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Background: Catheter ablation is a well-established therapy for rhythm control in patients who are refractory or intolerant to anti-arrhythmic drugs (AAD). Less is known about the efficacy of catheter ablation compared with AAD as a first-line strategy for rhythm control in atrial fibrillation (AF)., Objectives: We aimed to perform a systematic review and meta-analysis of catheter ablation vs. AAD in patients naïve to prior rhythm control therapies., Methods: PubMed, EMBASE, and Cochrane databases were searched for randomized controlled trials that compared catheter ablation to AAD for initial rhythm control in symptomatic AF and reported the outcomes of (1) recurrent atrial tachyarrhythmias (ATs); (2) symptomatic AF; (3) hospitalizations; and (4) symptomatic bradycardia. Heterogeneity was examined with I2statistics. P values of < 0.05 were considered statistically significant., Results: We included five trials with 994 patients, of whom 502 (50.5%) underwent catheter ablation. Mean follow-up ranged from one to five years. Recurrences of AT (OR 0.36; 95% CI 0.25-0.52; p<0.001) and symptomatic AF (OR 0.32; 95% CI 0.18-0.57; p<0.001), and hospitalizations (OR 0.25; 95% CI 0.15-0.42; p<0.001) were significantly less frequent in patients treated with catheter ablation compared with AAD. Symptomatic bradycardia was not significantly different between groups (OR 0.55; 95% CI 0.18-1.65; p=0.28). Significant pericardial effusions or tamponade occurred in eight of 464 (1.7%) patients in the catheter ablation group., Conclusion: These findings suggest that catheter ablation has superior efficacy to AAD as an initial rhythm control strategy in patients with symptomatic AF.

Introduction: The efficacy of endocardial catheter ablation for ventricular tachycardia (VT) can be limited by intramural or epicardial substrates. Adding epicardial mapping and ablation may improve arrhythmia outcomes compared with an endocardial-only approach., Methods: We performed a systematic review and meta-analysis of studies comparing a strategy of endo-epicardial catheter ablation to an endocardial-only approach for VT. Subanalyses were performed for ischemic and nonischemic cardiomyopathies., Results: A total of 22 studies including 1138 patients were included in the meta-analysis. Of those, 44% underwent an endo-epicardial approach. During intermediate to long-term follow-up (average 7 to 70 months), recurrent VT or appropriate implantable cardioverter defibrillator (ICD) therapies were significantly lower with the endo-epicardial strategy (OR, 0.52; P < .01). All-cause mortality was also lower in this group (OR, 0.50; P = .03). No difference between endo-epicardial and endocardial-only ablation was noted in nonischemic cardiomyopathies. Among 323 patients with ischemic cardiomyopathy, recurrent VT or appropriate ICD therapies was less frequent in the endo-epicardial group (OR, 0.39; P = .01), as was all-cause mortality (OR, 0.38; P = .05). In patients with arrhythmogenic right ventricular cardiomyopathy, recurrent VT or appropriate ICD therapy was also lower in the endo-epicardial group (OR, 0.42; P = .04)., Conclusion: These results suggest that a strategy of combined endo- and epicardial access for mapping and ablation of VT may provide superior efficacy to an endocardial-only approach in selected patients. Randomized trials are warranted to further investigate this question., (© 2019 Wiley Periodicals, Inc.)

Catheter ablation has been established as a rhythm control strategy in selected patients with atrial fibrillation (AF) who have failed or wish to avoid anti-arrhythmic drugs. Uninterrupted oral anticoagulation with vitamin K antagonists (VKAs) peri-ablation is associated with a lower risk of thromboembolic and bleeding complications as compared to interrupted oral anticoagulation and bridging heparin. However, a substantial portion of patients with AF are treated with non-vitamin K antagonist oral anticoagulants (NOACs). Herein, we perform an in-depth review and comparison of three recent randomized trials of uninterrupted oral anticoagulation with NOACs vs VKAs in patients undergoing AF catheter ablation. Furthermore, we report pooled results of these randomized trials. The pooled incidence of major bleeding was significantly lower with NOACs as compared to VKAs (2% vs 4.9%, respectively; odds ratio [OR] 0.40; 95% confidence intervals [CI] 0.16-0.99). Similarly, cardiac tamponade was also reduced in the NOAC group (0.4% vs 1.5%; OR 0.27; 95% CI 0.07-0.97). Thromboembolic complications were not significantly different between groups. Overall, these findings support the 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement's class I recommendation for uninterrupted NOAC use in patients undergoing AF catheter ablation., (© 2018 Wiley Periodicals, Inc.)

Background: Ablation approaches have been described for the management of symptomatic ventricular arrhythmias in patients with Brugada syndrome, but this treatment is still considered experimental., Objective: We aimed to perform a systematic review of the current evidence on the use of catheter ablation in Brugada syndrome., Methods: MEDLINE, Embase, and Scopus were searched for articles describing the use of catheter ablation for ventricular arrhythmia management in Brugada syndrome., Results: We included 11 case series and 11 case reports including a total of 233 patients. Ablation strategies included epicardial mapping with substrate modification (n = 180; 77.3%), endocardial-only mapping with substrate modification (n = 17; 7.3%), ventricular fibrillation (VF)-triggering premature ventricular complex ablation (n = 5; 2.1%), and mixed approaches (n = 31; 13.3%). During a 2.5- to 78-month follow-up period, the success rates in preventing ventricular tachycardia or VF (VT/VF) were 96.7%, 70.6%, and 80% with epicardial, endocardial, and triggering premature ventricular complex ablation approaches, respectively. Among patients who underwent both epicardial and endocardial mapping, there was no identifiable endocardial substrate in 92.9% of cases. Elimination of type 1 Brugada-pattern electrocardiogram was attained in 98.3% and 34.8% of the epicardial and endocardial ablation groups, respectively. VT/VF occurred in 7 of 9 patients (77.8%) who had persistent or recurrent J-ST elevation and in none of the 24 patients with complete resolution during follow-up. Pharmacologic provocation augmented the abnormal area., Conclusion: Epicardial substrate modification appears to be more effective than endocardial-only approach in preventing VT/VF. Persistent or recurrent J-ST elevation appears to represent a marker of failure of ablation. Ablation seems to be an acceptable strategy for patients with Brugada syndrome and VT/VF., (Copyright © 2018 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Catheter ablation is recommended as a first- or second-line rhythm control therapy for selected patients with atrial fibrillation (AF). There is a wide variability in the periprocedural management of oral anticoagulation in patients undergoing AF ablation., Objective: We aimed to perform an updated meta-analysis of novel oral anticoagulants (NOACs) vs vitamin K antagonists (VKAs) as uninterrupted anticoagulation in patients undergoing AF ablation., Methods: Databases and conference abstracts were searched. Studies were excluded if oral anticoagulants were held at any periprocedural period. The primary outcomes were stroke or transient ischemic attack (TIA) and major bleeding., Results: Twelve studies and 4962 patients were included. Stroke or TIA was rare (NOAC, 0.08%; VKA, 0.16%) and not different between groups (odds ratio [OR] 0.66; 95% confidence interval [CI] 0.19-2.30). The incidence of silent cerebral embolic events was also not significantly different between NOACs (8%) and VKAs (9.6%) (OR 0.86; 95% CI 0.42-1.76). Major bleeding was significantly reduced in the NOAC group (0.9%) as compared with VKA-treated patients (2%) (OR 0.50; 95% CI 0.30-0.84; P < .01). This finding was confirmed in a subgroup analysis of randomized and cohort studies with matched controls (OR 0.45; 95% CI 0.24-0.83; P = .01). There was no significant difference in the outcomes of individual NOACs and VKAs, although these analyses may have been underpowered to detect minor differences in such rare outcomes., Conclusion: In patients undergoing AF ablation, uninterrupted periprocedural NOACs are associated with a low incidence of stroke or TIA and a significant reduction in major bleeding as compared with uninterrupted VKAs., (Copyright © 2017 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Introduction: Radiofrequency (RF) and cryoballoon (CB) catheter ablation are effective for pulmonary vein isolation (PVI) in atrial fibrillation (AF). This report presents an updated meta-analysis comparing the efficacy and safety of CB versus RF ablations in AF., Methods: Databases and conference abstracts were systematically searched for studies that directly compared CB and RF PVI, and reported safety or efficacy outcomes in follow-up ≥12 months. Recurrent atrial tachyarrhythmias (AT) were defined as AF, atrial flutter, or atrial tachycardia., Results: Twenty-two studies and 8,668 patients were included. Freedom from AT was not significantly different between CB and RF ablations in the pooled population (OR 1.12; 95%CI 0.97-1.29; P = 0.13) and in randomized trials (OR 1.0; 95%CI 0.65-1.56; P = 0.99). Second-generation CB (CB2; 78.1%) and contact-force (CF) sensing RF (78.2%) have improved procedure success rate as compared to first-generation technology (57.9% CB, 58.1% RF). As compared to CF-RF, CB2 demonstrated similar freedom from recurrent AT (OR 1.04; 95%CI 0.71-1.51; P = 0.84). The incidence of pericardial effusions (OR 0.44; 95%CI 0.28-0.69; P < 0.01), tamponade (OR 0.31; 95%CI 0.15-0.64; P < 0.01), and non-AF AT (OR 0.46; 95%CI 0.26-0.83; P < 0.01) were significantly lower with CB ablation, whereas transient phrenic nerve palsy was more incident after CB (OR 7.40; 95%CI 2.56-21.34; P < 0.01)., Conclusion: There was comparable freedom from AT between CB and RF in patients with AF undergoing PVI. Additionally, freedom from AT was similar between CB2 and CF-RF. However, CB was associated with a lower incidence of pericardial effusions or tamponade, albeit with a higher rate of transient phrenic nerve palsies., (© 2016 Wiley Periodicals, Inc.)