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A growing body of evidence supports that the left atrium epicardial adipose tissue (LA-EAT) is related to the occurrence and recurrence of atrial fibrillation (AF). The relationship between LA-EAT and the recurrence after radiofrequency catheter ablation (RFCA) in patients with different types of AF is still unclear. This study aims to evaluate the predictive value of LA-EAT on the recurrence of AF after RFCA in patients with different types of AF. 301 AF patients who underwent RFCA for the first time were divided into the paroxysmal atrial fibrillation (PAF) group (n = 181) and the persistent atrial fibrillation (PersAF) group(n = 120), which were followed up at 3, 6, and 12 months. All patients underwent left atrial computed tomography angiography (CTA) examination before the operation, and LA-EAT was measured using software (Advantage Workstation4.6, GE, USA). After a median follow-up of 10.7 months, 73/301 patients (24.25%) had a recurrence of AF, including 43 /120(35.83%) patients with PersAF and 30/181(16.57%) patients with PAF. In multivariable Cox regression analysis, LA-EAT volume (OR = 1.053;95%CI: 1.024–1.083, p < 0.001), attenuation (OR = 0.949;95%CI:0.911–0.988, p = 0.012) and left atrial diameter (LAD) (OR = 1.063;95%CI:1.002–1.127， p = 0.043) were independent risk factors for recurrence in patients with PersAF but not in patients with PAF. LA-EAT volume and attenuation are independent risk factors for recurrence after RFCA in patients with PersAF. • Compared with other studies, our sample size is larger and more reliable. • LA-EAT volume and attenuation are independent risk factors for recurrence after RFCA in patients with PersAF. • LA-EAT has not been found to predict the recurrence in patients with PAF after RFCA. [ABSTRACT FROM AUTHOR]

Data on additional substrate modification using a cryoballoon beyond cryoballoon pulmonary vein isolation (CB-PVI) is limited. We sought to evaluate the efficacy and safety of substrate modification on the left atrial roof area using CBs (LAR-CBs) for atrial fibrillation (AF) patients. Eighty-one AF patients (70.0[62.5–77.0] years, 33 paroxysmal AF[PAF], 48 non-PAF) underwent LAR-CBs following CB-PVIs. Voltage maps were created with a high-resolution mapping system. Roof line conduction block was evaluated during the repeat procedure. The total number of applications for the CB-PVI and LAR-CB were 5.0 ± 1.2 and 3.8 ± 0.7, and both were significantly greater in non-PAF than PAF patients. LA roof areas had continuous scar in 61/79(77.2%) patients, and the mean balloon temperature was significantly lower in patients with continuous scar than those without (−39.3 ± 3.8 vs. −36.0 ± 4.6 °C, p = 0.004). The single procedure 1-year AF freedom was 87.6% (7.5% on antiarrhythmic drug) and was similar between PAF and non-PAF patients (p = 0.14). Twelve (14.8%) patients underwent a second procedure 5.5(2.2–7.5) months later, and a mean of 1.3 ± 0.5 PVs were reconnected in 7/12(58.3%) patients. Electrical conduction block across the roof line was proven in 3/12(25.0%) patients. There were 6(7.4%) complications related to the procedures, including iatrogenic roof dependent atrial tachycardia, takotsubo cardiomyopathy, and severe pericarditis in 1, 1, and 2 patients, respectively. LA roof area substrate modification using CBs yielded a high arrhythmia freedom after single procedures. However, a low incidence of electrical conduction block across the line during the chronic phase and delayed complications were the major concerns. • The CB roof ablation following the CB-PVI resulted in a high arrhythmia freedom regardless of the AF type. • A lower balloon temperature during the CB roof ablation was associated with a continuous LA roof scar during the acute phase. • Electrical conduction block across the roof line was proven in 25% of the patients during the chronic phase and the remaining 75% patients had an incomplete roof line block. • An iatrogenic roof dependent AT, takotsubo cardiomyopathy, and severe pericarditis were the major complications after the procedure. [ABSTRACT FROM AUTHOR]

The ablation therapy for persistent atrial fibrillation (PerAF) is still a challenge due to the high recurrence rate. This study was aimed to investigate the value of extensive linear ablation with contact force sensing techniques for PerAF. A total of 214 patients with PerAF were enrolled in five centers. The patients were randomly assigned to Group I (PVI + LA roof line+ LA anterior wall line) and Group II (PVI + LA roof line), mitral valve isthmus lines were added in both groups if the atrial fibrillation (AF) could not be terminated after all approaches above. Acute success rate of AF termination during the ablation procedure in Group I was significantly higher than Group II (P = 0.028). Two-years follow-up showed no significant difference in the sinus rhythm maintenance rate between the two groups (63.4% in group I vs. 57.2% in group II, P = 0.218). More patients in Group I recurred as organized atrial tachycardia (AT) and can be precisely mapped during repeat ablation procedures (15 vs. 2, P = 0.001). The Kaplan–Meier estimates of AF/AT-free survival after repeat ablation procedures were 76.2% in Group I and 47.1% in Group II (P = 0.039). Extensive linear ablation with contact force monitoring did not improve the long-term outcomes for PerAF patients. Repeat ablation procedure showed a possible higher chance of sinus rhythm restoration during follow-up. • Extensive linear ablation increased the rate of AF termination during procedure. • This strategy did not increase success rate at 24 months after single ablation. • This strategy increased sinus rhythm restoration after repeat ablation procedure. [ABSTRACT FROM AUTHOR]

There are no data concerning clinical outcome and left atrial (LA) function after LA roof ablation using a second-generation cryoballoon (CB) for treatment of persistent atrial fibrillation (AF). Here, we report the first follow-up results after pulmonary vein isolation (PVI) plus LA roof ablation with the CB technique in patients with symptomatic persistent AF. We enrolled 107 consecutive patients who underwent CB ablation at our institution with the aim of PVI and bidirectional conduction block across the LA roof. Clinical success was defined as freedom from >30-s recurrence of AF, atrial flutter, or atrial tachycardia after a 3-month blanking period. Follow-up data were collected during outpatient clinic visits. LA volume, LA emptying fraction, and LA expansion index (parameters of LA function) were evaluated by echocardiography before and 3 months after ablation. PVI was achieved in all patients, and bidirectional conduction block was verified in 91.6%. Median follow-up duration was 31 (interquartile range 11/44) months. PVI plus LA roof ablation was sufficient to restore and maintain sinus rhythm in 72.9% (n = 78) of patients. The overall complication rate was 1.8%. LA volumes decreased significantly after ablation (P < 0.05), whereas total LA emptying fraction (P = 0.25) and LA expansion index (P = 0.32) were preserved within the 3-month follow-up. LA roof ablation combined with PVI using the CB technique is a safe and effective adjuvant treatment with a promising midterm outcome and preserved LA function 3 months after ablation. • Left atrial roof ablation using second-generation cryoballoon was safe and effective. • Pulmonary vein isolation plus roof line ablation showed a promising outcome. • Left atrial function was not impaired during short-term follow-up. [ABSTRACT FROM AUTHOR]

Abstract Background Due to the lack of optimal ablation strategy, the success rate of persistent atrial fibrillation (AF) is still low. We hypothesize that a strategy that targeting pulmonary triggers and dispersion areas in atria improves prognosis of persistent AF. Methods We prospectively enrolled 142 persistent AF patients admitted for catheter ablation. These patients were randomly assigned in a 1:1 ratio to ablation with circumferential pulmonary vein isolation (CPVI) + ablation of electrogram dispersion areas (71 patients, group A) or stepwise ablation strategy (71 patients, group B). Results Procedural time and fluoroscopy time did not differ between group A and group B (204.6 ± 26.9 min vs 207.8 ± 26.3 min and 7.3 ± 1.3 min vs 7.1 ± 1.3 min, respectively, P > 0.05), however, radiofrequency delivery time in group A was significantly shorter than that in group B (70 ± 7.2 min vs 83.2 ± 9.1 min, P < 0.001). In total, 265 electrogram dispersion areas were identified in 67 patients, and the most prominent areas were roof, bottom, and inferoposterior wall. The rates of acute AF endpoint (including AF termination and AFCL elongation >30 ms) and termination in group A were significantly higher than that in group B (97.2% vs. 71.8% and 70.4% vs. 15.5%, respectively, P < 0.001). During a follow-up period of 204 ± 67 days, both AF-free and AF/AT-free survival in group A were significantly higher than that in group B (P = 0.012 and P = 0.014, respectively). Conclusion Dispersion-guided ablation in conjunction with CPVI is efficient, personalized, and accurate for persistent AF. Highlights • This is the first time to clarify the electrogram dispersion-guided driver ablation in adjunctive to CPVI is an efficient approach for persistent AF. • Our study further supports the notion that electrogram dispersion analyses can precisely locate drivers that sustained AF. • Smaller left atrial volume, longer atrial fibrillation cycle length and a history of AF lasted no longer than a year can achieve better results. [ABSTRACT FROM AUTHOR]

Abstract Background Persistent atrial fibrillation (AF) is associated with higher stroke and mortality risk than paroxysmal AF (pAF). Outcomes of catheter or surgical ablation are worse in patients with persistent AF than in pAF, and the optimal invasive rhythm control strategy has not been established. Purpose We provide a contemporary systematic overview on efficacy and safety of catheter and minimally-invasive surgical ablation for persistent AF. Methods We systematically searched EMBASE, MEDLINE and CENTRAL from inception to July 2018 for randomized trials on surgical and catheter ablation, and included all study arms on persistent AF. Outcome was AF freedom after ≥12 months follow-up without AAD use. Random effects models were used to calculate proportions with 95%-confidence intervals. Safety consisted of adverse events during treatment and follow-up. Results We included 6 studies on minimally-invasive surgical ablation and 56 on catheter ablation, involving 7624 patients with persistent AF. AF Freedom at 12 months was 69% (95%CI 64–74%) after surgical and 51% (95%CI 46–56%) after catheter ablation. More severe procedural adverse events occurred with surgery than with catheter ablation. Conclusions In persistent AF patients, minimally-invasive surgical ablation is associated with more procedural complications, but higher AF freedom. As adverse events after surgical ablation appear more severe than in catheter ablation, a patient-tailored therapy choice is warranted. Highlights • Freedom of atrial fibrillation recurrence was higher after minimally-invasive surgical ablation compared to catheter ablation in persistent AF • More severe procedural adverse events occurred with surgical ablation than with catheter ablation. • A patient-tailored therapy choice in patients with persistent atrial fibrillation is warranted. [ABSTRACT FROM AUTHOR]

Background Atrial fibrillation (AF) is associated with endothelial dysfunction. Studies have shown the incidence of cardiovascular events to be greater in patients with persistent AF (PeAF) than paroxysmal AF (PAF). Objective The aim of this study was to investigate whether endothelial dysfunction and the impact of catheter ablation on the endothelial function differs between PAF and PeAF. Methods We prospectively measured the endothelial function by reactive hyperemia peripheral arterial tonometry (RH-PAT) in 103 PAF, 75 PeAF, and 51 control patients at baseline, with follow-up in the AF patients at 6 and 12 months after the catheter ablation. Results The log-transformed RH-PAT index (ln RHI) was the highest in the control group, followed by the PAF and PeAF (0.67 ± 0.23, 0.57 ± 0.29, and 0.45 ± 0.3, respectively, p < 0.001) groups. PeAF was determined to be an independent factor of endothelial dysfunction (ln RHI < 0.55) even after adjustment for the conventional cardiovascular risk factors. For 12 months after the catheter ablation, 102 (99%) PAF and 72 (96%) PeAF patients maintained sinus rhythm. On average, the ln RHI in the PAF group did not change during the follow-up, but it significantly increased in the PeAF group to a level comparable to that of the PAF patients 6 months after the catheter ablation (0.53 ± 0.28, p = 0.034), and maintained the same level at 12 months after the catheter ablation. Conclusions The persistent form of AF may independently contribute to endothelial dysfunction. In addition, by catheter ablation, the maintenance of sinus rhythm may protect against exacerbations of endothelial dysfunction. [ABSTRACT FROM AUTHOR]

Background There is a lack of procedural and follow-up data on pulmonary vein isolation (PVI) with the second-generation pulmonary vein ablation catheter® (PVAC Gold) in patients with atrial fibrillation (AF). This study provides data on PVI procedures and 1-year follow-up results with PVAC Gold in patients with AF treated in clinical practice. Methods and results Three hundred and eighty four patients with documented symptomatic paroxysmal (n = 198) or persistent (n = 186) AF were included in a non-randomized prospectively designed database. Patients were enrolled consecutively at 2 high-volume centers. Procedural as well as 1 year follow-up data were systematically analyzed. Average procedure times ± standard deviations were 94 ± 23 min and 97 ± 23 min, respectively, in patients with paroxysmal and persistent AF. Average fluoroscopy times were 14.7 ± 5.4 min and 15.2 ± 5.6 min and total application times 18.1 ± 5.0 min and 18.8 ± 5.2 min, respectively, in the 2 patient cohorts. At 12 months, 70.7% (70/99) and 61.9% (70/113) of patients with paroxysmal and persistent AF, respectively, were free from AF. Four early complications occurred. In the group with persistent AF, 1 posterior cerebral infarction occurred 2 days after the procedure during initiation of anticoagulation. There was no phrenic nerve palsy or esophageal injury associated with the procedures. No thromboembolic events were recorded during follow-up. Conclusions In patients with paroxysmal or persistent AF, second generation multi-electrode-phased radiofrequency ablation delivers favorable mid-term PVI success rates with few procedure-related or follow-up complications. [ABSTRACT FROM AUTHOR]

Introduction Success rates for catheter ablation of longstanding persistent atrial fibrillation (AF) are significantly poorer than for recently persistent or paroxysmal forms. We report on single centre long term outcomes from ablation of very longstanding (> 2 years) persistent AF. Material and methods A retrospective analysis of outcomes for patients undergoing catheter ablation for symptomatic very longstanding persistent AF between 2008 and 2013 was performed. Results Twenty-nine patients were followed for a mean of 61 ± 15 months following the index ablation procedure. The mean duration of persistent AF prior was 64 ± 51 months (range 24–200), mean age 61 ± 6 years and mean CHA 2 DS 2 -VASc score 1.1 ± 1.2. Antral pulmonary vein electrical isolation only was performed in 14 (48%) with the remainder having additional lines and/or CFAE ablation also. At last follow-up 24 (83%) were in sinus rhythm but only 9 (31%) remained free of detectable arrhythmia, 25 (86%) were taking antiarrhythmic therapy and 18 (62%) required intermittent DC cardioversions. The mean time to first AF recurrence was 14 ± 14 months (range 2–48). Redo ablation was required in 13 (45%) at a mean follow-up time of 15 ± 12 months. The mean EHRA score improved from 3.5 ± 0.5 to 1.4 ± 0.4 (p < 0.0001). Conclusions The vast majority (83%) of very longstanding persistent AF patients maintained sinus rhythm at a mean follow-up time of 5 years following catheter ablation, associated with a significant improvement in symptom scores. Adjunctive therapies including antiarrhythmics, DC cardioversions and redo ablation were required in most patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: The aim of this study was to investigate the efficacy of catheter ablation in the treatment of persistent atrial fibrillation (AF) and the predictors of arrhythmia recurrence. Methods: Absence of atrial tachyarrhythmia (AT) recurrence during a mid-term follow-up was correlated with several clinical and procedural characteristics in a population of 82 patients aged 20–70years who had experienced at least one documented relapse of persistent AF during a single trial of antiarrhythmic drug therapy. Electrophysiological success of ablation was declared when all identified PVs were isolated (confirmation of entry and exit block). Patients were followed for a maximum of 24months after the blanking period with outpatient visits, ECG recordings, 24-hour Holter monitoring, and weekly transtelephonic monitoring for 30s. Results: Electrophysiological success was documented in 38/82 (46.3%) patients. During a mean follow-up of 24.7±4.2months, 69/82 (84.1%) patients presented at least one episode of AT after the 2month blanking period. According to univariate and multivariate logistic regression analyses, only an electrophysiologically successful ablation significantly correlated with the absence of documented AT relapse (OR 5.32, 95% CL 1.02–27.72; p=.0472). Conclusions: Mid-term outcome of a single procedure of catheter ablation without the adjunction of antiarrhythmic drug therapy is poor in patients with persistent AF. Documented PV isolation is useful to increase the success rate of circumferential PV ablation even in persistent AF patients. [Copyright &y& Elsevier]

Abstract: Atrial fibrillation (AF) is a common arrhythmia with important therapeutic and prognostic implications. An attempt to restore sinus rhythm is considered in most patients with AF. The aim of this study was to assess the value of echocardiographic examination and plasma atrial natriuretic peptide (ANP) evaluation in predicting the outcome of cardioversion and maintenance of sinus rhythm in patients with persistent AF. Methods: Eighty-one consecutive patients, aged 62±9 years, with AF of duration 4.7 months were subjected to an echocardiography examination and ANP assessment before cardioversion. The patients were predominantly hypertensive men with moderately enlarged left atrium and ejection fraction of left ventricle of about 50%. All patients were in controlled AF and had normalized blood pressure. In order to predict the outcome of cardioversion, and maintenance of sinus rhythm over a 1 month period, a multivariate logistic regression method was performed using the following variables: left atrial and left ventricular dimensions, left ventricular ejection fraction and plasma ANP levels. Results: Sixty-nine out of the 81 patients were successfully converted to sinus rhythm. At 1 month 57 patients remained in sinus rhythm. There were no statistical differences between sinus rhythm and AF group in baseline ANP levels (59.4 vs 64.2 pg/ml, consecutively), clinical and echocardiographic characteristics. In logistic regression analysis neither baseline echocardiographic variable nor ANP level, predicts successful cardioversion over a 1-month period of observation. Conclusion: Echocardiographic data and ANP level should not be included as an important variable when considering patients for cardioversion. [Copyright &y& Elsevier]

Background: Transesophageal echocardiography (TEE) guided cardioversion to restoration of sinus rhythm is a therapeutic option in patients with atrial fibrillation (AF). Anticoagulation at the time of and after cardioversion is necessary to prevent formation of new thrombus during atrial stunning period. We aimed to evaluate the efficacy and safety to TEE guided cardioversion with low molecular weight heparin (LMWH) in patients with atrial fibrillationMethods: We followed up 208 patients with persistent AF (mean age: 65.5±10.2 years) who were attempted TEE guided cardioversion. LMWH were used as an anticoagulant and warfarin therapy was continued. Results: Cardioversion were performed in 183 patients. Sinus rhythm restored in 144 patients (78.7%). Mean follow up duration was 155 days. No cardiac death occurred. In the early follow up period (within 30 day) one thromboembolic event (0.54%) occurred in a petient who was cardioverted. Two patients who had not been cardioverted because of left atrial thrombus presented embolic stroke, one in early and another in late follow up period. All embolic complications occurred in patients who had been taking warfarin and whose INR level was subtherapeutic at the time of stroke. Sinus rhythm was maintained in 64% and total hemorrhagic complications occurred in 4.8% of the patients in long-term follow-up. Conclusion: TEE guided cardioversion with a short-term anticoagulation protocol using low molecular weight heparin is a safe and effective method in restoring and maintaining sinus rhythm and enables us to make earlier cardioversion in atrial fibrillation. [Copyright &y& Elsevier]

Background: Maintenance of sinus rhythm is challenging in patients with longstanding persistent atrial fibrillation (PeAF). Minimally invasive surgical AF ablation may improve outcomes when combined with catheter ablation (the 'convergent' procedure). This study evaluates the safety and efficacy of the convergent procedure versus catheter ablation alone in longstanding PeAF., Methods: 43 consecutive patients with longstanding PeAF underwent subxiphoid endoscopic ablation of the posterior left atrium followed by catheter ablation from 2013 to 2018. The primary outcome was AF-free survival at 12 months; secondary outcomes included change in EHRA class, echocardiographic data, procedural complications, freedom from anti-arrhythmic drugs (AADs), and long term arrhythmia-free survival. Outcomes were compared with a matched group of 43 patients who underwent catheter ablation alone. Both groups underwent multiple catheter ablations as required. Baseline characteristics were similar between groups., Results: After 12 months, the convergent procedure was associated with increased AF-free survival on AADs (60.5% versus 25.6%, p = .002) and off AADs (37.2% versus 13.9%, p = .025), versus catheter ablation. Allowing for multiple procedures, after 30.5 ± 13.3 months' follow-up the convergent procedure was associated with increased arrhythmia-free survival on AADs (58.1% versus 30.2%, p = .016) and off AADs (32.5% versus 11.6%, p = .036) versus catheter ablation. There were more complications in the convergent procedure group (11.6% versus 2.3%, p = .2). Multivariate analysis identified only the convergent procedure (OR 3.06 (1.23-7.6), p = .017) as predictive of arrhythmia-free survival long term., Conclusions: In longstanding PeAF, the convergent procedure is associated with improved arrhythmia-free survival versus catheter ablation alone. Complication rates are significant but have been shown to depreciate with experience., Competing Interests: Declaration of competing interest Dr. Ahsan has received an educational grant and speaker fees from Atricure., (Copyright © 2019 Elsevier B.V. All rights reserved.)

Abstract: The optimal method to perform external electrical cardioversion of atrial fibrillation has not been fully determined yet. In order to define the effects of different pad positions on cardioversion success rates, shock energy requirements and serum myocardial proteins levels we studied 62 patients with persistent atrial fibrillation who underwent elective external electrical cardioversion using a standardized step-up protocol of increasing energy levels. Electrode positions were randomly assigned as anterolateral (Group A) or anteroposterior (Group B). After all shocks were delivered there was no difference in the cardioversion success rate between the two groups. However, a significantly greater proportion of patients in group B were restored to sinus rhythm after the second shock of 300 J was delivered (p =0.005). Mean shock energy requirements and peak serum creatine kinase levels were lower for group B than for group A (p =0.049 and p =0.021 respectively). Troponin T serum levels were not increased after the cardioversion attempts in either group. We conclude that an anteroposterior electrode position is more effective in achieving restoration of sinus rhythm in lower energy shock levels compared to the anterolateral position. [Copyright &y& Elsevier]

Objectives: The aim of this study was to determine whether altered calreticulin expression and distribution contribute to the pathogenesis of atrial fibrillation (AF) associated with valvular heart disease (VHD)., Background: AF affects electrophysiological and structural changes that exacerbate AF. Atrial remodeling reportedly underlies AF generation, but the precise mechanism of atrial remodeling in AF remains unclear., Methods: Right and left atrial specimens were obtained from 68 patients undergoing valve replacement surgery. The patients were divided into sinus rhythm (SR; n=25), paroxysmal AF (PaAF; n=11), and persistent AF (PeAF; AF lasting >6 months; n=32) groups. Calreticulin, integrin-α5, and transforming growth factor-β1 (TGF-β1) mRNA and protein expression were measured. We also performed immunoprecipitation for calreticulin with either calcineurin B or integrin-α5., Results: Calreticulin, integrin-α5, and TGF-β1 mRNA and protein expression were increased in the AF groups, especially in the left atrium in patients with mitral valve disease. Calreticulin interacted with both calcineurin B and integrin-α5. Integrin-α5 expression correlated with TGF-β1 expression, while calreticulin expression correlated with integrin-α5 and TGF-β1 expression. Despite similar cardiac function classifications, calreticulin expression was greater in the PeAF group than in the SR group., Conclusions: Calreticulin, integrin-α5, and TGF-β1 expression was increased in atrial tissue in patients with AF and was related to AF type, suggesting that calreticulin is involved in the pathogenesis of AF in VHD patients., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)