population and was comparable between CRYO-PVI-ONLY and RF-PVI+PWI (baseline median AFSSS of 11.5 and 11; reduced to 2 and 4 at 1 year, respectively; p = 0.44). Similarly, the proportion of patients who reported improvement in their overall QoL and AF related symptoms was high and similar between the study groups [92% (CRYO-PVI-ONLY) vs. 92.8% (RF-PVI+PWI); p = 0.88]. Arrhythmia recurrence was significantly more common in the CRYO-PVI-ONLY group (39.7%) compared to RF-PVI+PWI (27.7 %); p = 0.03. Comparable results were observed in paroxysmal and persistent AF., Conclusion: CRYO-PVI-ONLY and RF-PVI+PWI resulted in comparable improvements in patient reported outcomes including QoL and AF burden; with RF-PVI+PWI being more effective at reducing recurrences., (© 2024 Wiley Periodicals LLC.)

Purpose: The available data on the treatment strategy of pulsed field ablation (PFA) for patients with atrial fibrillation (AF) is limited. This study aims to provide a comparative analysis of the efficacy, safety, and procedural efficiency between PFA and cryoballoon ablation (CBA) for AF., Methods: We conducted a comprehensive search of the EMBASE, PubMed, Cochrane Library, and ClinicalTrials.gov databases to identify trials comparing PFA with CBA for AF from their inception until December 2023. The odds ratio (OR) and mean difference (MD), along with a 95% confidence interval (CI), were utilized as measures of treatment effect., Results: The analysis included 15 eligible trials with a total enrollment of 1880 patients. No significant differences were found in recurrent atrial arrhythmia (OR 0.83, 95% CI 0.64, 1.07) or periprocedural complications (OR 0.78, 95% CI 0.46, 1.30) between the two ablation techniques examined in this study. However, the PFA technique demonstrated a significantly shorter procedure time (MD -7.17, 95% CI -13.60, -0.73), but a longer fluoroscopy time (MD 2.53, 95% CI 0.87, 4.19). Similarly, PFA was found to be significantly associated with a decreased incidence of phrenic nerve palsy (OR 0.20, 95% CI 0.07, 0.59), but an increased incidence of cardiac tamponade (OR 4.07, 95% CI 1.15, 14.39). Moreover, there was a significantly higher release of troponin with PFA compared to CBA (MD 470.28, 95% CI 18.89, 921.67), while the increase in S100 protein and heart rate was significantly lower with PFA than with CBA (MD -64.41, 95% CI -105.46, -17.36), (MD -8.76, 95% CI -15.12, -2.40)., Conclusion: The utilization of PFA provides a safer, time-saving, and tissue-specific procedure compared to CBA, while maintaining comparable success rates. This has the potential to enhance procedural efficiency and optimize resource utilization in clinical practice. These findings underscore the feasibility and promise of PFA as an alternative technique for PVI in patients with AF., (© 2024 Wiley Periodicals LLC.)

Introduction: While atrial fibrillation (AF) ablation has proven beneficial for heart failure (HF) patients, most reports were performed with radiofrequency ablation. We aimed to evaluate the efficacy and safety of cryoballoon AF ablation in patients with HFrEF., Method: We comprehensively searched the databases of MEDLINE, EMBASE, and Cochrane database from inception to December 2022. Studies that reported the outcomes of freedom from atrial arrhythmia, complications, NYHA functional class (NYHA FC), and left ventricular ejection fraction (LVEF) after Cryoballoon AF ablation in HF patients were included. Data from each study were combined with a random-effects model., Result: A total of 9 studies observational studies with 1414 HF patients were included. Five studies had only HF with reduced ejection fraction (HFrEF), 1 study with HF with preserved ejection fraction (HFpEF), and others with mixed HF types. Freedom from AA in HFrEF at 12 months was 64% (95% CI 56-71%, I 2 58%). There was a significant improvement of LVEF in these patients with a standard mean difference of 13% (95% CI 8.6-17.5%, I 2 99% P < 0.001. The complication rate in HFrEF group was 6% (95% CI 4-10%, I 2 0%). The risk of recurrence of atrial arrhythmia was not significantly different between HF and no HF patients (RR 1.34, 95% CI 0.8-2.23, I2 76%)., Conclusion: Cryoballoon AF ablation is effective in HFrEF patients comparable to radiofrequency ablation. The complication rate was low., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Indian Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.)

Background: Pulsed-field ablation (PFA) is an alternative to thermal ablation (TA) in patients with atrial fibrillation (AF) receiving catheter-based therapy for pulmonary vein isolation (PVI). However, its efficacy and safety have yet to be fully elucidated., Objective: The purpose of this study was to compare the acute and long-term efficacies and safety of PFA and TA., Methods: We performed a systematic review and meta-analysis of randomized and nonrandomized controlled trials comparing PFA and TA in patients with AF undergoing their first PVI ablation. The TA group was divided into cryoballoon (CB) and radiofrequency subgroups. AF patients were divided into paroxysmal atrial fibrillation (PAF) and persistent atrial fibrillation (PersAF) subgroups for further analysis., Results: Eighteen studies involving 4998 patients (35.2% PFA) were included. Overall, PFA was associated with a shorter procedure time (mean difference [MD] -21.68; 95% confidence interval [CI] -32.81 to -10.54) but longer fluoroscopy time (MD 4.53; 95% CI 2.18-6.88) than TA. Regarding safety, lower (peri-)esophageal injury rates (odds ratio [OR] 0.17; 95% CI 0.06-0.46) and higher tamponade rates (OR 2.98; 95% CI 1.27-7.00) were observed after PFA. In efficacy assessment, PFA was associated with a better first-pass isolation rate (OR 6.82; 95% CI 1.37-34.01) and a lower treatment failure rate (OR 0.83; 95% CI 0.70-0.98). Subgroup analysis showed no differences in PersAF and PAF. CB was related to higher (peri)esophageal injury, and lower PVI acute success and procedural time., Conclusion: Compared to TA, PFA showed better results with regard to acute and long-term efficacy but significant differences in safety, with lower (peri)esophageal injury rates but higher tamponade rates in procedural data., (© 2024 Heart Rhythm Society. Published by Elsevier Inc.)

The relationship between epicardial adipose tissue (EAT) and atrial fibrillation (AF) has gained interest in recent years. The previous literature on the topic presents great heterogeneity, focusing especially on computed tomography imaging. The aim of the present study is to determine whether an increased volume of left atrial (LA) EAT evaluated at routine pre-procedural cardiac magnetic resonance imaging (MRI) relates to AF recurrences after catheter ablation. A total of 50 patients undergoing AF cryoballoon ablation and pre-procedural cardiac MRI allowing quantification of LA EAT were enrolled. In one patient, the segmentation of LA EAT could not be achieved. After a median follow-up of 16.0 months, AF recurrences occurred in 17 patients (34%). The absolute volume of EAT was not different in patients with and without AF recurrences (10.35 mL vs. 10.29 mL; p -value = 0.963), whereas the volume of EAT indexed on the LA volume (EATi) was lower, albeit non-statistically significant, in patients free from arrhythmias (12.77% vs. 14.06%; p -value = 0.467). The receiver operating characteristic curve testing the ability of LA EATi to predict AF recurrence after catheter ablation showed sub-optimal performance (AUC: 0.588). The finest identified cut-off of LA EATi was 10.65%, achieving a sensitivity of 0.5, a specificity of 0.82, a positive predictive value of 0.59 and a negative predictive value of 0.76. Patients with values of LA EATi lower than 10.65% showed greater survival, free from arrhythmias, than patients with values above this cut-off (84% vs. 48%; p -value = 0.04). In conclusion, EAT volume indexed on the LA volume evaluated at cardiac MRI emerges as a possible independent predictor of arrhythmia recurrence after AF cryoballoon ablation. Nevertheless, prospective studies are needed to confirm this finding and eventually sustain routine EAT evaluation in the management of patients undergoing AF catheter ablation.

Background: Long-term data showed that up to 27% of pulmonary veins are reconnected using cryoballoon ablation. This study aimed to evaluate the efficacy of the latest 4th-generation cryoballoon catheters using ultra high-resolution mapping., Methods: In patients with atrial fibrillation, a standard pulmonary vein isolation (PVI) with the latest 4th-generation cryoballoon catheter (Arctic Front Advance PRO, Medtronic Minneapolis, USA) and the spiral mapping catheter (Achieve Advance, Medtronic, Minneapolis, MN, USA) was performed. Subsequently, high-resolution mapping was achieved using the novel multipolar grid mapping catheter (Advisor HD Grid SE, Abbott Laboratories, USA). Follow-up was obtained after 6 months by means of a 7-day Holter electrocardiogram., Results: In our study, acute PVI was successfully achieved in all 31 patients. The latest 4th-generation cryoballoon catheter is safe in the acute phase of PVI. Additional high-resolution mapping (mean points per map 21,001 ± 4911) using the multipolar grid mapping catheter enabled us to identify residual gaps only in the carina pulmonary vein region; therefore, no additional ablation was performed. Three of 31 patients (10%) presented with atrial arrhythmia recurrence always related with pulmonary vein reconnection; using high-resolution mapping had no additional benefit in identifying pulmonary veins in which reconnection will occur., Conclusion: The utility of additional high-density mapping, facilitated by the HD Grid catheter after PVI with the 4th-generation cryoballoon catheter do not substantiate a discernible advantage over conventional mapping methodologies, particularly, the spiral mapping catheter. Residual carinal conduction was observed in a substantial cohort of patients (48%), highlighting a persistent challenge in achieving complete electrical isolation., Competing Interests: Conflict of interest disclosure MG was a speaker for Abbott, Bristol-Myers Squibb, Novartis, Pfizer, and an advisor for Boehringer Ingelheim., (Copyright © 2024 Hellenic Society of Cardiology. Published by Elsevier Inc. All rights reserved.)

Background: Pulsed-field ablation (PFA) has shown promising data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI), with similar long-term outcomes compared to radiofrequency ablation (RFA) and cryoballoon ablation (CBA) in patient with paroxysmal atrial fibrillation (AF) OBJECTIVE: To compare the procedural and long-term outcomes of patients with persistent AF undergoing PVI using PFA, CBA, or RFA., Methods: Consecutive patients with persistent AF undergoing a first PVI with PFA, CBA, or RFA were included. Patients underwent 7d-Holter-ECG at 3, 6, and 12 months post-ablation. The primary outcome was recurrence of any atrial arrhythmia after a 90-day blanking period. Safety outcomes included the composite of in-hospital major adverse events., Results: A total of 533 patients with persistent AF underwent PVI using PFA (n=214), CBA (n=190), or RFA (n=129). Procedures with PFA guided by fluoroscopy were shorter compared to CBA (median 60 min, IQR 53-80 vs. 84 min, IQR 68-101, p=<0.001), and procedures with PFA in combination with 3D-electroanatomical mapping were shorter compared to RFA (median 101 min, IQR 85-126 vs. 171 min, IQR 141-204, p<0.001). Acute safety events occurred in 2.3%, 2.6% and 0.8% in the PFA, CBA and RFA group (p=0.545). The 1-year confounder-adjusted estimate for freedom from atrial arrhythmias was 62.1% for CBA, 55.3% for PFA and 48.3% for RFA (CBA vs. PFA p=0.79, CBA vs. RFA p=0.009; PFA vs. RFA p=0.010)., Conclusion: In patients with persistent AF undergoing a first PVI, 1-year confounder-adjusted outcomes are better with PFA and CBA compared to RFA., (Copyright © 2024. Published by Elsevier Inc.)

Background: Pulsed-field ablation (PFA) is a novel nonthermal ablation technology. Its potential value for repeat procedures after unsuccessful thermal ablation for atrial fibrillation has not been assessed., Objective: The purpose of this study was to summarize our initial experience with patients undergoing repeat procedures using PFA., Methods: Consecutive patients with arrhythmia recurrences after a prior thermal ablation undergoing a repeat procedure using a multipolar PFA catheter from May 2021 and December 2022 were included. After 3-dimensional electroanatomic mapping, reconnected pulmonary veins (PVs) were reisolated and veins with only ostial isolation wither ablated to widen antral PV isolation. Posterior wall ablation was performed if all PVs were durably isolated or in case of low-voltage areas on the posterior wall at the discretion of the operator. Patients underwent follow-up with 7-day Holter electrocardiography after 3, 6, and 12 months., Results: A total of 186 patients undergoing a repeat procedure using PFA were included. The median number of previous ablations was 1 (range 1-6). The prior ablation modality was radiofrequency in 129 patients (69.4%), cryoballoon in 51 (27.4%), and epicardial ablation in 6 (3.2%). At the beginning of the procedure, 258 of 744 PVs (35%) showed reconnections. Additional antral ablations were applied in 236 of 486 still isolated veins (49%). Posterior wall ablation was added in 125 patients (67%). Major complications occurred in 1 patient (transient ischemic attack 0.5%). Freedom from arrhythmia recurrence in Kaplan-Meier-analysis was 78% after 6 months and 54% after 12 months., Conclusion: PFA is a versatile and safe option for repeat procedures after failed prior thermal ablation., (© 2024 Heart Rhythm Society. Published by Elsevier Inc.)

Background: Transmural injury plays a role in successful atrial fibrillation ablation. The effect of left atrial wall thickness (LAWT) on the efficacy of radiofrequency ablation has been identified, but data on the relationship between LAWT and cryoballoon for paroxysmal atrial fibrillation (PAF) are lacking. We aim to explore the relationship between LAWT and recurrence after cryoballoon ablation (CBA)., Methods: We studied 364 patients (mean age 62 years) with PAF who underwent a second-generation CBA and pre-procedure cardiac CTA. LAWT and left atrial volume index (LAVI) were obtained based on pre-procedure cardiac CTA measurements. Follow-up was at least 12 months and predictors of atrial tachyarrhythmia recurrence during follow-up were assessed., Results: Patients were followed up for a median of 19 (12-28) months, with an atrial tachyarrhythmia-free rate of 77.5% after cryoablation. Greater LAVI (50.0 ± 19.6 mL/m 2 vs. 44.3 ± 15.4 mL/m 2 , P = 0.018) and greater LAWT (1.67 ± 0.24 vs. 1.46 ± 0.25 mm, P < 0.001) were associated with atrial tachyarrhythmia recurrence. The mean LAWT of PV antrum correlated with TTI (R = 0.252, P < 0.001). Adding LAWT to the established risk model improved both the discrimination and reclassification effects (IDI: 0.099, 95% CI: 0.065-0.134, P < 0.001; NRI: 0.685, 95% CI: 0.455-0.915, P < 0.001). In a multivariable Cox proportional hazard model, the mean LAWT of PV antrum (hazard ratio [HR]:3.657, 95%CI: 2.319-5.765, P < 0.001) was an independent predictor of atrial tachyarrhythmia recurrence after cryoablation., Conclusions: The mean LAWT of PV antrum, obtained from preoperative measurements on CT, was associated with atrial tachyarrhythmia recurrence after cryoablation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The aims of this analysis were: to evaluate the impact of timing of ablation on the rate of atrial arrhythmias recurrence, verify if the timing of ablation impact differently in patients with paroxysmal and persistent AF., Methods: Three thousand two hundred and five patients (60.5 ± 10 years, female 28.4%%, 78.8%% paroxysmal AF) were included in the analysis. All patients underwent only cryoballoon (CB) pulmonary vein (PV) isolation during the index procedure., Results: The mean procedure time was 102.8 ± 50 min, with a mean fluoroscopy time of 26.3 ± 49 min. Acute PV isolation was achieved in 11760/11793 (99.7%) PVs. A total of 91 (2.8%) patients experienced a procedure-related complication. During the observation period 913/3205 (28.5%) patients had at least one atrial arrhythmias episode: 28% of patients with paroxysmal AF vs 33% of patients with persistent AF. In multivariate analysis, persistent AF together with time from symptomatic AF diagnosis to ablation, female sex, and ablation time showed to be significant predictors for AF recurrence. In particular, months from first symptomatic AF episode > 18 months was a significant predictor of AF recurrence (HR = 1.23, 95% CI = 1.03-1.46, p = 0.020). In patients with paroxysmal AF, the multivariate analysis confirmed that months from first symptomatic AF episode > 18 month was an independent predictor of AF recurrence together with age > 62 years and female sex. In patients with persistent AF, the time from persistent AF showed to be significant predictor for AF recurrence., Conclusions: In this multicenter analysis, time from first symptomatic AF episode > 18 months was a significant predictor of AF recurrence after CB PV isolation., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: Cryoablation therapy for pulmonary vein isolation (PVI) to treat paroxysmal atrial fibrillation (PAF) is well established. A novel 28 mm cryoballoon system designed to operate under low pressure to safely reach a lower nadir temperature and maintain constant balloon size during cooling has not been prospectively studied in a large patient population for safety and efficacy. The FROZEN AF (NCT04133168) trial was an international multicenter, open-label, prospective, single-arm study on the safety and performance of a novel cryoballoon system for treatment of PAF., Methods and Results: The study enrolled patients at 44 sites in 10 countries across North America, Europe, and Asia. Subjects were indicated for PVI treatment of PAF and had failed or were intolerant of one or more antiarrhythmic drugs. Procedural outcomes were defined based on the 2017 HRS consensus statement. Follow-up was performed at 7 days, 3, 6, and 12 months. Data are reported as mean ± SD or median (IQR). PVI was performed with a 28 mm cryoballoon in 325 drug refractory PAF patients. Complete PVI was achieved in 95.7% of patients. In cryoablation lesions longer than 60 s, 60.1% of PV isolations required only a single cryoballoon application. Procedure related complications included: phrenic nerve palsy [temporary 4 (1.2%), persistent 0 (0.0%)], cardiac tamponade/perforation 2 (0.6%), and air embolism 1 (0.3%). Freedom from documented atrial arrhythmia recurrence at 12 months was 79.9% (AF 82.7%, AFL 96.5%, AT 98.1%), antiarrhythmic drugs (AAD) were continued or re-initiated in 26.8% of patients after the 3-month blanking period. Additionally, an extension arm enrolled 50 pts for treatment with 28/31 mm variable size cryoballoon. A single temporary PNP occurred in this group, which resolved before discharge. Freedom from documented recurrence at 12 months in these pts was 82.0%., Conclusions: This novel cryoballoon may facilitate PVI to treat PAF, providing more options to address the variety of anatomies present in patients with PAF. This cryoballoon system proved to be safe and effective for treatment of patients with drug refractory or drug intolerant PAF., (© 2024 Wiley Periodicals LLC.)

Introduction: Atrial fibrillation often necessitates catheter ablation when antiarrhythmic drug therapy fails. Single-shot technologies using thermal energy, such as cryoballoon ablation, are commonly used, but pulsed field ablation (PFA), an innovative non-thermal ablation technique, is a potential alternative. This retrospective observational study aimed to compare the safety and efficacy of cryoballoon ablation and PFA in patients undergoing their first pulmonary vein isolation (PVI) procedure for atrial fibrillation treatment., Methods: We utilised real-world data from patients who underwent PVI using cryoballoon ablation or PFA. The primary outcome encompassed procedural complications, including phrenic nerve palsy, cardiac tamponade, thromboembolic complications, bleeding complications and mortality. Secondary outcomes were procedural characteristics including procedure duration, length of hospital admission, and re-do ablation rates within 6 months., Results: A total of 1714 procedures were analysed: 1241 in the cryoballoon group and 473 in the PFA group. Gender distribution (p = 0.03) and estimated glomerular filtration rate (p = 0.01) differed significantly. With regard to the primary outcome, the cryoballoon group demonstrated a higher incidence of phrenic nerve palsy compared with the PFA group (15 vs 0; p = 0.02). The procedure duration was shorter in the PFA group, even after adjusting for baseline characteristics (95.0 vs 74.0 min; p < 0.001). After adjustment for baseline characteristics, admission duration differed between the groups as well (p = 0.04)., Conclusion: The study results supported the safety and efficacy of PFA over cryoballoon ablation for PVI, highlighting advantages such as shorter procedure duration and absence of phrenic nerve palsy., (© 2024. The Author(s).)

Background: Cardioneuroablation (CNA) targeting ganglionated plexi has shown promise in treating vasovagal syncope. Only radiofrequency ablation has been used to achieve this goal thus far., Objective: The purpose of this study was to investigate the utility of cryoballoon ablation (CBA) of the pulmonary veins (PVs) as a potential simplified approach to CNA., Methods: We report our observations of autonomic modulation in a series of 17 patients undergoing CBA for atrial fibrillation and our early experience using CBA of the PVs in 3 patients with malignant vagal syncope. In 17 patients undergoing CBA of AF, sinus cycle length was recorded intraprocedurally after ablation of individual PVs., Results: The most pronounced shortening of the sinus cycle length was observed after isolation of the right upper PV, which was ablated last. Reduced sinus node recovery time and atrioventricular (AV) nodal effective refractory period were observed after CBA. Resting heart rate was elevated by 6-7 bpm after CBA and persisted during 12-month follow-up. CBA of the PVs was performed in 3 patients with recurrent vagal syncope mediated by sinus arrest (n = 2) and AV block (n = 1). In all patients, isolation of the right upper PV resulted in marked shortening of sinus cycle length. During follow-up of 178 ± 43 days (134-219 days), CNA resulted in abolition of pauses, bradycardia-related symptoms, and syncope in all patients., Conclusion: CBA of the PVs (particularly the right upper PV) may be a predictable anatomic CNA approach in patients with refractory vagal syncope due to sinus arrest and/or AV block and may warrant systematic investigation as a tool to perform CNA., (© 2024 Heart Rhythm Society. Published by Elsevier Inc.)

Background and Aims: Right phrenic nerve palsy is the most frequent complication of cryoballoon procedures. The SMARTFREEZE™ console (Boston Scientific, St. Paul, MN, USA) has integrated a new tool for diaphragm monitoring-the Diaphragm Movement Sensor; however, it has not been evaluated in clinical practice. We aimed to assess the diagnostic performance of the Diaphragm Movement Sensor based on compound motor action potential data recorded simultaneously., Methods: Thirty consecutive patients (mean age 63.2 ± 10.2 years) were included. We simultaneously recorded the compound motor action potential and the Diaphragm Movement Sensor during cryoapplications in the right pulmonary veins. The right phrenic nerve was paced at 60 per minute, 12 V and 2.9 ms. Compound motor action potential monitoring with a 30% decrease cutoff for the diagnosis of phrenic nerve threatening was considered the gold standard. The Diaphragm Movement Sensor decrease threshold was also set at 30%., Results: Considering compound motor action potential monitoring, phrenic nerve threatening occurred 11 times (in seven patients) among 84 cryoapplications (13.1%) at the right pulmonary veins. The sensitivity and specificity of the Diaphragm Movement Sensor were, respectively, 33% (95% CI: 7%-70%) and 49% (95% CI: 38%-61%; P  < 0.001). The predictive positive and negative values for the Diaphragm Movement Sensor were, respectively, 7% (95% CI: 2%-20%) and 86% (95% CI: 72%-95%). The Diaphragm Movement Sensor gave an erroneous diagnosis in 44/84 cryoapplications (52.4%)., Conclusions: The diagnostic performance of the Diaphragm Movement Sensor is low, and the relevance of its use in clinical practice may be debated., Competing Interests: FF is consultant for the company Circle Safe. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Schemoul, Tovmassian, Mancini, Koutbi, Biermé, Deharo, Franceschi and Maille.)

Background: Cryoballoon ablation is currently the gold standard technique for single-shot pulmonary vein isolation (PVI). Pulsed field ablation (PFA) has recently emerged as an interesting nonthermal alternative energy for PVI. The purpose of our study was to evaluate the safety and long-term efficacy of PVI using the pentaspline PFA catheter in comparison to cryoballoon ablation., Methods and Results: Between January 2021 and December 2022, we included all consecutive patients of our center in whom a first PVI-only procedure was performed using PFA or cryoballoon. The choice of the energy was based on patients' preference between general anesthesia (PFA) and local anesthesia (cryoballoon). The primary end point was freedom from documented atrial arrhythmia recurrence after a 3-month blanking period. A total of 301 patients (paroxysmal atrial fibrillation in 220 patients) underwent a first PVI procedure performed using PFA (n=151) or cryoballoon (n=150). Complete short-term PVI was obtained in 144 of 150 patients (96%) in the cryoballoon group and in all patients of the PFA group ( P =0.01). Procedure duration was significantly longer in the cryoballoon group. Transient and persistent phrenic nerve injuries were observed in the cryoballoon group only (13/150 and 2/150, respectively). One-year freedom from atrial arrhythmia was significantly higher in the PFA group compared with the cryoballoon group (87.9% versus 77.7%; adjusted hazard ratio, 0.53 [95% CI, 0.30-0.96]; P =0.037)., Conclusions: This prospective, comparative, real-life study suggested that PFA could overcome safety limitations of cryoballoon with optimal effectiveness. Randomized controlled studies are required to further investigate the potential superiority of PFA over cryoballoon.

Background: The cryoballoon (CB) has become a standard tool for pulmonary vein isolation (PVI), but the technology is limited in certain ways. A novel RF-balloon (Heliostar™, Biosense Webster, CA, USA) promises the advantages of a balloon technology in combination with 3D mapping., Methods: To assess procedural data and outcome, all patients undergoing RF-balloon PVI were included and compared with data from consecutive patients undergoing CB PVI for paroxysmal AF., Results: A total of 254 patients (63 ± 13 years, 54% male) were included: 30 patients undergoing RF-balloon and 224 patients CB PVI. Baseline parameters were comparable. Procedure duration (104.3 ± 35.3 min vs. 69.9 ± 23.1 min; p ≤ 0.001) and fluoroscopy time (16.3 ± 7.1 min vs. 11.6 ± 4.9 min; p ≤ 0.001) were longer using the RF-balloon; ablation time (43.5 ± 17.9 vs. 36.4 ± 15.6; p = 0.08) did not differ, and time-to-isolation (TTI) was shorter (18.2 ± 7.0 s vs. 62.8 ± 35.1 s; p ≤ 0.001). Second-generation RF-balloon cases showed shorter ablation time and TTI at comparable procedure duration and fluoroscopy time. One pericardial effusion occurred with the RF-balloon due to complicated transseptal access. During CB PVI in 4/224 patients (1.8%), a phrenic nerve palsy was observed. After 12 months, 78% of patients after RF-balloon and 81% of patients after CB PVI (p = 0.5) were free from atrial arrhythmias., Conclusion: The RF-balloon was safe and effective. Compared with the CB, TTI was shorter, but procedure durations and fluoroscopy times were longer. This can be attributed to a learning curve and the initial necessity for separate 3D map preparation. Considering the results with the second-generation RF-balloon, more experience is needed to determine the potential benefits., (© 2024. The Author(s).)

Background: Pulsed-field ablation (PFA) has shown favourable data in terms of safety and procedural efficiency for pulmonary vein isolation (PVI). We sought to compare procedural and 1-year follow-up data of patients with paroxysmal atrial fibrillation (AF) undergoing PVI using PFA, cryoballoon ablation (CBA) and radiofrequency ablation (RFA)., Methods: Consecutive patients with paroxysmal AF undergoing a first PVI with PFA at our institution were included. For comparison, patients with paroxysmal AF undergoing a first PVI with CBA and RFA were selected using a 1:2:2 propensity score matching. The PFA group followed the standard 32-applications lesion-set protocol, the CBA group a time-to-effect plus 2-min strategy, and the RFA group the CLOSE protocol. Patients were followed with 7d-Holter ECGs 3, 6, and 12 months after ablation. The primary endpoint was recurrence of atrial tachyarrhythmia (ATa) following a blanking period of 3 months., Results: A total of 200 patients were included (PFA n = 40; CBA n = 80; RFA n = 80). Median procedure times were shortest with CBA (75 min) followed by PFA (94 min) and RFA (182 min; p < 0.001). Fluoroscopy dose was lowest with RFA (1.6Gycm 2 ) followed by PFA (5.0Gycm 2 ) and CBA (5.7Gycm 2 ; p < 0.001). After a 1-year follow-up, freedom from ATa recurrence was 85.0% with PFA, 66.2% with CBA and 73.8% with RFA (p = 0.12 PFA vs. CBA; p = 0.27 PFA vs. RFA)., Conclusion: In a propensity score matched analysis of patients with paroxysmal AF, freedom from any ATa 1 year after PVI using PFA was favourable and at least as good as for PVI with CBA or RFA., (© 2023. The Author(s).)

Background: It remains uncertain whether the implication of early recurrence and blanking period can be applied to patients with atrial fibrillation (AF) treated with cryoballoon ablation (CBA). We aimed to explore the prognostic value of early recurrence in patients with AF treated with CBA., Methods: We studied consecutive AF patients who were treated with CBA between April 2019 and September 2020 in two tertiary medical institutes and followed for up to 12 months. The endpoint was the late recurrence of atrial arrhythmia, including AF, atrial flutter, and atrial tachycardia, following a 90-day blanking period. Atrial arrhythmia during the blanking period was defined as early recurrence and was not considered as an endpoint., Results: This study included 406 patients with AF who underwent CBA. During the follow-up, 147 (36.2%) cases of late recurrence were observed. Of the 104 patients with early recurrence, 85 experienced late recurrence during follow-up. Early recurrence was associated with an increased risk of late recurrence in the univariate and multivariate analyses (P < 0.001). When we classified the patients into paroxysmal AF and persistent AF groups, early recurrence was still significantly associated with a higher risk of late recurrence (P = 0.005 and P < 0.001, respectively)., Conclusion: Early recurrence after CBA was an independent risk factor for late recurrence in all patients as well as in those with paroxysmal AF and persistent AF. Therefore, further prospective studies could be considered to verify the risks and benefits of early rhythm control in patients with early recurrence., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Adding electroanatomical left atrial (LA) voltage mapping to cryoballoon ablation (CBA) improves validation of acute pulmonary vein isolation (PVI). Aims: To determine whether the addition of mapping can improve outcome and PVI durability. Methods: One-year outcome and PV reconnection (PVR) rate at first repeat ablation were studied in 400 AF patients in a propensity-matched analysis (age, AF type, CHA 2 DS 2 -VASc score) between Achieve catheter-guided CBA with additional EnSite LA voltage maps performed pre- and post-CBA (mapping group; N = 200) and CT- and Achieve catheter-guided CBA (control group; N = 200). Clinical success was defined as freedom of documented AF or atrial tachycardia (AT) > 30 s. PV reconnection patterns were characterized in repeat ablations. Results: At 1 year, 77 (19.25%) patients had recurrence of AF/AT, significantly lower than in the mapping group: 21 (10.5%) vs. 56 (28%), p < 0.001. Procedure time was shorter (72.2 ± 25.4 vs. 78.2 ± 29.3 min, p = 0.034) and radiation exposure lower (4465.0 ± 3454.6 Gy.cm 2 vs. 5940.5 ± 4290.5 Gy.cm 2 , p = 0.037). Use of mapping was protective towards AF/AT recurrence (HR = 0.348; 95% CI 0.210-0.579; p < 0.001), independent of persistent AF type (HR = 1.723; 95% CI 1.034-2.872; p = 0.037), and LA diameter (HR = 1.055; 95% CI 1.015-1.096; p = 0.006). At repeat ablation (N = 90), persistent complete PVI was seen in 14/20 (70.0%) versus 23/70 (32.9%) in the mapping and conventional group, respectively ( p = 0.03). Reconnection rate of the right inferior PV was lower with mapping (10.0% vs. 34,3%, p = 0.035). Conclusions: Adding electroanatomical LA voltage mapping to CBA improves 1-year clinical outcome and lowers both procedure time and radiation exposure. At repeat, use of mapping increases complete persistent PVI mainly by improving PVI durability of the RIPV.

Background: Pulmonary vein isolation with wide antral ablation leads to better clinical outcomes for the treatment of atrial fibrillation, but the isolation lesion is invisible in conventional cryoballoon ablation. In this study, we aim to investigate the efficacy of the wide pulmonary vein isolation technique that includes the intervenous carina region, guided by high-density mapping, compared with pulmonary vein isolation alone without the mapping system., Methods: We conducted a propensity score-matched comparison of 74 patients who underwent a wide cryoballoon ablation guided by high-density mapping (mapping group) and 74 controls who underwent conventional cryoballoon ablation in the same period (no-mapping group). The primary outcome was a clinical recurrence of documented atrial arrhythmias for >30 s during the 1-year follow-up., Results: Of 74 patients in the mapping group, residual local potential in the pulmonary vein antrum was found in 30 (40.5%) patients, and additional cryothermal applications were performed to achieve a wide pulmonary vein isolation. Compared with the no-mapping group, the use of the mapping system in the mapping group was associated with a longer fluoroscopic time (26.97 ± 8.07 min vs. 23.76 ± 8.36 min, P  = 0.023) and greater fluoroscopic exposure [339 (IQR181-586) mGy vs. 224 (IQR133-409) mGy, P  = 0.012]. However, no significant differences between the two groups were found in terms of procedural duration and left atrial dwell time (104.10 ± 18.76 min vs. 102.45 ± 21.01 min, P  = 0.619; 83.52 ± 17.01 min vs. 79.59 ± 17.96 min, P  = 0.177). The rate of 12-month freedom from clinical atrial arrhythmia recurrence was 85.1% in the mapping group and 70.3% in the no-mapping group (log-rank P  = 0.029)., Conclusion: Voltage and pulmonary vein potential mapping after cryoballoon pulmonary vein isolation can identify residual potential in the pulmonary vein antrum, and additional cryoablation guided by mapping leads to improved freedom from atrial arrhythmias compared with conventional pulmonary vein isolation without the mapping system., Clinical Trial Registration Number: ChiCTR2200064383., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Chen, Wang, Xuan, Liang, Jin, Ding, Sun, Zhang and Han.)

Background: Catheter ablation is a mainstay of atrial fibrillation (AF) treatment. Acute pericarditis after ablation is 1 of the frequently observed complications. There is a significant lack of data on the incidence and predictors of postablation pericarditis., Objectives: This study examines the incidence, characteristics, and predictors of pericarditis after AF ablation., Methods: Patients undergoing AF ablation from January 1, 2016, to March 31, 2022, at Johns Hopkins were prospectively enrolled in an AF ablation registry. A clinical diagnosis of acute pericarditis was established in accordance with 2015 European Society of Cardiology guidelines by the presence of at least 2 of the following characteristics: pleuritic chest pain, friction rub, typical electrocardiographic changes, or pericardial effusion within 3 months after the ablation procedure., Results: Of 1,540 patients who underwent AF ablation, 57 patients (3.7%) developed acute pericarditis. Baseline clinical characteristics including age, sex, and body mass index were comparable between the pericarditis and nonpericarditis groups. The median time to symptom onset was 1 day. Electrocardiographic changes were observed in 34 (59.6%) patients, pericardial effusion developed in 7 (12%) patients, and the mean duration of medical treatment was 7 days (25th-75th percentile: 3-14 days). Most pericarditis cases were treated medically with disease-specific nonsteroidal anti-inflammatory drugs (100%) and colchicine (81%). Effusion with tamponade necessitating pericardiocentesis was observed in 4 (7%) patients. Radiofrequency (RF) ablation was performed in 869 (58.6%) patients in the nonpericarditis group and 39 (68.4%) patients with pericarditis; cryoballoon ablation was performed in 486 (32.8%) patients in the nonpericarditis group and 11 (19.3%) patients with pericarditis. Multivariable logistic regression analysis identified RF ablation (OR: 2.09; 95% CI: 1.07-4.08; P = 0.03) as an independent predictor of acute pericarditis after AF ablation, whereas age per unit increase was associated with a decreased risk (OR: 0.97; 95% CI: 0.95-0.995; P = 0.02)., Conclusions: The incidence of acute pericarditis after catheter ablation in our study population was 3.7%. RF ablation and younger age were independent risk factors for postablation acute pericarditis., Competing Interests: Funding Support and Author Disclosures The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The impact of the P-wave morphology on clinical outcomes postcatheter ablation (post-CA) and recurrent arrhythmia characteristics or electrophysiologic findings in patients with paroxysmal atrial fibrillation (PAF) remains unclear. Patients with PAF who underwent cryoballoon ablation were enrolled. In 12-lead electrocardiography recorded within 1 month before CA, the P-wave duration (Pd) and P-wave vector magnitude (Pvm) (square root of the sum of the squared P-wave amplitude in leads II, V 6 , and one-half of the P-wave amplitude in V 2 ) were measured and divided into 2 groups: patients with high and low Pd/Pvm based on a statistically calculated cut-off value. We evaluated the incidence of late recurrence of atrial fibrillation (LRAF), myocardial injury (high-sensitive troponin I), and the electrophysiologic findings in repeat ablation sessions. This study included 269 patients with PAF. The median follow-up duration was 697 days. The cut-off value of the Pd/Pvm for predicting LRAF was 740.7 ms/mV (area under the curve = 0.81, sensitivity = 58.2%, and specificity = 89.6%). Multivariable Cox proportional hazards analysis showed that high Pd/Pvm (>740.7 ms/mV) was significantly associated with LRAF (p <0.001). The high-sensitive troponin I level was significantly lower, and the ratio of DR-FLASH score >3 was significantly higher in those with high than low Pd/Pvm (p = 0.044 and p = 0.002, respectively). In the repeat ablation sessions, the Pd/Pvm in patients with atrial tachycardia-induced or spontaneously occurring during the repeat CA sessions was significantly higher than in those without (p = 0.009). There was a significant difference between the Pd/Pvm and low-voltage area (p <0.001). In conclusion, the Pd/Pvm is significantly associated with LRAF after cryoballoon ablation in patients with PAF and predicts left atrial low-voltage areas and atrial tachycardia inducibility., Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Aim: The aim of this study is to investigate the value of inflammatory markers for atrial fibrillation (AF) recurrence prediction after cryo-balloon ablation (CA). Materials & methods: The study included 399 patients divided into two groups by AF recurrence after CA. Inflammatory markers including uric acid/albumin ratio (UAR), systemic immune inflammation index (SIII) and CRP/albumin ratio (CAR) were evaluated. Results: UAR, SIII, and CAR were independently associated with the risk of recurrence in AF patients following CA. In ROC curve analysis, CAR had a greater area under curve (AUC:0.73) value than either SIII (AUC:0.68) or UAR (AUC:0.64). Conclusion: Our study results indicate that CAR compared with SIII and UAR had a greater predictive value than others inflammatory markers in predicting AF recurrence post-CA.