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Introduction: Electrical isolation of pulmonary veins (PVI) is a cornerstone for atrial fibrillation (AF) ablation. The overall effect of AF ablation, and especially lesions beyond PVI, on left atrial (LA) function is currently poorly understood. Our aim was to determine if LA function is different in patients after extensive LA ablation compared to PVI only. We performed non‐inferiority analysis of LA function after PVI with additional nonpulmonary vein ablation lesions in LA (PVI+) and PVI alone. Methods: We studied 68 patients consecutive patients who underwent AF ablation and who had complete transthoracic echocardiogram (TTE) within 12 months before AF ablation and 1−12 months after the procedure. Patients were stratified into two groups: PVI only and PVI+. Primary outcome was change in LA reservoir strain (LASr). Noninferiority margin was defined at 6%. Results: The PVI only group had a higher proportion of patients with paroxysmal AF (70% vs. 30%). The PVI+ group was observed to have a slightly higher increase in LASr compared to PVI alone (5.0% vs. 4.3%, p <.01 for noninferiority). LASr noninferiority was confirmed when adjusted for age, sex, coronary artery disease, hyperlipidemia, and AF type, rhythm at preprocedure TTE in a multivariable linear regression model, 90% CI (−5.46 to 2.04), p <.01. Conclusion: LA functional improvement evaluated by LASr was noninferior after PVI with additional LA ablation lesions compared to PVI alone. These findings were confirmed when adjusted for confounding clinical variables, suggesting that more extensive ablation does not negatively affect LA function. [ABSTRACT FROM AUTHOR]

Introduction: Esophageal injury is rare but potentially a devastating complication of atrial fibrillation (AF) ablation. The goal here was to provide insight into the short‐term natural history of esophageal thermal injury (ETI) after radiofrequency catheter ablation (RFCA) for AFby esophagogastroduodenoscopy (EGD). Methods: We screened patients who underwent RFCA for AF and EGD based on esophageal late gadolinium enhancement (LGE) in postablation magnetic resonance imaging. Patients with ETI diagnosed with EGD were included. We defined severity of ETI according to Kansas City classification: type 1: erythema; type 2: ulcers (2a: superficial; 2b deep); type 3 perforation (3a: perforation; 3b: perforation with atrioesophageal fistula [AEF]). Repeated EGD was performed within 1−14 days after the last EGD if recommended and possible until any certain healing signs (visible reduction in size without deepening of ETI or complete resolution) were observed. Results: ETI was observed in 62 of 378 patients who underwent EGD after RFCA. Out of these 62 patients with ETI, 21% (13) were type 1, 50% (31) were type 2a and 29% (18) were type 2b at the initial EGD. All esophageal lesions, but one type 2b lesion that developed into an AEF, showed signs of healing in repeated EGD studies within 14 days after the procedure. The one type 2b lesion developing into an AEF showed an increase in size and ulcer deepening in repeat EGD 8 days after the procedure. Conclusion: We found that all ETI which did not progress to AEF presented healing signs within 14 days after the procedure and that worsening ETI might be an early signal for developing esophageal perforation. [ABSTRACT FROM AUTHOR]

Background: Class 1C antiarrhythmic drugs (AADs) are effective first‐line agents for atrial fibrillation (AF) treatment. However, these agents commonly are avoided in patients with known coronary artery disease (CAD), due to known increased risk in the postmyocardial infarction population. Whether 1C AADs are safe in patients with CAD but without clinical ischemia or infarct is unknown. Reduced coronary flow capacity (CFC) on positron emission tomography (PET) reliably identifies myocardial regions supplied by vessels with CAD causing flow limitation. Objective: To assess whether treatment with 1C AADs increases mortality in patients without known CAD but with CFC indicating significantly reduced coronary blood flow. Methods: In this pilot study, we compared patients with AF and left ventricular ejection fraction ≥50% who were treated with 1C AADs to age‐matched AF patients without 1C AAD treatment. No patient had clinically evident CAD (ie, reversible perfusion defect, known ≥70% epicardial lesion, percutaneous coronary intervention, coronary artery bypass grafting, or myocardial infarction). All patients had PET‐based quantification of stress myocardial blood flow and CFC. Death was assessed by clinical follow‐up and social security death index search. Results: A total of 78 patients with 1C AAD exposure were matched to 78 controls. Over a mean follow‐up of 2.0 years, the groups had similar survival (P =.54). Among patients with CFC indicating the presence of occult CAD (ie, reduced CFC involving ≥50% of myocardium), 1C‐treated patients had survival similar to (P =.44) those not treated with 1C agents. Conclusions: In a limited population of AF patients with preserved left ventricle function and PET‐CFC indicating occult CAD, treatment with 1C AADs appears not to increase mortality. A larger study would be required to confidently assess the safety of these drugs in this context. [ABSTRACT FROM AUTHOR]

Visually Guided PV Isolation Introduction Visually guided laser balloon (VGLB) ablation is unique in that the operator delivers ablative energy under direct visual guidance. In this multicenter study, we sought to determine the feasibility, efficacy, and safety of performing pulmonary vein isolation (PVI) using this VGLB. Methods Patients with symptomatic, drug-refractory paroxysmal atrial fibrillation (AF) underwent PVI using the VGLB with the majority of operators conducting their first-ever clinical VGLB cases. The primary effectiveness endpoint was defined as freedom from treatment failure that included: Occurrence of symptomatic AF episodes ≥1 minutes beyond the 90-day blanking, the inability to isolate 1 superior and 2 total PVs, occurrence of left atrial flutter or atrial tachycardia, or left atrial ablation/surgery during follow-up. Results A total of 86 patients (mean age 56 ± 10 years, 67% male) were treated with the VGLB at 10 US centers. Mean fluoroscopy, ablation, and procedure times were 39.8 ± 24.3 minutes, 205.2 ± 61.7 minutes, and 253.5 ± 71.3 minutes, respectively. Acute PVI was achieved in 314/323 (97.2%) of targeted PVs. Of 84 patients completing follow-up, the primary effectiveness endpoint was achieved in 50 (60%) patients. Freedom from symptomatic or asymptomatic AF was 61%. The primary adverse event rate was 16.3% (8.1% pericarditis, phrenic nerve injury 5.8%, and cardiac tamponade 3.5%). There were no cerebrovascular events, atrioesophageal fistulas, or significant PV stenosis. Conclusions This multicenter study of operators in the early stage of the learning curve demonstrates that PVI can be achieved with the VGLB with a reasonable safety profile and an efficacy similar to radiofrequency ablation. [ABSTRACT FROM AUTHOR]

Long-Term Outcome of AF Ablation in MMV Patients Introduction It is unclear whether extended pulmonary vein antrum isolation (PVAI) plus nonpulmonary vein (non-PV) trigger elimination prevents more arrhythmia recurrence than PVAI alone in patients with mechanical mitral valve (MMV) undergoing AF ablation. This study compared the efficacy and long-term outcome of 2 ablation strategies-PVAI alone versus extended PVAI plus non-PV trigger elimination-for the treatment of AF in patients with MMV. Methods and Results One hundred and nine consecutive AF patients with MMV were divided into 2 groups: standard PVAI was performed in group 1 (N = 45); in group 2 (N = 64) PVAI was extended to the LA posterior wall, LA septum, and CS; and all non-PV triggers were eliminated. Patients were followed up for 3 years. At the 12th month, 7 (15.6%) patients in group 1, and 39 (60.9%) patients in group 2 were arrhythmia free (log-rank P < 0.001). Four patients (8.9%; 3 cases of AT and 1 case of AF) from group 1, and 12 patients (18.8%; 9 cases of AT, and 3 cases of AFL) from group 2 experienced very late recurrence. At 36 ± 7 months follow-up, the cumulative recurrence after a single procedure was 42/45 (93.3%) in group 1, and 37/64 (57.8%) in group 2 (log-rank P < 0.001). Conclusion Compared with the standard PVAI alone, a strategy including extended PVAI and non-PV trigger elimination is associated with a higher 12-month and long-term arrhythmia-free survival in patients with MMV undergoing AF ablation. Very late recurrence may occur years after the initial procedure with focal AT as the most common type of recurrent arrhythmia. [ABSTRACT FROM AUTHOR]

Real-Time Contact Force Sensing for Pulmonary Vein Isolation Introduction The additional benefit of contact force (CF) technology during pulmonary vein isolation (PVI) for paroxysmal atrial fibrillation (AF) to improve mid-term clinical outcome is unclear. Methods and Results Eligible patients with symptomatic paroxysmal AF were enrolled in this prospective trial, comparing circular antral catheter ablation (guided by Carto 3 System, Biosense Webster) using either a new open-irrigated CF catheter (SmartTouch Thermocool, Biosense Webster) (CF group) or a non-CF open-irrigated catheter (EZ Steer Thermocool, Biosense Webster) (control group). Overall, 30 patients were enrolled in each group, with a standardized 12-month follow-up, free of antiarrhythmic therapy. Demographic, cardiovascular and anatomic characteristics were similar in both groups. Though complete PVI was eventually achieved in all cases in both groups, success using an exclusive anatomic approach was 80.0% in CF group versus 36.7% in control group ( P < 0.0001). CF use was associated with significant reductions in fluoroscopy exposure ( P < 0.01) and radiofrequency time ( P = 0.01). The incidence rates of AF recurrence were 10.5% (95% CI, 1.38-22.4) in the CF group, and 35.9% (95% CI, 12.4-59.4) in the control group (log rank test, P = 0.04). After adjustment on potential confounders, the use of CF catheter was found to be associated with a lower AF recurrence (OR 0.18, 95% CI 0.04-0.94, P = 0.04). Conclusion Our findings suggest a potential benefit of real-time CF sensing technology, in reducing AF recurrence during the first year after PVI. [ABSTRACT FROM AUTHOR]

Left Atrial Sphericity Predicts AF Ablation Outcome Background Atrial fibrillation (AF) ablation outcome is mainly determined by atrial remodeling that, nowadays, is only estimated through clinical presentation (persistent vs. paroxysmal) and left atrial (LA) dimension. The aim of the study was to stage the atrial remodeling process using the Left Atrial Sphericity (LASP) and determine whether this technique may help to predict AF ablation outcome. Methods Consecutive patients who underwent contrast-enhanced cardiac magnetic resonance angiography before AF ablation were included in the study. Three-dimensional reconstruction of LA excluding pulmonary veins and the LA appendage was used to define the LA cavity. The LASP was automatically obtained with self-customized software. Results 106 patients were included and categorized in 3 groups (Gs): discoid-LA (G1), intermediate-LA (G2), and spherical-LA (G3). The G3 patients had larger LA anteroposterior diameter than G1 and G2 patients (47 ± 7 vs 43 ± 6 and 39 ± 5mm; P < 0.001), greater LA volume (90 ± 39 vs 86 ± 24 and 73 ± 20 mm; P = 0.012), and higher prevalence of persistent AF (75% vs 48% and 29%; P = 0.034) structural heart disease (75% vs 19% and 19%; P < 0.001), and AF recurrence at 12 months follow-up (58% vs 29% and 5%, P < 0.001). The LASP had linear correlation to predicted probability of recurrence. Multivariate analysis identified LASP (OR 1.320 [1.096-1.591], P = 0.004) and hypertension (OR 3.694 [1.282-10.645]; P = 0.016) as independent risk factors for arrhythmia recurrence. Conclusion Left Atrial Sphericity is a new independent predictor of recurrence after AF ablation and may be useful in selecting the best candidates for AF ablation. [ABSTRACT FROM AUTHOR]

Arrhythmia Inducibility Post-AF Ablation Introduction Prior reports demonstrate prognostic value in noninducibility of atrial arrhythmias after atrial fibrillation (AF) ablation and suggest their utility in guiding additional ablation lesion sets. The type and mechanism of induced atrial arrhythmias, their relationship to the underlying atrial substrate, and prognostic significance of induced organized atrial arrhythmias are unknown. Methods and Results One hundred forty-four patients (30 women; median age 60 years; 54% with paroxysmal AF) undergoing AF ablation (circumferential pulmonary vein isolation and focal ablation of nonvein triggers on isoproterenol) were evaluated prospectively. All underwent a standardized postablation induction protocol from the coronary sinus and right atrium: 15 beat burst pacing at 250 milliseconds and decrementing to 180 milliseconds. Sustained rhythms were defined as greater than 2 minutes Of 144 patients, 55 patients (38.2%) did not have sustained inducible arrhythmias. Fifty-two (36.1%) had inducible AF and 37 (25.7%) had inducible organized arrhythmias. A logistic regression analysis showed that age (OR 2.10 per decade; P = 0.003) and hypertension (OR 4.15; P = 0.009) were predictive of inducibility. However, inducibility of either AF or organized arrhythmias was not prognostic of clinical recurrence at 1 year postablation (P = 0.65). Furthermore, inducibility of organized arrhythmias did not predict clinical recurrence of an organized arrhythmia. Only LA size (OR 2.18; 95% CI 1.02-4.67; P = 0.04) and persistent AF (OR 2.43; 95% CI 1.09-5.40; P = 0.03) predicted atrial arrhythmia recurrence. Conclusions Multisite atrial burst pacing post-AF ablation induced organized rhythms in 25.7% and AF in 36.1% of patients after AF ablation. Hypertension and age predict inducibility of arrhythmias, but inducibility did not predict clinical recurrence in follow-up. Distinguishing organized atrial arrhythmias from AF did not yield any further prognostic information. The utility of aggressive stimulation protocols after AF ablation for prognosis and to guide therapy appears limited. [ABSTRACT FROM AUTHOR]

Prognostic Impact of Inappropriate Shocks. Introduction: Recent studies suggest a worse impact of inappropriate shock therapies on the outcome of patients with an implantable cardioverter-defibrillator (ICD). However, it is not known whether the worse impact is attributed to the ICD shock itself or due to the underlying heart disease. The aim of the study was to evaluate the impact of inappropriate ICD shocks on clinical outcome by comparing ICD shocks triggered by atrial fibrillation (AF) with shocks caused by lead failure. Methods and Results: A total of 1,411 consecutive patients of the prospective single-center ICD-registry Ludwigshafen who underwent an ICD implantation between 1992 and 2008 for primary or secondary prevention of sudden cardiac death were analyzed. During the median follow-up of 3 years, 297 (21%) patients experienced inappropriate ICD shocks. Sixty percent of patients had inappropriate shocks due to AF and 24% due to lead defect or T-wave oversensing. Multiple ICD shocks (≥2) triggered by AF were associated with a worse prognosis, whereas a single shock due to AF or 1 or multiple shocks resulting from lead failure were not. ICD shocks caused by AF occurred more often in tandem with a serious adverse event than in patients with a lead failure (15% vs 6%, P < 0.05). Conclusion: Multiple ICD shocks triggered by AF are associated with a worse prognosis in ICD patients, whereas a single shock due to AF or shocks resulting from lead failure are not. These data support that the ICD shock itself has no worse impact on the outcome of ICD patients. (J Cardiovasc Electrophysiol, Vol. 23, pp. 735-740, July 2012) [ABSTRACT FROM AUTHOR]