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Background: Data on the roof line (RL) and mitral isthmus line (MIL) reconnections after atrial fibrillation (AF) catheter ablation (CA) are scarce. Objective: We studied the RL andMIL completeness and localization of reconnection sites in consecutive patients after their first-ever AF-CA. Methods: We prospectively included 41 consecutive AF patients who underwent predefined lesion sets of two circumferential lines (CLs) for ipsilateral pulmonary vein isolation (PVI) combinedwith a RL and lateral MIL. Three months after CA, all patients underwent invasive follow-up procedure for line persistency evaluation, irrespective of clinical outcome. Results: At the time of index ablation, PVI-CLs, RL, and MIL was completed in 41 (100%), 39 (95%), and 34 (83%) of patients, respectively. At the 3-month follow-up procedure, reconnections of PVI-CLs, RL, and MIL were found in 61% (25/41), 28% (11/39), and 24% (8/34) of patients, respectively. The 3-month reconnections were located commonly in the anterior and posterior PVI-CL segments, and rarely in the right third of RL and in the posterior part of MIL. The 3-month reconnections were rarely seen at the sites of acute reconnections during index procedure (6%, 20%, and 25% of the PVI-CL segments, RL segments, and MIL segments, respectively). Conclusions: To our knowledge, this is the first study systematically investigating the reconnection of standardized left atrium linear lesions such as RL and MIL after RF-CA for AF in consecutive patients. The RL and MIL 3-month reconnection rates were relatively low (28% and 24%), with poor anatomical concordance between the sites with acute and 3-month reconnections.

Impact of PFO on LA Linear Ablation. Introduction: We investigated the impact of the mode of left atrial (LA) access via patent foramen ovale (PFO) versus transseptal (TS) puncture on LA linear lesions during atrial fibrillation (AF) ablation. Methods and Results: We investigated 139 (PFO: 25) consecutive patients who underwent mitral isthmus (MI) and/or LA roof linear ablation. Technical endpoint was completeness of linear lesions and duration of radiofrequency (RF) application. During the initial procedure, complete MI and LA roof blocks were created in 13 of 19 (68%) and 14 of 17 (82%) patients in the PFO group, and in 57 of 94 (61%) and 54 of 70 (74%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (11.1 ± 8.9 and 15.1 ± 7.6 minutes, P = 0.11), and LA roof (10.1 ± 3.5 and 8.3 ± 5.0 minutes, P = 0.21) between the 2 groups. Among 28 patients who underwent repeat linear ablation, complete MI and LA roof blocks were created in 3 of 4 (75%) and 0 of 1 (0%) patients in the PFO group, and in 16 of 21 (76%) and 7 of 10 (70%) patients in the TS group, respectively (P = NS). There was no significant difference in RF durations at MI (15.3 ± 8.3 and 19.5 ± 18.3 minutes, P = 0.71), and LA roof (19.0 and 10.3 ± 5.4 minutes, P = 0.19) between the 2 groups. Clinical outcomes at 12 months were also similar. Conclusion: There were no significant differences in the procedural success rates, durations of RF application, 12-month clinical outcomes, and complication rates of LA linear ablation between the PFO and TS groups. Accessing the LA via a PFO is not an unfavorable approach toward LA linear ablation. © 2011 Wiley Periodicals, Inc.

Background-Achievement of complete conduction block across left mitral isthmus (MI) is challenging. Anticipation of perimitral conduction time (PMCT) associated with MI block may expedite this procedure. We evaluated the relationship between the preprocedural variables and the quantum of PMCT in patients with bidirectionally blocked MI. Methods and Results-We reviewed clinical and echocardiographic parameters in 290 consecutive patients with confirmed bidirectional MI block during atrial fibrillation (AF) ablation. PMCT was defined as the temporal delay to the latest of the double potentials on the line of block while pacing posteroseptal to it in the left atrium (LA). LA size and type of AF significantly influenced PMCT in multivariate analysis. A cumulative score based on LA size (0≦45 mm; 1>45 mm) and type of AF (0: paroxysmal; 1=nonparoxysmal) ranged from 0 to 2. PMCT was directly correlated to the cumulative score (0: 169 ms; n=78; 95% confidential interval, 156 to 181); 1: 187 ms; n=103; 95% confidential interval, 178 to 196; 2: 209 ms; n=109; 95% confidential interval, 200 to 217). In 61 patients who underwent AF ablation twice, the difference between 2 PMCT values was <30 ms in 75% patients. Another consecutive 143 patients with and without MI block after at least 15 minutes of radiofrequency application were analyzed. Perimitral conduction delay <130 ms ruled out bidirectional MI block. Perimitral conduction delay >173 ms predicted bidirectional block with an accuracy of 86%. Conclusions-LA size and AF type significantly influence PMCT in patients undergoing successful MI ablation. These parameters can be used to predict the time value associated with MI block, preprocedurally. © 2011 American Heart Association, Inc.

Sunaga A., Matsuoka Y., Nakatani D., et al. Extensive ablation for persistent atrial fibrillation patients with mitral regurgitation: Insights from the EARNEST-PVI prospective randomized trial. International Journal of Cardiology 410, 132231 (2024); https://doi.org/10.1016/j.ijcard.2024.132231., Background: Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients. Methods: This post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications. Results: The trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54–1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22–0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms. Conclusions: For persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management.

Sunaga A., Matsuoka Y., Nakatani D., et al. Extensive ablation for persistent atrial fibrillation patients with mitral regurgitation: Insights from the EARNEST-PVI prospective randomized trial. International Journal of Cardiology 410, 132231 (2024); https://doi.org/10.1016/j.ijcard.2024.132231., Background: Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients. Methods: This post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications. Results: The trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54–1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22–0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms. Conclusions: For persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management.