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Background: Transseptal catheterization (TSC) is performed during catheter ablation involving the lefthand side of the heart. TSC causes a transient iatrogenic atrial septal defect that can predispose patients to migraine episodes. However, isolated migraine aura episodes in patients undergoing TSC have not been described. Methods: Five hundred seventy-one procedures involving TSC were performed over a 3-year duration. Of these, 3 patients presented with visual symptoms in the first month after the procedure. One patient underwent a TSC during catheter ablation of left-sided accessory pathway and 2 patients underwent TSC during catheter ablation of atrial fibrillation. Results: The incidence of migraine aura in this patient population was 0.5%. In the first week after the procedure, all 3 patients experienced transient reversible visual symptoms of scintillating scotoma consistent with migraine aura. None of the patients had an associated headache. The workup for stroke or transient ischemic attack was negative. All the patients recovered completely within 1 hour of symptom onset and did not have any sequelae. Conclusion: This study reports for the first time the incidence and outcomes of isolated migraine aura in patients undergoing electrophysiology procedures involving TSC. For post-TSC patients who present with atypical neurologic symptoms, especially 'scintillating scotoma,' once transient ischemic attack or other neurologic event has been ruled out, an aura associated with the TSC should be entertained as a possible diagnosis. Electrophysiologists who perform TSC, need to be aware of this phenomenon and can reassure the patients of the transient and benign nature. [ABSTRACT FROM AUTHOR]

Atrial tachycardias represent the second front of atrial fibrillation (AF) ablation. They are frequently encountered during the index ablation for patients with persistent AF and are common following ablation of persistent AF, occurring in half of all patients who have had AF successfully terminated. An atrial tachycardia is rightly seen as a failure of AF ablation, as these tachycardias are poorly tolerated by patients. This article describes a simple, practical approach to diagnosis and ablation of these atrial tachycardias. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Typical atrial flutter (AFL) can be cured by catheter ablation of the cavotricuspid isthmus (CTI). The surface electrocardiogram (ECG) is not always diagnostic of isthmus dependence of AFL. The aim of this study was to evaluate clinical parameters for the prediction of isthmus-dependent AFL. METHODS AND RESULTS: Sixty consecutive adult patients without suspected atriotomy-related AFL, congenital heart disease, or previous AFL ablation, referred for catheter ablation of presumed typical AFL were studied. All patients had distinct flutter waves in the inferior leads, suggestive of CTI-dependent AFL, either on presentation to the electrophysiology (EP) lab or documented on prior ECG. Electrophysiology study was performed in the standard fashion. Patients who presented to the EP laboratory not in AFL underwent arrhythmia induction with a burst pacing protocol. A clinical history of persistent AFL (P = 0.0001) and existence of AFL on presentation to the EP laboratory (P = 0.0001) were strong predictors of CTI dependence. History of atrial fibrillation (P = 0.19), structural heart disease (P = 0.6), hypertension (P = 0.4), and previous cardiac surgery (P = 0.5), as well as the nature of AFL-related symptoms (P = 0.5), were not predictors of CTI-dependent AFL documented during EP study. CONCLUSION: In patients with ECG suggestive of typical AFL, the presence of persistent rather than paroxysmal AFL and presentation to the EP laboratory in AFL are strong predictors of CTI-dependent AFL. A paroxysmal pattern of AFL predicts noninducibility of CTI-dependent AFL during EP study. CTI ablation may therefore be less effective in these patients. [ABSTRACT FROM AUTHOR]

The precise techniques employed in the electrophysiology laboratory influence the nature of the electrograms that are recorded during mapping procedures. Unipolar recordings that are minimally filtered can be useful for mapping focal arrhythmia sources, but have substantial far-field signal that can obscure low-amplitude signals of interest in abnormal regions. Bipolar recordings are standard in most laboratories because rejection of far-field signal facilitates identification of local potentials in abnormal areas, but the signal of interest can be beneath either recording electrode and far-field signals do occur. Simultaneously obtained unipolar recordings are a useful adjunct to bipolar recordings in some situations. High pass filtering and digital sampling also influence electrogram characteristics. High pass filtering of unipolar recordings can be useful to reduce far-field components, but limits inferences from electrogram morphology. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation of the pulmonary veins (PVs) for prevention of recurrent atrial fibrillation requires precise anatomic information. We describe the characteristics of a new anatomic variant of PV anatomy using magnetic resonance angiography. Methods and Results: A 1.5-T magnetic resonance imaging system with a body coil or a torso phased- array coil was used before and after gadolinium injection. Magnetic resonance angiograms were acquired with a breath-hold three-dimensional fast spoiled gradient-echo imaging sequence in the coronal plane. Three-dimensional reconstruction with maximum intensity projections and multiplanar reformations was performed. A newly described variant PV ascending from the roof of the left atrium was found in 3 of 91 subjects. The mean ostial diameter of the roof PV was 7 ± 2 mm, the mean distance from the ostium to the first branching point was 22 ± 8.5 mm, and the mean distance to the right superior PV was 3.3 ± 0.6 mm. Conclusion: We refer to the newly described variant of PV anatomy as the 'right top pulmonary vein.' It is important to be aware of this anatomic pattern to avoid inadvertent catheter intubation, which can result in misleading mapping results and PV stenosis. [ABSTRACT FROM AUTHOR]

Introduction: More than 1 in 10 patients may develop recurrence of conduction after undergoing a successful radiofrequency catheter ablation procedure. The physiologic basis for recurrence following successful ablation procedures remains uncertain. The purpose of this study was to evaluate the role of electrode temperature as a predictor of recurrence following radiofrequency catheter ablation procedures. Methods and Results: The subjects of this study were 538 patients who underwent a successful attempt at radiofrequency catheter ablation of AV nodal reentrant tachycardia, an accessory pathway, and/or the AV junction. Patients were followed for a mean of 215 ± 138 days. Conduction recurred in 35 (6.5%) of the 538 patients. Recurrence of conduction occurred in 25 (9.3%) of 270 patients undergoing ablation of an accessory pathway, 7 (3.5%) of 201 patients undergoing ablation of AV nodal reentrant tachycardia, and in 3 <4.5%) of 67 patients undergoing ablation of the AV junction. The electrode temperature achieved at successful sites associated with recurrence was not different from the temperature achieved at successful sites without recurrence (61.1 ± 8.9 vs 61.6 ± 9.1; P = 0.8). The likelihood of developing a recurrence was higher following ablation of accessory pathways than following ablation of A V nodal reentrant tachycardia or the AV junction (P = 0.03). Patients experiencing a recurrence following ablation of an accessory pathway had longer procedure durations (P = 0.0001). Ablation of left free-wall pathways was associated with a lower incidence of recurrence as compared with all other locations (P = 0.008). Conclusion: The results of this study suggest that electrode temperature at the successful ablation site cannot be used to identify patients at highest risk of recurrence. [ABSTRACT FROM AUTHOR]

Introduction: The safety and efficacy of paroxysmal atrial fibrillation (PAF) ablation with the HELIOSTAR multielectrode radiofrequency (RF) balloon catheter have been demonstrated in European studies; data from elsewhere are lacking. This prospective, multicenter study conducted in the United States, Italy, and China investigated the safety and efficacy of pulmonary vein isolation (PVI) using HELIOSTAR in drug-refractory symptomatic PAF., Methods: The primary effectiveness endpoint (PEE) was 12-month freedom from documented atrial fibrillation/atrial flutter/atrial tachycardia plus freedom from acute procedural failure, nonstudy catheter failure, repeat ablation failure, direct current cardioversion (DCCV), and Class I/III antiarrhythmic drug (AAD) failure. The primary safety endpoint was the occurrence of early-onset primary adverse events (PAEs). Cerebral magnetic resonance imaging (MRI) and cardiac computed tomography were performed in a patient subset to assess silent cerebral lesions (SCLs) and severe pulmonary vein (PV) stenosis, respectively., Results: Across 36 centers, 257 eligible subjects in the main phase had the study catheter inserted. Acute PVI was achieved in all subjects, with the majority (94.1%) using the balloon catheter only. In 67.7% and 92.2% of subjects, respectively, PEE and freedom from repeat ablation were met; clinical success rate was 77.7%. The PAE rate was 5.1%. One of 15 (6.7%) subjects with MRI showed a new SCL at 1 month postablation, which resolved at 3 months. Clinically meaningful improvements in Atrial Fibrillation Effect on QualiTy-of-life scores were seen at 3 months and were sustained to 12 months postablation, and accompanied with reduction of Class I/III AAD use and DCCV., Conclusion: STELLAR confirmed the safety and efficacy of the HELIOSTAR catheter for PVI, with clinically meaningful improvements in quality of life in patients with drug-refractory symptomatic PAF. Most PVIs were achieved without focal touch-up, and > 90% of patients were free from repeat ablation at 12 months., Trial Registration: ClinicalTrials.gov Identifier: NCT03683030., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Arrhythmogenic cardiomyopathy (ACM) is a genetically heterogeneous inherited cardiomyopathy with an estimated prevalence of 1:5000-10 000 that predisposes patients to life-threatening ventricular arrhythmias (VA) and sudden cardiac death (SCD). ACM diagnostic criteria and risk prediction models, particularly for arrhythmogenic right ventricular cardiomyopathy (ARVC), the most common form of ACM, are typically genotype-agnostic, but numerous studies have established clinically meaningful genotype-phenotype associations. Early signs of ACM onset differ by genotype indicating the need for genotype-specific diagnostic criteria and family screening paradigms. Likewise, risk factors for SCD vary by genetic subtype, indicating that genotype-specific guidelines for management are also warranted. Of particular importance, genotype-specific therapeutic approaches are being developed. Results from a randomized controlled trial for flecainide use in ARVC patients are currently pending. Research in a plakophilin-2-deficient mouse model suggests this antiarrhythmic drug may be particularly useful for patients with likely pathogenic or pathogenic (LP/P) PKP2 variants. Additionally, the first gene therapy clinical trials in ARVC patients harboring LP/P PKP2 variants are currently underway. This review aims to provide clinicians caring for ACM patients with an up-to-date overview of the current literature in genotype-specific natural history of disease and management of ACM patients and describe scientific advances that have led to upcoming clinical trials., (© 2024 The Author(s). Journal of Cardiovascular Electrophysiology published by Wiley Periodicals LLC.)

Background: Studies have identified significant sex-based differences and disparities in the clinical presentation and treatment of atrial fibrillation (AF). Studies have shown women are less likely to be referred for catheter ablation, are older at the time of ablation, and are more likely to have recurrence after ablation. However, in most studies investigating AF ablation outcomes, the female cohorts were relatively small. The impact of sex on the outcome and safety of ablation procedures is still unclear., Objective: To investigate sex-based differences in outcomes and complications after AF catheter ablation, with a significant female cohort METHOD: In this retrospective study, patients undergoing AF ablation from January 1, 2014, to March 31, 2021, were included. We investigated clinical characteristics, duration and progression of AF, number of EP appointments from diagnosis to ablation, procedural data, and procedure complications., Results: Total of 1346 patients underwent first catheter ablation for AF during this period, including 896 (66.5%) male and 450 (33.4%) female patients. Female patients were older at the time of ablation (66.2 vs. 62.4 years; p < .001). Women had higher CHA 2 DS 2 -VASc (congestive heart failure, hypertension, age, diabetes, stroke, vascular disease, sex category) scores (3 vs. 2; p < .001) than men, expectedly, as the female sex warrants an additional point. 25.3% female patients had PersAF at the time of diagnosis versus 35.3% male patients (p < .001). At the time of ablation, 31.8% female patients had PersAF as compared to 43.1% male patients (p < .001), indicating progression of PAF to PersAF in both sexes. Women tried more AADs than men before ablation (1.13 vs. 0.98; p = .002). Male and female patients had no statistically significant difference in (a) arrhythmia recurrence at 1-year post ablation (27.7% vs. 30%; p = .38) or (b) procedural complication rate (1.8% vs. 3.1%; p = .56)., Conclusion: Female patients were older and had higher CHA 2 DS 2 -VASc scores compared to males at the time of AF ablation. Women tried more AADs than men before ablation. One-year arrhythmia recurrence rates and procedural complications were similar in both sexes. No sex-based differences were observed in safety and efficacy of ablation., (© 2023 Wiley Periodicals LLC.)

Introduction: Catheter ablation for atrial fibrillation (AF) is a common therapeutic strategy for patients with either paroxysmal AF (PAF) or persistent AF (persAF), but long-term ablation success rates are imperfect. Maintenance of sinus rhythm immediately before ablation with antiarrhythmic drug (AAD) therapy has been associated with improved outcomes in patients undergoing ablation. Amiodarone has superior efficacy relative to other AADs. Whether failure of amiodarone to maintain sinus rhythm before ablation for either PAF or persAF is associated with poor outcomes is unknown., Methods: A total of 307 patients who received amiodarone in a 1-year window before undergoing catheter ablation for AF were included. Patients were divided into amiodarone success (n = 183) and amiodarone failure (n = 124) groups based on the response to pre-ablation amiodarone treatment. Analysis of procedural outcomes as a function of response to amiodarone therapy was performed. Patients were followed for at least 12 months postablation, to assess outcomes (adverse events and arrhythmia recurrence). Procedural success was defined by the absence of documented arrhythmia (>30 s) without any antiarrhythmic agents beyond a 90-day blanking period., Results: Following ablation for either PAF or persAF, freedom from any recurrent atrial arrhythmia at 1 year was 57.7% for the entire cohort. One-year freedom from recurrent arrhythmia in the amiodarone success group was comparable to that in the amiodarone failure group (55.7% vs. 60.5%; p = .54). Success rates following ablation did not vary by the response to amiodarone when analyzed for PAF or persAF subgroups., Conclusion: Failure to restore and maintain sinus rhythm with amiodarone before ablation for either PAF or persAF is not a predictor of ablation procedural failure. Amiodarone failure alone should not deter practitioners from considering ablation therapy for patients with AF., (© 2023 Wiley Periodicals LLC.)

Introduction: Use of a novel magnetic sensor enabled optical contact force ablation catheter has been established to be safe and effective for treatment of symptomatic drug-refractory paroxysmal atrial fibrillation (AF) but has yet to be demonstrated in the persistent AF (PersAF) population., Methods: PERSIST-END was a multicenter, prospective, nonrandomized, investigational study designed to demonstrate the safety and effectiveness of TactiCath™ Ablation Catheter, Sensor Enabled™(SE) (TactiCath SE) for use in the treatment of subjects with documented PersAF refractory or intolerant to at least one Class I/III AAD. The ablation strategy included pulmonary vein isolation and additional targets at physician discretion. Follow-up through 15-months, including a 3-month blanking period and 3-month therapy consolidation period, was performed with cardiac event and Holter monitoring. Primary safety, primary effectiveness, clinical success, and quality of life (QOL) endpoints were analyzed., Results: Of 224 subjects enrolled at 21 investigational sites in the United States and Australia, 223 underwent ablation with the investigational catheter. The primary safety event rate was 3.1% (seven events in seven subjects). The Kaplan-Meier estimate of freedom from AF/atrial flutter/atrial tachycardia recurrence at 15-months was 61.6% and clinical success at 15 months was 89.8%. Subject QOL significantly improved following ablation as assessed via AFEQT (31.6 point increase, p < .0001) and EQ-5D-5L (10.7 point increase, p < .0001) and was met with a 53% reduction in all cause cardiovascular healthcare utilization., Conclusion: The sensor-enabled force-sensing catheter is safe and effective for the treatment of drug refractory recurrent symptomatic PersAF, reducing arrhythmia recurrence while improving QOL and healthcare utilization., (© 2022 Wiley Periodicals LLC.)

Background: Transesophageal echocardiography (TEE) is variably performed before atrial fibrillation (AF) ablation to evaluate left atrial appendage (LAA) thrombus. We describe our experience with transitioning to the pre-ablation cardiac computed tomography (CT) approach for the assessment of LAA thrombus during the COVID-19 pandemic., Methods: We studied consecutive patients undergoing AF ablation at our center. The study cohort was divided into pre- versus post-COVID groups. The pre-COVID cohort included ablations performed during the 1 year before the COVID-19 pandemic; pre-ablation TEE was used routinely to evaluate LAA thrombus in high-risk patients. Post-COVID cohort included ablations performed during the 1 year after the COVID-19 pandemic; pre-ablation CT was performed in all patients, with TEE performed only in patients with LAA thrombus by CT imaging. The demographics, clinical history, imaging, and ablation characteristics, and peri-procedural cerebrovascular events (CVEs) were recorded., Results: A total of 637 patients (pre-COVID n = 424, post-COVID n = 213) were studied. The mean age was 65.6 ± 10.1 years in the total cohort, and the majority were men. There was a significant increase in pre-ablation CT imaging from pre- to post-COVID cohort (74.8% vs. 93.9%, p ≤ .01), with a significant reduction in TEEs (34.6% vs. 3.7%, p ≤ .01). One patient in the post-COVID cohort developed CVE following negative pre-ablation CT. However, the incidence of peri-procedural CVE between both cohorts remained statistically unchanged (0% vs. 0.4%, p = .33)., Conclusion: Implementation of pre-ablation CT-only imaging strategy with selective use of TEE for LAA thrombus evaluation is not associated with increased CVE risk during the COVID-19 pandemic., (© 2021 Wiley Periodicals LLC.)

Background: Premature ventricular contractions (PVCs) may be found in any stage of arrhythmogenic right ventricular cardiomyopathy (ARVC) and have been associated with the risk of sustained ventricular tachycardia (VT)., Objective: To investigate the role of PVC ablation in ARVC patients., Methods: We studied consecutive ARVC patients who underwent PVC ablation due to symptomatic high PVC burden. Mean daily PVC burden and antiarrhythmic drug (AAD) use were assessed before and after the procedure. Complete long-term success was defined as more than 80% reduction in PVC burden off of membrane-active AADs., Results: Eight patients (37 ± 15 years; 4 males) underwent PVC ablation. The mean daily PVC burden before ablation ranged from 5.4% to 24.8%. A total of 7 (87.5%) patients underwent epicardial ablation. Complete acute elimination of PVCs was achieved in 4 (50%) patients (no complications). The mean daily PVC burden variation ranged from an 87% reduction to a 26% increase after the procedure. Over a median follow-up of 345 days (range: 182-3004 days), only one (12.5%) patient presented complete long-term success, and 6 (75%) patients either maintained or increased the need for Class I or Class III AADs. A total of 2 (25%) patients experienced sustained VT for the first time following the ablation procedure, requiring repeat ablation. No death or heart transplantation occurred., Conclusion: PVC ablation was not associated with a consistent reduction of the PVC burden in ARVC patients with symptomatic, frequent PVCs. PVC ablation may be reserved for highly symptomatic patients who failed AADs. Additional investigation is required to improve the efficacy of PVC ablation in ARVC patients., (© 2021 Wiley Periodicals LLC.)

Background: Data related to electrophysiologic characteristics of atypical atrial flutter (AFL) following atrial fibrillation (AF) ablation and its prognostic value on repeat ablation success are limited., Methods: We studied consecutive patients who underwent a repeat left atrial (LA) ablation procedure for either recurrent AF or atypical AFL, at least 3 months after index AF ablation, between January 2012 and July 2019. The demographics, clinical history, procedural data, complications, and 1-year arrhythmia-free survival rates were recorded for each subject after the first repeat ablation., Results: A total of 336 patients were included in our study. Among these 336 patients, 102 underwent a repeat ablation procedure for atypical AFL and 234 underwent a repeat ablation procedure for recurrent AF. The mean age was 63.7 ± 10.7 years, and 72.6% of patients were men. The atypical AFL cohort had significantly higher LA diameters (4.6 vs. 4.4 cm, p = .04) and LA volume indices (LAVi; 85.1 vs. 75.4 ml/m 2 , p = .03) compared to AF patients at repeat ablation. Atypical AFL patients were more likely to have had index radiofrequency (RF) ablation (as opposed to cryoballoon) than recurrent AF patients (98% vs. 81%, p = .01). Atypical AFLs were roof-dependent in 35.6% and peri-mitral in 23.8% of cases. Major complications at repeat ablation occurred in 0.9% of the total cohort. Arrhythmia-free survival at one year was significantly higher in the recurrent atypical AFL compared to the recurrent AF cohort (75.5 vs. 65.0%, p = .04)., Conclusion: In our series, roof-dependent flutter is the most common form of atypical atrial flutter post AF ablation. Patients developing atypical AFL after index AF ablation have greater LA dimensions than patients with recurrent AF. The success rate of first repeat ablation is significantly higher among patients with recurrent atypical AFL as compared to recurrent AF after index AF ablation., (© 2021 The Authors. Journal of Cardiovascular Electrophysiology Published by Wiley Periodicals LLC.)

Introduction: Success rates of catheter ablation in persistent atrial fibrillation (AF) remain suboptimal. A better and more targeted ablation strategy is urgently needed to optimize outcomes of AF treatment. We sought to assess the safety and efficacy of targeting atrial fibrosis during ablation of persistent AF patients in improving procedural outcomes., Methods: The DECAAF II trial (ClinicalTrials. gov identifier number NCT02529319) is a prospective, randomized, multicenter trial of patients with persistent AF. Patients with persistent AF undergoing a first-time ablation procedure were randomized in a 1:1 fashion to receive conventional pulmonary vein isolation (PVI) ablation (Group 1) or PVI + fibrosis-guided ablation (Group 2). Left atrial fibrosis and ablation induced scarring were defined by late gadolinium enhancement magnetic resonance imaging at baseline and at 3-12 months postablation, respectively. The primary endpoint is the recurrence of atrial arrhythmia postablation, including atrial fibrillation, atrial flutter, or atrial tachycardia after the 90-day postablation blanking period. Patients were followed for a period of 12-18 months with a smartphone ECG Device (ECG Check Device, Cardiac Designs Inc.). With an anticipated enrollment of 900 patients, this study has an 80% power to detect a 26% reduction in the hazard ratio of the primary endpoint., Results and Conclusion: The DECAAF II trial is the first prospective, randomized, multicenter trial of patients with persistent AF using imaging defined atrial fibrosis as a treatment target. The trial will help define an optimal approach to catheter ablation of persistent AF, further our understanding of influencers of ablation lesion formation, and refine selection criteria for ablation based on atrial myopathy burden., (© 2021 Wiley Periodicals LLC.)

Introduction: Atrial fibrillation (AF) ablation is successful in 60%-80% of optimal candidates, with many patients requiring repeat procedures. We performed a detailed examination of electrophysiologic findings and clinical outcomes associated with first repeat AF ablations in the era of contact force-sensing radiofrequency (RF) catheters., Methods: We retrospectively studied patients who underwent their first repeat AF ablations for symptomatic, recurrent AF at our center between 2013 and 2019. All repeat ablations were performed using contact force-sensing RF catheters. Pulmonary vein (PV) reconnections at repeat ablation and freedom from atrial arrhythmia 1 year after repeat ablation were evaluated. We further assessed these findings based on AF classification at the time of presentation for repeat ablation, index RF versus cryoballoon (CB) ablation, and duration (≥3 versus <3 years) between index and repeat procedures., Results: Among 300 patients, there were 136 (45.3%) who presented for their first repeat ablations in persistent AF. During repeat ablation, at least one PV reconnection was found in 257 (85.6%) patients, while 159 (53%) had three to four reconnections. There was a similar distribution of reconnections among patients with persistent versus paroxysmal AF (mean: 2.7 ± 1.3 vs. 2.9 ± 1.2; p = .341), index RF versus CB ablation (mean: 2.8 ± 1.3 vs. 2.9 ± 1.2; p = .553), and ≥3 versus <3 years between index and repeat procedures (mean: 3.0 ± 1.1 vs. 2.7 ± 1.3; p = .119). At repeat ablation, the PVs were re-isolated in all patients, and additional non-PV ablation was performed in 171 (57%) patients. Freedom from atrial arrhythmia at 1-year follow-up after repeat ablation was 66%, similar among those with persistent versus paroxysmal AF (65.4% vs. 66.5%; p = .720), index RF versus CB ablation (66.7% vs. 68.9%; p = .930), and ≥3 versus <3 years between index and repeat ablations (64.4% vs. 66.7%; p = .760). Major complications occurred in a total of 4 (1.3%) patients., Conclusion: In a contemporary cohort of patients receiving their first repeat AF ablations using contact force-sensing RF catheters, PV reconnections were common, and freedom from atrial arrhythmia was 66% at 1-year follow-up. The distributions of PV reconnections and rates of freedom from atrial arrhythmia were similar, based on persistent versus paroxysmal AF at presentation for repeat ablation, index RF versus CB ablation, and duration between index and repeat procedures. The incidence of major complications was very low., (© 2021 Wiley Periodicals LLC.)

Background: The effects of atrial fibrillation (AF) catheter ablation on the left atrium (LA) are poorly understood., Objectives: To examine short- and long-term associations of AF catheter ablation with LA function using cardiac magnetic resonance (CMR)., Methods: Fifty-one AF patients (mean age 56 ± 8 years) underwent CMR at baseline, 1 day (n = 17) and 11 ± 2 months after ablation (n = 38). LA phasic volumes, emptying fractions (LAEF), and longitudinal strain were measured using feature-tracking CMR. LA fibrosis was quantified using late gadolinium enhancement (LGE)., Results: There were no acute changes in volume; however, active, total LAEF, and peak LA strain decreased significantly compared to the baseline. During long-term follow-up, there was a decrease in maximum but not minimum LA volume (from 99 ± 5.2 ml to 89 ± 4.7 ml; p = .009) and a decrease in total LAEF (from 43 ± 1.8% to 39 ± 2.0%; p = .001). In patients with AF recurrence, LA volumes were unchanged. However, total LAEF decreased from 38 ± 3% to 33 ± 3%; p = .015. Patients without AF recurrence had no changes in LA functional parameters during follow-up. The amount of LA LGE at long-term follow-up was higher compared to the baseline, however, was significantly less compared to immediately post-procedure (37 ± 1.9% vs. 47 ± 2.8%; p = .015). A higher increase in LA LGE extent compared to the baseline was associated with a greater decrease in total LAEF (r = -.59; p < .001)., Conclusions: LA function is impaired acutely following AF catheter ablation. However, long-term changes of LA function are associated positively with the successful restoration of sinus rhythm and inversely with increased LA LGE., (© 2020 Wiley Periodicals LLC.)

Introduction: Advanced interatrial block (IAB) on a 12-lead electrocardiogram (ECG) is a predictor of stroke, incident atrial fibrillation (AF), and AF recurrence after catheter ablation. The objective of this study was to determine which features of IAB structural remodeling is associated with left atrium (LA) magnetic resonance imaging structure and function., Methods/results: We included 152 consecutive patients (23% nonparoxysmal AF) who underwent preprocedural ECG and cardiac magnetic resonance (CMR) in sinus rhythm before catheter ablation of AF. IAB was defined as P-wave duration ≥120 ms, and was considered partial if P-wave was positive and advanced if P-wave had a biphasic morphology in inferior leads. From cine CMR and late gadolinium enhancement, we derived LA maximum and minimum volume indices, strain, LA fibrosis, and LA dyssynchrony. A total of 77 patients (50.7% paroxysmal) had normal P-wave, 52 (34.2%) partial IAB, and 23 (15.1%) advanced IAB. Patients with advanced IAB had significantly higher LA minimum volume index (25.7 vs 19.9 mL/m 2 , P = .010), more LA fibrosis (21.9% vs 13.1%, P = .020), and lower LA maximum strain rate (0.99 vs 1.18, P = .007) than those without. Advanced IAB was independently associated with LA (minimum [P = .032] and fibrosis [P = .009]). P-wave duration was also independently associated with LA fibrosis (β = .33; P = .049) and LA mechanical dyssynchrony (β = 2.01; P = .007)., Conclusion: Advanced IAB is associated with larger LA volumes, lower emptying fraction, and more fibrosis. Longer P-wave duration is also associated with more LA fibrosis and higher LA mechanical dyssynchrony., (© 2020 Wiley Periodicals LLC.)

Catheter ablation has become an important element in the management of atrial fibrillation. Several technical advances allowed for better safety profiles and lower recurrence rates, leading to an increasing number of ablations worldwide. Despite that, major complications are still reported, and esophageal thermal injury remains a significant concern as atrioesophageal fistula (AEF) is often fatal. Recognition of the mechanisms involved in the process of esophageal lesion formation and the identification of the main determinants of risk have set the grounds for the development and improvement of different esophageal protective strategies. More sensitive esophageal temperature monitoring, safer ablation parameters and catheters, and different energy sources appear to collectively reduce the risk of esophageal thermal injury. Adjunctive measures such as the prophylactic use of proton-pump inhibitors, as well as esophageal cooling or deviation devices, have emerged as complementary methods with variable but promising results. Nevertheless, as a multifactorial problem, no single esophageal protective measure has proven to be sufficiently effective to eliminate the risk, and further investigation is still warranted. Early screening in the patients at risk and prompt intervention in the cases of AEF are important risk modifiers and yield better outcomes., (© 2020 Wiley Periodicals LLC.)

Introduction: The VICTORY AF Study was designed to evaluate the risk of the procedure and/or device-related strokes in patients with PersAF on warfarin undergoing ablation with a phased radiofrequency (RF) system., Methods: The VICTORY AF trial was a prospective, multicenter, single-arm, investigational study. PersAF patients on vitamin K antagonism without major structural heart disease or history of stroke/transient ischemic attack undergoing phased RF ablation for atrial fibrillation (AF) were included. The primary outcome was the incidence of the procedure and/or device-related stroke within 30 days of the ablation by a board-certified neurologist's assessment. The secondary outcomes were an acute procedural success, 6 months effectiveness (defined as the reduction in AF/atrial flutter episodes lasting ≥10 minutes by 48-hour Holter 6 months postablation) and the number of patients with pulmonary vein (PV) stenosis., Results: A total of 129 (108 PersAF, 21 long-standing PersAF) patients were treated (mean age: 60.6 ± 7.7; 79.8% male, 54.3% CHA2Ds2-VASc score ≥ 2). Two nondisabling strokes were reported (1.6%); one before discharge and the second diagnosed at the 30-day visit. Due to slow enrollment, the study was terminated before reaching the 95% one-sided upper confidence boundary for stroke incidence. Acute procedural success was 93.8%, and at 6 months, 72.8% of patients demonstrated ≥90% reduction in AF burden, 78.9% were off all antiarrhythmic drugs. There were no patients with PV stenosis of greater than 70%., Conclusions: VICTORY AF demonstrated a 1.6% incidence of stroke in PersAF undergoing ablation with a phased RF system which did not meet statistical confidence due to poor enrollment. The secondary outcomes suggest comparable efficacy to phased RF in the tailored treatment of permanent AF trial. Rigorous clinical evaluation of the stroke risk of new AF ablation technologies as well as restriction to Vitamin K antagonist anticoagulation appears to be unachievable goals in a clinical multicenter IDE trial of AF ablation in the current era., (© 2020 Wiley Periodicals, Inc.)

Introduction: Ablation of atrial vagal ganglia has been associated with improved pulmonary vein isolation (PVI) outcomes. Disruption of vagal reflexes results in heart rate (HR) increase. We investigated the association between HR change after PVI and freedom from atrial fibrillation (AF) at 1 year., Methods and Results: Patients who underwent PVI for paroxysmal AF were identified from the Johns Hopkins Hospital AF registry. Electrocardiograms taken pre-PVI and post-PVI were used to determine the change in HR. Patients followed-up at 3, 6, and 12 months. Of 257 patients (66% male, age 59+/-11 years), 134 (52%) remained free from AF at 1 year. The average HR increased from 60.6 ± 11.3 beats per minute (bpm) pre-PVI to 70.7 ± 12.0 bpm post-PVI. Patients with recurrence of AF had lower post-PVI HR than those who remained free from AF (67.8 ± 0.2 vs 73.3 ± 13.0 bpm; P <.001). The probability of AF recurrence at 1-year decreased as the change in HR increased (estimated odds ratio [OR], 0.83; 95% confidence interval [CI, 0.74-0.93]; P = .002). HR increase more than 15 bpm was associated with the lowest odds of AF recurrence (estimated OR, 0.39; 95% [0.17-0.85]; P = .018) compared to HR decrease., Conclusions: Resting HR was found to increase after PVI. Increase in HR more than 15 bpm has a positive association with remaining free from atrial fibrillation at 1 year., (© 2019 Wiley Periodicals, Inc.)

Pulmonary vein isolation (PVI) is the only proven ablation strategy for paroxysmal and persistent atrial fibrillation (AF). However, when AF recurs despite durable PVI in a subgroup of patients with persistent AF, there is no scientifically proven ablation strategy to pursue. Here, we summarized how we approach persistent AF at Johns Hopkins Hospital., (© 2019 Wiley Periodicals, Inc.)

Aims: The TactiCath Contact Force Ablation Catheter Study for Atrial Fibrillation (TOCCASTAR) clinical trial compared clinical outcomes using a contact force (CF) sensing ablation catheter (TactiCath) with a catheter that lacked CF measurement. This analysis links recorded events in the TOCCASTAR study and a large claims database, IBM MarketScan®, to determine the economic impact of using CF sensing during atrial fibrillation (AF) ablation., Methods and Results: Clinical events including repeat ablation, use of antiarrhythmic drugs, hospitalization, perforation, pericarditis, pneumothorax, pulmonary edema, pulmonary vein stenosis, tamponade, and vascular access complications were adjudicated in the year after ablation. CF was characterized as optimal if greater than or equal to 90% lesion was performed with greater than or equal to 10 g of CF. A probabilistic 1:1 linkage was created for subjects in MarketScan® with the same events in the year after ablation, and the cost was evaluated over 10 000 iterations. Of the 279 subjects in TOCCASTAR, 145 were ablated using CF (57% with optimal CF), and 134 were ablated without CF. In the MarketScan® cohort, 9811 subjects who underwent AF ablation were used to determine events and costs. For subjects ablated with optimal CF, total cost was $19 271 ± 3705 in the year after ablation. For ablation lacking CF measurement, cost was $22 673 ± 3079 (difference of $3402, P < .001). In 73% of simulations, optimal CF was associated with lower cost in the year after ablation., Conclusion: Compared to ablation without CF, there was a decrease in healthcare cost of $3402 per subject in the first year after the procedure when optimal CF was used., (© 2019 Wiley Periodicals, Inc.)

Introduction: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited progressive cardiomyopathy characterized by frequent life-threatening arrhythmias. The diagnosis of ARVC is challenging and is on the basis of a set of major and minor criteria as described by the modified Task Force Criteria (TFC). We report our clinical experience in a series of patients who were misdiagnosed with ARVC and subsequently underwent removal of their implantable cardioverter defibrillator (ICD) after a re-evaluation at our center., Methods and Results: We studied 12 patients who were misdiagnosed with ARVC and had ICD implantation before our assessment. All patients had a repeat evaluation and were scored according to TFC before ICD removal. Cardiac magnetic resonance imaging (CMR) studies performed at outside institutions during the initial evaluation were reported abnormal and classified as meeting major TFC in ninety percent of patients. The most common abnormality reported was fatty infiltration of the right ventricular (RV) free wall and/or presence of focal intra-myocardial fat in six patients (50%). On re-evaluation, none of these findings fulfilled the TFC for the diagnosis., Conclusion: This study demonstrated that high dependence on misinterpretation of CMR along with a misunderstanding of the TFC evaluation are the main reasons for the misdiagnosis of ARVC. Despite the updated criteria for almost a decade, this study reminds that the diagnosis of ARVC is complex and hence careful TFC evaluation and consideration of multiple cardiac test results should be the focused approach for clinicians when confronted with suspected ARVC patients., (© 2019 Wiley Periodicals, Inc.)

Background: Patients with cardiac sarcoidosis (CS) may present with arrhythmic events (AE): atrioventricular block (AVB) and/ or ventricular arrhythmias (VA). We sought to: (a) use regional analysis of cardiac magnetic resonance imaging (CMR) to describe anatomic and functional phenotypes of patients with CS and AE; (b) Assess the association of regional CMR abnormalities with the combined endpoint of death, heart transplantation (HT) and AE; and (c) use machine learning (ML) to predict the combined endpoint based on CMR features., Methods: we included 76 patients with CS and CMR. We analyzed cine images to determine regional longitudinal (LS) and radial strain (RS); and late gadolinium enhancement imaging to determine regional scar burden (%scar)., Results: Patients with AVB (n = 7), compared with those without, had higher %scar in the anterior (21.8 ± 27.4 vs 5.1 ± 8.9; P = 0.0005) and anteroseptal (19.3 ± 24.5 vs 3.5 ± 5.5; P < .0001) walls. Patients with VA (n = 12), compared with those without, had higher %scar in the basal inferoseptum (20.4 ± 30.8 vs 8.3 ± 13.4; P = .03). During mean follow-up of 4.4 ± 3.3 years, four patients died or underwent HT; eight had VA; and zero developed AVB. Multiple regional abnormalities were associated with the combined endpoint, including scar in the anteroseptal wall (HR 1.06 [1.02-1.09] per 1%scar increase, P = .002). The ML algorithm predicted the combined endpoint with a C-statistic of 0.91., Conclusion: Regional CMR abnormalities are associated with AE in patients with CS., (© 2019 Wiley Periodicals, Inc.)

Background: Left atrial appendage (LAA) closure with the Watchman device is increasingly used in patients with nonvalvular atrial fibrillation for stroke prevention. Though clinical trials have shown a similar combined risk of ischemic and hemorrhagic stroke, there is an increased risk of ischemic stroke in patients with a Watchman device compared with anticoagulation. Some ischemic strokes are related to a device-related thrombus (DRT), which may be attributable to delayed endothelialization of exposed fabric and metal., Methods and Results: Patients undergoing Watchman LAA occlusion between January 2016 and June 2018 were enrolled in a prospective registry. From this cohort, 46 patients who had both transesophageal echocardiogram (TEE) and computed tomography (CT) at 45 days follow-up were selected for this study. The degree of LAA occlusion and type of leak were assessed by CT and TEE. TEE identified no patients with a significant (>5 mm) peri-device leak, 27 (58.6%) with nonsignificant peri-device leak (<5 mm), and 19 (41.4%) with complete occlusion. CT identified contrast in the LAA in 28 (60%) patients. However, in 10 (21.8%) of these patients, contrast entered the LAA through the fabric rather than around the device. No DRT were identified., Conclusion: These data reveal that the Watchman device remains porous 6 weeks after implantation in a substantial percentage of patients, suggesting delayed endothelialization of the device. Cardiac CT may help to differentiate between peri-device and trans-fabric leak. Additional studies are required to test whether prolonged anticoagulation in patients with trans-fabric leak may help to reduce the risk of DRT and ischemic stroke., (© 2019 Wiley Periodicals, Inc.)

Background: Implantable defibrillators (ICD) are an important therapy for arrhythmogenic right ventricular cardiomyopathy (ARVC) patients at high risk of sudden death. Given the high appropriate ICD therapy rate, some have argued that the mere act of implanting an ICD inflates the malignant arrhythmia rate in ARVC., Objective: To report the arrhythmic course of ARVC patients without ICDs at the fulfillment of the 2010 Task Force Criteria and explore predictors of malignant ventricular arrhythmias., Methods: We included 131 definite ARVC patients (age 32 ± 15 years, male 39%, proband 50%) either without ICDs (N  =  47) or receiving an ICD at least 6 months after the fulfillment of the diagnostic criteria. The primary outcome was a composite of cardiac arrest (both resuscitated successfully and unsuccessfully) and sustained ventricular tachyarrhythmias (cycle length< 600 milliseconds, at least 30 seconds or requiring an intervention for termination)., Results: At the fulfillment of the diagnostic criteria, ICDs were not recommended to 59 (45%) patients and declined by 22 (17%) patients. Forty (31%) patients were not recognized as having ARVC by the treating physicians. Over 8 (interquartile interval: 3-12) years, 38 (29%) patients had primary outcomes (8 cardiac arrests [3 died] and 30 sustained ventricular arrhythmias) while not having ICDs. The 1-year and 5-year event-free survival was 92% and 72%. Spontaneous sustained ventricular arrhythmias, cardiac syncope, men, proband, and inducibility in electrophysiology study were significantly associated with the primary outcome., Conclusion: In a contemporary cohort, a considerable risk of malignant arrhythmias existed in ARVC when ICDs were not implanted., (© 2018 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals, Inc.)

Aims: Arrhythmogenic right ventricular cardiomyopathy (ARVC) is an inherited cardiomyopathy characterized by ventricular arrhythmias and sudden death. Currently 60% of patients meeting Task Force Criteria (TFC) have an identifiable mutation in one of the desmosomal genes. As much overlap is described between other cardiomyopathies and ARVC, we examined the prevalence of rare, possibly pathogenic sarcomere variants in the ARVC population., Methods: One hundred and thirty-seven (137) individuals meeting 2010 TFC for a diagnosis of ARVC, negative for pathogenic desmosomal variants, TMEM43, SCN5A, and PLN were screened for variants in the sarcomere genes (ACTC1, MYBPC3, MYH7, MYL2, MYL3, TNNC1, TNNI3, TNNT2, and TPM1) through either clinical or research genetic testing., Results: Six probands (6/137, 4%) were found to carry rare variants in the sarcomere genes. These variants have low prevalence in controls, are predicted damaging by Polyphen-2, and some of the variants are known pathogenic hypertrophic cardiomyopathy mutations. Sarcomere variant carriers had a phenotype that did not differ significantly from desmosomal mutation carriers. As most of these probands were the only affected individuals in their families, however, segregation data are noninformative., Conclusion: These data show variants in the sarcomere can be identified in individuals with an ARVC phenotype. Although rare and predicted damaging, proven functional and segregational evidence that these variants can cause ARVC is lacking. Therefore, caution is warranted in interpreting these variants when identified on large next-generation sequencing panels for cardiomyopathies., (© 2018 The Authors. Journal of Cardiovascular Electrophysiology published by Wiley Periodicals, Inc.)

Introduction: Catheter ablation is common for patients with symptomatic, drug-refractory atrial fibrillation (AF). Obesity is a known risk factor for incident AF. The impact of obesity on AF ablation outcomes is incompletely understood. We sought to determine the impact of elevated body mass index (BMI) on pulmonary vein isolation (PVI) procedural outcomes and associated complications., Methods and Results: We evaluated patients undergoing PVI from 2001 to 2015, dividing them into four groups: normal weight (BMI ≥ 18.5 to < 25), overweight (BMI ≥ 25 to < 30), obese (BMI > 30 to < 40), and morbidly obese (BMI ≥ 40). Demographic and procedural characteristics, complications, and ablation outcomes were compared among groups. A total of 701 patients (146 time-matched controls, 227 overweight, 244 obese, and 84 morbidly obese) with complete demographic, procedural, and follow-up data were included. Increasing BMI correlated positively with HTN, OSA, CHA 2 DS 2 -VASC score, and persistent AF (P ≤ 0.001 for all associations). Radiofrequency application time and intraprocedural heparin dose increased with BMI (P ≤ 0.001). Arrhythmia recurrence at 1 year was 39.9% in controls, while higher in all high-BMI groups (overweight, 51.3%; obese, 57%; morbidly obese, 58.1 %; P  =  0.007 for all versus controls). Impact of BMI on AF recurrence was not seen in persistent AF patients. Complication rates across groups were similar., Conclusions: AF recurrence after catheter ablation is higher in overweight, obese, and morbidly obese patients comparing to normal-weight controls, driven primarily by outcomes differences in paroxysmal AF patients. Complications were not associated with increased BMI., (© 2017 Wiley Periodicals, Inc.)

Introduction: Epicardial ablation is becoming an important part of management in patients with ventricular tachycardia (VT). Posterior epicardial access via the Sosa or needle-in-needle (NIN) approach for epicardial VT ablation is considered to be the method of choice for most electrophysiologists. Anterior epicardial access as an alternative technique has recently been proposed, but there are limited data about its safety, efficacy, and the rate of immediate complications. In this study, we report our experience with anterior epicardial access between 2009 and 2016., Methods: Between 2009 and June 2016, 100 consecutive patients underwent epicardial VT ablation using an anterior approach. The success rate, epicardial bleeding, and other complications related to the epicardial access in these patients were compared to the previously reported rate of complications in patients whom epicardial access was performed using the NIN or Sosa techniques., Results: Anterior epicardial access was obtained successfully in 100% of patients in the first attempt. The success rate of the anterior approach was comparable with the reported success rate of the NIN technique (100% vs. 100%, P value not significant) but better than the Sosa technique (100% vs. 94%, P = 0.012). None of the patients in the anterior approach series suffered from significant pericardial bleeding (defined as greater than 80 mL of blood loss), RV puncture/damage, or need for an emergent cardiac surgery., Conclusion: An anterior epicardial approach is feasible and appears to have an acceptable safety profile in comparison with other epicardial approaches., (© 2017 Wiley Periodicals, Inc.)