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Background Thromboembolic stroke is a rare but devastating consequence of atrial fibrillation (AF) ablation. Transesopheageal echocardiography (TEE) is recommended to rule out left atrial appendage thrombus (LAA); however, its utilization is variable. Objective To assess whether TEE is mandatory in patients undergoing AF ablation on uninterrupted DOACs. Methods Data from our prospective, multicenter registry of AF patients undergoing radiofrequency catheter ablation on uninterrupted DOACs was analyzed. All included patients were on anticoagulation for at least four-weeks before ablation. All AF ablation procedures were performed under ICE guidance. Prior to transseptal puncture, heparin bolus was administered, followed by continuous infusion, with target activated clotting time over 300 seconds. Results A total of 6186 patients [3180 (51.4%): apixaban, 2528 (40.9%): rivaroxaban, 404 (6.5%): dabigatran, and 74 (1.2%): edoxaban] were analyzed. The mean age of the study population was 69.4 ± 10.3 years, of which 4194 (67.8%) patients were male and 5120 (82.8%) patients had persistent and long-standing persistent AF. The mean CHA2DS2-VASc score was 2.86 ± 1.58; the mean CHADS2 score was 1.65 ± 1.14. ICE ruled out LAA and LA thrombus in all patients and revealed ‘smoke’ in 1672 (27.03%) patients. Transient ischemic attack was noted in one patient with long-standing persistent AF, in the setting of a missed dose of rivaroxaban prior to ablation. Conclusion Our study showed that performance of AF ablation in patients on uninterrupted DOACs without TEE is safe and feasible in high stroke-risk patients. Elimination of routine pre-ablation TEE would have significant economic and clinical implications.

Background Fragmented QRS (fQRS) on 12-lead electrocardiography is a noninvasive marker of intramyocardial conduction delay due to ventricular scarring that has not previously been studied in atrial fibrillation. Objective The purpose of this study was to assess the association of fQRS with left atrial (LA) scarring in patients with persistent atrial fibrillation (PsAF) undergoing first catheter ablation. Methods A total of 376 patients with PsAF were enrolled. Severity of LA scarring was assessed using electroanatomic mapping. Narrow fQRS was defined by the presence of an additional R wave (R′) or notching in the nadir of the S wave, or the presence of >1 R′ in 2 contiguous leads corresponding to inferior, lateral, or anterior myocardial regions. Results Both any degree (97.3% vs 63.3%) and severe (42.2% vs 6.3%) LA scarring were higher in patients with fQRS. Age and fQRS were found to be independent predictors of severe LA scarring. At multiple ventricular regions, fQRS had diagnostic accuracy of 79.8% for prediction of severe LA scarring. Nonpulmonary vein triggers were more often detected and ablated in patients with fQRS and severe LA scarring (84.4% vs 70%; P = .001). Atrial tachyarrhythmia recurrence was observed in 131 patients (34.8%) during 18.9 ± 7.7 months of follow-up, which was significantly higher in patients with fQRS (53.2% vs 16.8%). In multivariate analysis, fQRS was found to be a significant predictor of recurrence (hazard ratio 4.65; 95% interval confidence 2.91–7.42; P Conclusion The study results showed that fQRS is a simple, available, and noninvasive marker, and that fQRS at multiple ventricular regions is significantly associated with the severity of LA scarring in PsAF patients.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the authors. The authors inadvertently specified some ablation settings in the methods section that should not have been reported because they can be potentially linked to a specific pulsed field ablation technology that is currently under investigation for FDA approval. The Authors apologize for the inconvenience caused by this oversightinsert 'Reason' text (to be provided by the Editor-in-Chief or written by the Publisher and approved by the Editor-in-Chief and then approved by the RR panel). In case of (suspected) plagiarism, it is mandatory to refer to the plagiarized work here byAbbreviated Journal Title, volume (year) first page - last page, http://dx.doi.org/DOI of plagiarized work (in URL format) coded as inter-ref if possible.

Background Atrial fibrillation (AF) triggers within the coronary sinus (CS)/great cardiac vein (GCV) and the left atrial appendage (LAA) have been recognized as nonpulmonary vein triggers of AF. Objective The aim of this study was to describe an electrical connection between the LAA and CS/GCV and its importance in achieving LAA electrical isolation (LAAEI). Methods A total of 488 consecutive patients undergoing catheter ablation for persistent or long-standing persistent AF who showed firing from the LAA and/or from the CS/GCV were enrolled in this multicenter prospective study. In all patients, potential defragmentation of the CS/GCV to achieve isolation and LAAEI was attempted with both endocardial and epicardial ablation. Results In 7% (n = 34) of these patients, after attempting endocardial LAAEI, the LAA was isolated during epicardial ablation in the GCV. In 8% (n = 39) of patients after attempting endocardial LAA isolation, the LAA was isolated during ablation along the endocardial aspect of the GCV. The presence of a venous branch connecting the GCV with the LAA was found in all these patients. In 23% (n = 112) of patients, the isolation of the LAA also isolated the GCV. In all these patients, LAA dissociated firing was present together with the CS/GCV recordings. Conclusion These findings suggest the presence of a distinct electrical connection between the GCV and the LAA. The clinical relevance of our results requires further investigation. Ablation in the CS/GCV can result in inadvertent isolation of the LAA. Ablation of the GCV is relevant to achieve LAAEI. Considering the potential long-term implications, ablation in the distal CS/GCV should prompt assessment of LAA conduction.

Background Focal impulse and rotor modulation (FIRM)-guided ablation targets sites that are thought to sustain atrial fibrillation (AF). Objective The purpose of this study was to evaluate the acute and mid-term outcomes of FIRM-guided only ablation in patients with nonparoxysmal AF. Methods We prospectively enrolled patients with persistent and long-standing persistent (LSP) AF at three centers to undergo FIRM-guided only ablation. We evaluated acute procedural success (defined as AF termination, organization, or ≥10% slowing), safety (incidence of periprocedural complications), and long-term success (single-procedure freedom from atrial tachycardia [AT]/AF off antiarrhythmic drugs [AAD] after a 2-month blanking period). Results Twenty-nine patients with persistent (N = 20) and LSP (N = 9) AF underwent FIRM mapping. Rotors were presents in all patients, with a mean of 4 ± 1.2 per patient (62% were left atrial); 1 focal impulse was identified. All sources were successfully ablated, and overall acute success rate was 41% (0 AF termination, 2 AF slowing, 10 AF organization). There were no major procedure-related adverse events. After a mean 5.7 months of follow-up, single-procedure freedom from AT/AF without AADs was 17%. Conclusion In nonparoxysmal AF patients, targeted ablation of FIRM-identified rotors is not effective in obtaining AF termination, organization, or slowing during the procedure. After mid-term follow-up, the strategy of ablating FIRM-identified rotors alone did not prevent recurrence from AT/AF.

Background Management of ventricular tachycardia (VT) in patients with hypertrophic cardiomyopathy (HCM) is challenging. Objective The purpose of this study is to assess the value of radiofrequency catheter ablation (RFCA) for the treatment of the VTs in the setting of HCM. Methods Twenty-two patients (18 with ICD) with HCM and multiple episodes of VTs resistant to medical therapy underwent RFCA with an open irrigation catheter. Epicardial access was obtained if required. All patients were followed for at least 1 year after RFCA. Results Mean age was 50.4 ± 15.3, and mean ejection fraction was 34.3% ± 9.8%. RFCA was performed endocardially in all patients, while epicardial radiofrequency applications were needed in 13 patients. A previous endocardial ablation was unsuccessful in six patients. At 20 ± 9 months of follow-up, elimination of VTs reached 73%. No major complication was observed during and after the procedures in all patients. Conclusion Catheter ablation of VTs in patients with hypertrophic cardiomyopathy refractory to medical therapy is safe, feasible, and successful in eliminating VT. Epicardial VT mapping and ablation should be considered as an important access option for the treatment of these patients to increase the success rate.

Phrenic nerve (PN) injury, a known complication of radiofrequency (RF) catheter ablation of atrial fibrillation (AF), has been more commonly reported with balloon-based pulmonary vein isolation.We present a novel approach to locating the PN and predicting patients at higher risk of this complication.The study included 2 groups of patients. In the first group of 71 patients, computerized tomographic angiography (CTA) with 3-dimensional reconstruction of the left atrium (LA) was obtained prior to an RF ablation procedure. The location of the right pericardiophrenic artery (RPA) was identified on the axial CTA images, and the artery distance to the right superior pulmonary vein (RSPV) ostium was measured in the 3-dimensional image. During ablation, the location of the right PN was identified by pacing maneuvers. The distance to the ostium of the RSPV was measured by venography and compared with the CTA artery measurement. In the second group, CTA imaging from 37 subjects who were enrolled in 3 investigational balloon ablation trials were analyzed using the same PN location technique and compared against the clinical outcomes. In this analysis, the CTA segmentation and PN location was performed in a blinded fashion as to any clinical evidence of PN injury.The mean measurement difference between PN capture and imaged RPA was 0.8 mm (P = .539). In all cases, the imaged RPA could reliably identify the approximate location of the right PN (R-square 0.984, P.001). Moreover, this analysis suggests that a PN location within 10 mm of the RSPV poses a higher risk of PN injury using these balloon ablation devices.Imaging the right pericardiophrenic artery can reliably locate the right phrenic nerve. This technique might identify anatomy more vulnerable to phrenic nerve injury using balloon-based ablation systems.

Most atrial fibrillation (AF) ablation studies have consisted predominantly of males; accordingly, there is a paucity of information on the safety and efficacy of catheter ablation in a large cohort of female AF patients.The purpose of this study was to evaluate catheter ablation for AF in female patients.From January 2005 to May 2008, 3265 females underwent pulmonary vein antrum isolation. Success rates, patient profiles, and complications were collected.Approximately 16% of our population was female (P.001). Females were older (59 +/- 13 vs. 56 +/- 19 years; P.01) and had a lower prevalence of paroxysmal atrial fibrillation (PAF; 46% vs. 55%; P.001). Females failed more antiarrhythmics (4 +/- 1 vs. 2 +/- 3; P = .04) and were referred later for catheter ablation (6.51 +/- 7 vs. 4.85 +/- 6.5 years; P = .02) than males. More females failed ablation (31.5% vs. 22.5%; P = .001) and had nonantral sites of firing than males (P.001). Female patients had 11 (2.1%) hematomas versus 27 (0.9%) in males.Five times as many males underwent catheter ablation than females. Females failed more ablations possibly because of a higher prevalence of nonantral firing, non-PAF, and longer history of AF. Females had more bleeding complications than males.

Background During radiofrequency ablation, effective contact is crucial in determining lesions efficacy. Objective The purpose of this study was to compare operators' ability to assess contact pressure using visual and tactile feedbacks together or alone in an experimental model. Methods In a in vitro experimental setup replicating manual catheter manipulation and recording the applied force, evaluators were asked to identify three levels of force (first, ablation, and maximum contact) as the catheter contacted the tissue model using (1) visual feedback only by fluoroscopy, "blinded" to touch; (2) tactile feedback only, blinded to fluoroscopy; and (3) both tactile and visual feedback together. The latter was regarded as reference. The experiment was repeated using a catheter force sensing technology during robotic navigation. Results During manual navigation, tighter association was shown for the visual method than for the tactile method: median difference with reference: first contact –1 ( P = .97) vs –2 ( P = .90); ablation contact 2 ( P = .1) vs –7 ( P = .03); maximum contact 2 ( P = .06) vs –28 ( P = .02). Bland-Altman plot and Deming regression confirmed for the visual method the good agreement with reference and the absence of bias at any level and showed for the tactile higher values and proportional bias that reached statistical significance at ablation and maximum contact. During robotic navigation, agreement was higher for the tactile than for the visual only method. Conclusion During manual navigation, visual feedback alone is in better agreement with the reference compared to the tactile only approach. During robotic navigation, agreement is looser for the visual only approach. More objective feedback of contact pressure during ablation procedures is desirable.

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There have been no studies of atrial diastolic function after catheter ablation of atrial fibrillation (AF). We encountered a few patients with symptomatic left atrial (LA) diastolic dysfunction and associated pulmonary hypertension (PH) that developed after catheter ablation for atrial fibrillation. Similar findings were described in patients after cardiac surgery and were referred to as the "stiff left atrial syndrome."The purpose of this study was to prospectively quantify the incidence of patients developing PH associated with diastolic hemodynamic abnormalities of the LA after radiofrequency ablation of AF and to identify the possible predictors.Between January 2009 and July 2010, data on 1,380 consecutive patients were prospectively collected. Before ablation and at follow-up, all patients had an echocardiogram to assess for the presence of PH. Patients with no echocardiographic evidence of PH but complaining of unexplained dyspnea with LA diastolic abnormalities were evaluated with right heart catheterization (RHC). Patients were included in the analysis if they developed new or worsening PH postablation with evidence of LA diastolic dysfunction by RHC or direct LA pressure measurement. All patients were evaluated for pulmonary vein stenosis and excluded if this condition was identified.The mean age was 62 ± 11 (75% male), and nonparoxysmal AF was the predominant arrhythmia (71%). New or worsening PH with associated LA diastolic abnormalities was detected in 19 (1.4%) patients after ablation. The prevalence of PH did not differ between AF types (P = .612). Compared with patients who did not develop PH, LA scarring (P.001), diabetes (P = .026), and obstructive sleep apnea (OSA; P = .006) were more frequently observed among those who developed PH. In a multivariable logistic model, preprocedure LA size ≤45 mm (odds ratio [OR] = 6.13; P = .033), mean LA pressure (OR 1.14; P = .025), severe LA scarring (OR = 4.4; P = .046), diabetes mellitus (OR = 9.5; P = .004), and OSA (OR = 6.2; P = .009) were independently associated with the development of PH postablation.After radiofrequency catheter ablation of atrial fibrillation (RFCAF), PH with LA diastolic dysfunction or the so-called stiff LA syndrome is a rare but potentially significant complication of AF ablation. Severe LA scarring, LA ≤45 mm, diabetes mellitus, OSA, and high LA pressure are clinical variables that predict the development of this syndrome. The main clinical findings include dyspnea, congestive heart failure, PH, and large V waves on pulmonary capillary wedge pressure (PCWP) or LA pressure tracings in the absence of mitral regurgitation.

Radiofrequency catheter ablation of atrial fibrillation can be performed under general anesthesia or conscious sedation at the physician's preference.We randomized a series of consecutive patients with paroxysmal atrial fibrillation (AF) undergoing radiofrequency catheter ablation to either general anesthesia or conscious sedation to assess differences in pulmonary vein (PV) reconnection during redo procedures and impact on success rate.A total of 257 consecutive patients with paroxysmal AF undergoing AF ablation were enrolled and randomized to either conscious sedation with fentanyl or midazolam (128 patients, group 1) and general anesthesia (129 patients, group 2). In all patients, a high dosage of isoproterenol up to 30 μg/min was used to disclose PV reconnection or extra PV firings.Baseline clinical characteristics were not significantly different between the 2 groups. At 17 ± 8 month follow-up after the first ablation, 88 (69%) patients in group 1 were free of atrial arrhythmias off all antiarrhythmic drugs (AAD), as compared with 114 (88%) in group 2 (log-rank P.001). All patients with recurrence had a second procedure. At the repeat procedure, 42% (66 of 158) of PVs in group 1 had recovered PV conduction, compared with 19% (11 of 57) in group 2 (P = .003). Compared with group 1, group 2 had a significantly shorter fluoroscopy time (53 ± 9 min vs. 84 ± 21 min, P.001) and procedure time (2.4 ± 1.4 h vs. 3.6 ± 1.1 h, P.001).The use of general anesthesia is associated with higher cure rate with a single procedure, and it seems to reduce the prevalence of PV reconnection observed at the time of repeat ablation.

Background Catheter ablation of ventricular arrhythmias (VAs) with cryoenergy has not been widely reported. Objective The purpose of this study was to assess the feasibility and safety of cryoablation for VA. Methods Cases where cryoablation of VA was attempted as the initial strategy or was considered to prevent potential damage to other structures such as the coronary arteries, phrenic nerve, and His bundle were collected. Thirty-three patients with either normal heart or structural heart disease undergoing VA ablation using cryoenergy at six different institutions were enrolled in the study. Epicardial access was obtained when appropriate. Results Fifteen patients (7 men) underwent endocardial ablation, 13 (9 men) epicardial ablation (from the coronary sinus in 7), and 5 (2 men) aortic cusp ablation. Mean age was 54 ± 8 years, and ejection fraction was 45% ± 5%. In 15 (45%) patients, VAs were successfully ablated, whereas cryoablation was unsuccessful in the remaining 18 (55%) patients. Cryoablation was successful in all parahisian cases (100%). In three patients, epicardial cryoablation was successful after several failed attempts with open irrigated catheter. An aortic dissection occurred during catheter placement in the aortic cusp. At follow-up of 24 ± 5 months, all patients with acute success were free from clinical VA. Conclusion Use of cryoenergy for ablation of VA has excellent success for arrhythmias near the His bundle; however, success rates at other sites appear less favorable. Cryoablation may be considered as an alternative approach for reducing complications during ablation of VAs originating from sites close to other relevant cardiac structures (conduction system, coronary arteries, phrenic nerve) and, in rare cases, could be used epicardially when radiofrequency energy applications have failed.