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Aim: To explore the safety and efficacy of a novel strategy (bi-atrial linear catheter ablation guided by electrophysiological mapping) for persistent atrial fibrillation (PeAF) treatment. Methods: 83 patients with PeAF were enrolled for evaluation of ablation strategy. 43 patients were subjected to pulmonary vein isolation (PVI) strategy (PVI group). 40 patients were subjected to bi-atrial linear ablation strategy guided by electrophysiological mapping (PVI, left atrial BOX ablation, coronary sinus endocardial linear ablation, tailored left atrial anterior wall linear ablation, mitral isthmus linear ablation with necessary ethanol infusion into the vein of Marshall, right atrial posterior wall linear ablation and cavo-tricuspid isthmus ablation) (linear ablation group). Patients were followed up every 3 months. Results: During a median follow-up of 12 (4–16) months, freedom from atrial fibrillation/atrial tachycardia recurrence was 87.5% in the linear ablation group and 65.1% in the PVI group (P < 0.01). A Cox regression multivariate analysis revealed that ablation strategy group (tailored bi-atrial linear ablation) (HR 0.33, 95% CI 0.12–0.91, P = 0.03) was the only independent predictor of recurrence. Conclusion: Tailored bi-atrial linear ablation strategy guided by electrophysiological mapping resulted in improved outcomes without compromising safety for patients with PeAF. [ABSTRACT FROM AUTHOR]

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Abstract Aim To explore the safety and efficacy of a novel strategy (bi-atrial linear catheter ablation guided by electrophysiological mapping) for persistent atrial fibrillation (PeAF) treatment. Methods 83 patients with PeAF were enrolled for evaluation of ablation strategy. 43 patients were subjected to pulmonary vein isolation (PVI) strategy (PVI group). 40 patients were subjected to bi-atrial linear ablation strategy guided by electrophysiological mapping (PVI, left atrial BOX ablation, coronary sinus endocardial linear ablation, tailored left atrial anterior wall linear ablation, mitral isthmus linear ablation with necessary ethanol infusion into the vein of Marshall, right atrial posterior wall linear ablation and cavo-tricuspid isthmus ablation) (linear ablation group). Patients were followed up every 3 months. Results During a median follow-up of 12 (4–16) months, freedom from atrial fibrillation/atrial tachycardia recurrence was 87.5% in the linear ablation group and 65.1% in the PVI group (P

Abstract Aims Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF). The impact of ST‐segment depression before CA on LVEF recovery and clinical outcomes remains unknown. In the present study, we aimed to investigate the relationship between ST‐segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in persistent atrial fibrillation (PerAF) patients with HFrEF. Methods and results The present study included 122 PerAF patients (male; 98 patients, 80%, mean age: 69 [56, 76] years) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who had LVEF

Abstract Objective To investigate the effect of pulmonary vein antrum enlargement combined with left atrial roof cryoballoon ablation in patients with persistent atrial fibrillation (PeAF) by analyzing the relationship between left atrial isolation area surface area (ISA) and early postoperative recurrence. Methods 93 patients with PeAF were classified into recurrence and non-recurrence groups according to the results of the 1-year follow-up. Three-dimensional electroanatomical labeling map was constructed and merged with that of the left atrial pulmonary vein CTA, and the ISA and the left atrial surface area (LASA) were measured and analyzed to determine the relationship between ISA/LASA in relation to early postoperative recurrence. Results 93 patients were included and followed up for 1 year with AF-free recurrence rate of 75.3%. The ISA of the recurrence group was lower than that of the non-recurrence group. Left atrial internal diameter (LAD), left common pulmonary vein, the ISA, the ISA/LASA and early-term recurrence had statistical significance in both groups. The factors that significantly predicted early-term recurrence were left common pulmonary vein and the ISA/LASA. ISA/LASA (HR 0, 95% CI 0–0.005, P = 0.008) and left common pulmonary vein trunk (HR 7.754, 95% CI 2.256–25.651, P = 0.001) were the independent risk factors for early recurrence. ROC curve analysis showed that ISA/LASA predicted the best early recurrence after operation with a cut-off value of 15.2%. Conclusion A greater ISA/LASA reduces early recurrence after cryoablation in patients with PeAF. An ISA/LASA of 15.2% may be the best cut-off value for predicting early recurrence after cryoablation for PeAF.

Abstract Electrical cardioversion (ECV) a widely utilized intervention for persistent atrial fibrillation (AF) aimed at restoring sinus rhythm. However, ECV can be ineffective, raising questions about subsequent treatment options. This study aimed to compare the outcomes of non-ablation therapy versus ablation therapy following unsuccessful ECV. A total of 125 consecutive patients with persistent AF who underwent unsuccessful ECV between November 2017 and August 2023 was included in this retrospective analysis. Of these, 51.2% received only medical therapy (non-ablation therapy group, n = 64), while 48.8% underwent AF ablation (ablation therapy group, n = 61). Various ablation methods were employed, including catheter and thoracoscopic ablation. Ablation therapy was associated with significantly better AF-free survival compared to non-ablation therapy [hazard ratio (HR), 0.37; 95% confidence interval (CI) 0.22–0.61; p 5 year (HR 1.51; 95% CI 0.930–2.437; p = 0.10), BMI ≤ 25 kg/m2 (HR 1.61; 95% CI 1.004–2.581; p = 0.05) and diabetes (HR 2.38; 95% CI 0.902–6.266; p = 0.08) were considerable as predictor of AF recurrence. Ablation therapy following unsuccessful ECV was associated with maintaining sinus rhythm, regardless of the specific ablation method utilized.

Abstract The question of optimal timing for catheter ablation of atrial fibrillation (AF) to achieve best outcomes remains a crucial clinical issue. As AF occurs less frequently in younger patients, data regarding Diagnosis-to-Ablation Time (DAT) is especially limited in patients under the age of 55 years with persistent AF. We therefore analyzed the temporal relationship between initial AF presentation and timing of catheter ablation in this cohort. We conducted a retrospective single-centre study of patients ≤ 55 years with persistent AF who underwent first-time catheter ablation at our center. The cohort was divided into patients that underwent catheter ablation after diagnosis of persistent AF within a DAT of ≤ 12 months and patients with a DAT of > 12 months. A total of 101 patients (median age 51 years; female n = 19 (18.8%)) with persistent AF were included. Ablation was performed within 12 months (“early DAT”) in 51 patients and > 12 months (“late DAT”) in 50 patients. Pulmonary vein isolation was performed using high-power short-duration (HPSD) radiofrequency ablation. Median DAT was 5 months (1–12 months) in the early ablation group and 36 months (13–240 months) in the late ablation group. The median follow-up was 11.3 months (0.03–37.1 months). The rate of any atrial arrhythmia recurrence after a 30-day blanking period was significantly lower in the early DAT group (13/51 patients; 25.5%) as compared to the late DAT group (26/50 patients; 52.0%) (log rank test; p = 0.003). Catheter ablation performed > 12 months after the initial AF diagnosis was an independent predictor for the occurrence of any atrial arrythmia (OR: 2.58; (95%-CI: 1.32–5.07). Early first-time catheter ablation (DAT ≤ 12 months) in patients ≤ 55 years with persistent AF is associated with a significantly lower rate of arrhythmia recurrence.

The question of optimal timing for catheter ablation of atrial fibrillation (AF) to achieve best outcomes remains a crucial clinical issue. As AF occurs less frequently in younger patients, data regarding Diagnosis-to-Ablation Time (DAT) is especially limited in patients under the age of 55 years with persistent AF. We therefore analyzed the temporal relationship between initial AF presentation and timing of catheter ablation in this cohort. We conducted a retrospective single-centre study of patients ≤ 55 years with persistent AF who underwent first-time catheter ablation at our center. The cohort was divided into patients that underwent catheter ablation after diagnosis of persistent AF within a DAT of ≤ 12 months and patients with a DAT of > 12 months. A total of 101 patients (median age 51 years; female n = 19 (18.8%)) with persistent AF were included. Ablation was performed within 12 months ("early DAT") in 51 patients and > 12 months ("late DAT") in 50 patients. Pulmonary vein isolation was performed using high-power short-duration (HPSD) radiofrequency ablation. Median DAT was 5 months (1–12 months) in the early ablation group and 36 months (13–240 months) in the late ablation group. The median follow-up was 11.3 months (0.03–37.1 months). The rate of any atrial arrhythmia recurrence after a 30-day blanking period was significantly lower in the early DAT group (13/51 patients; 25.5%) as compared to the late DAT group (26/50 patients; 52.0%) (log rank test; p = 0.003). Catheter ablation performed > 12 months after the initial AF diagnosis was an independent predictor for the occurrence of any atrial arrythmia (OR: 2.58; (95%-CI: 1.32–5.07). Early first-time catheter ablation (DAT ≤ 12 months) in patients ≤ 55 years with persistent AF is associated with a significantly lower rate of arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

Electrical cardioversion (ECV) a widely utilized intervention for persistent atrial fibrillation (AF) aimed at restoring sinus rhythm. However, ECV can be ineffective, raising questions about subsequent treatment options. This study aimed to compare the outcomes of non-ablation therapy versus ablation therapy following unsuccessful ECV. A total of 125 consecutive patients with persistent AF who underwent unsuccessful ECV between November 2017 and August 2023 was included in this retrospective analysis. Of these, 51.2% received only medical therapy (non-ablation therapy group, n = 64), while 48.8% underwent AF ablation (ablation therapy group, n = 61). Various ablation methods were employed, including catheter and thoracoscopic ablation. Ablation therapy was associated with significantly better AF-free survival compared to non-ablation therapy [hazard ratio (HR), 0.37; 95% confidence interval (CI) 0.22–0.61; p < 0.01]. There was no difference of AF-free survival between catheter ablation and thoracoscopic ablation groups (HR 0.79, 95% CI 0.34–1.83; p = 0.58). AF duration > 5 year (HR 1.51; 95% CI 0.930–2.437; p = 0.10), BMI ≤ 25 kg/m2 (HR 1.61; 95% CI 1.004–2.581; p = 0.05) and diabetes (HR 2.38; 95% CI 0.902–6.266; p = 0.08) were considerable as predictor of AF recurrence. Ablation therapy following unsuccessful ECV was associated with maintaining sinus rhythm, regardless of the specific ablation method utilized. [ABSTRACT FROM AUTHOR]

Currently, pulmonary vein isolation (PVI) is the gold standard in catheter ablation for atrial fibrillation (AF). However, PVI alone may be insufficient in the management of persistent AF, and complementary methods are being explored. One such method takes an anatomical approach—improving both its success rate and lesion durability may lead to improved treatment outcomes. An additional approach complementary to the anatomical one is also attracting attention, one that focuses on epicardial conduction. This involves ethanol ablation of the vein of Marshall (VOM) and can be very effective in blocking epicardial conduction related to Marshall structure; it is becoming incorporated into standard treatment. However, the pitfall of this "Marshall-PLAN", a method that combines an anatomical approach with ethanol infusion within the VOM (Et-VOM), is that Et-VOM and other line creations are not always successfully completed. This has led to cases of AF and/or atrial tachycardia (AT) recurrence even after completing this lesion set. Investigating effective adjunctive methods will enable us to complete the lesion set with the aim to lower the rates of recurrence of AF and/or AT in the future. [ABSTRACT FROM AUTHOR]

Objective: To investigate the effect of pulmonary vein antrum enlargement combined with left atrial roof cryoballoon ablation in patients with persistent atrial fibrillation (PeAF) by analyzing the relationship between left atrial isolation area surface area (ISA) and early postoperative recurrence. Methods: 93 patients with PeAF were classified into recurrence and non-recurrence groups according to the results of the 1-year follow-up. Three-dimensional electroanatomical labeling map was constructed and merged with that of the left atrial pulmonary vein CTA, and the ISA and the left atrial surface area (LASA) were measured and analyzed to determine the relationship between ISA/LASA in relation to early postoperative recurrence. Results: 93 patients were included and followed up for 1 year with AF-free recurrence rate of 75.3%. The ISA of the recurrence group was lower than that of the non-recurrence group. Left atrial internal diameter (LAD), left common pulmonary vein, the ISA, the ISA/LASA and early-term recurrence had statistical significance in both groups. The factors that significantly predicted early-term recurrence were left common pulmonary vein and the ISA/LASA. ISA/LASA (HR 0, 95% CI 0–0.005, P = 0.008) and left common pulmonary vein trunk (HR 7.754, 95% CI 2.256–25.651, P = 0.001) were the independent risk factors for early recurrence. ROC curve analysis showed that ISA/LASA predicted the best early recurrence after operation with a cut-off value of 15.2%. Conclusion: A greater ISA/LASA reduces early recurrence after cryoablation in patients with PeAF. An ISA/LASA of 15.2% may be the best cut-off value for predicting early recurrence after cryoablation for PeAF. [ABSTRACT FROM AUTHOR]

Aims: Catheter ablation (CA) of atrial fibrillation (AF) improves left ventricular ejection fraction (LVEF) in patients with heart failure with reduced ejection fraction (HFrEF). The impact of ST‐segment depression before CA on LVEF recovery and clinical outcomes remains unknown. In the present study, we aimed to investigate the relationship between ST‐segment depression during AF rhythm before CA and improvement in the LVEF and clinical outcomes in persistent atrial fibrillation (PerAF) patients with HFrEF. Methods and results: The present study included 122 PerAF patients (male; 98 patients, 80%, mean age: 69 [56, 76] years) from the Osaka Rosai Atrial Fibrillation ablation (ORAF) registry who had LVEF < 50% and underwent an initial ablation. The patients who underwent percutaneous coronary intervention or coronary artery bypass grafting within the past 1 month were not included in the enrolled patients. We assigned the patients based on the presence of ST‐segment depression before CA during AF rhythm and evaluated improvement in the LVEF (LVEF ≥ 15%) 1 year after CA and the relationship between ST‐segment depression and heart failure (HF) hospitalization/major adverse cardiovascular events (MACE), which are defined as a composite of HF hospitalization, cardiovascular death, hospitalization due to coronary artery disease, ventricular arrhythmia requiring hospitalization and stroke. The percentage of patients with improvement in the LVEF 1 year after CA was significantly lower in the patients with ST‐segment depression than those without (58.6% vs. 79.7%, P = 0.012). Multiple regression analysis showed ST‐segment depression was independently and significantly associated with improvement in the LVEF 1 year after CA (HR: 0.35; 95% CI: 0.129–0.928, P = 0.035). Kaplan–Meier analysis showed that the patients with ST‐segment depression significantly had higher risk of HF hospitalization and MACE than those without (log rank P = 0.022 and log rank P = 0.002, respectively). Multivariable Cox proportional hazards analysis showed that ST‐segment depression was independently and significantly associated with a higher risk of MACE (HR: 2.82; 95% CI: 1.210–6.584, P = 0.016). Conclusions: ST‐segment depression before CA during AF rhythm was useful prognostic predictor of improvement in the LVEF and clinical outcomes including HF hospitalization and MACE in PerAF patients with HFrEF. [ABSTRACT FROM AUTHOR]

Background: The aim of this single-center retrospective study was to evaluate the long-term outcomes after the convergent procedure (CP) for treatment of AF. Methods: We analyzed the outcomes of patients that underwent CP from January 2009 until July 2020. A total of 119 patients with paroxysmal AF (23.5%), persistent AF (5.9%), or long-standing persistent AF (70.6%) that attended long-term follow-up were included. The outcomes were assessed 1 year after the CP and at long-term follow-up. At the 1-year follow-up, rhythm and AF burden were assessed for patients with an implantable loop recorder (61.2%). For others, rhythm was assessed by clinical presentation and 12-lead ECG. At long-term follow-up, patients with sinus rhythm (SR) or an unclear history were assessed with a 7-day Holter ECG monitor, and AF burden was determined. Long-term success was defined as freedom from AF/atrial flutter (AFL) with SR on a 12-lead ECG and AF/AFL burden < 1% on the 7-day Holter ECG. Results: At 1-year follow-up, 91.4% of patients had SR and 76.1% of patients had AF/AFL burden < 1%. At long-term follow-up (8.3 ± 2.8 years), 65.5% of patients had SR and 53.8% of patients had AF/AFL burden < 1% on the 7-day Holter ECG. Additional RFAs were performed in 32.8% of patients who had AF or AFL burden < 1%. At long-term follow-up, age, body mass index, and left atrial volume index were associated with an increased risk of AF recurrence. Conclusions: CP resulted in high long-term probability of SR maintenance. During long-term follow-up, additional RFAs were required to maintain SR in a substantial number of patients. [ABSTRACT FROM AUTHOR]

Despite advances in ablative therapies, outcomes remain less favorable for persistent atrial fibrillation often due to presence of non-pulmonary vein triggers and abnormal atrial substrates. This review highlights advances in ablation technologies and notable scientific literature on clinical outcomes associated with pursuing adjunctive ablation targets and substrate modification during persistent atrial fibrillation ablation, while also highlighting notable future directions. [ABSTRACT FROM AUTHOR]

Background: Circumferential pulmonary vein isolation (CPVI) has a high recurrence rate in managing persistent atrial fibrillation (AF). While some studies suggest that augmenting CPVI with additional left atrial BOX ablation can diminish this recurrence rate among patients with persistent AF, this approach remains controversial. This meta-analysis assesses the safety and efficacy of adjunctive left atrial BOX ablation in treating persistent atrial fibrillation. Methods: We conducted a comprehensive literature search across China National Knowledge Infrastructure (CNKI), PubMed, Web of Science, and Cochrane Library, focusing on randomized controlled trials. The primary outcome was the recurrence rate of any atrial arrhythmias (AAs) within one-year post-treatment, with the secondary outcome being the frequency of adverse events related to the surgery. Results: The combination of CPVI and left atrial BOX ablation did not lead to a significant reduction in the overall recurrence rate of atrial arrhythmias (risk ratios (RR) = 0.86, 95% confidence interval (CI) = 0.73–1.02, I² = 35%). However, subgroup analyses revealed that this therapeutic approach significantly decreased the recurrence rates of all atrial arrhythmias (RR = 0.67, 95% CI = 0.49–0.92, I² = 15%) and specifically atrial fibrillation (RR = 0.53, 95% CI = 0.37–0.77, I² = 0%) in patients with a left atrial diameter ≤44 mm. Notably, there was no significant increase in the incidence of procedure-related adverse events (RR = 1.04, 95% CI = 0.56–1.94, I² = 0%). However, the durations of both the ablation (mean difference (MD) = 19.77, 95% CI = 15.84–23.70, I² = 0%) and the overall procedure (MD = 15.64, 95% CI = 6.99–24.29, I² = 0%) were longer due to the additional ablation steps. Conclusions: In patients with smaller left atrial diameters, augmenting CPVI with left atrial BOX ablation significantly lowers the recurrence rates of atrial arrhythmias and atrial fibrillation without elevating surgical risk levels. [ABSTRACT FROM AUTHOR]

Background: Low-voltage area (LVA) ablation, in addition to pulmonary vein isolation (PVI), has been proposed as a new strategy in patients with atrial fibrillation (AF), but clinical trials have shown conflicting results. We performed a systematic review and meta-analysis to assess the impact of LVA ablation in patient undergoing AF ablation (PROSPERO-registered CRD42024537696). Methods: Randomized clinical trials investigating the role of LVA ablation in addition to PVI in patients with AF were searched on PubMed, Embase, and the Cochrane Library from inception to 22 April 2024. Primary outcome was atrial arrhythmia recurrence after the first AF ablation procedure. Secondary endpoints included procedure time, fluoroscopy time, and procedure-related complication rate. Sensitivity analysis including only patients with LVA demonstration at mapping and multiple subgroups analyses were also performed. Results: 1547 patients from 7 studies were included. LVA ablation in addition to PVI reduced atrial arrhythmia recurrence (odds ratio [OR] 0.65, 95% confidence interval [CI] 0.52–0.81, p < 0.001) with a number needed to treat to prevent recurrence of 10. No difference in procedure time (mean difference [MD] −5.32 min, 95% CI −19.01–8.46 min, p = 0.45), fluoroscopy time (MD −1.10 min, 95% CI −2.48–0.28 min, p = 0.12) and complication rate (OR 0.81, 95% CI 0.40–1.61, p = 0.54) was observed. Consistent results were demonstrated when considering only patients with LVA during mapping and in prespecified subgroups for AF type (paroxysmal vs. persistent), multicentric vs. monocentric trial, and ablation strategy in control group. Conclusions: In patients with AF, ablation of LVAs in addition to PVI reduces atrial arrhythmia recurrence without a significant increase in procedure time, fluoroscopy time, or complication rate. [ABSTRACT FROM AUTHOR]

BackgroundAtrial fibrillation (AF) is a prevalent cardiac arrhythmia, with ventricular rate control being a critical therapeutic target. However, the optimal range for ventricular rate control remains unclear. Additionally, the relationship between different levels of ventricular rate control and cardiac remodeling in patients with atrial fibrillation remains unclear.ObjectiveThis study aims to explore the relationship between different levels of heart rate control and cardiac remodeling in patients with early persistent atrial fibrillation.MethodsA bi-center prospective cohort study was conducted, enrolling patients with newly diagnosed persistent AF and rapid ventricular rates, yet with a normal cardiac size, from March 2019–May 2020 at the people's hospital of Chongqing Hechuan and the First Affiliated Hospital of Zhengzhou University. Patients were divided into four groups based on their average ventricular rate levels from 24 h Holter monitoring: Group I (40 ≤ average rate

Abstract Background Cor triatriatum sinister (CTS) is an uncommon congenital cardiac anomaly. Atrial fibrillation (AF) is commonly the initial symptom in patients with CTS, occurring in approximately 32% of the cases. The complexity of performing AF catheter ablation, particularly in cases with persistent AF, increases in patients with CTS due to its unique structural challenges. Case presentation We report the treatment course of a 60-year-old male patient diagnosed with CTS, who underwent catheter ablation of drug-refractory, persistent AF. The complex anatomical structure of the condition made catheter ablation of AF challenging. To navigate these challenges, we performed comprehensive assessments using transthoracic echocardiography and transesophageal echocardiography, along with cardiac computed tomography angiography, prior to treatment initiation. The intricate anatomy of CTS was further clarified during the procedure via intracardiac echocardiography (ICE). Additionally, the complexity of catheter manipulation was further reduced with the aid of the VIZIGO sheath and the vein of Marshall ethanol infusion to achieve effective mitral isthmus blockage, thereby circumventing the impact of the CTS membrane. Conclusions This case underscores the complexity and potential of advanced ablation techniques in managing cardiac arrhythmias associated with unusual cardiac anatomies. During the procedure, ICE facilitated detailed modeling of the left atrium, including the membranous structure and its openings, thus providing a clearer understanding of CTS. It is noteworthy that the membrane within the CTS may serve as a potential substrate for arrhythmias, which warrants further validation through larger sample studies.

Background: Cor triatriatum sinister (CTS) is an uncommon congenital cardiac anomaly. Atrial fibrillation (AF) is commonly the initial symptom in patients with CTS, occurring in approximately 32% of the cases. The complexity of performing AF catheter ablation, particularly in cases with persistent AF, increases in patients with CTS due to its unique structural challenges. Case presentation: We report the treatment course of a 60-year-old male patient diagnosed with CTS, who underwent catheter ablation of drug-refractory, persistent AF. The complex anatomical structure of the condition made catheter ablation of AF challenging. To navigate these challenges, we performed comprehensive assessments using transthoracic echocardiography and transesophageal echocardiography, along with cardiac computed tomography angiography, prior to treatment initiation. The intricate anatomy of CTS was further clarified during the procedure via intracardiac echocardiography (ICE). Additionally, the complexity of catheter manipulation was further reduced with the aid of the VIZIGO sheath and the vein of Marshall ethanol infusion to achieve effective mitral isthmus blockage, thereby circumventing the impact of the CTS membrane. Conclusions: This case underscores the complexity and potential of advanced ablation techniques in managing cardiac arrhythmias associated with unusual cardiac anatomies. During the procedure, ICE facilitated detailed modeling of the left atrium, including the membranous structure and its openings, thus providing a clearer understanding of CTS. It is noteworthy that the membrane within the CTS may serve as a potential substrate for arrhythmias, which warrants further validation through larger sample studies. [ABSTRACT FROM AUTHOR]

Aims Technological advancements have contributed to the enhanced precision and lesion flexibility in pulsed-field ablation (PFA) by integrating a three-dimensional mapping system combined with a point-by-point ablation strategy. Data regarding the feasibility of this technology remain limited to some clinical trials. This study aims to elucidate initial real-world data on catheter ablation utilizing a lattice-tip focal PFA/radiofrequency ablation (RFA) catheter in patients with persistent atrial fibrillation (AF). Methods and results Consecutive patients who underwent catheter ablation for persistent AF via the lattice-tip PFA/RFA catheter were enrolled. We evaluated acute procedural data including periprocedural data as well as the clinical follow-up within a 90-day blanking period. In total, 28 patients with persistent AF underwent AF ablation either under general anaesthesia (n = 6) or deep sedation (n = 22). In all patients, pulmonary vein isolation was successfully achieved. Additional linear ablations were conducted in 21 patients (78%) with a combination of successful anterior line (n = 13, 46%) and roof line (n = 19, 68%). The median procedural and fluoroscopic times were 97 (interquartile range, IQR: 80–114) min and 8.5 (IQR: 7.2–9.5) min, respectively. A total of 27 patients (96%) were interviewed during the follow-up within the blanking period, and early recurrent AF was documented in four patients (15%) including one case of recurrent AF during the hospital stay. Neither major nor minor procedural complication occurred. Conclusion In terms of real-world data, our data confirmed AF ablation feasibility utilizing the lattice-tip focal PFA/RFA catheter in patients with persistent AF. [ABSTRACT FROM AUTHOR]

BackgroundPulmonary vein isolation (PVI) is successful in approximately 50% of patients with persistent atrial fibrillation (PsAF) at one year. Identifying pre-procedurally the patients who respond favorably to a PVI alone strategy could improve their management. The present study aims to assess the predictive value of clinical response to pre-ablation electrical cardioversion (ECV) to identify the responders to PVI.MethodsConsecutive patients undergoing catheter ablation for PsAF were retrospectively classified, as “ECV successful” vs. “ECV failure”, according to the rhythm of presentation after an ECV performed ≥4 weeks. Clinical and procedural data were analyzed in both groups according to the ablation strategy applied (PVI vs. PVI + substrate modification).ResultsIn total, 58 patients (39.4%) had successful ECVs and 89 (60.6%) had failed ECV. Preprocedural characteristics were similar in both groups. Compared to the ECV failure group, patients with successful ECV presented less frequently (34% vs. 60%; P = 0.004) and less extended (21.3 ± 22.2% vs. 38.9 ± 27.4% of LA surface, P = 0.008) low-voltage areas. Over 55 ± 19 weeks of follow-up, AF-free survival was similar in both groups (72.7% vs. 67.8%, p = 0.39). PVI alone resulted in 83% AF-free survival among patients in the ECV successful group at 13 months.ConclusionIn approximately 40% of patients with PsAF, sinus rhythm can be restored by ECV and maintained for at least 1 month prior to catheter ablation. This clinical response is associated with less abnormal substrate as identified by left atrial voltage mapping and a procedural success rate of >80% with PVI alone.

Abstract Objective To assess the efficacy of ibutilide administration during radiofrequency catheter ablation of persistent atrial fibrillation (AF), to explore the success rate of conversion and related influential factors, and to analyze the effects of ibutilide on postoperative recurrence. Methods A total of 192 patients with persistent AF who underwent catheter ablation from January 1, 2019, to December 31, 2021. These patients failed in conversion of AF to normal sinus rhythm by intraoperative catheter ablation. Patients were categorized into effective group (115 cases) and ineffective group (77 cases) based on whether sinus rhythm was restored after application of ibutilide. Results The overall success rate of conversion using ibutilide administration was 59.9%. The success rate was associated with weight ((68.12 ± 11.72 vs. 72.83 ± 12.08) kg, P = 0.008), the duration of AF ((34.67 ± 55.68 vs. 66.52 ± 95.21) months, p = 0.008), diameter of left atrium (LAD) ((44.39 ± 5.80 vs. 47.36 ± 6.10) mm,P = 0.002), and N-terminal pro-brain natriuretic peptide (NT-proBNP) level ((854.85 ± 770.84 vs. 662.88 ± 659.18) pg/ml,P = 0.030). The results showed the duration of AF was associated with early recurrence, while early recurrence was not a risk factor for late recurrence. And duration of AF was associated with postoperative maintenance time of normal sinus rhythm, whereas successful conversion into normal sinus rhythm using ibutilide administration had no influence on postoperative maintenance time of normal sinus rhythm. Conclusion Ibutilide showed to be effective in catheter ablation of AF, the success rate of conversion was correlated with the duration of AF, LA diameter, and NT-proBNP level. Besides, the duration of AF was found as a risk factor for early postoperative recurrence, while ibutilide administration for successful conversion had no influence on predicting postoperative recurrence and had no influence on postoperative maintenance time of sinus rhythm.

Objective: To assess the efficacy of ibutilide administration during radiofrequency catheter ablation of persistent atrial fibrillation (AF), to explore the success rate of conversion and related influential factors, and to analyze the effects of ibutilide on postoperative recurrence. Methods: A total of 192 patients with persistent AF who underwent catheter ablation from January 1, 2019, to December 31, 2021. These patients failed in conversion of AF to normal sinus rhythm by intraoperative catheter ablation. Patients were categorized into effective group (115 cases) and ineffective group (77 cases) based on whether sinus rhythm was restored after application of ibutilide. Results: The overall success rate of conversion using ibutilide administration was 59.9%. The success rate was associated with weight ((68.12 ± 11.72 vs. 72.83 ± 12.08) kg, P = 0.008), the duration of AF ((34.67 ± 55.68 vs. 66.52 ± 95.21) months, p = 0.008), diameter of left atrium (LAD) ((44.39 ± 5.80 vs. 47.36 ± 6.10) mm,P = 0.002), and N-terminal pro-brain natriuretic peptide (NT-proBNP) level ((854.85 ± 770.84 vs. 662.88 ± 659.18) pg/ml,P = 0.030). The results showed the duration of AF was associated with early recurrence, while early recurrence was not a risk factor for late recurrence. And duration of AF was associated with postoperative maintenance time of normal sinus rhythm, whereas successful conversion into normal sinus rhythm using ibutilide administration had no influence on postoperative maintenance time of normal sinus rhythm. Conclusion: Ibutilide showed to be effective in catheter ablation of AF, the success rate of conversion was correlated with the duration of AF, LA diameter, and NT-proBNP level. Besides, the duration of AF was found as a risk factor for early postoperative recurrence, while ibutilide administration for successful conversion had no influence on predicting postoperative recurrence and had no influence on postoperative maintenance time of sinus rhythm. [ABSTRACT FROM AUTHOR]

Background and Aims: Noninvasive mapping allows the identification of patient-specific atrial rotational activity (RA) that might play a key role in the perpetuation of persistent atrial fibrillation (PsAF). So far, the impact of pulmonary vein isolation by cryoballoon (Cryo-PVI) on RA is unclear. Moreover, the long-term effect of periprocedural termination of AF during the ablation procedure is controversial. Methods: Noninvasive electrocardiographic mapping with a 252-electrode vest was performed in 42 patients with PsAF. After the first analysis, Cryo-PVI was performed. The RA was analyzed again and then targeted by radiofrequency catheter ablation. The primary clinical endpoint was periprocedural termination of AF. The secondary endpoint was freedom from any atrial arrhythmia >30 s during a 12-month follow-up. Results: In 33 patients (79%), right atrial RA was identified leading to biatrial ablation, and nine patients (21%) had left atrial RA only. Twelve patients (28.6%) converted from AF to sinus rhythm (SR) (Group A). Thirteen patients (30.9%) converted to atrial tachycardia (AT) (Group B). In 17 patients (40.5%), AF was not terminated by ablation (Group C). After a mean follow-up time of 13.8 months, 26 patients were free from AF and AT (61.9%). In terms of rhythm, control Group A (75%) and B (83.3%) showed higher success rates than Group C (33.3%) (p < 0.01). Cryo-PVI had no substantial impact on RA. Conclusions: The RA-based ablation approach showed acceptable success rates. Periprocedural termination of AF had a positive predictive impact on the outcome. No difference was observed between conversion to SR or to AT. Cryo-PVI had no impact on RA. [ABSTRACT FROM AUTHOR]

Background: Valvular calcification (VC) is an independent risk factor for cardiovascular diseases. The relationship between VC and atrial fibrillation is not clear. Hypothesis: We treated the aortic valve, mitral valve, and tricuspid valve as a whole and considered the possible association between VC and recurrence of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). Methods: This study involved 2687 PsAF patients who underwent RFCA. Data were collected to explore the relationship between VC and outcome. VC was defined by echocardiography in aortic valve, mitral valve, or tricuspid valve. After 1 year follow‐up, subgroup analysis, mixed model regression analysis, and score system analysis were performed. The external validation of 133 patients demonstrated the accuracy of this clinical prediction model. Results: Overall, 2687 inpatients were assigned to the recurrence group (n = 682) or the no recurrence group (n = 2005) with or without VC. Compared to patients with no recurrence, the incidence of VC was higher in recurrence patients. Recurrence was present in 18.5%, 34.9%, 39.3%, and 52.0% of the four groups, which met VC numbers of 0, 1, 2, and 3, respectively. After adjustment for potential confounding factors, VC was an independent risk factor for AF recurrence in several models. For multivariable logistic regression, a scoring system was established based on the regression coefficient. The receiver operating characteristic area of the scoring system was 0.787 in the external validation cohort. Conclusions: VC was an independent risk factor for AF recurrence in PsAF after RFCA. The scoring system may be a useful clinical tool to assess AF recurrence. [ABSTRACT FROM AUTHOR]

Catheter ablation therapy for persistent atrial fibrillation (PeAF) is both difficult and has limited outcomes. The mechanisms underlying the development and persistence of atrial fibrillation (AF) are not fully understood; therefore, ablation strategies are diverse. A 45-year-old man was referred to our hospital for persistent atrial fibrillation to undergo radiofrequency catheter insertion (RFCA). In the first session we conducted pulmonary vein isolation and additional linear ablation, including that of the roof line and posterior inferior line (posterior box lesion) as the stepwise ablation. However, AF was recurred in six months, therefore he was readmitted for second session ablation preoperative 3D computed tomography (CT) scan for drug-refractory PeAF was performed. The additional isolation of the left superior pulmonary vein and potential drivers of AF by mapping wavefront propagation using multipolar catheters by CARTOFINDER (Biosense Webster, Inc, Diamond Bar, CA, USA) was conducted. However, AF did not terminate. Tomography revealed that the left atrial (LA) diverticulum (LAD) was found uniquely. Electrophysiological findings showed focal firing of the myocardial sleeve and LA diverticulum by an approach for defragmented potentials by re-visiting in interval confidence level (ICL) mode included in the electroanatomical mapping system (CARTO 3, Biosense Webster, Inc, Diamond Bar, CA, USA) and the ablation by encircling this site finally made AF terminate. The AF has not recurred for more than 12 months without the use of antiarrhythmic drugs. This case report suggests that additional ablation around substrates in LAD may be effective for treating refractory AF. [ABSTRACT FROM AUTHOR]

Background Ablation of persistent atrial fibrillation (AF) remains challenging, with atrial substrate modification often being performed as an adjunct to pulmonary vein isolation (PVI). Pulsed field ablation (PFA) is a novel ablation modality that carries a favourable safety profile, which could facilitate complex procedures. Case summary We present the case of a 60-year-old male undergoing catheter ablation for symptomatic persistent AF. The procedure was performed with the Farapulse™ PFA system in a stepwise manner, including PVI and linear lesions for the isolation of the posterior left atrial wall and the ablation of the mitral isthmus. The final step of the procedure included the ablation of areas exhibiting spatiotemporal electrogram dispersion, identified with the help of artificial intelligence–based software (VX1, Volta Medical) in both atria. Sinus rhythm was restored after the abolition of an electrogram dispersion zone in the right atrium. The procedure was carried out without any complications. Discussion Complex ablation procedures for persistent AF can be successfully performed with PFA. In the context of such extensive ablation strategies, PFA is an attractive energy source, given its non-thermal nature that is known to prevent damage to surrounding tissue and result in less chronic fibrosis. However, caution should be exercised to avoid excessive ablation when using the currently available multispline PFA catheter, as it may inadvertently target adjacent areas of healthy myocardium. [ABSTRACT FROM AUTHOR]

Background: The TactiFlex™ ablation catheter, Sensor Enabled™ (Abbott, Minneapolis, MN, USA), is an open-irrigation radiofrequency (RF) ablation catheter with flexible tip technology. This catheter delivers high-power short-duration (HPSD) RF ablations and has been adopted for atrial fibrillation (AF) ablation. HPSD is well-established not only in pulmonary vein isolation (PVI) but also when targeting extra-pulmonary vein (PV) targets. This study aims to determine the safety, effectiveness, and acute outcomes of PVI plus posterior wall isolation (PWI) in patients with persistent atrial fibrillation (Pe-AF) using HPSD and the TactiFlex™ ablation catheter. Methods: Consecutive patients who underwent the ablation of Pe-AF in our centre between February 2023 and February 2024 were prospectively enrolled in the study. All patients underwent PVI plus PWI using TactiFlex™ and the HPSD strategy. The RF parameters were 50 W on all the PV segments and the roof, and within the posterior wall (PW). Left atrial mapping was performed with the EnSite X mapping system and the high-density multipolar Advisor HD Grid, Sensor Enabled™ mapping catheter. We compared the procedural data using HPSD with TactiFlex™ (n = 52) vs. a historical cohort of patients who underwent PVI plus PWI using HPSD settings and the TactiCath ablation catheter (n = 84). Results: Fifty-two consecutive patients were included in the study. PVI and PWI were achieved in all patients in the TactiFlex™ group. First-pass PVI was achieved in 97.9% of PVs (n = 195/199). PWI was obtained in all cases by delivering extensive RF lesions within the PW. There were no significant differences compared to the TactiCath group: first-pass PVI was achieved in 96.3% of PVs (n = 319/331). Adenosine administration revealed PV reconnection in 5.7% of patients, and two reconnections of the PW were documented. Procedure and RF time were significantly shorter in the TactiFlex™ group compared to the TactiCath group, 73.1 ± 12.6 vs. 98.5 ± 16.3 min, and 11.3 ± 1.5 vs. 23.5 ± 3.6 min, respectively, p < 0.001. The fluoroscopy time was comparable between both groups. No intraprocedural and periprocedural complications related to the ablation catheter were observed. Patients had an implantable loop recorder before discharge. At the 6-month follow-up, 76.8% of patients remained free from atrial arrhythmia, with no significant differences between groups. Conclusions: HPSD PVI plus PWI using the TactiFlex™ ablation catheter is effective and safe. Compared to a control group, the use of TactiFlex™ to perform HPSD PVI plus PWI is associated with a similar effectiveness but with a significantly shorter procedural and RF time.

Abstract Background In patients with non-paroxysmal AF (atrial fibrillation), various ablation strategies have been attempted to target non-pulmonary vein (PV) foci or to achieve substrate modification beyond pulmonary vein isolation. The efficacy of empirical ablation of the SVC, one of the most common non-PV foci, is unclear. The aim of this study was to investigate the efficacy and safety of additional superior vena cava (SVC) isolation in patients with non-paroxysmal AF undergoing thoracoscopic surgical ablation. Methods/results A total of 191 patients with persistent or long-standing persistent AF was enrolled. All patients underwent total thoracoscopic surgical ablation for AF, and half of them also received empirical SVC isolation. We compared the atrial tachyarrhythmia (ATa)-free survival rate and procedure-related complications in the two groups of patients. The 3-year ATa-free survival rate was 53% in the SVC isolation group and 52% in the no-SVC isolation group (p = 0.644). There were no differences between the two groups with respect to AF type or LA size. Procedure-related complications occurred in 12 patients (6%). Pacemakers were implanted only in three patients from the SVC isolation group. The only factor influencing recurrence of ATa was LA diameter. Conclusions Empirical SVC isolation during thoracoscopic ablation for persistent AF did not improve patient outcomes.

Abstract Background Ethanol infusion of the vein of Marshall (EI-VOM) has been widely used to facilitate mitral isthmus (MI) ablation. According to the literature, the success rate of achieving a bidirectional conduction block across the MI ranges from 51 to 96%, with no standardized strategy or method available for cardiac electrophysiologists. Objectives This study aimed to introduce and evaluate a novel ablation method of MI. Methods Consecutive patients with persistent atrial fibrillation (PeAF) that underwent catheter ablation were included. The MI ablation procedure followed a stepwise approach. In step 1, ethanol infusion of the vein of Marshall (EI-VOM) was performed. In step 2, a “V-shape” endocardial linear ablation connecting the left inferior pulmonary vein (LIPV) to mitral annulus (MA) was performed. In step 3, earliest activation sites(EASs) near the ablation line were identified using activation mapping followed by reinforced ablation. In step 4, precise epicardial ablation was performed, with the catheter introduced into the coronary sinus(CS) to target key ablation targets (KATs). Results 135 patients with PeAF underwent catheter ablation with the stepwise ablation method adopted in 119 cases. Bidirectional conduction blocks were achieved in 117 patients (98.3%). The block rates of every step were 0%, 58.0%, 44.0%, and 92.9%, and the cumulative block rates for the four steps were 0%, 58.0%, 76.5%, and 98.3%, respectively. No patient experienced fatal complications. Conclusions Our novel stepwise catheter ablation method for MI yielded a high bidirectional block rate with high reproducibility.

BackgroundThe mechanisms of AF development and progression are still not completely understood. Despite the relative efficacy of ablation, the risk of AF recurrence is substantial, particularly in patients with persistent AF (perAF). At present we do not have any reliable intra-procedural electrophysiologic predictors of long-term success of AF ablation other than pulmonary vein isolation. We evaluated selected intraprocedural pulmonary vein characteristics that may be helpful in future guidance of persistent AF ablation.Methods390 consecutive procedures using cryoballoon for initial AF ablation were divided by clinical presentation (paroxysmal or persistent AF), and by pulmonary vein (PV) response to pacing after completion of ablation (discrete electrogram elicited with pacing—“PV capture” or not—“Control”). Patients were followed (median 20 months) for recurrent atrial arrhythmias as the primary end point of the study.ResultsPV capture was identified in 20.3% and 17.1% and patients with paroxysmal and persistent AF respectively (ns). In patients with persistent AF presence of PV capture was associated with significantly better outcomes compared to patients without PV capture (p

Aims: The optimal ablation strategy for recurrent persistent atrial fibrillation (persAF) after initially successful catheter ablation (CA) remains debatable. Dipole density (DD) guided CA using the AcQMap system has been proven to be feasible and effective in patients with persAF. So far, long-term outcome data for DD-guided CA in patients with recurrence of persAF are sparse. This study sought to assess long-term outcome data in patients undergoing a DD-guided CA for recurrence of persAF after previous CA in comparison to conventional repeat CA. Methods and Results: Patients undergoing DD-guided CA for recurrence of persAF after previous ablation were compared to patients undergoing conventional substrate modification (CSM). A total of 64 patients (32 DD-guided and 32 CSM) were included in this analysis. Procedure duration (DD: 236 ± 61 min; CSM: 198 ± 59 min; p = 0.004) and fluoroscopy time (DD: 36 ± 15 min; CSM: 20 ± 11 min; p = 0.0001) were significantly longer in the DD group. After a long-term median follow-up (FU) of 27 months (interquartile range 12.8–34.3), DD-guided CA was inferior to CSM regarding overall arrhythmia-free survival (DD: 6 patients (19%), CSM: 11 patients (34%); HR 1.47; p = 0.04). Freedom from AF did not differ between both groups (DD: 16 patients (50%); CSM: 18 patients (56%), HR 0.99, p = 0.47). During FU, more patients underwent repeat CA after DD-guided ablation (DD: 16 patients (50%), CSM: 7 patients (22%), p = 0.04). No major complications occurred overall. Conclusions: Dipole density-guided CA is equally safe but associated with longer procedure duration compared to conventional substrate modification for treatment of recurrent persAF after previous CA. Of note, long-term arrhythmia-free survival is significantly worse after DD-guided ablation, and more patients undergo redo procedures. [ABSTRACT FROM AUTHOR]

Persistent atrial fibrillation (AF) is a diverse condition that includes various subtypes and underlying causes of arrhythmia. Progress made in catheter ablation technology in recent years has significantly enhanced the durability of ablation. Despite these advances however, the effectiveness of ablation in treating persistent AF is still relatively modest. Studies exploring the mechanisms behind persistent AF have identified substrate-driven focal and re-entrant sources within the atrial body as crucial in sustaining AF among individuals with persistent AF. Furthermore, the widespread adoption of atrial late gadolinium enhancement cardiac magnetic resonance (CMR) imaging and the ongoing refinement of invasive voltage mapping techniques have allowed for detailed assessment of fibrotic remodelling prior to or at the time of procedure. Translation into clinical practice, however, has yielded overall disappointing results. The clinical application of AF mapping in ablation procedures has not shown any substantial advantages beyond the use of pulmonary vein isolation (PVI) alone and adjunct ablation of fibrotic areas has yielded conflicting results in recent randomized trials. The emergence of pulsed field ablation represents a welcome development in the field and several studies have demonstrated an enhanced safety profile and increased procedural efficiency with this non-thermal energy modality. Pulsed field ablation also holds promise for safe and efficient substrate ablation beyond the pulmonary veins, but further trials are needed to assess its impact on longer term success rates. Continued advancements in our comprehension of AF mechanisms, alongside ongoing developments in catheter technology aimed at safe formation of transmural lesions, are essential for achieving better clinical outcomes for patients with persistent AF. [ABSTRACT FROM AUTHOR]

Aims Validating mapping systems that identify atrial fibrillation (AF) sources (focal/rotational activity) is confounded by the absence of ground truth. A key concern of prior mapping technologies is spatiotemporal instability, manifesting as poor map reproducibility. Electrographic flow (EGF) employs a novel algorithm that visualizes atrial electrical wavefront propagation to identify putative AF sources. We analysed both intra- (3 min) and inter- (>3 months) procedure EGF map reproducibility. Methods and results In 23 persistent AF patients, after pulmonary vein isolation (PVI), EGF maps were generated from 3 serial 1 min recordings using a 64-electrode basket mapping catheter (triplets) at right and left atrial locations. Source prevalence from map triplets was compared between recordings. Per protocol, 12 patients returned for 3-month remapping (1 non-inducible): index procedure post-PVI EGF maps were compared with initial EGF remapping at 3-month redo. Intra-procedure reproducibility : analysing 224 map triplets (111 right atrium, 113 left atrium) revealed a high degree of map consistency with minimal min-to-min shifts: 97 triplets (43%), exact match of leading sources on all 3 maps; 95 triplets (42%), leading source within 1 electrode space on 2 of 3 maps; and 32 triplets (14%), chaotic leading source pattern. Average deviation in source prevalence over 60 s was low (6.4%). Inter-procedure reproducibility : spatiotemporal stability of EGF mapping >3 months was seen in 16 of 18 (89%) sources mapped in 12 patients with (re)inducible AF. Conclusion Electrographic flow mapping generates reproducible intra- and inter-procedural maps, providing rationale for randomized clinical trials targeting these putative AF sources. [ABSTRACT FROM AUTHOR]

Objective: to retrospectively investigate the efficacy and safety of the application of 28 mm cryoballoon for pulmonary vein electrical isolation (PVI) combined with top left atrial linear ablation and pulmonary vein vestibular expansion ablation for persistent atrial fibrillation. Methods: From July 2016 to December 2020, 413 patients diagnosed with persistent atrial fibrillation were evaluated, including 230 (55.7%) in the PVI group (PVI only) and 183 (44.3%) in the PVIPLUS group (PVI plus ablation of the left atrial apex and pulmonary vein vestibule). The safety and efficacy of the two groups were retrospectively analyzed. Results: The AF/AT/AFL-free survival rates at 6, 12, 18, 24 and 30 months after procedure was 86.6%, 72.6%, 70.0%, 61.1% and 56.3% in the PVI group and 94.5%, 87.0%, 84.1%, 75.0% and 67.9% in the PVIPLUS group, respectively. At 30 months after procedure, the AF/AT/AFL-free survival rate was significantly higher in the PVIPLUS group than in the PVI group (P = 0.036; HR:0.63; 95% CI:0.42 to 0.95). Conclusion: The application of 28-mm cryoballoon for pulmonary vein electrical isolation combined with linear ablation of the left atrial apex and expanded ablation of the pulmonary vein vestibule improves the outcome of persistent atrial fibrillation.

IntroductionA high recurrence rate of atrial fibrillation was monitored after catheter ablation for persistent atrial fibrillation. Sacubitril/valsartan can improve outcomes for patients with heart failure and ventricular tachycardia, but few studies examined whether it can reduce recurrence or improve cardiovascular outcomes in patients with persistent atrial fibrillation after catheter ablation. In this study, we will assess the effect of sacubitril/valsartan on sinus rhythm maintenance and incidence of major adverse cardiovascular events (MACE) in patients with persistent atrial fibrillation after catheter ablation through a randomized controlled trial (RCT).MethodsThis is a multi-center, randomized, controlled, open-label, superiority clinical trial involving 462 patients without reduced ejection fraction heart failure after catheter ablation of persistent atrial fibrillation. Patients will be randomized to (1) receive the standard treatment strategy plus sacubitril/valsartan titration, or (2) receive the standard treatment strategy without taking sacubitril/valsartan. The primary outcome will be sinus rhythm maintenance rate over 12 months, monitored by random electrocardiogram and 24-h Holter electrocardiogram.DiscussionThis study is designed to evaluate the effect of sacubitril/valsartan on sinus rhythm maintenance and incidence of major adverse cardiovascular events (MACE) in patients with persistent atrial fibrillation after catheter ablation. The results will evaluate sacubitril/valsartan as a novel treatment for improving prognosis and a complement to conventional drug therapy. Trial RegistrationRegistered with Chinese Clinical Trials Registry on 27 August 2022, identifier: ChiCTR2200062995.

BackgroundIncreasing age is a significant risk factor for atrial fibrillation (AF) recurrence after catheter ablation (CA). We accomplished this study to evaluate the efficacy and safety of the vein of Marshall (VOM) ethanol infusion (VOM-EI) with CA in elderly patients with persistent AF (PsAF).MethodsThis retrospective observational study included 360 consecutive adult patients with PsAF, of which 141 were in the Elder group (age ≥65 years) and 219 were in the Younger group (age

BackgroupIbutilide has already been used for cardioversion of persistent atrial fibrillation (PsAF) after radiofrequency catheter ablation (RFCA). The purpose of this study was to determine the effect of Ibutilide-guided cardioversion on clinical outcomes after individualized ablation of PsAF.MethodsFrom October 2020 to September 2021, consecutive patients with PsAF accepted for RFCA were prospectively enrolled. After individualized ablation including pulmonary vein isolation plus left atrial roof line ablation and personalized linear ablation based on left atrial low-voltage zones, patients were divided into the spontaneous conversion (SCV) group, direct current synchronized cardioversion (DCC) group and Ibutilide group according to different cardioversion types during ablation. The rates of freedom from atrial tachyarrhythmia (ATT) among the three groups were evaluated after follow-up.ResultsIn this study, 110 patients were enrolled, including 12 patients with SCV, 50 patients receiving DCC and 48 patients receiving Ibutilide cardioversion after individualized ablation. Among the three groups, the SCV group had shorter AF duration {12 months [interquartile range (IQR) 12–16], P = 0.042} and smaller left atrial diameter (LAD) [35 mm (IQR: 33–42), P = 0.023]. A 12-month freedom from ATT rate was 83.3% in SCV group, 69.4% in DCC group, and 79.2% in Ibutilide group, respectively (Log-rank, P = 0.745). During the follow-up [17 months (IQR: 15–19)], the rate of freedom from ATT of SCV group (83.3%), and Ibutilide group (72.9%) were both higher than that of DCC group (53.1%, P = 0.042). Moreover, Kaplan–Meier analysis showed a significantly higher sinus rhythm (SR) maintenance in Ibutilide group than in DCC group (Log-rank, P = 0.041). After adjusting for risk factors of AF recurrence, the hazard ratio for AF recurrence of the DCC group with reference to the Ibutilide group was 4.10 [95% confidence interval (CI) (1.87–8.98), P

Background: In patients with non-paroxysmal AF (atrial fibrillation), various ablation strategies have been attempted to target non-pulmonary vein (PV) foci or to achieve substrate modification beyond pulmonary vein isolation. The efficacy of empirical ablation of the SVC, one of the most common non-PV foci, is unclear. The aim of this study was to investigate the efficacy and safety of additional superior vena cava (SVC) isolation in patients with non-paroxysmal AF undergoing thoracoscopic surgical ablation. Methods/results: A total of 191 patients with persistent or long-standing persistent AF was enrolled. All patients underwent total thoracoscopic surgical ablation for AF, and half of them also received empirical SVC isolation. We compared the atrial tachyarrhythmia (ATa)-free survival rate and procedure-related complications in the two groups of patients. The 3-year ATa-free survival rate was 53% in the SVC isolation group and 52% in the no-SVC isolation group (p = 0.644). There were no differences between the two groups with respect to AF type or LA size. Procedure-related complications occurred in 12 patients (6%). Pacemakers were implanted only in three patients from the SVC isolation group. The only factor influencing recurrence of ATa was LA diameter. Conclusions: Empirical SVC isolation during thoracoscopic ablation for persistent AF did not improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Left atrial posterior wall isolation (LAPWI) may improve rhythm control in addition to pulmonary vein isolation (PVI) in persistent atrial fibrillation (persAF) patients undergoing catheter ablation (CA). However, LAPWI may be challenging when using thermal energy sources. Objective: This study aimed to investigate the efficacy and safety of LAPWI performed by non-thermal pulsed field ablation (PFA) in CA for persAF. Methods: Consecutive persAF patients from two German centers were prospectively enrolled. There were two study cohorts: (1) the LAPWI cohort, which included PFA-guided (re-)PVI with LAPWI for first-time and/or repeat ablation procedures; and (2) a comparative persAF cohort with a PFA PVI-only approach without LAPWI for first-time ablation within the same timeframe. Patients were followed up by routine Holter ECGs. Results: In total, 79 persistent AF patients were included in the study: 59/79 patients were enrolled in the LAPWI cohort, including 16/59 index (27%) and 43/59 repeat ablation procedures (73%). Sixteen patients (16/79; 21%) were in the PVI-only cohort without LAPWI. Of the patients treated with LAPWI, procedure time and fluoroscopy time was 91 ± 30 min and 15 ± 7 min, respectively. The acute PVI rate was 100% in all first-time ablation patients (32 patients (16 PVI only, 16 PVI plus LAPWI), 196/196 PVs). Of the 43 re-do patients in the LAPWI cohort, re-PVI was necessary in 33% (14/43) of patients (27 PVs; 1.9 PV per-patient); in 67% (29/43), all PVs were isolated, and antral ablation of the PV ostia was performed in 48% (14/29). LAPWI was performed successfully in all 59 (100%) patients of the LAPWI cohort. Two minor complications occurred. No esophageal lesion was detected in the LAPWI cohort (n = 33/59 (56%) patients underwent endoscopy). After 354 ± 197 days of follow-up, freedom from atrial arrhythmias was 79.3% (95-CI: 62–95%) in the complete LAPWI cohort (n = 14/59 (24%) on AAD: class Ic n = 9, class III n = 5). There was no difference regarding acute procedural and clinical outcome compared to the PVI-only cohort. Conclusion: LAPWI guided by PFA is feasible and safe in patients undergoing CA for persAF and shows favorable outcomes. In the context of durable PVI, PFA-guided LAPWI may be an effective adjunctive treatment option. [ABSTRACT FROM AUTHOR]

Background: Radiofrequency catheter ablation (RFCA) has been shown to have low efficacy for the treatment of persistent atrial fibrillation (AF) in patients with hypertrophic cardiomyopathy (HCM). We conducted this study to evaluate the benefit of adjunctive vein of Marshall (VOM) ethanol infusion during RFCA for persistent AF (PsAF) in patients with non-obstructive HCM. Methods: This multicenter retrospective observational study included 102 consecutive non-obstructive HCM patients with PsAF who underwent RFCA plus VOM ethanol infusion (VOM-EI) (RFCA + VOM, n = 56) or RFCA alone (RFCA, n = 46) for the first time. The efficacy endpoint was survival without AF or atrial tachycardia (AT) after the blanking period. Results: We completed the VOM-EI in 92.9% (52/56) patients. The left pulmonary vein antrum ablation time (RFCA + VOM: 19.9 ± 6.1 min vs. RFCA: 27.2 ± 9.3 min), mitral isthmus (MI) ablation time (RFCA + VOM: 16.9 ± 3.7 min vs. RFCA: 28.4 ± 7.8 min), and rate of coronary sinus (CS) vein ablation (RFCA + VOM: 57.69% vs. RFCA: 80.43%) were lower but the acute success rate of MI block (RFCA + VOM: 98.1% vs. RFCA: 84.8%) were higher in the RFCA + VOM group than those in the RFCA group (all p < 0.05). After twelve months follow-up, 84.6% of patients (44/52) survived without AF/AT in the RFCA + VOM group, compared to 65.2% of patients (30/46) in the RFCA group (p = 0.03; odds ratio = 2.93, 95% CI: 1.18–7.79). Conclusions: VOM-EI combined with RFCA decreased the recurrence rate of AF/AT at 12 months in HCM patients with PsAF. VOM-EI simplified the ablation of the left pulmonary vein antrum and MI and increased the success rate of MI bidirectional block. [ABSTRACT FROM AUTHOR]

Background: High-power short-duration (HPSD) radiofrequency (RF) ablation has been adopted to improve atrial fibrillation (AF) ablation. Although the role of HPSD is well-established in pulmonary vein isolation (PVI), fewer data have assessed the impact of HPSD when addressing extra-pulmonary veins (PVs) targets. Therefore, this study aims to determine the safety, effectiveness, and acute outcomes of HPSD lesion index (LSI)-guided posterior wall isolation (PWI) in addition to PVI as an initial strategy in persistent atrial fibrillation (Pe-AF). Methods: Consecutive patients who underwent ablation of Pe-AF in our center between August 2021 and January 2022 were retrospectively enrolled. All patients' ablation strategy was PVI plus PWI using HPSD LSI-guided isolation. RF parameters included 50 W targeting LSI values of ≥5 on the anterior part of the PVs and anterior roofline and ≥4 for the posterior PVs aspect, bottom line, and within the posterior wall (PW). We compared the LSI values with and without acute conduction gaps after the initial first-pass PWI. Left atrial mapping was performed with the EnSite X mapping system and a high-density multipolar Grid-shaped mapping catheter. We compared the procedural characteristics using HPSD (n = 35) vs. a control group (n = 46). Results: Thirty-five consecutive patients were included in the study. PWI on top of PVI was achieved in all cases in the HPSD group. First-pass PVI was achieved in 93.3% of PVs (n = 126/135). First-pass roofline block was obtained in most patients (n = 31, 88.5%), while first-pass block of the bottom line was only achieved in 51.4% (n = 18). There were no significant differences compared to the control group; first-pass PVI was achieved in 94.9% of PVs (n = 169/178), first-pass roofline block in 89.1%, and bottom-line in 45.6% of patients. To achieve complete PWI with HPSD, scattered RF applications within the PW were necessary. No electrical reconnection of the PW was found after adenosine administration and the waiting period. The procedure and RF times were significantly shorter in the HPSD group compared to the control group, with values of 116.2 ± 10.9 vs. 144.5 ± 11.3 min, and 19.8 ± 3.6 vs. 26.3 ± 6.4 min, respectively, p < 0.001. Fluoroscopy time was comparable between both groups. No procedural complications were observed. At the 12-month follow-up, 71.4% of patients remained free from AF, with no differences between the groups. Conclusions: HPSD LSI-guided PWI on top of PVI seems effective and safe. Compared to a control group, HPSD is associated with similar rates of first-pass PWI and PVI but with a shorter procedural and RF time. [ABSTRACT FROM AUTHOR]

Abstract Background Postcardiac injury syndrome (PCIS) is an easy-to-miss diagnosis, but it is not an uncommon complication. The phenomenon of echocardiography (ECHO) showing both severe pulmonary arterial hypertension (PAH) and severe tricuspid regurgitation (TR) is indeed rare in PCIS after extensive radiofrequency ablation. Case presentation A 70-year-old male was diagnosed with persistent atrial fibrillation. The patient received radiofrequency catheter ablation due to his atrial fibrillation being refractory to antiarrhythmic drugs. After the anatomical three-dimensional models were created, ablations were performed on the left and right pulmonary veins, roof linear and bottom linear of the left atrium, and the cavo-tricuspid isthmus. The patient was discharged in sinus rhythm (SR). After 3 days, he was admitted to the hospital for gradually worsening dyspnea. Laboratory examination showed a normal leukocyte count with an increased percentage of neutrophils. The erythrocyte sedimentation rate, C-reactive protein concentration, interleukin-6, and N-terminal pro-B-type natriuretic peptide were elevated. ECG exhibited SR, V1-V4 of precordial lead P-wave amplitude which was increased but not prolonged, PR segment depression, and ST-segment elevation. Computed tomography angiography of the pulmonary artery revealed that the lung had scattered high-density flocculent flakes and a small amount of pleural and pericardial effusion. Local pericardial thickening was seen. ECHO showed severe PAH with severe TR. Diuretics and vasodilators did not relieve the symptoms. Tumors, tuberculosis, and immune system diseases were all excluded. Considering the patient’s diagnosis of PCIS, the patient was treated with steroids. The patient recovered on the 19th day post ablation. The patient’s condition was maintained until 2 years of follow-up. Conclusions The phenomenon of ECHO showing severe PAH with severe TR is indeed rare in PCIS. Due to the lack of diagnostic criteria, such patients are easily misdiagnosed, leading to a poor prognosis.

Abstract Pulmonary vein isolation is an well-established treatment strategy for atrial fibrillation (AF), and it is especially effective for patients with paroxysmal AF. However, the success rate is limited for patients with persistent AF, because non-pulmonary vein triggers which increase AF recurrence are frequently found in these patients. The major non-pulmonary vein triggers are from the left atrial posterior wall, left atrial appendage, ligament of Marshall, coronary sinus, superior vena cava, and crista terminalis, but other atrial sites can also generate AF triggers. All these sites have been known to contain atrial myocytes with potential arrhythmogenic electrical activity. The prevalence and clinical characteristics of these non-pulmonary vein triggers are well studied; however, the clinical outcome of catheter ablation for persistent AF is still unclear. Here, we reviewed the current ablation strategies for persistent AF and the clinical implications of major non-pulmonary vein triggers.

Atrial fibrillation (AF) is characterized by disorganized rapid atrial electrical activity, which leads to impaired atrial function, adverse hemodynamic effects, and increased thromboembolic risk. The paroxysmal forms of AF can be effectively treated with current pharmacological and non-pharmacological modalities by targeting the arrhythmia triggers. Persistent AF, however, is more difficult to treat due to remodeling processes which may become major factors in the maintenance of the arrhythmia, rendering trigger-targeting treatment options less effective. We will systematically review the recent findings of the development and maintenance of persistent AF, including genetic, cellular, organ level, and systemic processes. As AF remains the most common sustained arrhythmia with the ongoing need to find effective treatment, we will also discuss potential treatment options targeting the remodeling processes.