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Background: A novel lattice tip ablation catheter that can toggle between radiofrequency and pulsed-field energy is able to perform not only pulmonary vein isolation, but also linear lesions under general anesthesia (GA)., Objective: We aimed to evaluate the concerns associated with the use of deep sedation and the clinical data related to linear ablation., Methods: Clinical data from two Germany high-volume atrial fibrillation (AF) centers were collected. The objectives of this study are to confirm the feasibility and safety of linear lesion ablation using the lattice tip catheter without GA. Acute procedural and short-term follow-up data were collected., Results: This study included 55 patients who underwent AF ablation (15 with GA vs 40 with deep sedation) including linear lesion ablation for atrial tachyarrhythmia using a lattice tip catheter. Bidirectional block of linear lesions was achieved in 21 of 21 linear lesions in the GA and in 74 of 76 (97%) linear lesions in the deep sedation group (P = 1.000) including roof line in 41 of 41 (100%), posterior wall isolation in 4 of 4 (100%), anterior mitral isthmus (MI) line in 5 of 5 (100%) vs 24 of 25 (96%), posterior MI line in 1 of 1 (100%) vs 4 of 5 (80%), cavotricuspid isthmus line in 15 of 15 (100%), and 1 left atrial appendage isolation. The overall incidence rate of complications was 1.8% (1 cardiac tamponade). There was no other procedural related complication., Conclusion: This preliminary clinical study demonstrates feasibility and safety of bidirectional block of linear lesions using a lattice tip catheter under deep sedation. Need to toggle between energy sources was low., Competing Interests: Disclosures Dr Schmidt is a consultant for—and has received honoraria as well as research funding from—Abbott, Medtronic, Boston Scientific, and Biosense Webster. Dr Bordignon has received honoraria from Medtronic and Biosense Webster. Dr Metzner is a consultant for—and has received honoraria from—Abbott, Medtronic, Boston Scientific, and Biosense Webster. Dr Chun is a consultant for—and has received honoraria as well as research funding from—Abbott, Medtronic, Boston Scientific, and Biosense Webster. The other authors have no conflicts of interest to disclose., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Extensive ablation in addition to pulmonary vein isolation (PVI) in patients with persistent atrial fibrillation (AF) has not yielded consistent results, indicating diversity in their efficacy. Mitral regurgitation (MR) associated with AF may indicate a higher prevalence of arrhythmogenic substrate, suggesting potential benefits of extensive ablation for these patients., Methods: This post-hoc analysis of the EARNEST-PVI trial compared PVI alone versus an extensive ablation strategy (PVI-plus) in persistent AF patients, stratified by MR presence. The primary endpoint of the study was the recurrence of AF. The secondary endpoints included death, cerebral infarction, and procedure-related complications., Results: The trial included 495 eligible patients divided into MR and non-MR groups. The MR group consisted of 192 patients (89 in the PVI-alone arm and 103 in the PVI-plus arm), while the non-MR group had 303 patients (158 in the PVI-alone arm and 145 in the PVI-plus arm). In the non-MR group, recurrence rates were similar between PVI-alone and PVI-plus arms (Log-rank P = 0.47, Hazard ratio = 0.85 [95%CI: 0.54-1.33], P = 0.472). However, in the MR group, PVI-plus was significantly more effective in preventing AF recurrence (Log-rank P = 0.0014, Hazard ratio = 0.40 [95%CI: 0.22-0.72], P = 0.0021). No significant differences were observed in secondary endpoints between the two arms., Conclusions: For persistent AF patients with mild or greater MR, receiving PVI-plus was superior to PVI-alone in preventing AF recurrence. Conversely, for patients without MR, the effectiveness of extensive ablation was not demonstrated. These findings suggest tailoring ablation strategies based on MR presence can lead to better outcomes in AF management., Competing Interests: Declaration of competing interest Y. Sotomi has received grants from Roche Diagnostics, FUJIFILM Toyama Chemical, TOA EIYO, Bristol-Myers Squibb, Biosense Webster, Abbott Medical Japan, and NIPRO, and personal fees from Abiomed, Abbott Medical Japan, AstraZeneca, Amgen Astellas BioPharma, Biosensors, Boehringer Ingelheim, Bristol-Myers Squibb, Boston Scientific Japan, Bayer, Daiichi Sankyo, Eli Lilly, Novartis, TERUMO, Medtronic, and Pfizer Pharmaceuticals. S. Hikoso has received grants from Roche Diagnostics, FUJIFILM Toyama Chemical, Actelion Pharmaceuticals; and personal fees from AstraZeneca, Daiichi Sankyo, Astellas Pharma, Bayer, Pfizer Pharmaceuticals, Boehringer Ingelheim Japan, Kowa Company, and Ono Pharmaceutical. D. Nakatani has received personal fees from Roche Diagnostics. T. Dohi has received grants from Medtronic, Johnson & Johnson, and Abbott, during the conduct of the study. A. Sunaga has received grants from Medtronic, Johnson & Johnson, and Abbott, during the conduct of the study and personal fees from Bayer, Daiichi Sankyo, and Medtronic, outside the submitted work. M. Masuda has received personal fees from Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, Johnson & Johnson, Boston Scientific, Abbott, Nihon Kohden, Otsuka Pharmaceutical, AstraZeneca, and Medtronic, outside the submitted work. T. Watanabe has received personal fees from Biosense Webster, Abbott, Bristol-Myers Squibb, Pfizer, Boehringer Ingelheim, Bayer, Daiichi Sankyo, Nihon Kohden, and Fukuda Denshi, outside the submitted work. H. Minamiguchi has received grants from Medtronic, Johnson & Johnson, and Abbott, during the conduct of the study, and personal fees from Medtronic, Abbott, Johnson & Johnson, Nihon Kohden, Biotronik, Japan Lifeline, Daiichi Sankyo, Bayer, Pfizer, Squibb, Boehringer Ingelheim, Kowa, Ono Pharmaceutical, and Otsuka Pharmaceutical, outside the submitted work. Y. Egami has received personal fees from Japan Lifeline and Medtronic, and non-financial support from Johnson & Johnson, Abbott, and Medtronic, outside the submitted work; T. Oka has received personal fees from Medtronic, Biotronik, Abbott, Daiichi Sankyo, Beyer, Bristol-Myers Squibb, Boehringer Ingelheim, MSD, and AstraZeneca, outside the submitted work. Y. Matsuda has received personal fees from Daiichi Sankyo, Boehringer Ingelheim, Bayer, Medtronic, Boston Scientific Japan, Japan Lifeline, Asahi Kasei ZOLL Medical, Synaptic Medical Japan and Biotronik, outside the submitted work. M. Kawasaki has received personal fees from Medtronic, Bayer, Boehringer Ingelheim, Daiichi Sankyo, Bristol-Myers Squibb, and Abbott, and grants from Osaka Heart Club, outside the submitted work. K. Inoue has received personal fees from Bayer, Bristol-Myers Squibb, Boehringer Ingelheim, Daiichi Sankyo, Johnson & Johnson, and Medtronic, outside the submitted work. Y. Sakata has received personal fees from Otsuka Pharmaceutical, Ono Pharmaceutical, Daiichi Sankyo, Mitsubishi Tanabe Pharma Corporation, AstraZeneca K.K. and Actelion Pharmaceuticals, and grants from Roche Diagnostic, FUJIFILM Toyama Chemical, Bristol-Myers Squibb, Co, Biosense Webster, Inc., Abbott Medical Japan, Otsuka Pharmaceutical, Daiichi Sankyo Company, Mitsubishi Tanabe Pharma Corporation, Astellas Pharma, Kowa Company, Boehringer Ingelheim Japan, and Biotronik. Other authors have nothing to disclose., (Copyright © 2023. Published by Elsevier B.V.)

Introduction: We describe the use of a ablating system to compartmentalise and regionally isolate the atria in paroxysmal and persistent atrial fibrillation (AF). Methods: 40 patients were studied, 25 paroxysmal AF and 14 persistent AF. One patient enrolled was later found to be in left atrial flutter and was excluded. The Cardima Revelation® TX catheter system with Intellitemp® Radiofrequency (RF) energy control device and a Medtronic Atakar® RF generator were used to place wide area circumferential ablations to achieve conduction block into the left and right sided pulmonary veins. Roof lines and mitral isthmus lines were also performed. In patients with persistent AF and in repeat procedures, right atrial compartmentalisation was performed with an anterior superior vena cava (SVC) to inferior vena cava (IVC) line and a septal SVC to IVC line. Results: At 6 months, 18 of the 39 patients were asymptomatic, 10 had improved symptoms and 22 were in sinus rhythm. In the paroxysmal group, 11 were asymptomatic, 7 had improved symptoms and 16 (64%) were in sinus rhythm. In the persistent group, 7 were asymptomatic, 3 had improved symptoms and 6 (43%) were in sinus rhythm. The total group AF burden was 37.8±5.4 hrs pre-procedure and 23.1±5.1 hrs at 6 months post procedure. Mean temperature, impedance and power recorded at each pole demonstrated effective power delivery at all poles. No catheter charring was observed, complication rates were comparable to standard AF ablation technique. Conclusion: Linear ablation in the left and right atria to mimic Cox’s Maze is feasible and safe using this ablating system.

Background: 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., Methods: 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., Results: 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)., Conclusions: 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., (Copyright © 2020. Published by Elsevier B.V.)

Background: Clinical utility of irrigation-tip ablation catheters for cavo-tricuspid isthmus (CTI) ablation is established. Recently, new-generation enhanced-cooling irrigation-tip catheters were introduced into clinical use. This study compared the performance of different types of novel irrigation-tip catheters in CTI ablation., Methods: One hundred patients undergoing CTI ablation with novel irrigated-tip catheters were included. Ablation was performed with a power output of 30-35W using either 4-mm flexible tip catheters [FlexAbility (FAs) St. Jude Medical, St. Paul, MN, USA] or 3.5-mm enhanced-cooling ring-tip catheters without [ThermoCool SurroundFlow (SFs), Biosense Webster, Diamond Bar, CA, USA] and with contact force sensing [ThermoCool SmartTouch SurroundFlow (STSFs), Biosense Webster] in 32, 34, and 34 patients, respectively., Results: The successful CTI block creation rate was significantly higher for FAs than SFs/STSFs [32/32 (100%), 30/34 (88.2%), and 27/34 (79.4%), p=0.006]. In all 11 failed procedures, block was created by additional 5 (2-7) applications with 8-mm tip catheters. The radiofrequency (RF) application number (p=0.001) and energy (p=0.021) were significantly lower, and total RF time (p=0.005) and procedure time (p=0.036) significantly shorter in the FA than SF/STSF groups. The FA catheter was associated with significantly higher tip temperature readings (34.9°C vs. 32.0/33.0°C, p<0.001) and lower initial impedances than SF/STSF catheters (both p<0.001). The tip temperature reached the maximum temperature setting in 15/295 (5.1%) FA catheter applications among 11 (34.3%) patients, 0/521 (0%) ST applications, and 0/448 (0%) STSF applications. The mean RF power achieved during RF applications was significantly lower for FA than SF/STSF catheters (28.6W vs. 30.4/30.8W, p<0.001). Audible steam pops were detected in 1/448 applications in only the STSF group., Conclusions: In human CTI ablation, flexible irrigation-tip catheters showed a significantly better performance than rigid enhanced-cooling irrigation-tip catheters., (Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Background: To achieve sinus rhythm, ablation of long-standing persistent atrial fibrillation (LSPAF) usually requires substrate modification in addition to pulmonary vein isolation (PVI). In the present article, we aimed to compare clinical and substrate modification effects of 2 distinct PVI strategies during stepwise ablation in patients with LSPAF: (1) Combined approach: cryoballoon (CB) for PVI and radiofrequency (RF) ablation for substrate modification and (2) RF-only approach: RF ablation for both PVI and substrate modification., Materials and Methods: A total of 34 patients were divided into 2 groups: 19 in the combined group and 15 in the RF group. Left atrial (LA) complex fractionated atrial electrogram (CFAE) maps were acquired before and after PVI and compared between groups. The groups were compared for acute atrial fibrillation termination (AFT) rates and long-term arrhythmia-free survival., Results: A significant reduction on total LA CFAE area was observed with PVI in both groups. In the CB group, when pulmonary veins were excluded, the reduction of LA CFAE area was the most significant on the posterior wall of left atrium and which was greater than in the RF group. Although the ratio of AFT was higher in the CB group (44% versus 33%, respectively), single-procedure arrhythmia-free survival at 1 year was comparable between groups (68% in the CB group versus 66% in the RF group). Times of total procedure, fluoroscopy and post-PVI RF were all shorter in the CB group., Conclusions: CB may cause greater substrate modification on the posterior wall and increase AFT rate during LSPAF ablation., (Copyright © 2017 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.)

Background: The benefits and risks of additional left atrium (LA) linear ablation in patients with paroxysmal atrial fibrillation (AF) remain unclear., Methods: Randomized controlled trials were identified in the PubMed, Web of Science, Embase and Cochrane databases, and the relevant papers were examined. Pooled relative risks (RR) and 95% confidence interval (95% CI) were estimated using random effects models. The primary endpoint was the maintenance of sinus rhythm after a single ablation., Results: Nine randomized controlled trials involving 1138 patients were included in this analysis. Additional LA linear ablation did not improve the maintenance of the sinus rhythm following a single procedure (RR, 1.03; 95% CI, 0.93-1.13; P=0.60). A subgroup analysis demonstrated that all methods of additional linear ablation failed to improve the outcome. Additional linear ablation significantly increased the mean procedural time (166.53±67.7 vs. 139.57±62.44min, P<0.001), the mean fluoroscopy time (54.56±38.7 vs. 44.32±31.6min, P<0.001) and the mean radiofrequency (RF) energy application time (78.94±28.39 vs. 59.74±22.38min, P<0.001). No statistically significant differences in the rates of complications were noted (RR, 0.57; 95% CI, 0.27-1.19; P=0.13)., Conclusions: Additional LA linear ablation did not exhibit any benefits in terms of sinus rhythm maintenance for paroxysmal AF patients following a single procedure. Additional linear ablation significantly increased the mean procedural, fluoroscopy and RF application times. This additional ablation was not associated with a statistically significant increase in complication rates. This finding must be confirmed by further large, high-quality clinical trials., (Copyright © 2016. Published by Elsevier Ireland Ltd.)

Background: Recurrent perimitral atrial tachycardia (AT) is a challenging arrhythmia and is frequently encountered in the context of atrial fibrillation (AF) ablation., Objective: The purpose of this study was to investigate the clinical characteristics and the procedural and clinical outcomes in patients with recurrent perimitral atrial tachycardia (PMAT) after AF ablation., Methods: Among 520 consecutive ablation procedures for recurrent AT/AF after AF ablation, 40 procedures (patients) were performed for clinically recurrent PMAT 12.1 ± 13.6 months after the last procedure (total 2.2 ± 1.3 procedures). Previously, mitral isthmus (MI) linear ablation was performed in 26 of 40 procedures, including 13 procedures with complete block and 13 with 159.0 ± 23.0 ms of conduction delay without block. As a reference group, conduction delay was evaluated in 55 patients with incomplete MI block and absence of spontaneous PMAT during the follow-up period., Results: Recurrent PMATs were terminated by MI linear ablation in 26 of 40 patients. Bidirectional block across the MI and anterior line joining the mitral annulus and left atrial roof was achieved in 33 (82.5%) and 2 (5%) patients, respectively. At mean follow-up of 26.7 ± 14.5 months, 2 patients (5%) underwent reablation for spontaneously recurrent PMAT. At 12 months after the ablation procedure for PMAT, 73.5% of the patients were free from AT/AF. Conduction delay >149 ms predicted the occurrence of spontaneous PMAT with 80.0% sensitivity and 87.3% specificity., Conclusion: PMAT can recur even after successful bidirectional MI linear block. Substantial conduction delay without block across the MI from a previous procedure(s) could predispose to recurrent PMAT. Although most clinical PMATs can be successfully treated by catheter ablation, very late recurrence is possible., (Copyright © 2015 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Although a large isolated surface area of the left atrium (LA) may improve the success rate of catheter ablation (CA) for paroxysmal atrial fibrillation (AF), little is known about the relation between clinical outcomes and the amount of atrial mass reduction (AMR: ratio of total isolated and ablated areas to LA surface area) in different ablation strategies for patients with long-standing persistent AF (L-PeAF)., Methods: We randomly assigned 119 consecutive L-PeAF patients to adjunctive linear ablation (n=60) or complex fractionated atrial electrogram (CFAE)-guided ablation (n=59) after circumferential antral pulmonary vein isolation (PVI). Linear lesions included roof and anterior lines with conduction block. LA defragmentation was performed with an automated CFAE-detection algorithm. Cavotricuspid isthmus block was performed in all patients. Creatine kinase-MB (CK-MB) and troponin-T levels were measured 1 day post-CA., Results: CK-MB and troponin-T levels were higher, ablation time was longer, and AMR was greater in the CFAE-guided ablation group than in the linear ablation group. AF termination during CA was more frequently observed in the linear ablation group than in the CFAE-guided ablation group (P=0.031). Twelve months after a single procedure, recurrence occurred in 16 (26.7%) patients with linear ablation and 27 (45.8%) patients with CFAE-guided ablation (P=0.023). On multivariate analysis, LA volume and ablation method were the only independent risk factors for arrhythmia recurrence., Conclusion: Conduction block through linear lines+PVI was an efficient ablation strategy for L-PeAF, whereas the AMR amount did not influence clinical outcomes., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)