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To investigate the relationship between epicardial adipose tissue (EAT) volume and distribution and the parameters of global cardiac and regional left atrial (LA) sympathetic activity in patients with atrial fibrillation (AF). The data of the 45 consecutive patients scheduled for an index catheter ablation (CA) for AF were analyzed. Total and peri-atrial EAT volumes were measured by cardiac CT. Parameters of global cardiac sympathetic activity and discrete sympathetic regions around LA were assessed by 123I-mIBG SPECT/CT. The patients were followed up for AF recurrences assessment during 12 months after CA. A total of 133 (mean per patient 2.96 ± 1.07) discrete 123I-mIBG uptake areas (DUAs), corresponding to typical anatomical locations of LA ganglionated plexi (GP), were identified. Peri-atrial EAT volume was associated with the number of DUAs (regression estimate, 5.1 [95% CI, 0.3–9.9], p = 0.03). There was no statistically significant association between either total or peri-atrial EAT volumes and risks of AF recurrence. The washout rate (WR) was associated with reduced risk of AF recurrence (HR = 0.95; 95% CI 0.92–0.99; p = 0.01), while left ventricular (LV) myocardium 123I-mIBG summed defect score (SDS) was linked to increased hazards of AF recurrence (HR = 1.04; 95% CI 1.01–1.08; p = 0.03). Peri-atrial EAT volume is associated with regions of sympathetic activity corresponding to typical anatomical locations of LA GP. The WR was associated with reduced risk of AF recurrence while LV myocardial SDS was linked to increased hazards of AF recurrence.

Objectives This study sought to determine the impact of adjunctive renal sympathetic denervation to catheter ablation in patients with atrial fibrillation (AF) and history of hypertension. Background There are limited data regarding the impact of upstream adjunctive renal sympathetic denervation (RSDN) to pulmonary vein isolation (PVI) in patients with symptomatic atrial fibrillation (AF) and hypertension. Methods The data for this study were obtained from 2 prospective randomized pilot studies, the HFIB (Adjunctive Renal Denervation to Modify Hypertension and Sympathetic tone as Upstream Therapy in the Treatment of Atrial Fibrillation)-1 (n = 30) and HFIB (Adjunctive Renal Denervation to Modify Hypertension and Sympathetic tone as Upstream Therapy in the Treatment of Atrial Fibrillation)-2 (n = 50) studies, and we performed a meta-analysis including all published studies comparing RSDN+PVI versus PVI alone up to January 25, 2020, in patients with AF and hypertension. Results At 24 months, AF recurrence occurred in 53% and 38% in the PVI and PVI+RSDN groups (p = 0.43) in the HFIB-1 study, respectively, and 27% and 25% in the PVI and PVI+RSDN groups (p = 0.80) in the HFIB-2 study, respectively. When combined in a meta-analysis including 6 studies (n = 725), adjunctive RSDN significantly decreased the risk of AF recurrence (risk ratio [RR]: 0.68; 95% confidence interval [CI]: 0.55 to 0.83; p = 0.0002; I2 = 0%) when compared with PVI. Six renal artery complications occurred in the HFIB-1 study and none occurred in the HFIB-2 study with RSDN. However, in the meta-analysis, there were no significant differences in overall complications between both groups (RR: 1.43; 95% CI: 0.63 to 3.22; p = 0.40; I2 = 7%). When compared with baseline, RDSN significantly reduced the systolic blood pressure (–12.1 mm Hg; 95% CI: –20.9 to –3.3 mm Hg; p Conclusions The pilot HFIB-1 and HFIB-2 studies did not demonstrate a benefit with RSDN as an adjunctive upstream therapy during PVI. However, in the meta-analysis, adjunctive RSDN to PVI appears to be safe, and improves clinical outcomes in AF patients with a history of hypertension.

Oral anticoagulation reduces the ischemic stroke risk in patients with nonvalvular atrial fibrillation (NVAF) but inherently increases the bleeding risk. Percutaneous left atrial appendage occlusio...

Background Pulmonary artery denervation (PADN) procedure has not been applied to patients with residual chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA). Objectives This study sought to assess the safety and efficacy of PADN using remote magnetic navigation in patients with residual CTEPH after PEA. Methods Fifty patients with residual CTEPH despite medical therapy at least 6 months after PEA, who had mean pulmonary artery pressure ≥25 mm Hg or pulmonary vascular resistance (PVR) > 400 dyn‧s‧cm−5 based on right heart catheterization were randomized to treatment with PADN (PADN group; n = 25) using remote magnetic navigation for ablation or medical therapy with riociguat (MED group; n = 25). In the MED group, a sham procedure with mapping but no ablation was performed. The primary endpoint was PVR at 12 months after randomization. Key secondary endpoint included 6-min walk test. Results After PADN procedure, 2 patients (1 in each group) developed groin hematoma that resolved without any consequences. At 12 months, mean PVR reduction was 258 ± 135 dyn‧s‧cm−5 in the PADN group versus 149 ± 73 dyn‧s‧cm−5 in the MED group, mean between-group difference was 109 dyn‧s‧cm−5 (95% confidence interval: 45 to 171; p = 0.001). The 6-min walk test distance was significantly increased in the PADN group as compared to distance in the MED group (470 ± 84 m vs. 399 ± 116 m, respectively; p = 0.03). Conclusions PADN in patients with residual CTEPH resulted in substantial reduction of PVR at 12 months of follow-up, accompanied by improved 6-min walk test.

ObjectivesThe association between obesity and atrial fibrillation (AF) is well-established. We aimed to evaluate the impact of index body mass index (BMI) on AF recurrence at 12 months following catheter ablation using propensity-weighted analysis. In addition, periprocedural complications and fluoroscopy details were examined to assess overall safety in relationship to increasing BMI ranges.MethodsBaseline, periprocedural and follow-up data were collected on consecutive patients scheduled for AF ablation. There were no specific exclusion criteria. Patients were categorised according to baseline BMI in order to assess the outcomes for each category.ResultsAmong 3333 patients, 728 (21.8%) were classified as normal (BMI 2), 1537 (46.1%) as overweight (BMI 25.5–29.0 kg/m2) and 1068 (32.0%) as obese (BMI ≥30.0 kg/m2). Procedural duration and radiation dose were higher for overweight and obese patients compared with those with a normal BMI (p=0.002 and p2led to a 1.2-fold increased likelihood of experiencing recurrent AF at 12-months follow-up as compared with overweight patients (HR 1.223; 95% CI 1.047 to 1.429; p=0.011), while no significant correlation was found between overweight and normal BMI groups (HR 0.954; 95% CI 0.798 to 1.140; p=0.605) and obese versus normal BMI (HR 1.16; 95% CI 0.965 to 1.412; p=0.112).ConclusionsPatients with a baseline BMI ≥30 kg/m2have a higher recurrence rate of AF following catheter ablation and therefore lifestyle modification to target obesity preprocedure should be considered in these patients.

Transcatheter procedures offer an alternative to cardiac surgery in select patients with structural heart disease (SHD). Unfortunately, inadvertent disruption of electrical pathways and subsequent development of new onset conduction disturbances can occur in up to 5–70% of percutaneous interventions, result in pacemaker implantation, and confer a worse prognosis. The physical proximity between the conduction system (atrioventricular node, bundle of His, and bundle branches) and the site of percutaneous repair is increasingly recognized as a key factor influencing new onset conduction disturbance development in procedures located near the conduction system. This review covers the incidence, clinical significance, and mechanisms of new onset conduction disturbances and discusses current and emerging strategies to address this complication in these populations.

Background Atrial fibrillation (AF) is the most common arrhythmia after cardiac surgery with typical appearance at early days after operation and leads to increase morbidity and mortality in the short and long term follow up. Spinal cord stimulation (SCS) was proven to be effective in chronic pain and intractable angina pectoris treatment. Recently, animal studies demonstrated that spinal cord stimulation could suppress AF and reduce AF burden. Aim To test safety and efficacy of the temporary SCS in early postoperative period in patients undergoing coronary artery bypass grafting Methods Fifteen patients (10 men, mean age 61±7.5 years) with indications for coronary artery bypass grafting (CABG) and history of paroxysmal AF underwent percutaneous lead placement for temporary SCS. Under local anesthesia and fluoroscopic guidance, the leads were placed at C7-Th4 level according to patient's sense of paresthesia and connected with spinal cord stimulator externally fixed on patient's chest. Temporary SCS was performed 3 days before CABG and turned off during surgery. At the end of CABG, the SCS was turned on in the intensive care unit and continued for 7 days. After that the temporary leads were removed. The primary safety objective was to test safety of the temporary SCS in early postoperative period, including 30 days occurrence of MACE (Death, stroke or TIA, myocardial infarction), acute spinal cord and kidney injury. The efficacy endpoint included occurrence of AF or any atrial tachyarrhythmias lasting ≥30 seconds during 30 days after surgery. All patients had continuous external ECG monitoring for 30 days after surgery. Results In all (100%) patients temporary leads for SCS were implanted successfully and standard on-pump elective CABG was performed thereafter. There were no any adverse events related to temporary SCS in either patient till the end of follow up. There were no significant differences in CK-MB and creatinine levels as compared with baseline data (p=0.2 and 0.3, respectively). No patients developed AF or atrial tachyarrhythmias during follow up according 30-days ECG monitoring. Conclusions The first results of the temporary spinal cord stimulation to prevent AF after coronary surgery demonstrated safety and efficacy of this therapy. The parallel group randomizes study is under way (NCT 03539354) Funding Acknowledgement Type of funding source: None

OnBehalf EHRA-ESC EORP AFA LT registry Introduction Despite the effectiveness of atrial fibrillation (AF) catheter ablation (CA), antiarrhythmic therapy (AAT) remains an important part of the complex treatment. Purpose To analyze AAT dynamics in Russian patients undergoing AF ablation, and to reveal potential factors associated with ongoing AAT in patients without arrhythmia recurrence. Methods The ESC-EHRA AF ablation registry was conducted in 2012-2016 in EHRA countries. The current analysis included 476 patients (57.1 male; 57.1 ± 8.7 years) who underwent AF ablation in 13 Russian clinics. AAT before, during and at 12-month follow-up (12-FU) was assessed. At baseline, paroxysmal AF was present in 320 (67.2%) patients, persistent AF - in 94 (19.7%), long-standing persistent AF- in 53 (11,1%), in 9 (1.9%) AF type was unknown. Hypertension (H) was present in 355 (74.6%) patients; congestive heart failure (CHF) (NYHA≥2) in 184 (38.7%) patients; coronary artery disease (CAD) in 132 (27.7%) patients. The CA was the first in 396 (83.2%) cases, redo ablation was performed in 80 (16.8%) cases. AF recurrences were registered according to local clinical practice. Any atrial tachyarrhythmia >30s was considered as a recurrence. Results A three-month FU (3-FU) visit was performed in 476 (100%) patients, 12-FU - in 390 (81.9%). Prior to PV isolation 439 (92.2%) patients received AAT, while after ablation there was an increase in the number of patients on AAT - 459 (96.4%). The highest number of patients on AAT was detected at 3-FU - 463 (97.3%). During 12 months at least one episode of arrhythmia recurrence was documented in 203 (52.1%) patients, and 370 (94.8%) patients were on AAT at the 12-month visit. After the 12-month visit 307 (78.7%) patients continued to receive AAT, and in 187 (47.9%) of them there was no arrhythmia recurrence after the index ablation. Five (2.7%) of these patients continued a Ic class AAT drug, 35 (18.7%) patients - class III, 129 (69.0%) patients - β-blockers (BB) and 18 (9.6%) patients - calcium channel blockers (CCB). All 187 patients had co-morbidities (75.4% - H; 41.7% - CHF (NYHA≥2; 31.6% - CAD). There were no statistically significant predictors of AAT use in patients without arrhythmia reccurence. According to the univariant regression analysis, the use of AAT III class (mainly-sotalol) at 12 months had a small but statistically significant negative association with left atrial size enlargement (OR = 0.917; 0.860-0.997); class III AAT was negatevely associated with BB therapy (OR = 0.057; 0.016-0.198); CCB therapy was associated with an older age (OR = 1.073; 1.053-1.151). Conclusions About one-half of patients without apparent arrhythmia recurrence following AF ablation do receive AAT. There were no clinical or procedure-related factors associated with AAT after effective AF ablation. Paradoxically, patients with a smaller left atrial size and without arrhythmia recurrence had more chances to receive class III AAT, what requires further analysis.

IMPORTANCE: Renal denervation can reduce cardiac sympathetic activity that may result in an antiarrhythmic effect on atrial fibrillation. OBJECTIVE: To determine whether renal denervation when added to pulmonary vein isolation enhances long-term antiarrhythmic efficacy. DESIGN, SETTING, AND PARTICIPANTS: The Evaluate Renal Denervation in Addition to Catheter Ablation to Eliminate Atrial Fibrillation (ERADICATE-AF) trial was an investigator-initiated, multicenter, single-blind, randomized clinical trial conducted at 5 referral centers for catheter ablation of atrial fibrillation in the Russian Federation, Poland, and Germany. A total of 302 patients with hypertension despite taking at least 1 antihypertensive medication, paroxysmal atrial fibrillation, and plans for ablation were enrolled from April 2013 to March 2018. Follow-up concluded in March 2019. INTERVENTIONS: Patients were randomized to either pulmonary vein isolation alone (n = 148) or pulmonary vein isolation plus renal denervation (n = 154). Complete pulmonary vein isolation to v an end point of elimination of all pulmonary vein potentials; renal denervation using an irrigated-tip ablation catheter delivering radiofrequency energy to discrete sites in a spiral pattern from distal to proximal in both renal arteries. MAIN OUTCOMES AND MEASURES: The primary end point was freedom from atrial fibrillation, atrial flutter, or atrial tachycardia at 12 months. Secondary end points included procedural complications within 30 days and blood pressure control at 6 and 12 months. RESULTS: Of the 302 randomized patients (median age, 60 years [interquartile range, 55-65 years]; 182 men [60.3%]), 283 (93.7%) completed the trial. All successfully underwent their assigned procedures. Freedom from atrial fibrillation, flutter, or tachycardia at 12 months was observed in 84 of 148 (56.5%) of those undergoing pulmonary vein isolation alone and in 111 of 154 (72.1%) of those undergoing pulmonary vein isolation plus renal denervation (hazard ratio, 0.57; 95% CI, 0.38 to 0.85; P = .006). Of 5 prespecified secondary end points, 4 are reported and 3 differed between groups. Mean systolic blood pressure from baseline to 12 months decreased from 151 mm Hg to 147 mm Hg in the isolation-only group and from 150 mm Hg to 135 mm Hg in the renal denervation group (between-group difference, −13 mm Hg; 95% CI, −15 to −11 mm Hg; P

Aims The ESC EORP EHRA Atrial Fibrillation (AF) Ablation Long-Term registry was designed to assess management and outcomes of AF catheter ablation procedures in Europe. To investigate the current ablation approaches and their outcomes for patients with paroxymal AF (PAF) and non-PAF in Europe. Methods and results Data from index ablations were collected in 27 European countries at 104 centres in a prospective fashion. Pre-procedural, procedural, and 1-year follow-up data were captured on a web-based electronic case record form. Data on the ablation procedure were available for 3446 patients. Of these, 2513 patients and 933 patients underwent pulmonary vein isolation (PVI) or PVI plus (PVIplus) additional ablation, respectively. The ablation strategy was limited to PVI in 81% and 56% of patients in the PAF and non-PAF group, respectively (P Conclusion In patients with PAF and non-PAF, the ablation strategies of PVI and PVIplus led to similar arrhythmia-free survival rates after 1 year. A considerable hospital readmission rate was noted.

Aims Hypertension (HTN) is a well-known contributor to cardiovascular disease, including heart failure (HF) and coronary artery disease, and is the leading risk factor for premature death world-wide. A J- or U-shaped relationship has been suggested between blood pressure (BP) and clinical outcomes in different studies. However, there is little information about the significance of BP on the outcomes of patients with coronary artery disease and left ventricular dysfunction. This study aimed to determine the relationship between BP and mortality outcomes in patients with ischaemic cardiomyopathy. Methods and results The influence of BP during a median follow-up of 9.8 years was studied in a total of 1212 patients with ejection fraction ≤35% and coronary disease amenable to coronary artery bypass grafting (CABG) who were randomized to CABG or medical therapy alone (MED) in the STICH (Surgical Treatment for Ischaemic Heart Failure) trial. Landmark analyses were performed starting at 1, 2, 3, 4, and 5 years after randomization, in which previous systolic BP values were averaged and related to subsequent mortality through the end of follow-up with a median of 9.8 years. Neither a previous history of HTN nor baseline BP had any significant influence on long-term mortality outcomes, nor did they have a significant interaction with MED or CABG treatment. The landmark analyses showed a progressive U-shaped relationship that became strongest at 5 years (χ2 and P-values: 7.08, P = 0.069; 8.72, P = 0.033; 9.86; P = 0.020; 8.31, P = 0.040; 14.52, P = 0.002; at 1, 2, 3, 4, and 5-year landmark analyses, respectively). The relationship between diastolic BP (DBP) and outcomes was similar. The most favourable outcomes were observed in the SBP range 120-130, and DBP 75-85 mmHg, whereas lower and higher BP were associated with worse outcomes. There were no differences in BP-lowering medications between groups. Conclusion A strong U-shaped relationship between BP and mortality outcomes was evident in ischaemic HF patients. The results imply that the optimal SBP might be in the range 120-130 mmHg after intervention, and possibly be subject to pharmacologic action regarding high BP. Further, low BP was a marker of poor outcomes that might require other interactions and treatment strategies. Clinical trial registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00023595.

Background: The risk of sudden cardiac death (SCD) in patients with heart failure after coronary artery bypass graft surgery (CABG) has not been examined in a contemporary clinical trial of surgical revascularization. This analysis describes the incidence, timing, and clinical predictors of SCD after CABG. Methods: Patients enrolled in the STICH trial (Surgical Treatment of Ischemic Heart Failure) who underwent CABG with or without surgical ventricular reconstruction were included. We excluded patients with prior implantable cardioverter-defibrillator and those randomized only to medical therapy. The primary outcome was SCD as adjudicated by a blinded committee. A Cox model was used to examine and identify predictors of SCD. The Fine and Gray method was used to estimate the incidence of SCD accounting for the competing risk of other deaths. Results: Over a median follow-up of 46 months, 113 of 1411 patients who received CABG without (n = 934) or with (n = 477) surgical ventricular reconstruction had SCD; 311 died of other causes. The mean left ventricular ejection fraction at enrollment was 28±9%. The 5-year cumulative incidence of SCD was 8.5%. Patients who had SCD and those who did not die were younger and had fewer comorbid conditions than did those who died of causes other than SCD. In the first 30 days after CABG, SCD (n=5) accounted for 7% of all deaths. The numerically greatest monthly rate of SCD was in the 31- to 90-day time period. In a multivariable analysis including baseline demographics, risk factors, coronary anatomy, and left ventricular function, end-systolic volume index and B-type natriuretic peptide were most strongly associated with SCD. Conclusions: The monthly risk of SCD shortly after CABG among patients with a low left ventricular ejection fraction is highest between the first and third months, suggesting that risk stratification for SCD should occur early in the postoperative period, particularly in patients with increased preoperative end-systolic volume index or B-type natriuretic peptide. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT0002359.

Aims Cardiac arrhythmias following acute myocardial infarction (AMI) can be associated with major adverse cardiovascular events. Data on the “real incidence” of post-MI arrhythmias are limited. We aimed to determine the rate and burden of cardiac arrhythmias by the use of insertable cardiac monitors (ICM) in patients with preserved left ventricular ejection fraction (LVEF) after AMI. Methods and results In this prospective observational study, patients with LVEF ≥40% who underwent PCI within 7 days following AMI were enrolled to receive an ICM. Primary outcome was the incidence of new-onset atrial fibrillation (AF) measured by the ICM during a follow-up of 2 years; results: Of 165 consecutive patients with AMI, 50 (30.3%) eligible patients were recruited (mean age 57.8 ± 8.3, 88% male). During follow-up, AF was the most frequently detected arrhythmia. Twenty-nine (58%, 95% CI: 42–70%) patients developed new-onset AF, with a cumulative rate of all detected arrhythmias of 65%. Median time to the first detected AF episode was 4.8 months and the peak cumulative AF burden was detected between 3 and 6 months. Twenty-seven (93%) out of 29 patients with AF were asymptomatic. Cox regression analysis found that baseline troponin level (hazard ratio [HR] for 1 ng/mL increment: 1.03, 95% CI: 1.01–1.06, P = 0.01) and CHA2DS2-VASc score of 4 (HR: 11.42, 95% CI: 1.01–129.06, P = 0.04) were independent risk factors of new-onset AF post-AMI. Conclusion AF is a frequent but largely underestimated cardiac arrhythmia after AMI. More rigorous monitoring strategies resulting in crucial medical interventions (e.g. implementation of oral anti-coagulation) are needed. Clinical Trial Registration . Unique identifier: [NCT02492243][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02492243&atom=%2Feuropace%2Fearly%2F2017%2F01%2F08%2Feuropace.euw344.atom

Background/Introduction Pulmonary endarterectomy (PEA) is the gold standard of CTEPH treatment. However, residual CTEPH develops in 10–40% of patients after PEA, which leads to progression of right ventricular insufficiency. Currently, the only way to treat residual CTEPH is PAH-specific drug therapy. However, this treatment is not indicated for all patients because of the arterial hypotension and dyspeptic disorders. Purpose To assess the safety and efficacy of radiofrequent pulmonary artery denervation (PADN) in patients with residual CTEPH after PEA. Methods In 2015, a randomized pilot study was conducted to evaluate PADN in patients with residual CTEPH (NCT 02745106). 278 patients with CTEPH after PEA were screened. In 62 of them, according to the echocardiography, residual CTEPH (systolic pulmonary artery pressure (PAP) ≥45 mm Hg) was detected. In 50 patients, residual CTEPH was confirmed during right heart catheterization (RHC): mean PAP ≥25 mmHg and pulmonary vascular resistance (PVR) >400 dyn s cm–5. Patients were randomized into two groups: 25 in PADN group and 25 in drug therapy group with riociguat. Mean age was 39 years [26; 51]. The mean duration after PEA was 4.5 years [1; 8.5]. The primary end point was PVR in the short-term and long-term follow-up. Secondary end points were: mean PAP, cardiac output, 6-minute walk test (6MWD) and NYHA functional class. All patients were followed up for 12 months after discharge. The PADN procedure was performed using electrophysiological catheter Navistar RMT Thermocool, Biosense Webster, Diamond Bar, CA, USA and non-fluroscopic 3D navigation system. Results There was no mortality. In two patients (one in each group) hematoma developed in femoral vein puncture site without any consequences. The mean surgery time was 105 [93; 120] minutes. After 12 months, PVR was significantly lower in the PADN group compared with the drug treatment group (343±149 dyn s cm–5 vs 444±145 dyn s cm–5, respectively; mean difference −101, 95% confidence interval from −193 to −10; p=0.032). The mean PAP was also significantly lower in the PADN group (25.8±7.3 mm Hg vs. 33.8±6.4 mm Hg, p Conclusions The PADN technique showed its safety and efficacy in the treatment of patients with residual CTEPH and can be used in clinical practice. The obtained first results showed that the proposed PADN, together with optimal medical therapy, can take a place in the treatment of residual CTEPH after PEA.

Aims Delay of progression from paroxysmal to persistent atrial fibrillation (AF) is an important measure of long-term success of AF treatment. However, published data on the impact of catheter ablation on AF progression are limited. This study evaluates whether radiofrequency (RF) catheter ablation delays the progression of AF compared with antiarrhythmic drug (AAD) treatment using current AF management guidelines. Methods This prospective, randomized, controlled, two-arm, open-label trial was conducted at 29 hospitals and medical centres across 13 countries. Patients were randomized 1 : 1 to RF ablation or AAD treatment. The primary endpoint was the rate of persistent AF/atrial tachycardia (AT) at 3 years. Results After early study termination following slow enrolment, 255 (79%) of the planned 322 patients were enrolled (RF ablation, n = 128, AAD, n = 127); 36% of patients in the RF ablation group and 41% in the AAD group completed 3 years of follow-up. For the primary endpoint, the Kaplan–Meier estimate of the rate of persistent AF/AT at 3 years was significantly lower with RF ablation [2.4% (95% confidence interval (CI), 0.6–9.4%)] than with AAD therapy [17.5% (95% CI, 10.7–27.9%); one-sided P = 0.0009]. Patients ≥65 years were ∼4 times more likely to progress to persistent AF/AT than patients Conclusions Radiofrequency ablation is superior to guideline-directed AAD therapy in delaying the progression from paroxysmal to persistent AF.

Background— Animal models suggest that the neurotransmitter inhibitor, botulinum toxin, when injected into the epicardial fat pads can suppress atrial fibrillation inducibility. The aim of this prospective randomized double-blind study was to compare the efficacy and safety of botulinum toxin injection into epicardial fat pads for preventing atrial tachyarrhythmias. Methods and Results— Patients with history of paroxysmal atrial fibrillation and indication for coronary artery bypass graft surgery were randomized to botulinum toxin (Xeomin, Merz, Germany; 50 U/1 mL at each fat pad; n=30) or placebo (0.9% normal saline, 1 mL at each fat pad; n=30) injection into epicardial fat pads during surgery. Patients were followed for 1 year to assess maintenance of sinus rhythm using an implantable loop recorder. All patients in both groups had successful epicardial fat pad injections without complications. The incidence of early postoperative atrial fibrillation within 30 days after coronary artery bypass graft was 2 of 30 patients (7%) in the botulinum toxin group and 9 of 30 patients (30%) in the placebo group ( P =0.024). Between 30 days and up to the 12-month follow-up examination, 7 of the 30 patients in the placebo group (27%) and none of the 30 patients in the botulinum toxin group (0%) had recurrent atrial fibrillation ( P =0.002). There were no complications observed during the 1-year follow-up. Conclusions— Botulinum toxin injection into epicardial fat pads during coronary artery bypass graft provided substantial atrial tachyarrhythmia suppression both early as well as during 1-year follow-up, without any serious adverse events. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01842529.

Background ― Cadmium zinc telluride (CZT) solid-state detectors have been recently introduced in the field of nuclear medicine in cardiology. The aim of the current study was to investigate the scintigraphic patterns of total uptake and the regional distribution of iodine-123 metaiodobenzylguanidine (123I-mIBG) in healthy volunteers and patients with atrial fibrillation (AF) using a gamma camera equipped CZT detectors. Material and Methods ― The total number of included subjects was 30 (15 patients with a paroxysmal form of AF and 15 healthy volunteers). Using a novel single-photon emission computed tomography (SPECT) cardiac dedicated gamma camera equipped CZT-detectors the scintigraphy was performed 15 minutes and 4 hours after intravenous administration of norepinephrine structural analogue 123I-mIBG. Thus, data from early and delayed phases were obtained. The heart-to-mediastinum ratio of 123I-mIBG uptake at 15 minutes (HMRe) and 4 hours (HMRd), as well as the washout rate (WR) and summed 123I-mIBG score (SMSe, SMSd) were measured. Results ― Patients and volunteers showed comparable results of the median ratio of 123I-mIBG uptake in the heart and mediastinum (HMR) in the early and delayed phases (p>0.05). In 14 (93%) patients with AF, 123I-mIBG uptake defects in LV myocardium were detected as compared with 8 (53%) healthy individuals (p

Botulinum toxin (BTX) injections into epicardial fat pads in patients undergoing coronary artery bypass grafting (CABG) has resulted in suppression of atrial fibrillation (AF) during the early postoperative period through 1-year of follow-up in a pilot program.The purpose of this study was to report 3-year AF patterns by the use of implantable cardiac monitors (ICMs).Sixty patients with a history of paroxysmal AF and indications for CABG were randomized 1:1 to either BTX or placebo injections into 4 posterior epicardial fat pads. All patients received an ICM with regular follow-up for 3 years after surgery. The primary end point of the extended follow-up period was incidence of any atrial tachyarrhythmia after 30 days of procedure until 36 months on no antiarrhythmic drugs. The secondary end points included clinical events and AF burden.At the end of 36 months, the incidence of any atrial tachyarrhythmia was 23.3% in the BTX group vs 50% in the placebo group (hazard ratio 0.36; 95% confidence interval 0.14-0.88; P = .02). AF burden at 12, 24, and 36 months was significantly lower in the BTX group than in the placebo group: 0.22% vs 1.88% (P = .003), 1.6% vs 9.5% (P.001), and 1.3% vs 6.9% (P = .007), respectively. In the BTX group, 2 patients (7%) were hospitalized during follow-up compared with 10 (33%) in the placebo group (P = .02).Injection of BTX into epicardial fat pads in patients undergoing CABG resulted in a sustained and substantial reduction in atrial tachyarrhythmia incidence and burden during 3-year follow-up, accompanied by reduction in hospitalizations.

Whether right ventricular dysfunction affects clinical outcome after coronary artery bypass grafting with or without surgical ventricular reconstruction is still unknown. The aim of the study was to assess the impact of right ventricular dysfunction on clinical outcome in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting with or without surgical ventricular reconstruction.Of 1000 patients in the Surgical Treatment for Ischemic Heart Failure with coronary artery disease, left ventricular ejection fraction 35% or less, and anterior dysfunction, who were randomized to undergo coronary artery bypass grafting or coronary artery bypass grafting + surgical ventricular reconstruction, baseline right ventricular function could be assessed by echocardiography in 866 patients. Patients were followed for a median of 48 months. All-cause mortality or cardiovascular hospitalization was the primary end point, and all-cause mortality alone was a secondary end point.Right ventricular dysfunction was mild in 102 patients (12%) and moderate or severe in 78 patients (9%). Moderate to severe right ventricular dysfunction was associated with a larger left ventricle, lower ejection fraction, more severe mitral regurgitation, higher filling pressure, and higher pulmonary artery systolic pressure (all P.0001) compared with normal or mildly reduced right ventricular function. A significant interaction between right ventricular dysfunction and treatment allocation was observed. Patients with moderate or severe right ventricular dysfunction who received coronary artery bypass grafting + surgical ventricular reconstruction had significantly worse outcomes compared with patients who received coronary artery bypass grafting alone on both the primary (hazard ratio, 1.86; confidence interval, 1.06-3.26; P = .028) and the secondary (hazard ratio, 3.37; confidence interval, 1.36-8.37; P = .005) end points. After adjusting for all other prognostic clinical factors, the interaction remained significant with respect to all-cause mortality (P = .022).Adding surgical ventricular reconstruction to coronary artery bypass grafting may worsen long-term survival in patients with ischemic cardiomyopathy with moderate to severe right ventricular dysfunction, which reflects advanced left ventricular remodeling.

Objective To test the hypothesis that perioperative OMEGA-3 polyunsaturated fatty acid infusion would reduce the incidence of postoperative atrial fibrillation in patients after coronary artery bypass grafting as assessed by an implantable continuous cardiac monitor. Design Prospective, randomized, double-blind, placebo-controlled study. Setting Tertiary cardiothoracic referral center. Participants Thirty-nine patients with coronary artery disease who underwent surgery with cardiopulmonary bypass. Interventions Patients were assigned randomly to receive either OMEGA-3 polyunsaturated fatty acids (200 mg/kg/day starting before anesthesia induction for 24 hours followed by 100 mg/kg/day for 7 days) or placebo. The primary outcome was freedom from atrial fibrillation at 2-year follow-up. Reveal ® cardiac monitor was implanted subcutaneously in all patients. Data from the cardiac monitor were collected on the 10th day and 3, 6, 12, and 24 months postoperatively. Measurement and Main Results Postoperative atrial fibrillation developed in 4 (19%) patients in the control group and in 5 (27.8%) patients in the study group at 10-day follow-up (p = 0.88). At 2-year follow-up, 5 (27.8%) patients in the control group and 6 (35.3%) patients in the study group had atrial fibrillation (p = 0.9). Atrial fibrillation duration predicted risk of cardiovascular hospitalization at the 2-year follow-up (regression coefficient estimate = 0.24, standard error 0.02, p 2 = 0.74). Conclusions Infusion of OMEGA-3 polyunsaturated fatty acids failed to prevent the occurrence of atrial fibrillation in 2 years after coronary artery bypass grafting surgery. The cumulative atrial fibrillation duration registered by the continuous cardiac monitor at the 2-year follow-up was a significant predictor of an adverse outcome.

Although catheter ablation of isthmus-dependent atrial flutter (AFL) is successful at eliminating the target arrhythmia, many patients subsequently experience new-onset atrial fibrillation (AF).The aim of this study was to determine whether AF can be prevented by prophylactic pulmonary vein ablation in patients with AFL.A prospective, single-blind, randomized clinical trial in patients whose sole arrhythmia was AFL without AF was conducted. Patients were randomized to cavotricuspid isthmus ablation alone or with concomitant pulmonary vein isolation. All patients received an implantable cardiac monitor.Fifty patients completed the trial, and patients were well matched. Isthmus ablation was successful in all patients; pulmonary vein isolation was successful in 25 (100%) randomized patients. Procedure (P.0001) and fluoroscopy (P.0001) times were longer in the combined ablation group. More patients in the isthmus ablation-only group experienced new-onset AF during follow-up (52% vs. 12%; P = .003). The 1-year AF burden also favored the combined ablation group compared with the isthmus ablation-only group (8.3% vs. 4.0%; P = .034). In the isthmus ablation-only group, 8 (32%) patients subsequently underwent another ablation for AF. The performance of pulmonary vein isolation and male sex were independent predictors of freedom from AF.In the PREVENT-AF Study I randomized clinical trial of patients in whom only typical AFL had been observed clinically, the addition of pulmonary vein isolation to cavotricuspid isthmus ablation resulted in a marked reduction of new-onset AF during clinical follow-up as assessed with a continuous implantable cardiac monitor.

Objectives The aim of this study was to investigate whether the combination of conventional pulmonary vein isolation (PVI) by circumferential antral ablation with ganglionated plexi (GP) modification in a single ablation procedure, yields higher success rates than PVI or GP ablation alone, in patients with paroxysmal atrial fibrillation (PAF). Background Conventional PVI transects the major left atrial GP, and it is possible that autonomic denervation by inadvertent GP ablation plays a central role in the efficacy of PVI. Methods A total of 242 patients with symptomatic PAF were recruited and randomized as follows: 1) circumferential PVI (n = 78); 2) anatomic ablation of the main left atrial GP (n = 82); or 3) circumferential PVI followed by anatomic ablation of the main left atrial GP (n = 82). The primary endpoint was freedom from atrial fibrillation (AF) or other sustained atrial tachycardia (AT), verified by monthly visits, ambulatory electrocardiographic monitoring, and implantable loop recorders, during a 2-year follow-up period. Results Freedom from AF or AT was achieved in 44 (56%), 39 (48%), and 61 (74%) patients in the PVI, GP, and PVI+GP groups, respectively (p = 0.004 by log-rank test). PVI+GP ablation strategy compared with PVI alone yielded a hazard ratio of 0.53 (95% confidence interval: 0.31 to 0.91; p = 0.022) for recurrence of AF or AT. Fluoroscopy duration was 16 ± 3 min, 20 ± 5 min, and 23 ± 5 min for PVI, GP, and PVI+GP groups, respectively (p Conclusions Addition of GP ablation to PVI confers a significantly higher success rate compared with either PVI or GP alone in patients with PAF.

OBJECTIVES: The efficacy of concomitant ablation techniques in patients with paroxysmal atrial fibrillation (AF) undergoing mitral valve surgery remains under debate. The aim of this prospective, randomized, single-centre study was to compare pulmonary vein isolation (PVI) only versus a left atrial maze (LAM) procedure in patients with paroxysmal AF during mitral valve surgery. METHODS: Between February 2009 and June 2011, 52 patients with a mean age of 54.2 (standard deviation 7.2 years) underwent mitral valve surgery and concomitant bipolar radiofrequency ablation for paroxysmal AF. Patients were randomized into the PVI group (n= 27) and the LAM group (n= 25). After surgery, an implantable loop recorder for continuous electrocardiography (ECG) monitoring was implanted. Patients with an AF burden (AF%) of

Background— The aim of this prospective randomized study was to assess whether an early reablation was superior to antiarrhythmic drug (AAD) therapy in patients with previous failed pulmonary vein isolation. Methods and Results— Patients with paroxysmal atrial fibrillation (AF) eligible for AAD therapy or reablation after a previously failed initial pulmonary vein isolation procedure were eligible for this study and were followed up for 3 years to assess rhythm by means of an implanted cardiac monitor. After the blanking period postablation, 154 patients had symptomatic AF recurrences and were randomized to AAD (n=77) or repulmonary vein isolation (n=77). At the end of follow-up, 61 (79%) patients in the AAD group and 19 (25%) patients in the reablation group demonstrated AF% progression ( P P P P Conclusions— Redo AF ablation was substantially more effective than AAD in reducing the progression and prevalence of AF after the failure of an initial ablation. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT01709682.

Background: Advancing age is associated with a greater prevalence of coronary artery disease in heart failure with reduced ejection fraction and with a higher risk of complications after coronary artery bypass grafting (CABG). Whether the efficacy of CABG compared with medical therapy (MED) in patients with heart failure caused by ischemic cardiomyopathy is the same in patients of different ages is unknown. Methods: A total of 1212 patients (median follow-up, 9.8 years) with ejection fraction ≤35% and coronary disease amenable to CABG were randomized to CABG or MED in the STICH trial (Surgical Treatment for Ischemic Heart Failure). Results: Mean age at trial entry was 60 years; 12% were women; 36% were nonwhite; and the baseline ejection fraction was 28%. For the present analyses, patients were categorized by age quartiles: quartile 1, ≤54 years; quartile, 2 >54 and ≤60 years; quartile 3, >60 and ≤67 years; and quartile 4, >67 years. Older versus younger patients had more comorbidities. All-cause mortality was higher in older compared with younger patients assigned to MED (79% versus 60% for quartiles 4 and 1, respectively; log-rank P =0.005) and CABG (68% versus 48% for quartiles 4 and 1, respectively; log-rank P P =0.388) or CABG group (39% versus 35% for quartiles 4 and 1, respectively; log-rank P =0.103). Cardiovascular deaths accounted for a greater proportion of deaths in the youngest versus oldest quartile (79% versus 62%). The effect of CABG versus MED on all-cause mortality tended to diminish with increasing age ( P interaction =0.062), whereas the benefit of CABG on cardiovascular mortality was consistent over all ages ( P interaction =0.307). There was a greater reduction in all-cause mortality or cardiovascular hospitalization with CABG versus MED in younger compared with older patients ( P interaction =0.004). In the CABG group, cardiopulmonary bypass time or days in intensive care did not differ for older versus younger patients. Conclusions: CABG added to MED has a more substantial benefit on all-cause mortality and the combination of all-cause mortality and cardiovascular hospitalization in younger compared with older patients. CABG added to MED has a consistent beneficial effect on cardiovascular mortality regardless of age. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT00023595.

The aim of this prospective randomized study was to assess the impact of renal artery denervation in patients with a history of refractory atrial fibrillation (AF) and drug-resistant hypertension who were referred for pulmonary vein isolation (PVI).Hypertension is the most common cardiovascular condition responsible for the development and maintenance of AF. Treating drug-resistant hypertension with renal denervation has been reported to control blood pressure, but any effect on AF is unknown.Patients with a history of symptomatic paroxysmal or persistent AF refractory to ≥2 antiarrhythmic drugs and drug-resistant hypertension (systolic blood pressure160 mm Hg despite triple drug therapy) were eligible for enrolment. Consenting patients were randomized to PVI only or PVI with renal artery denervation. All patients were followed ≥1 year to assess maintenance of sinus rhythm and to monitor changes in blood pressure.Twenty-seven patients were enrolled, and 14 were randomized to PVI only, and 13 were randomized to PVI with renal artery denervation. At the end of the follow-up, significant reductions in systolic (from 181 ± 7 to 156 ± 5, p0.001) and diastolic blood pressure (from 97 ± 6 to 87 ± 4, p0.001) were observed in patients treated with PVI with renal denervation without significant change in the PVI only group. Nine of the 13 patients (69%) treated with PVI with renal denervation were AF-free at the 12-month post-ablation follow-up examination versus 4 (29%) of the 14 patients in the PVI-only group (p = 0.033).Renal artery denervation reduces systolic and diastolic blood pressure in patients with drug-resistant hypertension and reduces AF recurrences when combined with PVI.

Recurrences are common within the first months following atrial fibrillation (AF) ablation. However, prior studies using only intermittent ECG recording have not shown a powerful correlation with ultimate response.The purpose of this study was to use continuous AF monitoring with an implanted monitor to assess the AF burden measured continuously during the first months postablation and the relationship to subsequent AF recurrences.Six hundred thirteen patients with symptomatic drug-refractory AF (17% with persistent AF) were part of this retrospective analysis. All patients underwent circumferential pulmonary vein isolation and were implanted with a subcutaneous AF monitor (Reveal XT, Medtronic) for collecting data on AF burden (AF%) during a 12-month follow-up period. AF freedom (responders) was defined as AF% ≤0.5% during each monthly telemetric follow-up. A receiver operating characteristic curve analysis was performed to identify the value in AF% during the first months in the postablation blanking period that was predictive of later recurrence of AF. Sensitivity of 90% was selected as the target value.After the first ablation procedure, 396 of the 613 patients (65%) were responders (AF ≤0.5%) at 12 months: 346 of 508 (68%) in the paroxysmal AF group and 50 of 105 (47%) in the persistent AF group. Using the receiver operating characteristic curve, the specificity corresponding to 90% sensitivity was 85% for AF% at 2 months. The corresponding threshold in the AF burden during the blanking period able to identify patients at risk for late recurrences was 4.5%, corresponding to a cumulative 65.9 hours (2.75 days) spent in AF during the first 2 months. In a multivariate analysis, AF%4.5% during the first 2 months was highly significant (P.001), and the odds ratio of responders/nonresponders was 39.8 (95% CI, 19.1-82.9).The AF burden measured during the blanking period can predict the response to catheter ablation at 12 months. AF% ≥4.5% at 2 months assessed by continuous monitoring is a powerful predictor of subsequent AF recurrences after initial ablation, thus providing relevant clinical information to select patients for early reintervention.

Background: The effectiveness of ganglionated plexi (GP) ablation in patients with atrial fibrillation (AF) is ambiguous. Some researchers had already suggested that additional identification of complex fractionated atrial electrograms (CFAE) around the areas with a positive reaction to high-frequency stimulation (HFS) might improve the accuracy of GP's boundaries location, then enhancing the success rate of ablation. The purpose of this study was to assess the safety and efficacy of GP ablation directed by HFS and CFAE in patients with paroxysmal AF (PAF). Methods and Results: Sixty-two patients with PAF (age 57±8 years) underwent GP ablation. Ablation targets were the sites where vagal reflexes were evoked by HFS and additional extended ablation CFAE area around the areas where vagal reflexes were evoked. At 12 months, 71% of patients were free of symptomatic AF. At 3 months after ablation the root mean square successive differences and HF were significantly lower in patients without AF recurrence (P < 0.0001 and P = 0.004). The LF/HF ratio was significantly higher in patients without AF recurrence (P = 0.02). Conclusion: Enhanced GP ablation directed by HFS and CFAE can be safely performed and enables maintenance of sinus rhythm in the majority of patients with PAF for a 12-month period. Denervation of the intrinsic cardiac autonomic nervous system may be the preferable target of catheter ablation of AF. (PACE 2012;XX:1–9)

The PREVENT AF I study demonstrated that prophylactic pulmonary vein isolation (PVI) in patients with typical atrial flutter (AFL) resulted in substantial reduction of new onset atrial fibrillation (AF) during 1-year follow up as assessed by continuous implantable loop recorder (ILR). To assess the

A novel cardiac gamma camera utilises physiologic uptake of Iodine-123 Meta -iodobenzylguanidine (123I –m IBG) to visualise cardiac sympathetic innervation. Physiologic uptake of 123I – m IBG provides anatomical quantification of autonomic nervous system (ANS) structures with discrete uptake

Background: Modification of left atrial ganglionated plexi (GP) is a promising technique for the treatment of paroxysmal atrial fibrillation (AF) but its therapeutic efficacy is not established. This study aimed at evaluating the effectiveness of anatomic GP modification by means of an implantable arrhythmia monitoring device. Methods: In 56 patients with paroxysmal AF, radiofrequency ablation at anatomic sites, where the main clusters of GP have been identified in the left atrium, was performed. In all patients, an electrocardiogram monitor (Reveal XT, Medtronic Inc., Minneapolis, MN, USA) was implanted before (n = 7) or immediately after (n = 49) AF ablation. Results: Average duration of the procedure was 142 ± 18 min and average fluoroscopy time 20 ± 7 min. In total, 53–81 applications of RF energy were delivered (mean of 18.2 ± 3.8 at each of the four areas of GP ablation). Heart rate variability was assessed in 31 patients. Standard deviation of RR intervals over the entire analyzed period, the root mean square of differences between successive RR intervals, and high frequencies decreased, while HRmin, HRmean, and LF to HF ratio increased immediately postablation; these values returned to baseline 6 months after the procedure. At end of 12-month follow-up, 40 (71%) patients were free of arrhythmia recurrence. Ten patients had AF recurrence, two patients had left atrial flutter, and four patients had episodes of flutter as well as AF recurrence. Duration of episodes of AF after ablation gradually decreased over the follow-up period. Conclusions: Regional ablation at the anatomic sites of the left atrial GP can be safely performed and enables maintenance of sinus rhythm in 71% of patients with paroxysmal AF for a 12-month period. (PACE 2010; 33:1231–1238)

Background: Epicardial implantation of a cardiac resynchronization therapy (CRT) system during coronary artery bypass grafting (CABG) may be an additional treatment method for improving left ventricle (LV) systolic function and dyssynchrony in patients with ischemic heart failure. Objective: The objective was to compare the long-term results in patients with severe ischemic heart failure who underwent CABG alone or CABG combined with concomitant epicardial implantation of a CRT system. Methods: One hundred sixty-four consecutive patients with severe ischemic heart failure and LV dyssynchrony were enrolled into 2 groups: CABG alone (n = 80) and epicardial CRT implantation during CABG (CABG + CRT) (n = 84). This prospective, randomized, and single-blind study was designed to compare clinical and echocardiography data after 6, 12, and 18 months of follow-up. Results: In the CABG group, LV systolic function, dyssynchrony signs, and quality of life did not change postoperatively, compared with preoperative data. In contrast, these parameters significantly improved in the CABG + CRT group. The 2 treatment groups did not differ with respect to postoperative improvement in Canadian Cardiovascular Society class ( P = .68). The improvement in the New York Heart Association functional class was much more pronounced in the CABG + CRT group than in the CABG group ( P = .029). In the CABG group, 21 patients (26.2%) had died by the 18-month follow-up, compared with 9 patients (10.7%) in the CABG + CRT group (P = .012, log-rank test). Conclusion: Epicardial implantation of a CRT system concomitantly with CABG facilitates the early postoperative period, improves LV systolic function, improves the quality of life, and decreases LV dyssynchrony. Moreover, mortality in the CABG + CRT group was significantly lower than in the CABG group.

This report describes a case of left atrial appendectomy after a failed endocardial catheter ablation of a continuous drug-refractory left atrial appendage (LAA) tachycardia in a 9-year-old boy. Electrophysiologic study showed atrial tachycardia (AT) originating in the LAA. Numerous radiofrequency applications with an irrigated-tip catheter were ineffective. During surgery, direct pressure on the apex of the LAA by forceps immediately terminated the AT and restored sinus rhythm. After a left atrial appendectomy, the patient remained free of any arrhythmias during a follow-up period of 18 months.

Background Selective ganglionated plexi (GP) ablation guided by high-frequency stimulation has been proposed for the treatment of paroxysmal atrial fibrillation (AF), but the efficacy of the method is not established. Objective This study sought to compare selective ablation of GP identified by high-frequency stimulation with extensive regional ablation targeting the anatomic areas of GP in patients with paroxysmal AF. Methods Eighty patients with paroxysmal AF (age 53 ± 9 years) were randomized to undergo selective GP ablation or regional left atrial ablation at the anatomic sites of GP. For selective GP ablation (n = 40), ablation targets were the sites where vagal reflexes were evoked by high-frequency stimulation. Vagal reflexes were defined as prolongation of the R-R interval by >50% and a concomitant decrease in blood pressure (>20 mm Hg) during AF. The end point of the procedure was failure to reproduce vagal reflexes with repeated high-frequency stimulation. For anatomic ablation, lesions were delivered at the sites of GP clustering. Results At 13.1 ± 1.9 months, 42.5% of patients with selective GP and 77.5% of patients with anatomic ablation were free of symptomatic paroxysmal AF (PAF) ( P = .02). Parasympathetic denervation was more prominent in patients with anatomic than selective GP ablation, and in patients free of AF compared to these with AF recurrence immediately after ablation, but this trend was abolished at 6 months. Conclusion Selective GP ablation directed by high-frequency stimulation does not eliminate paroxysmal AF in the majority of patients. An anatomic approach for regional ablation at the sites of GP confers better results.

Aim To compare the quality of life (QoL) of patients with persistent atrial fibrillation (AF) and ischaemic heart disease after modified mini-maze (MM) procedure or pulmonary vein isolation (PVI) using radiofrequency ablation (RFA) with patients in the control group (coronary artery bypass graft [CABG]) alone. Methods In this prospective randomised study, we included 95 patients with persistent AF and coronary heart disease who underwent open-heart surgery combined with intraoperative irrigated RFA (irrRFA). Patients were randomly assigned to three groups: CABG and PVI using irrRA (CABG+PVI, n=31), CABG and MM procedure using irrRA (CABG+MM, n=30), and isolated CABG (CABG alone, n=34). All patients received implantable loop recorders (ILRs). Patient QoL was assessed using the Short Form 36 (SF-36) preoperatively, and one and two years post-operatively. The study primary end point was freedom from AF one year after operation, measured by implantable loop recorders (ILRs); secondary endpoint included long-term clinical outcomes. Results No reoperations or hospital mortalities were recorded. Mean follow-up was 14.4±9.7 months. The percentages of patients free from AF determined by ILR were 80%, 86.2%, and 44.1% in the CABG+PVI, CABG+MM, and in the CABG alone groups, respectively. The QoL significantly improved in CABG+PVI and CABG+MM groups compared with CABG alone group in most domains. Conclusion Effective elimination of AF during CABG surgery improves QoL in all physical health domains of the SF-36 and the role-emotional functioning domain. Thus, patients with concomitant AF and coronary heart disease may benefit from intraoperative radiofrequency ablation to prevent relapse of the arrhythmia.

Renal artery denervation (RDN) has provided incremental atrial fibrillation (AF) suppression after pulmonary vein isolation (PVI) in patients with AF in the setting of drug-resistant hypertension, but the antiarrhythmic mechanism by which RND functions is unknown. All patients from two randomized

The combination of left atrial appendage (LAA) occlusion with pulmonary vein isolation (PVI) potentially represents a comprehensive treatment for atrial fibrillation (AF), controlling symptoms while at the same time reducing the risk of stroke and the need for chronic anticoagulation. The aim of this randomized clinical trial was to assess the impact of LAA closure added to PVI in patients with high-risk AF. Patients with a history of symptomatic paroxysmal or persistent AF refractory to ≥2 antiarrhythmic drugs, CHA2DS2-VASc score ≥2, and HAS-BLED score ≥3 were randomized to PVI-only (n = 44) or PVI with LAA closure (n = 45). Six patients in PVI + LAA closure group crossed over to PVI-only group due to failure of LAA closure device implantation. On-treatment comparisons at the 24 month follow-up revealed that 33 (66 %) of the 50 PVI group and 23 (59 %) of the 39 PVI with LAA closure group were AF-free on no antiarrhythmic drugs (p = 0.34). The PVI + LAA closure treatment was significantly associated with a higher AF burden during the blanking period: 9.7 ± 10.8 vs 4.2 ± 4.1 % (p = 0.004). At the end follow-up, there were no serious complications and no strokes or thromboembolic events in either group. The combination of LAA closure device implantation with PVI was safe but was not observed to influence the success of PVI in patients with symptomatic refractory AF. Early AF after ablation, however, is increased by LAA closure. URL: http://www.clinicaltrials.gov . Unique identifier: NCT01695824.

A novel cardiac gamma camera utilises the radiopharmaceutical Iodine-123 Meta- iodobenzylguanidine (123I –m IBG) to visualise cardiac sympathetic innervation. Physiologic uptake of 123I –m IBG provides anatomical quantification of autonomic nervous system (ANS) structures, with discrete uptake

Catheter ablation is less successful for persistent atrial fibrillation (Pers AF) than for paroxysmal atrial fibrillation. Some studies suggest that left atrial appendage (LAA) isolation in addition to pulmonary vein isolation (PVI) is required in persistent atrial fibrillation. We randomly

Background Renal artery denervation (RDN) has provided incremental atrial fibrillation (AF) suppression after pulmonary vein isolation (PVI) in patients with AF in the setting of drug-resistant hypertension. Objective To assess the relationship between changes of mean blood pressure (BP) and AF recurrences/AF burden after PVI combined with RDN. Methods All patients from two randomized studies with symptomatic paroxysmal AF and/or persistent AF and resistant hypertension who underwent PVI-only (n=37) or PVI with RDN (n=39), and implantable cardiac monitor (ICM) implantation were eligible for this study. Mixed-effects linear models were used to investigate the effect of RDN on mean BP and mean AF burden and associations between the two during the 12-month follow-up. Results Concomitant RDN was associated with a significant reduction in both mean AF burden (2.43 [95% CI: 1.76-3.09] % vs 6.95 [95% CI: 5.44-8.45] %) and mean BP (104 [95% CI: 103-106] mm Hg vs 112 [95% CI: 110-113] mm Hg). Decrease in mean BP was positively correlated with decline in mean AF burden: reduction of 5-10 mm Hg was accompanied by a 7.0% decreased mean AF burden, with greater reduction (up to 20 mm Hg) associated with on average 17.7% lower mean AF burden. Conclusions Renal artery denervation when added to PVI decreases AF recurrences, AF burden, and mean BP. Reduction in mean BP is associated with both AF burden and recurrences. Further large-scale studies are needed to define the mechanistic pathway(s) of the antiarrhythmic effects of RDN.