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

Background: It has not been fully elucidated which patients with persistent atrial fibrillation (PerAF) should undergo substrate ablation plus pulmonary vein isolation (PVI). This study aimed to identify PerAF patients who required substrate ablation using intraprocedural assessment of the baseline rhythm and the origin of atrial fibrillation (AF) triggers., Methods and results: This was a post hoc subanalysis using extended data of the EARNEST-PVI trial, a prospective multicenter randomized trial comparing PVI-alone and PVI-plus (i.e., PVI with added catheter ablation) arms. We divided 492 patients into 4 groups according to baseline rhythm and the location of AF triggers before PVI: Group A (n=22), sinus rhythm with pulmonary vein (PV)-specific AF triggers (defined as reproducible AF initiation from PVs only); Group B (n=211), AF with PV-specific AF triggers; Group C (n=94), sinus rhythm with no PV-specific AF trigger; Group D (n=165), AF with no PV-specific AF trigger. Among the 4 groups, only in Group D (AF at baseline and no PV-specific AF triggers) was arrhythmia-free survival significantly lower in the PVI-alone than PVI-plus arm (P=0.032; hazard ratio 1.68; 95% confidence interval 1.04-2.70)., Conclusions: Patients with sinus rhythm or PV-specific AF triggers did not receive any benefit from substrate ablation, whereas patients with AF and no PV-specific AF trigger benefited from substrate ablation.

Background: The optimal duration of atrial fibrillation (AF) persistence for predicting poor outcomes after catheter ablation of long-standing AF (LsAF) and the best ablation strategy for these patients remain unclear., Objective: We aimed to assess the impact of the duration of AF persistence on outcomes after catheter ablation of AF., Methods: We analyzed the Efficacy of Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation (EARNEST-PVI) trial data comparing pulmonary vein isolation (PVI) alone (PVI-alone) with additional linear ablation or defragmentation (PVI-plus) in persistent AF (PerAF). Patients who received catheter ablation by contact force-sensing catheter were enrolled in the study. In patients with LsAF, the optimal cutoff duration of AF persistence was evaluated. With use of the threshold, patients with LsAF were divided into 2 groups and compared with PerAF <1 year for arrhythmia-free survival after a 3-month blanking period., Results: The optimal cutoff duration was 2.4 years. Of 458 patients, arrhythmia-free survival rates for LsAF 1-2.4 years were comparable to those of PerAF (hazard ratio [HR], 1.01; 95% CI, 0.67-1.52). However, LsAF >2.4 years had a higher recurrence risk than PerAF (HR, 2.22; 95% CI, 1.42-3.47). In LsAF >2.4 years, the PVI-plus strategy showed advantages over the PVI-alone strategy (HR, 0.36; 95% CI, 0.14-0.89). However, the interaction effect between LsAF 1-2.4 years and LsAF >2.4 years did not reach statistical significance (P = .116)., Conclusion: Whereas LsAF 1-2.4 years has similar outcomes to those of PerAF, LsAF >2.4 years was linked to higher arrhythmia recurrence risks. For LsAF >2.4 years, the PVI-plus strategy showed a potential to be superior to the PVI-alone strategy., Competing Interests: Disclosures Drs Minamiguchi, Dohi, Nakatani, Hikoso, and Sakata have received grants from Medtronic, Johnson & Johnson, and Abbott during the conduct of the study. Other authors have nothing to disclose related to the submitted work. Conflict of interest outside the submitted work is found in a supplemental file., (Copyright © 2024 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Identifying patients who would benefit from extensive catheter ablation along with pulmonary vein isolation (PVI) among those with persistent atrial fibrillation (AF) has been a subject of controversy. The objective of this study was to apply uplift modeling, a machine learning method for analyzing individual causal effect, to identify such patients in the EARNEST-PVI trial, a randomized trial in patients with persistent AF. We developed 16 uplift models using different machine learning algorithms, and determined that the best performing model was adaptive boosting using Qini coefficients. The optimal uplift score threshold was 0.0124. Among patients with an uplift score ≥ 0.0124, those who underwent extensive catheter ablation (PVI-plus) showed a significantly lower recurrence rate of AF compared to those who received only PVI (PVI-alone) (HR 0.40; 95% CI 0.19-0.84; P-value = 0.015). In contrast, among patients with an uplift score < 0.0124, recurrence of AF did not significantly differ between PVI-plus and PVI-alone (HR 1.17; 95% CI 0.57-2.39; P-value = 0.661). By employing uplift modeling, we could effectively identify a subset of patients with persistent AF who would benefit from PVI-plus. This model could be valuable in stratifying patients with persistent AF who need extensive catheter ablation before the procedure., (© 2024. The Author(s).)

Background Modification of arrhythmogenic substrates with extensive ablation comprising linear and/or complex fractional atrial electrogram ablation in addition to pulmonary vein isolation (PVI-plus) can theoretically reduce the recurrence of atrial fibrillation. The DR-FLASH score (score based on diabetes mellitus, renal dysfunction, persistent form of atrial fibrillation, left atrialdiameter >45 mm, age >65 years, female sex, and hypertension) is reportedly useful for identifying patients with arrhythmogenic substrates. We hypothesized that, in patients with persistent atrial fibrillation, the DR-FLASH score can be used to classify patients into those who require PVI-plus and those for whom a PVI-only strategy is sufficient. Methods and Results This study is a post hoc subanalysis of the a multicenter, randomized controlled, noninferiority trial investigating efficacy and safety of pulmonary vein isolation alone for recurrence prevention compared with extensive ablation in patients with persistent atrial fibrillation (EARNEST-PVI trial). This analysis focuses on the relationship between DR-FLASH score and the efficacy of different ablation strategies. We divided the population into 2 groups based on a DR-FLASH score of 3 points. A total of 469 patients were analyzed. Among those with a DR-FLASH score >3 (N=279), the event rate of atrial arrhythmia recurrence was significantly lower in the PVI-plus arm than in the PVI-only arm (hazard ratio [HR], 0.45 [95% CI, 0.28-0.72]; P <0.001). In contrast, among patients with a DR-FLASH score ≤3 (N=217), no differences were observed in the event rate of atrial arrhythmia recurrence between the PVI-only arm and the PVI-plus arm (HR, 1.08 [95% CI, 0.61-1.89]; P =0.795). There was significant interaction between patients with a DR-FLASH score >3 and DR-FLASH score ≤3 ( P value for interaction=0.020). Conclusions The DR-FLASH score is a useful tool for deciding the catheter ablation strategy for patients with persistent atrial fibrillation. Registration URL: https://clinicaltrials.gov; Unique identifier: NCT03514693.

Background: Women experience more severe arrhythmogenic substrates. This study hypothesized that an extensive ablation strategy, such as linear ablation and/or complex fractionated atrial electrogram (CFAE) ablation in addition to pulmonary vein isolation (PVI-plus), might be effective for women, whereas the PVI alone strategy (PVI-alone) might be sufficient for men to maintain sinus rhythm. The aim of this study was to test this hypothesis., Methods and results: This study is a post-hoc subanalysis of the EARNEST-PVI trial focusing on sex differences in the efficacies of different ablation strategies. The EARNEST-PVI trial was a prospective, multicenter, randomized, and open-label non-inferiority trial in patients with persistent AF. The primary endpoint was recurrence of AF, atrial flutter, or atrial tachycardia. The EARNEST-PVI trial randomized 376 (76%) men (PVI-alone 186, PVI-plus 190) and 121 (24%) women (PVI-alone 63, PVI-plus 58). The event rate was significantly lower for men and numerically lower for women in the PVI-plus than the PVI-alone group, and there was no interaction between men and women (hazard ratio, 0.641; 95% confidence interval, 0.417-0.985; P value, 0.043 for men vs. hazard ratio, 0.661; 95% confidence interval, 0.352-1.240; P value, 0.197 for women; P value for interaction, 0.989)., Conclusions: The superiority of the extensive ablation strategy vs. the PVI-alone strategy for persistent AF was consistent across both sexes.

Background: Extensive ablation in addition to pulmonary vein isolation (PVI) would be effective for modification of non-pulmonary vein (non-PV) substrates, whereas PVI might be sufficient for elimination of PV triggers. This study aimed to test the hypothesis that in patients with reproducible atrial fibrillation (AF) triggered by premature atrial contractions originating only from PVs, PVI alone can be sufficient to maintain sinus rhythm., Methods and results: This study is a prespecified subanalysis of the EARNEST-PVI randomized controlled trial. This study investigated the efficacy of the PVI-alone strategy (PVI-alone) in comparison with the extensive strategy (PVI-plus) for persistent AF with a trigger-based mechanism vs. a substrate-based mechanism. Patients were stratified into 3 groups based on AF mechanisms: (1) Substrate group (N=236); (2) PV trigger group (N=236); and (3) non-PV trigger group (N=24). The hazard ratios for AF recurrence of the PVI-alone strategy with reference to the PVI-plus strategy were 1.456 (95% confidence interval [CI] [0.864-2.452]) in the substrate group, 1.648 (95% CI 0.969-2.801) in the PV trigger group, and 0.937 (95% CI 0.252-3.488) in the non-PV trigger group. No significant interaction between ablation strategy and AF mechanism was observed (P for interaction=0.748)., Conclusions: This study indicated that the efficacies of the PVI-alone strategy compared with the PVI-plus strategy were consistent across persistent AF with trigger-based and substrate-based mechanisms.

Recurrence rates of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are higher in patients with a left atrial low-voltage area (LVA) than those without. However, the efficacy of LVA guided ablation is still unknown. The purpose of this study-the Efficacy and Safety of Left Atrial Low-voltage Area Guided Ablation for Recurrence Prevention Compared to Pulmonary Vein Isolation Alone in Patients with Persistent Atrial Fibrillation trial (SUPPRESS-AF trial)-is to elucidate whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF. The Osaka Cardiovascular Conference will conduct a multicenter, randomized, open-label trial aiming to examine whether LVA guided ablation in addition to PVI is superior to PVI alone in patients with persistent AF and LVAs. The primary outcome is the recurrence of AF documented by scheduled or symptom-driven electrocardiography (ECG) during the 1 year follow-up period after the index ablation. The key secondary endpoints include all-cause death, symptomatic stroke, bleeding events, and other complications related to the procedure. A total of 340 patients with an LVA will be enrolled and followed up to 1 year. The SUPPRESS-AF trial is a randomized controlled trial designed to assess whether LVA guided ablation in addition to PVI is superior to PVI alone for patients with persistent AF and LVAs detected while undergoing their first catheter ablation., (© 2021 The Authors. Clinical Cardiology published by Wiley Periodicals LLC.)

Aims: Previous studies could not demonstrate any benefit of more intensive ablation in addition to pulmonary vein isolation (PVI) including complex fractionated atrial electrogram (CFAE) and linear ablation for recurrence in the initial catheter ablation of persistent atrial fibrillation (AF). This study aimed to establish the non-inferiority of PVI alone to PVI plus these additional ablation strategies., Methods and Results: Patients with persistent AF who underwent an initial catheter ablation (n = 512, long-standing persistent AF; 128 cases) were randomly assigned in a 1:1 ratio to either PVI alone (PVI-alone group) or PVI plus CFAE and/or linear ablation (PVI-plus group). After excluding 15 cases who did not receive procedures, we analysed 249 and 248 patients, respectively. The primary endpoint was recurrence of AF, atrial flutter, and/or atrial tachycardia, and the non-inferior margin was set at a hazard ratio of 1.43. In the PVI-plus group, 85.1% of patients had linear ablation and 15.3% CFAE ablation. After 12 months, freedom from the primary endpoint occurred in 71.3% of patients in the PVI-alone group and in 78.3% in the PVI-plus group [hazard ratio = 1.56 (95% confidence interval: 1.10-2.24), non-inferior P = 0.3062]. The procedure-related complication rates were 2.0% in the PVI-alone group and 3.6% in the PVI-plus group (P = 0.199)., Conclusion: This randomized trial did not establish the non-inferiority of PVI alone to PVI plus linear ablation or CFAE ablation in patients with persistent AF, but implied that the PVI plus strategy was promising to improve the clinical efficacy (NCT03514693)., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2020. For permissions, please email: journals.permissions@oup.com.)

Aims: Before the discovery of contact-force guidance, eliminating pacing capture along the pulmonary vein (PV) isolation line had been reported to improve PV isolation durability and rhythm outcomes. DRAGON (UMIN-CTR, UMIN000015332) aimed to elucidate the efficacy of pace-capture-guided ablation following contact-force-guided PV isolation ablation in paroxysmal atrial fibrillation (AF) patients., Methods and Results: A total of 156 paroxysmal AF patients with AF-trigger ectopies from any of the four PVs induced by isoproterenol were randomly assigned to undergo pace-capture-guided ablation along a contact-force-guided isolation line around AF-trigger PVs (PC group, n = 76) or contact-force-guided PV isolation ablation alone (control group, n = 80). Follow-up of at least 1 year commenced with serial 24 h Holter and symptom-triggered ambulatory monitoring. There was no significant difference in acute PV reconnection rates during a 20 min waiting period after the last ablation or adenosine infusion testing between the PC and the control groups (per patient, 21% vs. 27%, P = 0.27; per AF-trigger PV, 5.9% vs. 7.3%, P = 0.70; and per non-AF-trigger PV, 7.1% vs. 7.4%, P = 0.92). Atrial tachyarrhythmia-free survival rates off antiarrhythmic drugs after the initial session were comparable at 19.3 ± 6.2 months between the two groups (82% vs. 80%, P = 0.80). Among 22 patients who required a second ablation procedure, there was no difference between the PC and the control groups in the PV reconnection rates at both previously AF-trigger (29% vs. 43%, P = 0.70) and non-AF-trigger PVs (18% vs. 19%, P = 0.88)., Conclusions: Pace-capture-guided ablation performed after contact-force-guided PV isolation demonstrated no improvement in PV isolation durability or rhythm outcome.

Aims: An elevated left atrial pressure has been reported to play an important role in the development of atrial remodelling in atrial fibrillation (AF) patients. The study aimed at elucidating the association between the diastolic early transmitral flow velocity/mitral annular velocity (E/e', a non-invasive surrogate of left atrial pressure) and left atrial low-voltage-area existence, and the prognostic impact of the E/e' on procedural outcomes in patients undergoing AF ablation., Methods and Results: Total of 215 consecutive patients were divided into 3 groups based on the estimated left atrial pressure: normal (E/e' < 8.0, n = 58), undetermined (E/e' = 8.0-14.0, n = 114), and elevated (E/e' > 14.0, n = 43). Left atrial endocardial voltage mapping was performed following pulmonary vein isolation. Patients with a high E/e' more frequently had low-voltage areas (E/e' < 8.0, 31%, E/e' = 8.0-14.0, 35%; E/e' > 14.0, 67%; P = 0.0001). After adjusting for other correlates, a high E/e' was an independent predictor of low-voltage-area existence (HR = 1.11, 95% CI = 1.02-1.21, P = 0.017). During a mean follow-up period of 12 ± 6 months, recurrent atrial tachyarrhythmias occurred in 22 (10%) patients after multiple (1.4 ± 0.5) procedures. Patients with an E/e' > 14 had more frequent recurrent atrial tachyarrhythmias after multiple ablation procedures than those with an E/e' ≤ 14 (23% vs. 7%, P = 0.001)., Conclusion: A high E/e' obtained by pre-ablation echocardiography was associated with a left atrial arrhythmogenic substrate in patients undergoing AF ablation. Furthermore, a high E/e' predicted poor procedural outcomes after pulmonary vein isolation.

A bipolar voltage reflects a thick musculature where formation of a transmural lesion may be hard to achieve. The purpose of this study was to explore the association between local bipolar voltage and conduction gap in patients with persistent atrial fibrillation (AF) who underwent atrial roof or septal linear ablation. This prospective observational study included 42 and 36 consecutive patients with persistent AF who underwent roof or septal linear ablations, respectively. After pulmonary vein isolation, left atrial linear ablations were performed, and conduction gap sites were identified and ablated after first-touch radiofrequency application. Conduction gap(s) after the first-touch roof and septal linear ablation were observed in 13 (32%) and 19 patients (53%), respectively. Roof and septal area voltages were higher in patients with conduction gap(s) than in those without (roof, 1.23 ± 0.77 vs 0.73 ± 0.42 mV, p = 0.010; septal, 0.96 ± 0.43 vs 0.54 ± 0.18 mV, p = 0.001). Trisected regional analyses revealed that the voltage was higher at the region with a conduction gap than at the region without. Complete conduction block across the roof and septal lines was not achieved in 3 (7%) and 6 patients (17%), respectively. Patients in whom a linear conduction block could not be achieved demonstrated higher ablation area voltage than those with a successful conduction block (roof, 1.91 ± 0.74 vs 0.81 ± 0.51 mV, p = 0.001; septal, 1.15 ± 0.56 vs 0.69 ± 0.31 mV, p = 0.006). In conclusion, a high regional bipolar voltage predicts failure to achieve conduction block after left atrial roof or septal linear ablation. In addition, the conduction gap was located at the preserved voltage area., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: The influence of left atrial (LA) enlargement on the efficacy of steerable sheath usage during pulmonary vein (PV) isolation is poorly understood. Here, we compared the catheter-tissue contact force (CF) and clinical outcomes between steerable and non-steerable sheaths among patients with different severities of LA enlargement., Methods: In this prospective observational study, 90 consecutive atrial fibrillation patients scheduled for PV isolation (paroxysmal, 67 %) were enrolled and divided into tertiles of the LA volume (LA1, <124 cm 3 ; LA2, 124 to 145 cm 3 ; LA3, ≥146 cm 3 ). An ipsilateral PV isolation was completed using either a steerable (n = 57) or non-steerable sheath (n = 33)., Results: The average CF of each ipsilateral PV was lower in the LA3 group (right 13.8 ± 5.8 g; left 9.7 ± 5.2 g) than LA1 (right 15.6 ± 6.8 g, p = 0.005; left 12.5 ± 5.6 g, p < 0.0001) or LA2 (right 15.2 ± 7.3 g, p = 0.04; left 12.6 ± 5.3 g, p < 0.0001) groups. In total, the average CF around the left PVs was significantly higher with steerable sheaths than without (12.7 ± 5.5 vs. 10.2 ± 4.9 g, p = 0.03). Subgroup analysis revealed that a tendency toward higher CF around the left PVs was observed in the LA3 group (12.3 ± 7.3 vs. 8.5 ± 3.9 g, p = 0.08) but was not in the LA1 and LA2 groups. Further, in the LA3 group, steerable sheath usage showed better clinical outcomes: shorter procedural (55 ± 29 min vs. 81 ± 39 min, p = 0.04) and fluoroscopic times (27 ± 11 min vs. 37 ± 17 min, p = 0.045) and a tendency toward a lower 1-year AF recurrence rate (39 vs. 12 %, p = 0.09)., Conclusions: The beneficial effects of using steerable sheaths were more prominent in patients with severe LA enlargement.

Background: Recurrent atrial tachyarrhythmias occur as a result of residual atrial arrhythmogenic substrates after atrial fibrillation (AF) ablation. In patients with AF, electrograms with reduced amplitudes indicate diseased myocardium., Objective: The purpose of this study was to investigate the association between the distribution of low-voltage areas and the type of induced atrial tachyarrhythmias., Methods: Our prospective observational study enrolled 152 consecutive AF patients scheduled for an initial ablation (46% persistent AF). After pulmonary vein isolation, voltage mapping was performed during sinus rhythm, and regions with reduced electrogram amplitudes (<0.5 mV) were defined as low-voltage areas. Burst pacing was performed to investigate the inducibility of atrial tachyarrhythmias., Results: Low-voltage areas were more frequently observed in patients with persistent AF than paroxysmal AF (50% vs. 34%, P = .048). A higher proportion of patients with low-voltage areas presented with inducibility of atrial tachyarrhythmias than those without, as follows: AF 70% vs. 16% (P = .0001); perimitral macroreentrant atrial tachycardia (AT) 18% vs. 0% (P = .0001); and roof-dependent macroreentrant AT 13% vs. 0% (P = .01). Investigation into the regional distribution of low-voltage areas revealed that patients with perimitral macroreentrant AT more frequently coincided with low-voltage areas than those without in the septal (100% vs. 18%, P <.0001) and anterior regions (55% vs. 11%, P = .001), and those with roof-dependent AT in the roof (75% vs. 15%, P <.0001) and posterior regions (75% vs. 15%, P = .0001)., Conclusion: Low-voltage areas are associated with high inducibility of atrial tachyarrhythmias after pulmonary vein isolation. In addition, the distribution of low-voltage areas is specific for each type of macroreentrant AT., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Background: Recurrence after catheter ablation of persistent atrial fibrillation (AF) remains an unsolved issue. This study aimed to explore the association between the left atrial appendage peak flow velocity (LAAV) and AF recurrence after ablation in persistent AF patients., Methods: Fifty-three consecutive patients who underwent an initial catheter ablation of persistent AF were enrolled [age, 65±10 years; male, 42 (79%)]. The LAAV was obtained by transesophageal echocardiography before ablation. All the patients underwent pulmonary vein isolation and were followed up for 12 months. The LAAV and other clinical factors (AF duration, CHA2DS2VASc score, left atrial diameter, left atrial volume, and left ventricular ejection fraction) were tested using a Cox proportional hazards regression analysis as predictors of AF recurrence during the 1-year follow-up., Results: AF recurrence occurred in 16 (30%) patients. The patients with AF recurrences had lower LAAVs (23.3±7.2cm/s vs. 33.3±15.1cm/s, p=0.002) than those without AF recurrence. In the multivariable analysis, a low LAAV independently predicted AF recurrence (hazard ratio, 3.04; 95% confidence interval, 1.05-8.79; p=0.040). A Kaplan-Meier analysis also demonstrated a lower survival rate free from AF recurrence in the low LAAV group than in the high LAAV group (p=0.030)., Conclusion: A low LAAV was associated with AF recurrence after the initial catheter ablation of persistent AF., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Concealed sinus node dysfunction (SND) may become manifest after restoration of sinus rhythm by ablation in patients with persistent atrial fibrillation (AF). The purpose of this study was to investigate the predictors of SND after catheter ablation of persistent AF., Methods: Two hundred two consecutive patients who underwent ablation for persistent AF were enrolled. Ipsilateral pulmonary vein isolation followed by, if necessary, electrical cardioversion were performed in all patients. SND was defined when temporary and/or permanent pacemakers were needed due to sinus bradycardia after ablation., Results: SND developed in 12 (5.9 %) patients. There was no difference between the patients with and without SND in terms of the age (with SND, 67 ± 9 and without, 66 ± 10 years old, P = 0.599) and sex (male; 58 vs. 79 %, P = 0.186). However, the patients with SND had a lower amplitude of the fibrillatory waves (0.115 ± 0.086 vs. 0.176 ± 0.077 mV, P = 0.009) and larger left atrial volume index (LAVI; 66 ± 31 vs. 34 ± 13, P = 0.007) than those without. A receiver operating characteristic curve identified a fibrillatory wave amplitude of 0.145 mV (AUC = 0.742; sensitivity = 65 %; specificity = 83 %) and LAVI of 47.5 ml/m(2) (AUC = 0.837; sensitivity = 82 %; specificity = 87 %) as the optimal cutoff values for predicting SND. A multivariate analysis revealed that the amplitude of the fibrillatory waves (odds ratio = 0.84 for 0.010 mV increase, 95 % CI = 0.71-0.98, P = 0.031) and LAVI (odds ratio = 1.08 for 1.0 cm(3)/m(2) increase, 95 % CI = 1.04-1.12, P < 0.001) were independent risk factors for SND., Conclusions: A low amplitude of the fibrillatory waves and a large LAVI were predictors of SND after restoration of sinus rhythm by ablation in patients with persistent AF.

Aims: Previous studies could not demonstrate any benefit of more intensive ablation in addition to pulmonary vein isolation (PVI) including complex fractionated atrial electrogram (CFAE) and linear ablation for recurrence in the initial catheter ablation of persistent atrial fibrillation (AF). This study aimed to establish the non-inferiority of PVI alone to PVI plus these additional ablation strategies.Methods and Results: Patients with persistent AF who underwent an initial catheter ablation (n = 512, long-standing persistent AF; 128 cases) were randomly assigned in a 1:1 ratio to either PVI alone (PVI-alone group) or PVI plus CFAE and/or linear ablation (PVI-plus group). After excluding 15 cases who did not receive procedures, we analysed 249 and 248 patients, respectively. The primary endpoint was recurrence of AF, atrial flutter, and/or atrial tachycardia, and the non-inferior margin was set at a hazard ratio of 1.43. In the PVI-plus group, 85.1% of patients had linear ablation and 15.3% CFAE ablation. After 12 months, freedom from the primary endpoint occurred in 71.3% of patients in the PVI-alone group and in 78.3% in the PVI-plus group [hazard ratio = 1.56 (95% confidence interval: 1.10-2.24), non-inferior P = 0.3062]. The procedure-related complication rates were 2.0% in the PVI-alone group and 3.6% in the PVI-plus group (P = 0.199).Conclusion: This randomized trial did not establish the non-inferiority of PVI alone to PVI plus linear ablation or CFAE ablation in patients with persistent AF, but implied that the PVI plus strategy was promising to improve the clinical efficacy (NCT03514693). [ABSTRACT FROM AUTHOR]

Aims: Before the discovery of contact-force guidance, eliminating pacing capture along the pulmonary vein (PV) isolation line had been reported to improve PV isolation durability and rhythm outcomes. DRAGON (UMIN-CTR, UMIN000015332) aimed to elucidate the efficacy of pace-capture-guided ablation following contact-force-guided PV isolation ablation in paroxysmal atrial fibrillation (AF) patients.Methods and results: A total of 156 paroxysmal AF patients with AF-trigger ectopies from any of the four PVs induced by isoproterenol were randomly assigned to undergo pace-capture-guided ablation along a contact-force-guided isolation line around AF-trigger PVs (PC group, n = 76) or contact-force-guided PV isolation ablation alone (control group, n = 80). Follow-up of at least 1 year commenced with serial 24 h Holter and symptom-triggered ambulatory monitoring. There was no significant difference in acute PV reconnection rates during a 20 min waiting period after the last ablation or adenosine infusion testing between the PC and the control groups (per patient, 21% vs. 27%, P = 0.27; per AF-trigger PV, 5.9% vs. 7.3%, P = 0.70; and per non-AF-trigger PV, 7.1% vs. 7.4%, P = 0.92). Atrial tachyarrhythmia-free survival rates off antiarrhythmic drugs after the initial session were comparable at 19.3 ± 6.2 months between the two groups (82% vs. 80%, P = 0.80). Among 22 patients who required a second ablation procedure, there was no difference between the PC and the control groups in the PV reconnection rates at both previously AF-trigger (29% vs. 43%, P = 0.70) and non-AF-trigger PVs (18% vs. 19%, P = 0.88).Conclusions: Pace-capture-guided ablation performed after contact-force-guided PV isolation demonstrated no improvement in PV isolation durability or rhythm outcome. [ABSTRACT FROM AUTHOR]

Background The efficacy of low-voltage-guided ablation in addition to pulmonary vein (PV) isolation for atrial fibrillation (AF) has been reported with voltage mapping being performed during sinus rhythm (SR) or AF. The study aimed to compare the left atrial voltage between SR and AF in association with the electrogram waveform. Methods This prospective observational study included 30 consecutive patients with persistent AF. After completion of PV isolation, electrogram points were taken during both SR and AF at the identical locations evenly throughout the left atrium. Electrograms were divided into two types: normal (sharp electrogram with ≤3 peaks or duration <50 ms) and fractionated (>3 peaks and duration ≥50 ms). Results During SR, 14 (47%) patients had low-voltage (0.5 mV) substrate with an area of 6.8 ± 4.5 cm2. In a total of 1,063 point pairs, 135 (13%) demonstrated a fractionated electrogram during SR and 483 (45%) during AF. The locations with fractionated electrograms during AF more frequently showed fractionation during SR compared to those with normal electrograms during AF (23% vs 5%, P < 0.0001), and had lower amplitude during SR (1.47 ± 1.29 mV vs 2.03 ± 1.19 mV, P < 0.0001). Electrogram amplitude was higher during SR than that during AF (1.77 ± 1.27 mV vs 0.96 ± 0.77 mV, P < 0.0001) with a weak correlation (r = 0.56, P < 0.0001). Subgroup analyses revealed that the correlation was relatively strong (r = 0.73, P < 0.0001) among the electrogram amplitudes with normal waveform during SR and AF. Conclusions Significant differences in electrogram voltage and fractionation degree may exist between SR and AF at the same locations in patients with persistent AF. [ABSTRACT FROM AUTHOR]

Introduction: Although catheter ablation (CA) improves the outcome of the atrial fibrillation (AF) patients with low left ventricular ejection fraction (LVEF), it is still unknown whether the outcome of all AF patients with cardiomyopathy (CM) was improved by CA. Hypothesis: AF patients with some types of CM may get a good outcome by CA but AF patients with other types of CM may not. Methods: In multicenter, 60 AF patients with CM who underwent CA at the first time and whose LVEF was 50% or less were studied. All of them were well treated by medication before CA. They were classified by the type of CM into group 1 (dilated CM or tachycardia-induced CM, n=48) and group 2 (Fabry disease, ischemic CM or hypertrophic CM, n=12). Results: There was no difference between the two group in age (group 1; 62±11 years old vs. group 2; 65±15 years old, P=0.461) and LVEF (group 1; 38±9% vs. group 2; 38±10%, P=0.854). Forty patients in group 1 and 5 patients in group 2 were male (83% vs. 42%, P=0.003). Twelve patients in group 1 and 6 patients in group 2 had paroxysmal AF (25% vs. 50%, P=0.091). In group 1, their New York Heart Association (NYHA) classification (before; 1.7 ± 0.9 vs. after; 1.2 ± 0.4, P=0.001) and brain natriuretic peptide (BNP) level (before; 253 ± 397 pg/mL vs. after; 94 ± 140 pg/mL, P<0.001) were significantly improved after CA compared with before CA. In group 2, their NYHA classification (before; 1.8 ± 1.1 vs. after; 1.8 ± 0.9, P=1.000) and BNP level (before; 458 ± 292 pg/mL vs. after; 354 ± 345 pg/mL, P=0.182) were not significantly changed after CA compared with before CA. The improvement of LVEF between before and after CA was significantly higher in group 1 than group 2 (18±11% vs. 5±11%, P=0.001). The mean follow-up period was 1189±696 days. AF recurred more frequently in group2 than group1 (7/12 [58%] vs. 12/48 [25%], Log rank P=0.045). Conclusion: AF patients with dilated CM or tachycardia-induced CM got a good outcome by CA but AF patients with Fabry disease, ischemic CM or hypertrophic CM might not. [ABSTRACT FROM AUTHOR]