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Introduction: Management of patients with long‐standing persistent atrial fibrillation (LSPAF) presents a clinical challenge. Hybrid convergent ablation has been shown to have superior efficacy compared to endocardial‐only ablation. However, data on concomitant left atrial appendage (LAA) management along with hybrid ablation is sparse. Methods: We aimed to evaluate the effectiveness of concomitant hybrid convergent ablation and LAA clipping in patients with LSPAF. We conducted a retrospective analysis of all patients with LSPAF who underwent hybrid surgical ablation with LAA clipping at our institution. The primary endpoint was a recurrence of atrial arrhythmias at 12 months. Further, the durability of surgical left atrial posterior wall ablation was examined during the endocardial catheter ablation using standing electrophysiological criteria. Results: A total of 79 patients were included. Mean age was 63.5 ± 9.6 years, and 71% were males. LAA clipping was performed in 99% of patients. The mean time between the surgical and endocardial stages of the procedure was 2.6 ± 1.7 months. Persistent posterior wall activity was observed in 34.2% (n = 27/79) patients during the endocardial phase of the procedure. Cardiac implantable electronic device was used in 74% of patients for monitoring of recurrence of atrial fibrillation (AF). The primary effectiveness of AF freedom at 12 months was 73.8% (45/61). Over a 12‐month follow‐up period, 11.4% (9/79) of patients required repeat catheter ablation, of which 88.9% (8/9) had evidence of persistent posterior wall activity. Conclusion: Concomitant hybrid convergent ablation and LAA exclusion with an atrial clip provides reasonable long‐term AF‐free survival in patients with LSPAF. Persistent posterior wall activity is seen commonly in patients presenting with recurrent AF following hybrid convergent AF ablation. [ABSTRACT FROM AUTHOR]

Introduction: High‐frequency low‐tidal‐volume (HFLTV) ventilation during radiofrequency catheter ablation (RFCA) for paroxysmal atrial fibrillation (PAF) has been shown to be superior to standard ventilation (SV) in terms of procedural efficiency, acute and long‐term clinical outcomes. Our study aimed to compare ablation lesions characteristics utilizing HFLTV ventilation versus SV during RFCA of PAF. Methods: A retrospective analysis was conducted on patients who underwent pulmonary vein isolation (PVI) for PAF between August 2022 and March 2023, using high‐power short‐duration ablation. Thirty‐five patients underwent RFCA with HFLTV ventilation and were matched with another cohort of 35 patients who underwent RFCA with SV. Parameters including ablation duration, contact force (CF), impedance drop, and ablation index were extracted from the CARTONET database for each ablation lesion. Results: A total of 70 patients were included (HFLTV = 35/2484 lesions, SV = 35/2830 lesions) in the analysis. There were no differences in baseline characteristics between the groups. While targeting the same ablation index, the HFLTV ventilation group demonstrated shorter average ablation duration per lesion (12.3 ± 5.0 vs. 15.4 ± 8.4 s, p <.001), higher average CF (17.0 ± 8.5 vs. 10.5 ± 4.6 g, p <.001), and greater impedance reduction (9.5 ± 4.6 vs. 7.7 ± 4.1 ohms, p <.001). HFLTV ventilation group also demonstrated shorter total procedural time (61.3 ± 25.5 vs. 90.8 ± 22.8 min, p <.001), ablation time (40.5 ± 18.6 vs. 65.8 ± 22.5 min, p <.001), and RF time (15.3 ± 4.8 vs. 22.9 ± 9.7 min, p <.001). Conclusion: HFLTV ventilation during PVI for PAF was associated with improved ablation lesion parameters and procedural efficiency compared to SV. [ABSTRACT FROM AUTHOR]

Background: CARTONET® enables automatic ablation site classification and reconnection site prediction using machine learning. However, the accuracy of the site classification model and trends of the site prediction model for potential reconnection sites are uncertain. Methods: We studied a total of 396 cases. About 313 patients underwent pulmonary vein isolation (PVI), including a cavotricuspid isthmus (CTI) ablation (PVI group) and 83 underwent PVI and additional ablation (i.e., box isolation) (PVI+ group). We investigated the sensitivity and positive predictive value (PPV) for automatic site classification in the total cohort and compared these metrics for PV lesions versus non‐PV lesions. The distribution of potential reconnection sites and confidence level for each site was also investigated. Results: A total of 29,422 points were analyzed (PV lesions [n = 22 418], non‐PV lesions [n = 7004]). The sensitivity and PPV of the total cohort were 71.4% and 84.6%, respectively. The sensitivity and PPV of PV lesions were significantly higher than those of non‐PV lesions (PV lesions vs. non‐PV lesions, %; sensitivity, 75.3 vs. 67.5, p <.05; PPV, 91.2 vs. 67.9, p <.05). CTI and superior vena cava could not be recognized or analyzed. In the potential reconnection prediction model, the incidence of potential reconnections was highest in the posterior, while the confidence was the highest in the roof. Conclusion: The automatic site classification of the CARTONET®R12.1 model demonstrates relatively high accuracy in pulmonary veins excluding the carina. The prediction of potential reconnection sites feature tends to anticipate areas with poor catheter stability as reconnection sites. [ABSTRACT FROM AUTHOR]

Introduction: The underlying risks of asymptomatic embolization during high‐power short‐duration (HPSD) ablation for atrial fibrillation remain unclear. We aimed to evaluate microembolic signals (MESs) during HPSD ablation with power settings of 50 and 90 W in comparison with those during cryoballoon (CB) ablation using a novel carotid ultrasound‐Doppler system that classifies solid and air bubble signals using real‐time monitoring. Methods and Results: Forty‐seven patients underwent HPSD ablation using radiofrequency (RF), and 13 underwent CB ablation. MESs were evaluated using a novel pastable soft ultrasound probe equipped with a carotid ultrasound during pulmonary vein isolation. We compared the detailed MESs and their timing between RF and CB ablations. The number of MESs and solid signals were significantly higher in the RF group than in CB group (209 ± 229 vs. 79 ± 32, p =.047, and 83 ± 89 vs. 28 ± 17, p =.032, respectively). In RF ablation, the number of MESs, solid, and bubble signals per ablation point, or per second, was significantly higher at 90 W than at 50 W ablation. The MESs, solid, and bubble signals were detected more frequently in the bottom and anterior walls of the left pulmonary vein (LPV) ablation. In contrast, many MESs were observed before the first CB application and decreased chronologically as the procedure progressed. Signals were more prevalent during the CB interval rather than during the freezing time. Among the 28 patients, 4 exhibited a high‐intensity area on postbrain magnetic resonance imaging (MRI). The MRI‐positive group showed a trend of larger signal sizes than did the MRI‐negative group. Conclusion: The number of MESs was higher in the HPSD RF group than in the CB group, with this risk being more pronounced in the 90 W ablation group. The primary detection site was the anterior wall of the LPV in RF and the first interval in CB ablation. [ABSTRACT FROM AUTHOR]

Background: Currently, two types of cryoballoon (CB) systems are available for catheter ablation of atrial fibrillation (AF). Since the POLARx (Boston Scientific) is softer during freezing than the Arctic Front Advance Pro (AFA‐Pro; Medtronic), it tends to go more deeply into the pulmonary vein (PV), risking PV stenosis. Methods: Ninety‐one patients underwent initial CB ablation for paroxysmal AF (AFA‐Pro 56; POLARx 35). Twenty‐six from each group were extracted using propensity score matching. The PV cross‐sectional area (PVA) was measured by tracing the area within the PV plane at 5‐mm intervals from the PV ostium in a distal direction for 20 mm or to the bifurcation in each PV. The PVA was compared before and 3 months after ablation. Results: Time to balloon temperatures of −30 and − 40°C was significantly shorter and the nadir temperature was significantly lower with POLARx than with AFA‐Pro. In the left inferior (LI) PV and right superior (RS) PV, the freezing balloon position was significantly deeper in POLARx than in AFA‐pro. The freezing position in RSPV with mild to moderate narrowing was deeper than those without (10.2 ± 3.3 mm vs. 8.2 ± 1.8 mm, p =.01). In RSPV, the reduction of PVA tended to be greater with the POLARx than with the AFA‐Pro (26.1% ± 14.1% vs. 19.9% ± 10.3%, p =.07). Conclusion: There was no significant difference in the incidence of PV stenosis between POLARx and AFA‐Pro. However, if POLARx goes deep into the PVs, we will still have to be careful. [ABSTRACT FROM AUTHOR]

Background: Management of atrial fibrillation (AF) in very severe obese patients is challenging. Cryoballoon ablation (CBA) represents an effective rhythm control strategy. However, data in this patient group were limited. Methods: Highly symptomatic AF patients with body mass index (BMI) ≥ 40 kg/m2 who had failed antiarrhythmic drug therapy and electrocardioversion and failure to achieve targeted body‐weight‐reduction underwent CBA. Results: Data of 72 very severe obese AF patients (Group A) and 129 AF patients with normal BMI (Group B, BMI < 25 kg/m2) were consecutively collected. Group A had significantly younger age (60.6 ± 10.4 vs. 69.2 ± 11.2 years), higher BMI (44.3 ± 4.3 vs. 22.5 ± 1.6 kg/m2). Procedural pulmonary vein isolation (PVI) was successful in all patients (2 touch‐up ablation in Group A). Compared to Group B, Group A had similar procedural (61.3 ± 22.6 vs. 57.5 ± 19 min), similar fluoroscopy time (10.1 ± 5.5 vs. 9.2 ± 4.8 min) but significantly higher radiation dose (2852 ± 2095 vs. 884 ± 732 µGym2). We observed similar rates of real‐time‐isolation (78.6% vs. 78.5%), single‐shot‐isolation (86.5% vs. 88.8%), but significantly longer time‐to‐sustained‐isolation (53.5 ± 33 vs. 43.2 ± 25 s). There was significantly higher rate of puncture‐site‐complication (6.9% vs. 1.6%) in Group A. One‐year clinical success in paroxysmal AF was (Group A: 69.4% vs. Group B: 80.2%; p <.001), in persistent AF was (Group A: 58.1% vs. Group B: 62.8%; p =.889). In Re‐Do procedures Group A had a numerically lower PVI durability (75.0% vs. 83.6%, p =.089). Conclusion: For very severe obese AF patients, CBA appears feasible, leads to relatively good clinical outcome. [ABSTRACT FROM AUTHOR]

Introduction: According to current guidelines, pulmonary vein isolation as first‐line therapy should be considered for patients with atrial fibrillation (AF), however, optimal timing of the procedure is still unknown in patients with heart failure (HF). We aimed to evaluate the effect of early catheter ablation (CA) in patients with HF and left ventricular ejection fraction (LVEF) below 50%. Methods: We analyzed data from a structured registry comprising 227 patients with paroxysmal or persistent AF and HF with LVEF < 50% who underwent radiofrequency CA between 2015 and 2022. Early CA was defined as a procedure performed within 12 months of AF diagnosis. The median follow‐up duration was 1748 (1176.3–2353.5) days, with a minimum follow‐up of 365 days. Our endpoints were AF recurrence after a 3‐months blanking period and all‐cause mortality. Results: Among the 227 patients with a median age of 64.3 years, 97 (42.7%) experienced AF recurrence and 55 (24.2%) died during the follow‐up period. The median LVEF was 40% for early CA and 38% for delayed CA (p =.053). Early CA significantly reduced AF recurrence (HR = 0.25 [0.15–0.42], p <.001), however, the timing of procedure did not affect all‐cause mortality (p =.16). These findings were consistent regardless of AF subtype or the burden of comorbidities, as assessed by the CHA2DS2‐VASc score. Conclusion: The timing of CA of AF appears to be an important factor in patients with HF. Early CA reduced AF recurrence, although it does not impact all‐cause mortality. We found similar results regardless of AF subtype or burden of comorbidities. [ABSTRACT FROM AUTHOR]

Introduction: Numerous P‐wave indices have been explored as biomarkers to assess atrial fibrillation (AF) risk and the impact of therapy with variable success. Objective: We investigated the utility of P‐wave alternans (PWA) to track the effects of pulmonary vein isolation (PVI) and to predict atrial arrhythmia recurrence. Methods: This medical records study included patients who underwent PVI for AF ablation at our institution, along with 20 control subjects without AF or overt cardiovascular disease. PWA was assessed using novel artificial intelligence‐enabled modified moving average (AI‐MMA) algorithms. PWA was monitored from the 12‐lead ECG at ~1 h before and ~16 h after PVI (n = 45) and at the 4‐ to 17‐week clinically indicated follow‐up visit (n = 30). The arrhythmia follow‐up period was 955 ± 112 days. Results: PVI acutely reduced PWA by 48%–63% (p <.05) to control ranges in leads II, III, aVF, the leads with the greatest sensitivity in monitoring PWA. Pre‐ablation PWA was ~6 µV and decreased to ~3 µV following ablation. Patients who exhibited a rebound in PWA to pre‐ablation levels at 4‐ to 17‐week follow‐up (p <.01) experienced recurrent atrial arrhythmias, whereas patients whose PWA remained reduced (p =.85) did not, resulting in a significant difference (p <.001) at follow‐up. The AUC for PWA's prediction of first recurrence of atrial arrhythmia was 0.81 (p <.01) with 88% sensitivity and 82% specificity. Kaplan–Meier analysis estimated atrial arrhythmia‐free survival (p <.01) with an adjusted hazard ratio of 3.4 (95% CI: 1.47–5.24, p <.02). Conclusion: A rebound in PWA to pre‐ablation levels detected by AI‐MMA in the 12‐lead ECG at standard clinical follow‐up predicts atrial arrhythmia recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) is often performed under general anaesthesia (GA) or deep sedation. Anaesthetic availability is limited in many centers, and deep sedation is prohibited in some countries without anaesthetic support. Very high‐power short duration (vHPSD—90W/4 s) PVI using the Q‐Dot catheter is generally well tolerated under mild conscious sedation (MCS) though an understanding of catheter stability and long‐term effectiveness is lacking. We analyzed lesion metrics and 12‐month freedom from atrial arrythmia with this approach. Methods: Our approach to radiofrequency (RF) PVI under MCS is standardized and includes a single catheter approach with a steerable sheath. We identified patients undergoing Q‐Dot RF PVI between March 2021 and December 2022 in our center, comparing those undergoing vHPSD ablation under MCS (90W/MCS) against those undergoing 50 W ablation under GA (50 W/GA) up to 12 months of follow‐up. Data were extracted from clinical records and the CARTO system. Results: Eighty‐three patients met our inclusion criteria (51 90W/MCS; 32 50 W/GA). Despite shorter ablation times (353 vs. 886 s; p <.001), the 90 W/MCS group received more lesions (median 87 vs. 58, p <.001), resulting in similar procedure times (149.3 vs. 149.1 min; p =.981). PVI was achieved in all cases, and first pass isolation rates were similar (left wide antral circumferential ablation [WACA] 82.4% vs. 87.5%, p =.758; right WACA 74.5% vs. 78.1%, p =.796; 90 W/MCS vs. 50 W/GA respectively). Analysis of 6647 ablation lesions found similar mean impedance drops (10.0 ± 1.9 Ω vs. 10.0 ± 2.2 Ω; p =.989) and mean contact force (14.6 ± 2.0 g vs. 15.1 ± 1.6 g; p =.248). Only median 2.5% of lesions in the 90 W/MCS cohort failed to achieve ≥ 5 Ω drop. In the 90 W/MCS group, there were no procedural related complications, and 12‐month freedom from atrial arrhythmia was observed in 78.4%. Conclusion: vHPSD PVI is feasible under MCS, with encouraging acute and long‐term procedural outcomes. This provides a compelling option for centers with limited anaesthetic support. [ABSTRACT FROM AUTHOR]

Background: Periesophageal vagal nerve injury (PNI) is an unpredictable and serious complication of atrial fibrillation (AF) ablation. We aimed to identify the factors associated with symptomatic PNI. Methods: This study included 1391 patients who underwent ablation index-guided pulmonary vein isolation (PVI) using the CARTO system. The target ablation index was set at 550, except for the left atrial (LA) posterior wall near the esophagus, where radiofrequency (RF) power and duration were limited. Ten patients (0.72%) were diagnosed with symptomatic PNI. We randomly selected 40 patients without PNI (1:4 ratio) matched based on age, sex, body mass index, LA diameter, type of AF, and esophageal location. We measured the shortest distance from the RF lesions to the esophagus (LED) and classified the RF lesions according to the LED into four groups: 0--5, 5--10, 10--15, and 15--20 mm. We conducted a comparative analysis of classified RF lesions between patients with PNI (n = 10) and those without (n = 40). Results: The contact force at LED 0--5 mm was significantly higher in patients with PNI than in those without (14.6 ± 1.7 vs. 12.0 ± 2.9 g; p = .01). Multivariate logistic analysis revealed that the independent factor for PNI was contact force at an LED of 0--5 mm (odds ratio: 1.506; 95% confidence interval: 1.053--2.153; p = .025). Conclusions: The symptomatic PNI was significantly associated with a higher contact force near the esophagus. Strategies for regulating contact force near the esophagus may aid in the prevention of PNI. [ABSTRACT FROM AUTHOR]

Introduction: Pulsed field ablation (PFA) has emerged as an innovative technique for pulmonary vein isolation (PVI). Typically, a transeptal puncture (TSP) with a standard sheath precedes a switch to the larger diameter sheath in the left atrium. This study aimed to describe the safety and feasibility of direct TSP using the large diameter Faradrive sheath before performing PVI with PFA. Methods: We prospectively enrolled 166 consecutive patients with paroxysmal or persistent atrial fibrillation (AF) undergoing PVI with PFA at our institution. TSP was performed in all cases with transesophageal echocardiography guidance, using the Faradrive sheath and a 98 cm matched Brockenbrough needle. The primary endpoint was the occurrence of pericardial tamponade during or within the first 48 h after the procedure. The secondary endpoint was the occurrence of any major complication. Results: All 166 patients were included into the final analysis (44% female): 64% of patients had paroxysmal AF and 36% persistent AF (68 ± 11 years old, median CHA2DS2Vasc Score 3, median left atrial volume index 31). The median duration of the procedure was 60 min, median time to TSP was 15 min, and the median fluoroscopy dose was 595 cGy × cm2. The primary endpoint occurred in one patient: a non‐TSP related pericardial tamponade, which was managed with pericardial puncture. Conclusion: Direct TSP with skipping sheath exchange using the large diameter Faradrive sheath for PVI with PFA was safe, feasible, and reduced costs in all patients. Large scale studies and registries are needed to verify this workflow. [ABSTRACT FROM AUTHOR]

Introduction: The optimized ablation index (AI) value for catheter ablation of atrial fibrillation (AF) remains to be defined. We aimed to compare the efficacy and safety of CLOSE protocol and lower AI protocol in paroxysmal AF. Methods and Results: Patients with symptomatic, drug‐resistant paroxysmal AF for first ablation were prospectively enrolled from September 2020 to January 2022. The patients were randomly divided into CLOSE group (AI ≥ 550 for anterior/roof segments and ≥400 for posterior/inferior segments) and lower AI group (AI ≥ 450 for anterior/roof segments and ≥350 for posterior/inferior segments). First‐pass isolation, acute pulmonary vein (PV) reconnections, 1‐year arrhythmia recurrence, and major complications were assessed. Of the 270 enrolled patients, 238 completed 1‐year follow‐up (118 in CLOSE group and 120 in lower AI group). First‐pass isolation in left PVs was higher in CLOSE group (71.2% vs. 53.3%, p =.005). Acute PV reconnections were comparable between groups (9.3% vs. 14.2%, p =.246). At 1 year, 86.4% in CLOSE group versus 81.7% in lower AI group were free from atrial arrhythmia (log rank p =.334). The proportion difference was −4.8% (95% CI: −14.1% to 4.6%), and p =.475 for noninferiority. Stroke occurred in four patients of lower AI group, and no cardiac tamponade, atrioesophageal fistula, major bleeding or death occurred post procedure. Conclusion: For patients with paroxysmal AF and treated by AI‐guided PV ablation, lower AI is not noninferior to CLOSE protocol. [ABSTRACT FROM AUTHOR]

Introduction: During atrial fibrillation ablation (AFA), achievement of first pass isolation (FPI) reflects effective lesion formation and predicts long‐term freedom from arrhythmia recurrence. We aim to determine the clinical and procedural predictors of pulmonary vein FPI. Methods: We reviewed AFA procedures in a multicenter prospective registry of AFA (REAL‐AF). A multivariate ordinal logistic regression, weighted by inverse proceduralist volume, was used to determine predictors of FPI. Results: A total of 2671 patients were included with 1806 achieving FPI in both vein sides, 702 achieving FPI in one, and 163 having no FPI. Individually, age, left atrial (LA) scar, higher power usage (50 W), greater posterior contact force, ablation index >350 posteriorly, Vizigo™ sheath utilization, nonstandard ventilation, and high operator volume (>6 monthly cases) were all related to improved odds of FPI. Conversely sleep apnea, elevated body mass index (BMI), diabetes mellitus, LA enlargement, antiarrhythmic drug use, and center's higher fluoroscopy use were related to reduced odds of FPI. Multivariate analysis showed that BMI > 30 (OR 0.78 [0.64–0.96]) and LA volume (OR per mL increase = 1.00 [0.99–1.00]) predicted lower odds of achieving FPI, whereas significant left atrial scarring (>20%) was related to higher rates of FPI. Procedurally, the use of high power (50 W) (OR 1.32 [1.05–1.65]), increasing force posteriorly (OR 2.03 [1.19–3.46]), and nonstandard ventilation (OR 1.26 [1.00–1.59]) predicted higher FPI rates. At a site level, high procedural volume (OR 1.89 [1.48–2.41]) and low fluoroscopy centers (OR 0.72 [0.61–0.84]) had higher rates of FPI. Conclusion: FPI rates are affected by operator experience, patient comorbidities, and procedural strategies. These factors may be postulated to impact acute lesion formation. [ABSTRACT FROM AUTHOR]

Background: The lesion index (LSI) has been used to estimate lesion formation after radiofrequency catheter ablation. However, the impedance drop and decrease in bipolar amplitude of intracardiac electrograms, which are parameters that are traditionally used to predict effective ablation lesions, are not used to calculate LSI. Therefore, we aimed to investigate the association between LSI and traditional parameters. Methods: We retrospectively investigated 1355 ablation points from 31 patients who underwent LSI‐guided pulmonary vein isolation (PVI) using TactiCath. All points were classified into 3 groups based on the impedance drop: (i) <10 Ω (n = 67), (ii) 10–20 Ω (n = 909), and (iii) >20 Ω (n = 379). The LSI targets were 4.5 for the posterior left atrium and 5.2 for the anterior left atrium. After excluding 583 points at which it was difficult to measure the amplitude, 772 ablation points during sinus rhythm were included in the analysis of bipolar amplitude. Results: The target LSI was achieved at 1177 points (86.9%). The median total impedance drop and amplitude just after ablation were 16.0 [13.0–20.0] Ω and 0.21 [0.14–0.30] mV, respectively. There were significant differences among the 3 groups in the impedance and amplitude before ablation, power, target LSI, final LSI, contact force, and interlesion distance. An impedance drop of >10 Ω or an amplitude reduction of >50% was achieved at 95% and 82% of the study points, respectively. There were no major complications at any of the ablation points. Conclusion: LSI‐guided PVI seemed to be useful for making sufficient ablation lesions, as assessed by the conventional parameters of impedance and amplitude change. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. General anesthesia (GA) resolves the problem of pain intolerability and provides regular respiratory mode which might improve the catheter maneuverability of AF ablation. This study aims to compare the procedural performance of PVI under GA versus conscious sedation (CS) from multiple perspectives. Methods: A total of 36 consecutive patients undergoing first AF ablation under GA were enrolled in GA group. Another 109 patients receiving AF ablation under CS in the same period were selected as the control group. After propensity score matching, 29 matched pairs with similar baseline characteristics were available for further analysis. The AIFV (using AI to analyze the raw data from CARTO3 system) system was used to evaluate six procedural parameters in each PVI procedure. Results: Compared with CS, PVI under GA had a significantly shorter total PVI time (51.4 min vs. 67.8 min; p =.003) and higher radiofrequency ratio (62.6% vs. 55.8%; p =.032). The number of gaps (1.0 vs. 3.0; p <.001) and the rate of break point were significantly lower in the GA group. GA was also associated with a higher effective ablation‐index ratio (87.5% vs. 74.1%; p <.001) and effective force‐over‐time ratio (85.3% vs. 69.2%; p =.001). After a medium follow‐up time of 24 months, 12/29 (41.4%) patients in the CS group and 6/29 (20.7%) patients in the GA group suffered from AF recurrence (p =.156). Conclusions: GA improves the lesion quality and procedural efficiency of PVI from multiple perspectives evaluated by the AIFV system. [ABSTRACT FROM AUTHOR]

Introduction: Pulsed field ablation (PFA) represents a novel, nonthermal energy modality that can be applied for single‐shot pulmonary vein isolation (PVI) in atrial fibrillation (AF). Comparative data with regard to deep sedation to established single‐shot modalities such as cryoballoon (CB) ablation are scarce. The aim of this study was to compare a deep sedation protocol in patients receiving PVI with either PFA or CB. Methods: Prospective, consecutive AF patients undergoing PVI with a pentaspline PFA catheter were compared to a retrospective CB‐PVI cohort of the same timeframe. Study endpoints were the requirements of analgesics, cardiorespiratory stability, and sedation‐associated complications. Results: A total of 100 PVI patients were included (PFA n = 50, CB n = 50, mean age 66 ± 10.6, 61% male patients, 65% paroxysmal AF). Requirement of propofol, midazolam, and sufentanyl was significantly higher in the PFA group compared to CB [propofol 0.14 ± 0.04 mg/kg/min in PFA vs. 0.11 ± 0.04 mg/kg/min in CB (p =.001); midazolam 0.00086 ± 0.0004 mg/kg/min in PFA vs. 0.0006295 ± 0.0003 mg/kg/min in CB (p =.002) and sufentanyl 0.0013 ± 0.0007 µg/kg/min in PFA vs. 0.0008 ± 0.0004 µg/kg/min in CB (p <.0001)]. Sedation‐associated complications did not differ between both groups (PFA n = 1/50 mild aspiration pneumonia, CB n = 0/50, p >.99). Nonsedation‐associated complications (PFA: n = 2/50, 4%, CB: n = 1/50, 2%, p >.99) and procedure times (PFA 75 ± 31, CB 84 ± 32 min, p =.18) did not differ between groups. Conclusions: PFA is associated with higher sedation and especially analgesia requirements. However, the safety of deep sedation does not differ to CB ablation. This study sought to compare the requirements and safety of deep sedation in patients undergoing pulmonary vein isolation (PVI) with either a pentaspline pulsed field ablation (PFA) catheter, a novel energy modality, or cryoballoon (CB) ablation, an established energy source. In 100 patients undergoing PVI (PFA: n = 50, CB: n = 50), the requirement of analgosedation was significantly higher in the PFA group compared to CB, especially with regard to analgesics. There was no difference in sedation‐associated and nonsedation‐associated complications between groups. [ABSTRACT FROM AUTHOR]

Introduction: The circular catheter compatible with current cryoballoon system for atrial fibrillation (AF) ablation is exclusively sensed by impedance‐based electro‐anatomical mapping (EAM) system, limiting the accuracy of maps. We aim to investigate the feasibility and safety of a magnetic‐based circular mapping catheter for AF ablation with cryoballoon. Methods: Nineteen consecutive patients who underwent pulmonary vein isolation (PVI) with cryoballoon for paroxysmal or persistent AF were included. EAMs of left atrium (LA) created by the LASSOSTAR™NAV catheter (Lassostar map) before and after PVI were compared to that generated by a high‐density mapping catheter (Pentaray map) from different aspects including structural similarity, PV angle, LA posterior wall (LAPW) and low voltage areas (LVAs), and the amplitude of far field electrograms (FFEs) recorded by catheters. Results: All patients had successful PVI without major complications. With similar mapping time and density, the LA volume calculated from the Pentaray map and Lassostar map were comparable. There were no significant differences in PV angle of all PVs and PW area (16.8 ± 3.2 vs. 17.1 ± 2.8, p =.516) between Pentaray map and Lassostar map. High structural similarity score was observed between two maps (0.783 in RAO/LAO view and 0.791 in PA view). Lassostar map detected lesser but not statistically significant extension of LVA (13.9% vs. 18.3%, p =.07). Amplitude of FFE was larger at the right superior PV on Lassostar map (0.21 ± 0.16 vs. 0.14 ± 0.11 mV, p =.041) compared to that on the Pentaray map. Conclusion: In our initial experience, PVI with cryoballoon and magnetic‐based circular LASSOSTAR™NAV catheter was safe and effective based on the accurate LA geometry it created. [ABSTRACT FROM AUTHOR]

Introduction: Carina breakthrough (CB) at the right pulmonary vein (RPV) can occur after circumferential pulmonary vein isolation (PVI) due to epicardial bridging or transient tissue edema. High‐power short‐duration (HPSD) ablation may increase the incidence of RPV CB. Currently, the surrogate of ablation parameters to predict RPV CB is not well established. This study investigated predictors of RPV CB in patients undergoing ablation index (AI)‐guided PVI with HPSD. Methods: The study included 62 patients with symptomatic atrial fibrillation (AF) who underwent AI‐guided PVI using HPSD. Patients were categorized into two groups based on the presence or absence of RPV CB. Lesions adjacent to the RPV carina were assessed, and CB was confirmed through residual voltage, low voltage along the ablation lesions, and activation wavefront propagation. Results: Out of the 62 patients, 21 (33.87%) experienced RPV CB (Group 1), while 41 (66.13%) achieved first‐pass RPV isolation (Group 2). Despite similar AI and HPSD, patients with RPV CB had lower contact force (CF) at lesions adjacent to the RPV carina. Receiver operating characteristic (ROC) curve analysis identified CF < 10.5 g as a predictor of RPV CB, with 75.7% sensitivity and 56.2% specificity (area under the curve: 0.714). Conclusion: In patients undergoing AI‐guided PVI with HPSD, lower CF adjacent to the carina was associated with a higher risk of RPV CB. These findings suggest that maintaining higher CF during ablation in this region may reduce the occurrence of RPV CB. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolations (PVI) are being performed using a high‐power, short‐duration (HPSD) strategy. The purpose of this study was to compare the clinical efficacy and safety outcomes of an HPSD versus low‐power, long‐duration (LPLD) approach to PVI in patients with paroxysmal atrial fibrillation (AF). Methods: Patients were grouped according to a HPSD (≥40 W) or LPLD (≤35 W) strategy. The primary endpoint was the 1‐year recurrence of any atrial arrhythmia lasting ≥30 s, detected using three 14‐day ambulatory continuous ECG monitoring. Procedural and safety endpoints were also evaluated. The primary analysis were regression models incorporating propensity scores yielding adjusted relative risk (RRa) and mean difference (MDa) estimates. Results: Of the 398 patients included in the AWARE Trial, 173 (43%) underwent HPSD and 225 (57%) LPLD ablation. The distribution of power was 50 W in 75%, 45 W in 20%, and 40 W in 5% in the HPSD group, and 35 W with 25 W on the posterior wall in the LPLD group. The primary outcome was not statistically significant at 30.1% versus 22.2% in HPSD and LPLD groups with RRa 0.77 (95% confidence interval [CI]) 0.55–1.10; p =.165). The secondary outcome of repeat catheter ablation was not statistically significant at 6.9% and 9.8% (RRa 1.59 [95% CI 0.77–3.30]; p =.208) respectively, nor was the incidence of any ECG documented AF during the blanking period: 1.7% versus 8.0% (RRa 3.95 [95% CI 1.00–15.61; p =.049) in the HPSD versus LPLD group respectively. The total procedure time was significantly shorter in the HPSD group (MDa 97.5 min [95% CI 84.8–110.4)]; p <.0001) with no difference in adjudicated serious adverse events. Conclusions: An HPSD strategy was associated with significantly shorter procedural times with similar efficacy in terms of clinical arrhythmia recurrence. Importantly, there was no signal for increased harm with a HPSD strategy. [ABSTRACT FROM AUTHOR]

Background: Atrial esophageal fistula (AEF) is a lethal complication that can occur post atrial fibrillation (AF) ablation. Esophageal injury (EI) is likely to be the initial lesion leading to AEF. Endoscopic examination is the gold standard for a diagnosis of EI but extensive endoscopic screening is invasive and costly. This study was conducted to determine whether fecal calprotectin (Fcal), a marker of inflammation throughout the intestinal tract, may be associated with the existence of esophageal injury. Methods: This diagnostic study was conducted in a cohort of 166 patients with symptomatic AF undergoing radiofrequency catheter ablation from May 2020 to June 2021. Fcal tests were performed 1–7 days after ablation. All patients underwent endoscopic ultrasonography 1 or 2 days after ablation. Results: The levels of Fcal were significantly different between the EI and non‐EI groups (404.9 µg/g (IQR 129.6–723.6) vs. 40.4 µg/g (IQR 15.0–246.2), p <.001). Analysis of ROC curves revealed that a Fcal level of 125 µg/g might be the optimal cut‐off value for a diagnosis of EI, giving a 78.8% sensitivity and a 65.4% specificity. The negative predictive value of Fcal was 100% for ulcerated EI. Conclusions: The level of Fcal is associated with EI post AF catheter ablation. 125 µg/g might be the optimal cut‐off value for a diagnosis of EI. Negative Fcal could predict the absence of ulcerated EI, which could be considered a precursor to AEF. [ABSTRACT FROM AUTHOR]

Introduction: Atrial tachyarrhythmia recurrence during the blanking period (early ATA) after pulmonary vein isolation (PVI) is associated with an increased risk of later recurrence, but its relationship with pulmonary vein reconduction (PVR) is poorly understood. The objective of the present study was to evaluate the relationship between early ATA and PVR. Second, to provide data on the optimal blanking period by (a) evaluating how the predictive values of ATA for PVR are affected by blanking period duration, and (b) assessing the temporal development in atrial fibrillation (AF) burden. Methods: In this RACE‐AF substudy, 91 patients with paroxysmal AF undergoing PVI randomized to radiofrequency or cryoballoon ablation were included. All patients received an implantable cardiac monitor and underwent a protocol‐mandated repeat procedure after 4–6 months for assessment of PVR. ATA ≥ 30 s. ≤ 90 days after PVI constituted early ATA. Results: PVR was found in 37/54 (69%) patients with early ATA and in 11/37 (30%) patients without (p <.001). The positive predictive value of ATA for PVR was independent of blanking period duration (range 0–90 days). In both patients with and without PVR, AF burden was higher in the first month after PVI, but AF burden from the second month was similar to AF burden after the conventional blanking period. Conclusion: Early ATA indicates PVR, and the positive predictive value is independent of the blanking period duration. Altogether, the results of this study support substantially shortening the blanking period after PVI for paroxysmal AF. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) is a pivotal part of ablative therapy for atrial fibrillation (AF). Currently, there are multiple techniques available to realize PVI, including: manual‐guided cryoballoon (MAN‐CB), manual‐guided radiofrequency (MAN‐RF), and robotic magnetic navigation‐guided radiofrequency ablation (RMN‐RF). There is a lack of large prospective trials comparing contemporary RMN‐RF with the more conventional ablation techniques. This study prospectively compared three catheter ablation techniques as treatment of paroxysmal AF. Methods: This multicenter, prospective study included patients with paroxysmal AF who underwent their first ablation procedure. Procedural parameters (including procedural efficiency), complication rates, and freedom of AF during 12‐month follow‐up, were compared between three study groups which were defined by the utilized ablation technique. Results: A total of 221 patients were included in this study. Total procedure time was significantly shorter in MAN‐CB (78 ± 21 min) compared to MAN‐RF (115 ± 41 min; p <.001) and compared to RMN‐RF (129 ± 32 min; p <.001), whereas it was comparable between the two radiofrequency (RF) groups (p =.062). A 3% complication rate was observed, which was comparable between all groups. At 12‐month follow‐up, AF recurrence was observed in 40 patients (19%) and was significantly lower in the robotic group (MAN‐CB 19 [24%], MAN‐RF 16 [23%], RMN‐RF 5 [8%] AF recurrences, p =.045) (multivariate hazard ratio of RMN‐RF on AF recurrence 0.32, 95% confidence interval: 0.12–0.87, p =.026). Conclusion: RMN‐guided PVI results in high freedom of AF in patients with paroxysmal AF, when compared to cryoablation and manual RF ablation. Cryoablation remains the most time‐efficient ablation technique, whereas RMN nowadays has comparable efficiency with manual RF ablation. [ABSTRACT FROM AUTHOR]

Background: Pulsed‐field ablation (PFA) has emerged as a nonthermal energy source for cardiac ablation, with potential safety advantages over radiofrequency ablation (RFA) and cryoballoon ablation. Objective: To report the preclinical results of a novel hexaspline PFA catheter for pulmonary vein isolation (PVI), and to verify the influence of PFA on esophagus by comparing with RFA. Methods: This study included a total of 15 canines for the efficacy and safety study and four swine for the esophageal safety study. The 15 canines were divided into an acute cohort (n = 3), a 30‐day follow‐up cohort (n = 5) and a 90‐day follow‐up cohort (n = 7), PVI was performed with the novel hexaspline PFA ablation catheter. In the esophageal safety study, four swine were divided into PFA cohort (n = 2) and RFA cohort (n = 2), esophageal injury swine model was adopted, the esophagus was intubated with an esophageal balloon retractor, under fluoroscopy, the DV8 device was inflated with a mixture of saline and contrast and rotated to displace the esophagus rightward and anteriorly toward the ablation catheter in the inferior vena cava (IVC) and right inferior pulmonary vein (PV). Nine PFA applications were delivered at four locations on IVC and two locations on the right inferior PV in the PFA cohort, six RFA applications were delivered at each location in the RFA group. Histopathological analysis of all PVs, esophagus, IVC, and the adjacent lungs was performed. Results: Acute PV isolation was achieved in all 15 canines (100%), with energy delivery times of less than 3 min/animal. In the 30 and 90 days group, the overall success rates were 88.9% and 88.5% per PVs, respectively. Two right superior pulmonary veins (RSPVs) in the 30‐day group, two RSPVs and one left superior PV in the 90‐day group with recovered potentials. At follow‐up, gross pathological examination revealed the lesions around the PVs were continuous and transmural. Masson's trichrome staining revealed the myocardial cells in the PVs became fibrotic, but small arteries and nervous tissue were preserved. Results of swine esophageal injury model revealed the esophageal luminal surface was smooth and without evidence for esophageal injury in the PFA group, whereas obvious ulceration was detected on the esophagus tunica mucosa in the RFA group. Conclusion: In the chronic canine study, PFA‐based PVI were safe and effective with demonstrable sparing of nerves and venous tissue. Compared with RFA, there was also good evidence for safety of PFA, avoiding PV stenosis and esophageal injury. This preclinical study provided the scientific basis for the first‐in‐human endocardial PFA studies. [ABSTRACT FROM AUTHOR]

Introduction: Electrophysiological characteristics of epicardial connections (ECs) in atria and pulmonary veins (PVs) are unclear despite their important contributions to atrial fibrillation (AF). Unidirectional conduction associated with source‐sink mismatch can occur in ECs due to their fine fibers with abrupt changes in orientation. We detailed the prevalence and electrophysiological characteristics of unidirectional conduction in the atria and investigated its association with the clinical manifestation of AF. Methods: This study retrospectively reviewed electrophysiological studies and radiofrequency catheter ablation in 261 consecutive patients with AF. Results: Unidirectional conduction was observed during ablation encircling the PVs in eight (3.1%) patients, and all occurred in the suspected (N = 4) or definitively (N = 4) recognized ECs. These ECs included three intercaval bundles, four septopulmonary bundles, and one Marshall bundle, and were first manifested in a second procedure in 6 (75%) patients. The unidirectional property was from PV to atrium (exit conduction) in all intercaval bundles and three septopulmonary bundles, and from atrium to PV (entrance conduction) in the remaining two bundles. Intercaval bundles acted as a limb of bi‐atrial macro‐reentrant tachycardia (50%, three of the six including previous cases). Ablation of the exit outside the PVs, including the right atrium, eliminated ECs in three (38%) patients. All patients remain free from arrhythmia recurrence after a mean 13‐month follow‐up. Conclusion: A unidirectional conduction property was closely associated with the EC, as estimated by histological findings. Recognition of this fact by electrophysiologists may help to clarify mechanisms for AF and atrial tachycardia and guide the creation of efficient and safe ablation lesion sets. [ABSTRACT FROM AUTHOR]

Introduction: Pulsed field ablation (PFA) is a nonthermal ablative strategy that achieves cell death via electroporation. Herein, we investigated the preclinical safety and efficacy of PFA using two novel 8‐French, 16‐electrode spiral PFA/mapping catheters (ElePulse; CRC EP, Inc.). Methods: Bipolar PFA (>1.8 kV) was performed using 30 s, single‐shot, QRS‐gated applications. Altogether, 94 atrial structures were ablated in 23 swine, one canine, and one ovine, including right and left atria and atrial appendages, pulmonary veins, and superior and inferior (IVC) vena cavae. We also examined the impact of PFA on the phrenic nerve (14 swine) and on a deviated esophagus after delivery of PFA from inside the IVC (five swine). Results: All applications were single‐shot without catheter repositioning. Minimal microbubbling was observed without significant skeletal muscle twitching/activation (mean acceleration: 0.05 m/s2). There was a marked reduction in post‐PFA versus pre‐PFA atrial electrogram amplitude (0.17 ± 0.21 vs. 1.18 ± 1.08 mV; p <.0001). Lesion durability was demonstrated up to 3 months in all targeted tissues. Histologically, lesions were contiguous and transmural, except in the atrial appendage, and without any thermal effects. Magnetic resonance, gross, and histologic examinations of the brain, rete mirabile, and kidneys revealed no thromboembolism. No acute/long‐term phrenic nerve dysfunction was encountered. Although within 2 h of ablation, histologic examinations of the esophagus revealed acute PFA‐related changes in the muscular layer, these completely resolved by 21 ± 5 days. Conclusion: A novel, single‐shot, spiral PFA system is capable of safely creating large, durable atrial lesions without significant adverse effects on the phrenic nerve or the esophagus. [ABSTRACT FROM AUTHOR]

Background: High‐power‐short‐duration (HPSD) radiofrequency (RF) ablation is a viable alternative to low‐power‐long‐duration (LPLD) RF for pulmonary vein isolation (PVI). Nevertheless, trials showed conflicting results regarding atrial fibrillation (AF) recurrences and few data concerning complications. Therefore, we conducted a meta‐analysis of randomized trials comparing HPSD versus LPLD. Methods: We systematically searched the electronic databases for studies published from inception to March 31, 2023 focusing on HPSD versus LPLD. The study endpoints were AF recurrence, procedural times and overall complications. Results: Five studies enrolling 424 patients met the inclusion criteria (mean age 61.1 years; 54.3% paroxysmal AF; mean LVEF 58.2%). Compared to LPLD, HPSD showed a significantly lower AF recurrence rate [16.3% vs. 30,1%; RR: 0.54 (95% CI: 0.38–0.79); p = 0.001] at a mean 10.9 months follow‐up. Moreover, HPSD led to a significant reduction in total procedural time [MD: −26.25 min (95%CI: −42.89 to −9.61); p = 0.002], PVI time [MD: −26.44 min (95%CI: −38.32 to −14.55); p < 0.0001], RF application time [MD: −8.69 min (95%CI: −11.37 to −6.01); p < 0.00001] and RF lesion number [MD: −7.60 (95%CI: −10.15 to −5.05); p < 0.00001]. No difference was found in either right [80.4% vs. 78.2%; RR: 1.04 (95% CI: 0.81–1.32); p = 0.77] or left [92.3% vs. 90.2%; RR: 1.02 (95% CI: 0.94–1.11); p = 0.58] first‐pass isolation and overall complications [6% vs. 3.7%; RR: 1.45 (95%CI: 0.53–3.99); p = 0.47] between groups. Conclusion: In our metanalysis of randomized trials, HPSD ablation appeared to be associated to a significantly improved freedom from AF and shorter procedures, without increasing the risk of complications. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) remains the cornerstone in the treatment of atrial fibrillation (AF). PVI using cryoballoon (CB) technology has emerged as a standard procedure in many centers. Recently, pulsed field ablation (PFA) has been introduced and used to achieve PVI. First data show high acute and favorable long‐term outcomes. So far, data comparing these new "single shot" devices are sparse. We sought to compare procedural and outcome data for first time PFA users versus CB in patients undergoing de novo PVI. Furthermore, potentially postprocedural discomfort and affection of autonomic ganglia were assessed. Methods and Results: A retrospective analysis and comparison of all de novo PVIs with PFA and CB was performed. Furthermore, PFA PVI learning curve was evaluated. During follow‐up, repeat outpatient visits and Holter electrocardiogram were performed to analyze arrhythmia‐free survival. Discomfort analysis was obtained by prescribed analgesic medication within first 48 h after PVI. Potential changes in heart rate (HR) between baseline and at 3‐month follow‐up were evaluated. A total of 108 patients (54 PFA and 54 CB; PFA; 33 (30%) female) with paroxysmal and persistent AF were analyzed. Type of AF was comparable (Patients suffering from PAF: PFA: 16 (30%), CB: 17 (31%), p = 1.0). In 107 (99%) patients, successful PVI was achieved. Transient phrenic palsy omitted complete PVI in one CB patient. A trend for a shorter overall procedure duration was observed in the PFA group (PFA: 64.5 ± 17.5 min; CB: 73.0 ± 24.8 min; p = 0.07). Excluding LA mapping time (first 14 cases), procedure time was significantly shorter using PFA (PFA: 58.0 ± 12.5 min, CB: 73.0 ± 24.8 min, p = 0.0001). Fluoroscopy time was significantly longer for PFA (PFA: 15.3 ± 4.7 min, CB: 12.3 ± 5.3 min; p = 0.001), but significantly less contrast medium was used (PFA: 12 ± 6 mL; CB: 51 ± 29 mL, p < 0.0001). Subgroup analysis of the PFA group revealed a significant shortening of procedure duration over time (first tertile: 72.7 ± 13.5 min, second tertile: 67.3 ± 21.7 min, third tertile: 53.4 ± 9.8 min, first vs. third tertile p < 0.0001). Two cardiac tamponades occurred in the PFA group (p = 0.495), of which one was most likely related to complex transseptal puncture. In the first 48 h after PVI, the number of prescribed analgesics due to postprocedural pain was equal between both groups (PFA: 7 (13%) patients, CB: 10 (19%) patients, p = 0.598). After a FU of 273 ± 129 days, 35 of 47 patients (74%) after PFA and 36 of 50 patients (72%) after CB PVI were free of any atrial arrhythmia (HR: 0.98, p = 0.88). Only in the PFA group, a significant increase in HR 3 months after PVI was observed (pre‐PVI: 61 ± 8 beats/min, post‐PVI: 65 ± 9 beats/min, p = 0.008). Conclusion: The new PFA technology is equally effective and safe as compared to CB for complete PVI with potentially shorter procedure time and significantly less contrast medium. However, AF recurrence rates after PFA PVI seem to be comparable to CB PVI. [ABSTRACT FROM AUTHOR]

Background: Recurrence rates of atrial fibrillation (AF) remain high even after complete wide area circumferential pulmonary vein isolation (PVI). In recent years adjunct posterior wall isolation (PWI) has been performed in patients with more persistent forms of AF but the benefits remain unclear. Aim: The objective of this meta‐analysis was to evaluate the efficacy of adjunct posterior wall isolation in reducing recurrence rates of AF using cryoballoon ablation (CBA). Methods: We searched PubMed, Google Scholar, Clinicaltrials.gov and Cochrane CENTRAL. We included studies comparing PVI to PVI + PWI in patients with either persistent or paroxysmal AF (PAF) undergoing CBA. After data extraction and quality assessment of the studies, we assessed recurrence rates of atrial tachy‐arrhythmias (AF, atrial flutter, and atrial tachycardia) as well as total ablation time and procedural adverse events. Risk ratio (RR), mean difference (MD), and 95% confidence interval (CI) were calculated using Review Manager. Results: Concomitant PWI exhibited a substantial reduction in the risk of AF recurrence (RR: 0.51; 95% CI: 0.42–0.63, p <.00001), as well as all atrial arrhythmias (RR: 0.58; 95% CI: 0.49–0.68, p <.00001). On subgroup analysis, in patients with only PAF, adjunct PWI resulted in significant reduction in recurrence risk of AF (RR: 0.56; 95% CI: 0.41–0.76, p =.0002) as well. There was no significant difference in adverse events between both groups (RR: 0.90; 95% CI: 0.44–1.86; p =.78), whereas total ablation time was significantly increased in PVI + PWI group (MD: 21.75; 95% CI: 11.13–32.37, p <.0001). Conclusion: Adjunct PWI when compared to PVI alone decreases recurrence rates of atrial fibrillation after CBA of patients with persistent as well as paroxysmal atrial fibrillation. [ABSTRACT FROM AUTHOR]

Background: Real‐world clinical data on the adverse events related to the use of cryoballoon catheter for pulmonary vein isolation remains limited. Objective: To report and describe the adverse events related to the use of Artic Front cryoballoon catheters (Arctic Front, Arctic Front Advance, and Arctic Front Advance Pro) reported in the Food and Drug Administration's (FDA) Manufacturers and User Defined Experience (MAUDE) database. Methods: We reviewed all the adverse events reported to the FDA MAUDE database over a 10.7‐year study period from January 01, 2011 to September 31, 2021. All events were independently reviewed by two physicians. Results: During the study period, a total of 320 procedural‐related adverse events reported in the MAUDE database were identified. The most common adverse event was transient or persistent phrenic nerve palsy (PNP), accounting for 48% of all events. This was followed by cardiac perforation (15%), pulmonary vein stenosis (8%), transient ischemic attack or stroke (6%), vascular injury (4%), transient or persistent ST‐elevation myocardial infarction (3%), hemoptysis (2%), pericarditis (2%), and esophageal ulcer or fistula (1%). There were six reported intra‐procedural death events as a result of cardiac perforation. Conclusion: The two most common procedural adverse events associated with cryoballoon ablation were PNP and cardiac perforation. All cases of procedural mortality were due to cardiac perforation. [ABSTRACT FROM AUTHOR]

Introduction: Although left atrial wall thickness (LAWT) is known to be varied, a fixed target Ablation Index (AI) based pulmonary vein isolation (PVI) has been suggested in catheter ablation for atrial fibrillation (AF). We aimed to evaluate the efficacy and safety of PVI applying tailored AI based on LAWT assessed by cardiac computed tomography (CT). Methods: The thick segment was defined as the segment including ≥LAWT grade 3 (≥1.5 mm). The fixed AI strategy was defined as AI targets were 450 on the anterior/roof segments and 350 on the posterior/inferior/carina segments regardless of LAWT. The tailored AI strategy consisted of AI increasing the targets to 500 on the anterior/roof segments and to 400 on the posterior/inferior/carina segments when ablating the thick segment. After PVI, acute pulmonary vein (PV) reconnection, defined by the composite of residual potential and early reconnection, was evaluated. Results: A total of 156 patients (paroxysmal AF 72%) were consecutively included (86 for the fixed AI group and 70 for the tailored AI group). The tailored AI group showed a significantly lower rate of segments with acute PV reconnection than the fixed AI group (8% vs. 5%, p =.007). The tailored AI group showed a trend for shorter ablation time for PVI. One‐year AF/atrial tachycardia free survival rate was similar in two groups (87.2% in the fixed AI group and 90.0% in the tailored AI group, p =.606). Conclusion: Applying tailored AI based on the LAWT was a feasible and effective strategy to reduce acute PV reconnection after PVI. [ABSTRACT FROM AUTHOR]

Introduction: Pulsed‐field ablation (PFA) and the multielectrode radiofrequency balloon (RFB) are two novel ablation technologies to perform pulmonary vein isolation (PVI). It is currently unknown whether these technologies differ in lesion formation and lesion extent. We compared the acute lesion extent after PVI induced by PFA and RFB by measuring low‐voltage area in high‐density maps and the release of biomolecules reflecting cardiac injury. Methods: PVI was performed with a pentaspline catheter (FARAPULSE) applying PFA or with the compliant multielectrode RFB (HELIOSTAR). Before and after PVI high‐density mapping with CARTO 3 was performed. In addition, blood samples were taken before transseptal puncture and after post‐PVI remapping and serum concentrations of high‐sensitive Troponin I were quantified by immunoassay. Results: Sixty patients undergoing PVI by PFA (n = 28, age 69 ± 12 year, 60% males, 39.3% persistent atrial fibrillation [AF]) or RFB (n = 32, age 65 ± 13 year, 53% males, 21.9% persistent AF) were evaluated. Acute PVI was achieved in all patients in both groups. Mean number of PFA pulses was 34.2 ± 4.5 and mean number RFB applications was 8.5 ± 3 per patient. Total posterior ablation area was significantly larger in PFA (20.7 ± 7.7 cm²) than in RFB (7.1 ± 2.09 cm²; p <.001). Accordingly, posterior ablation area for each PV resulted in larger lesions after PFA versus RFB (LSPV 5.2 ± 2.7 vs. 1.9 ± 0.8 cm², LIPV 5.5 ± 2.3 vs. 1.9 ± 0.8 cm², RSPV 4.7 ± 1.9 vs. 1.6 ± 0.5 cm², RIPV 5.3 ± 2.1 vs. 1.6 ± 0.7 cm,² respectively; p <.001). In a subset of 38 patients, increase of hsTropI was higher after PFA (625 ± 138 pg/mL, n = 28) versus RFB (148 ± 36 pg/mL, n = 10; p =.049) supporting the evidence of larger lesion extent by PFA. Conclusion: PFA delivers larger acute lesion areas and higher troponin release upon successful PVI than multielectrode RFB‐based PVI in this single‐center series. [ABSTRACT FROM AUTHOR]

Introduction: Catheter ablation for atrial fibrillation (AF) reduces symptoms and improves the quality of life compared with medical treatment. It is unclear if frailty impacts on the outcome of catheter ablation in patients with symptomatic AF. We sought to evaluate the association between frailty as measured by the validated NHS electronic Frailty Index (eFI) and outcomes post‐AF ablation. Methods: Two hundred forty eight patients who had undergone AF ablation with a mean age of 72.9 ± 5.16 were included in the study retrospectively. The primary endpoint for success was defined as freedom from atrial arrhythmia lasting >30 s beyond the 3‐month blanking periods. Frailty was based on the eFI, and the cohort split into four groups: fit (no frailty), mild, moderate and severe frailty. Results: Frailty was categorized as fit (118/248; 47.6%), mild (66/248; 26.6%), moderate (54/248; 21.8%), and severe (10/248; 4.0%). Freedom from arrhythmia occurred in 167 of 248 (67.3%) patients after a mean follow‐up of 25.8 +/– 17.3 months. Fit patients had significantly greater freedom from arrhythmia (92/118; 78%) compared to mild frailty (40/66; 60.6%, p‐value =.020), moderate frailty (31/54; 57.4%, p‐value =.006), or severe frailty (4/10; 40.0%, p‐value <.001). There was also a significant difference in arrhythmia occurrence between patients with mild frailty and severe frailty (p‐value =.044). Conclusion: Frailty is associated with poorer outcomes in patients undergoing AF ablation. The eFI may be used in the prognostic evaluation of AF ablation outcomes. Further studies are essential to confirm the findings of this study. [ABSTRACT FROM AUTHOR]

Background: Brain natriuretic peptide (BNP) is a marker of myocardial stretch and may have prognostic significance in patients with atrial fibrillation (AF) without heart failure (HF). We investigated the association between baseline BNP levels and arrhythmia recurrence following pulmonary vein isolation (PVI) among patients with persistent AF without HF. Methods: We analyzed 125 patients with persistent AF without HF who had baseline BNP measured from the DECAAF II trial. The primary outcome was arrhythmia recurrence following ablation. The baseline characteristics across the two groups were compared using Chi‐square test and Wilcoxon rank test accordingly. Cox regression analysis was used to analyze the association between baseline BNP levels and the primary outcome. Results: Across the entire cohort, 64 (51%) patients experienced arrhythmia recurrence. When comparing patients who experienced arrythmia recurrence to patients who did not, patients with recurrent arrhythmia had higher levels of pre‐ablation BNP, as evidenced by differences in means (330.05 pg/mL) compared to patients without recurrent arrhythmia (182.39 pg/mL) (p <.05). A cut‐off BNP value of 300 pg/mL provided the largest area under curve (AUC) of receiver‐operating characteristic (ROC) curve on univariate logistic regression. On unadjusted Cox analysis, for every 100 unit increase in BNP, the hazard ratio for the primary outcome increased 1.09 (1.026–1.158) times (p =.004). After adjusting for sex, hypertension, and stroke, the results remained significant (HR = 1.8516, CI 95% [1.0139 – 3.381], p =.045). Conclusion: In the non‐heart failure population, BNP levels predict AF recurrence following PVI in persistent AF patients. [ABSTRACT FROM AUTHOR]

Background: The efficiency of pulmonary vein isolation (PVI) depends on the durability of RF lesions. Recent studies documented sustained continuity of ablation lines, improvements in durability, and expected clinical outcomes through altered settings in duration and power. However, the ablation strategy has not been adapted to this new approach and different biophysics of lesion formation. Purpose: The aim of this study was to demonstrate that by adjusting the ablation approach to the broader geometry of lesions by increasing the minimal spacing between adjacent RF, a further significant reduction of procedural time while maintaining sufficient long‐term outcomes is achievable. Methods: The presented study was a prospective, observational multi‐center trial. The periprocedural data were compared with data from a consecutively collected historical cohort. Results: In total, 196 patients were included (mean age 62 ± 11 years, male 64.3%). Procedural duration, RF time, and LA dwelling time were significantly shorter in the HPSD group compared with the standard group (73 ± 26 min vs. 98 ± 36 min, p <.001; 14 ± 7 min vs. 33 ± 12 min, p <.001; and 59 ± 21 min vs. 77 ± 32 min, p <.001, respectively). Mean AF‐free survival in the first year of follow‐up was 304 ± 14 days in the HPSD group versus 340 ± 10 days in the standard group (log‐rank p =.403). There were no statistically significant differences in the complication rates between the groups. Conclusion: Increasing the minimal distance between individual application points simplifies AF ablation and further reduces procedure time without negative effects on efficacy and safety. Larger studies are needed to optimally utilize this approach. [ABSTRACT FROM AUTHOR]

Introduction: Patients with persistent atrial fibrillation (AF) represent a challenging population for rhythm control therapies. Catheter ablation (CA) with pulmonary vein isolation (PVI) is an effective treatment option for the reduction of the arrhythmic burden. Data regarding the comparability between radiofrequency (RF) and cryoballoon ablation (CRYO) in persistent AF are limited. Methods: This is a prospective, randomized, single‐center study designed to compare the efficacy in terms of rhythm control between RF and CRYO in persistent AF. Eligible participants were randomized 2:1 in two arms: RF and CRYO. The primary endpoint of the study was arrhythmia relapse in the early postprocedural period (first 3 months) and in the middle term follow‐up (3 months to 12 months). Secondary endpoints included procedure duration, fluoroscopy time, and complications. Results: A total of 199 patients participated in the study (133 patients in the RF arm, 66 in the CRYO arm). No statistically significant difference occurred between the two groups regarding the primary endpoint (recurrences ≤3 months: 35.5% RF vs. 37.9% CRYO, p.755, recurrences >3 months: 26.3% RF vs. 27.3% CRYO, p.999). From the secondary endpoints, CRYO was a procedure of significantly shorter duration (75.15 ± 17.21 in CRYO vs. 136.6 ± 43.33 in RF group, p <.05). Conclusion: CRYO and RF ablation appear to be equally effective for rhythm control in patients with persistent AF. CRYO ablation is advantageous in terms of procedure duration. [ABSTRACT FROM AUTHOR]

Background: Although pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation of atrial fibrillation (AF), several studies have illustrated clinical benefits associated with PVI with posterior wall isolation (PWI). Methods: This retrospective study investigated the outcomes of PVI alone versus PVI+PWI performed using the cryoballoon in patients with cardiac implantable electronic devices (CIEDs) and paroxysmal AF (PAF) or persistent AF (PersAF). Results: Acute PVI was achieved in all patients using cryoballoon ablation. Compared to PVI alone, PVI+PWI was associated with longer cryoablation, fluoroscopy, and total procedure times. Adjunct radiofrequency was required to complete PWI in 29/77 patients (37.7%). Adverse events were similar with PVI alone versus PVI+PWI. But at 24 ± 7 months of follow‐up, not only cryoballoon PVI+PWI was associated with improved freedom from recurrent AF (74.3% vs. 46.0%, P =.007) and all atrial tachyarrhythmias (71.4% vs. 38.1%, P =.001) in patients with PersAF, cryoballoon PVI+PWI also yielded greater freedom from AF (88.1% vs. 63.7%, P =.003) and all atrial tachyarrhythmias (83.3% vs. 60.8%, P =.008) in those with PAF. Additionally, PVI+PWI was associated with higher reductions in atrial tachyarrhythmia burden (97.9% vs. 91.6%, P <.001), need for cardioversion (5.2% vs. 23.6%, P <.001) and repeat catheter ablation (10.4% vs. 26.1%, P =.005), and a longer time‐to‐arrhythmia recurrence (16 ± 6 months vs. 8 ± 5 months, P <.001) in both PersAF and PAF patients. Conclusion: In CIED patients with PersAF or PAF, cryoballoon PVI+PWI is associated with a greater freedom from recurrent AF and atrial tachyarrhythmias, as compared to PVI alone during long‐term follow‐up. [ABSTRACT FROM AUTHOR]

Background: Catheter ablation (CA) remains challenging due to suboptimal success rates in persistent atrial fibrillation (AF). Existing mapping technologies cannot reliably distinguish sources in this patient population. Recently, the novel electrographic flow (EGF) mapping system was developed using a modified Horn‐Schunk optical flow algorithm to detect and quantify patterns of electrical wavefront propagation in the atria. Objectives: To test the hypothesis that targeted source ablation based on EGF mapping is superior to empiric AF ablation. Methods: We included all consecutive patients undergoing EGF guided ablation for persistent AF. All patients underwent pulmonary vein isolation (PVI) and were treated with the same EAM system (CARTO). The outcome of PVI+EGF guided CA was compared with data of PVI‐only procedures (PVI‐only group) and PVI plus additional empiric adjunctive linear and substrate ablations (PVI+LINES group). 12‐months outcome as freedom from AF and atrial tachycardia/flutter (AT/AFL), procedural safety and efficiency characterized by procedure duration, fluoroscopy use, radiofrequency applications and duration, were analyzed. Both intention‐to‐treat and per protocol analysis were conducted. Results: A total number of 70 patients (39 in PVI+EGF, 16 in PVI‐only and 15 patients in PVI+LINES group) were enrolled. Intention‐to‐treat analysis showed fewer AF recurrences in PVI+EGF as compared with the PVI‐only or PVI+LINES groups at 12 months (25.6% vs. 62.5% vs. 53.3%, p =.02). There were no differences in AT/AFL recurrence (17.9% vs. 37.5% vs. 20.0%, p =.37). Procedure times were longer in PVI+EGF group (p <.01), and there were no differences in fluoroscopy use (p =.67). Conclusion: Our data suggest that patients treated with EGF‐guided CA developed fewer AF recurrences. Although the procedure times are longer, it seems to be safe and offers a more targeted, patient‐specific ablation strategy beyond PVI than adjunctive empiric lines and substrate ablation in this complex group of patients. [ABSTRACT FROM AUTHOR]

Background: Durable electrical isolation of pulmonary veins (PVs) is associated with better outcomes after atrial fibrillation (AF) ablation, but previous studies of AF recurrence have reported high rates of reconnection despite successful acute isolation. This study aims to quantify historical trends in the durability of PV isolation (PVI) as radiofrequency (RF) ablation catheters, additional ablation technologies, and associated workflows have evolved. Methods: The study population included adult patients receiving a first repeat ablation for AF between September 2013 and July 2019 at the study site. All index ablations were performed at the same site with an RF catheter and included PVI. Three generations of irrigated RF catheters based on the same technology platform were used by the site during the timeframe of this study. Results: A total of 224 patients were included in the analysis. At repeat ablation, the mean number of patients with at least one reconnected PV dropped significantly with subsequent catheter generation, from 78.3% to 56.7% to 27.0% (p <.0001). Moreover, the mean number of reconnected PVs were significantly reduced from 1.48 to 0.92 to 0.47 (p <.0001), representing a 68.3% reduction across the 3 generations of devices. Conclusion: Significant improvement in durable PVI was seen with successive generations of RF catheter over a 6‐year period. In addition to catheter technology, ancillary advances in ablation technologies, workflows, and operator experience likely contributed to these improvements. [ABSTRACT FROM AUTHOR]

Introduction: Routine ultrasound (US) guidance for femoral venous access to decrease vascular complications of atrial fibrillation (AF) ablation procedures has been advocated. However, the benefit has not been unequivocally demonstrated by randomized‐trial data. Methods: Consecutive patients undergoing pulmonary vein isolation (PVI) on uninterrupted anticoagulant treatment were included. A quasi‐random allocation to either US‐guided or conventional puncture group was based on which of the two procedure rooms the patient was scheduled in, with only one of the rooms equipped with a US machine including a vascular transducer. The same four novice operators in rotation, with no relevant previous experience in US‐guided vascular access performed venous punctures in both rooms. Major and minor vascular complications and the rate of prolonged hospitalization were compared. Major vascular complication was defined as groin hematoma, arteriovenous fistula, or pseudoaneurysm. Hematoma was considered as a major vascular complication if it met type 2 or higher Bleeding Academic Research Consortium criteria (requiring nonsurgical, medical intervention by a health care professional; leading to hospitalization or increased level of care, or prompting evacuation). Results: Of the 457 patients 199 were allocated to the US‐guided puncture group, while the conventional, palpation‐based approach was performed in 258 cases. Compared with the conventional technique, US guidance reduced the rate of any vascular complication (11.63% vs. 2.01%, p <.0001), including both major (4.26% vs. 1.01%, p =.038) and minor (7.36% vs. 1.01%, p =.001) vascular complications. In addition, the rate of prolonged hospitalization was lower in the US‐guided puncture group (5.04% vs. 1.01%, p =.032). Conclusion: The use of US for femoral vein puncture in patients undergoing PVI decreased the rate of both major and minor vascular complications. This quasi‐randomized comparison strongly supports adapting routine use of US for AF ablation procedures. [ABSTRACT FROM AUTHOR]

Introduction: Preliminary data suggest that high power short duration (HPSD) ablation for pulmonary vein isolation (PVI) are safe. Limited data are available on its effectiveness. Aim was to evaluate HPSD ablation in atrial fibrillation ablation using a novel Qdot Micro catheter. Methods and Results: Prospective multicenter study evaluating safety and efficacy of PVI with HPSD ablation. First pass isolation (FPI) and sustained PVI was assessed. If FPI was not achieved additional ablation index (AI)‐guided ablation with 45 W was performed and metrics predictive of this were determined. Sixty‐five patients and 260 veins were treated. Procedural and LA dwell time was 93.9 ± 30.4 and 60.5 ± 23.1 min, respectively. FPI was achieved in 47 (72.3%) patients and 231 veins (88.8%) with an ablation duration of 4.6 ± 1.0 min. Twenty‐nine veins required additional AI‐guided ablation to achieve initial PVI with 24 anatomical sites ablated with the right posterior carina being the most common site (37.5%). A contact force of ≥8 g (area under the curve [AUC]: 0.81; p < 0.001) and catheter position variation of ≤1.2 mm (AUC: 0.79; p < 0.001) with HPSD were strongly predictive of not requiring additional AI‐guided ablation. Out of the 260 veins, only 5 (1.9%) veins showed acute reconnection. HPSD ablation was associated with shorter procedure times (93.9 vs. 159.4 min; p < 0.001), ablation times (6.1 vs. 27.7 min; p < 0.001), and lower rates of PV reconnection (9.2% vs. 30.8%; p = 0.004) compared to moderate power cohort. Conclusions: HPSD ablation is an effective ablation modality which results in effective PVI whilst maintaining a safety profile. Its superiority needs to be evaluated in randomized controlled trials. [ABSTRACT FROM AUTHOR]

Guidelines recommend using the CHA₂DS₂‐VASc score to determine anticoagulation decisions in atrial fibrillation (AF) patients, including those who undergo pulmonary vein isolation (PVI), however this may not consistently occur in the real‐world setting because of other clinical factors. We sought to evaluate the anticoagulation prescription rates patterns in AF patients 1 year PVI at our institution. Consecutive AF patients undergoing PVI in our prospective registry during 2014−2018 who were alive at 1‐year post‐PVI were studied. Anticoagulation prescription rates at this time‐point were adjudicated, and correlated to CHA₂DS₂‐VASc score, sex, and heart rhythm status at 1 year. Amongst 4596 patients undergoing PVI, mean age was 64.2 ± 10.0 years, 1328 (28.9%) were female, and based on CHA₂DS₂‐VASc score anticoagulation was not indicated, can be considered and indicated in 872 (19.0%), 1183 (25.7%), and 2541 (55.3%) patients, respectively. At 1‐year after PVI, 3504 (76.2%) patients were on anticoagulation, and 792 (17.2%) had recurrence of AF. Anticoagulation was continued in over half of AF patients without classic CHA₂DS₂‐VASc indication particularly in those with AF recurrence and women, while they were mildly under‐prescribed in those with indication, especially for those without AF recurrence and men. In a large real world cohort of patients after PVI, anticoagulation prescription is not solely depending on the CHA₂DS₂‐VASc score and sex, but also heart rhythm status and other clinical or imaging factors. [ABSTRACT FROM AUTHOR]

Introduction: Reconnections to pulmonary vein (PV) triggers of atrial fibrillation (AF) are the primary cause of AF recurrence after PV isolation (PVI) with radiofrequency (RF) or cryoballoon catheter ablation (CRYO), but method‐specific contributions to PV reconduction pattern and conductive gap location are incompletely understood. Methods: The objective of this radiofrequency versus cryoballoon catheter ablation for paroxysmal atrial fibrillation substudy was to determine procedure‐specific patterns of PV reconduction in a randomized population with protocol‐mandated repeat procedures, irrespective of AF recurrence. Each PV was assessed in turn and PV reconnection sites were identified by high‐density electroanatomical mapping and locating the earliest activation site. Gap locations were verified by PV re‐isolation. Results: In 98 patients, 81% versus 76% previously isolated PVs remained isolated after CRYO versus RF (risk ratio [RR]: 1.06; 95% confidence interval [CI]: 0.96–1.18; p =.28). There were no significant differences for any PV: left superior PV: 90% versus 80%; left inferior PV: 80% versus 78%; right superior PV: 81% versus 80%, and right inferior PV: 76% versus 73%. For each reconnected PV, 34% of ipsilateral PVs were also reconnected after CRYO compared with 64% after RF (RR: 0.54; 95% CI: 0.32–0.90; p =.01). After RF, gaps were clustered by the carina and adjacent segments, whereas they were more heterogeneously distributed after CRYO. Conclusion: Although RF and CRYO produce similar proportions of durably isolated PVs, gap locations appear to develop in procedure‐specific patterns. After RF, ipsilateral PV reconduction is more frequent and gap sites cluster by the carina, suggesting that this region should be selectively ablated for more durable PVI. [ABSTRACT FROM AUTHOR]

The C2HEST score ((coronary artery disease (CAD) or chronic obstructive pulmonary disease (COPD) [C2, 1 point each]; hypertension [H, 1 point]; elderly [E, age ≥75 years, 2 points]; systolic heart failure [S, 2 points]; thyroid disease [T, hyperthyroidism, 1 point]) has been validated for predicting incidental atrial fibrillation (AF) in both the general population and patients with ischemic stroke. The present study evaluated the performance of this score in predicting AF recurrence in 252 patients following cryoballoon ablation (CRYO) for paroxysmal AF. The AF recurrence rate in 3–12 months following CRYO was 20,2%. The predictive value of the C2HEST score was significantly better than that of the CHA2DS2-VASc score ((congestive heart failure, hypertension, age (>65 = 1 point, >75 = 2 points), diabetes, previous stroke/transient ischemic attack (2 points), vascular disease, age 65–74 years, and sex category)) (area under curve [AUC]:.881 vs.741; P =.0017). C2HEST score of ≥2, increased atrial diameter, and E/e' ratio as well as, the presence of COPD and systolic heart failure (SHF) were independent predictors for AF recurrence (P <.05). In patients undergoing CRYO for paroxysmal AF, the C2HEST, a simple clinical score, could be useful to assess the risk of AF recurrence. [ABSTRACT FROM AUTHOR]

Introduction: Pulmonary vein isolation (PVI) is effective at treating 50% of unselected patients with persistent atrial fibrillation (AF). Alternatively, PVI combined with a new ablation strategy entitled the Marshall‐PLAN ensures a 78% 1‐year sinus rhythm (SR) maintenance rate in the same population. However, a substantial subset of patients could undergo the Marshall‐PLAN unnecessarily. It is therefore essential to identify those patients who can be treated with PVI alone versus those who may truly benefit from the Marshall‐PLAN before ablation is performed. In this context, we hypothesized that electrical cardioversion (EC) could help to select the most appropriate strategy for each patient. Methods: In this multicentre, prospective, randomized study, patients with AF recurrence within 4 weeks after EC will be randomized 1:1 to PVI alone or the Marshall‐PLAN. Conversely, patients in whom SR is maintained for ≥4 weeks after EC will be treated with PVI only and included in a prospective registry. The primary endpoint will be the 1‐year SR maintenance rate after a single ablation procedure. Results and Conclusion: The Marshall‐PLAN might be necessary in patients with an advanced degree of persistent AF (i.e., where SR is not maintained for ≥4 uninterrupted weeks after EC). Conversely, in patients with mild or moderate persistent AF (i.e., where SR is maintained for ≥4 weeks after EC), PVI alone might be a sufficient ablation strategy. The PACIFIC trial is the first study designed to assess whether rhythm monitoring after EC could help to identify patients who should undergo adjunctive ablation strategies beyond PVI. [ABSTRACT FROM AUTHOR]

Introduction: Local impedance (LI) parameters of IntellaNav STABLEPOINT for successful pulmonary vein isolation (PVI) of atrial fibrillation (AF) remain unclear. The purpose of this study was to seek LI data achieving successful PVI. Methods: Consecutive AF patients who underwent catheter ablation with STABLEPOINT were prospectively enrolled in two centers. PVI was performed under a constant 35‐or 40‐watt power, 20‐s duration, and >5‐g contact force. The operators were blinded to the LI data. The characteristics of all ablation points with/without conduction gaps (Unsuccess or Success tags) after the first‐attempt PVI were evaluated for the right/left PVs and anterior/posterior wall (RPV/LPV and AW/PW, respectively), and cutoff values of LI data were calculated for successful lesion formation. Results: A total of 5257 ablation points in 102 patients (65 [58–72] years old, 65.7% male) were evaluated. The LI drop values were higher in the Success tags than Unsuccess tags on the LPV‐AW and RPV‐AW/PW (p <.001), except for the LPV‐PW (p =.105). The %LI drop values (LI drop/initial LI) were higher for the Success tags in all areas (15.8 [12.2%–19.6%] vs. 11.6 [9.7%–15.6%] in LPV‐AW: p <.001, 15.0 [11.5%–19.3%] vs. 11.4 [8.7%–17.3%] in LPV‐PW: p =.035, 15.3 [11.5%–19.4%] vs. 9.9 [8.1%–13.7%] in RPV‐AW: p <.001, and 13.3 [10.1%–17.4%] vs. 8.1 [6.3%–9.5%] in RPV‐PW, p <.001). The LI drop and %LI drop cutoff values were 20.0 ohms and 11.6%, respectively. Conclusions: An insufficient LI drop with STABLEPOINT was associated with a gap formation during PVI, and the best cutoff values for the LI drop and %LI drop were 20.0 ohms and 11.6%, respectively. [ABSTRACT FROM AUTHOR]

Background: Renal denervation (RDN) can reduce cardiac sympathetic activity maintained by arterial hypertension (aHT). Its potential antiarrhythmic effect on rhythm outcome in patients with multi‐drug resistant aHT undergoing catheter ablation for atrial fibrillation (AF) is unclear. Methods: The RDN+AF study was a prospective, randomized, two‐center trial. Patients with paroxysmal or persistent AF and uncontrolled aHT (mean systolic 24‐h ambulatory BP > 135 mmHg) despite taking at least three antihypertensive drugs were enrolled. Patients were 1:2 randomized to either RDN+AF ablation or AF‐only ablation. Primary endpoint was freedom from any AF episode > 2 min at 12 months assessed by implantable loop recorder (ILR) or 7d‐holter electrocardiogram. Secondary endpoints included rhythm outcome at 24 months, blood pressure control, periprocedural complications, and renovascular safety. Results: The study randomized 61 patients (mean age 65 ± 9 years, 53% men). At 12 months, RDN+AF patients tended to have a greater decrease in ambulatory BPs but did not reach statistical significance. No differences in rhythm outcome were observed. Freedom from AF recurrence in the RDN+AF and AF‐only group measured 61% versus 53% p =.622 at 12 months and 39% versus 47% p =.927 at 24 months, respectively. Periprocedural complications occurred in 9/61 patients (15%). No patient died. Conclusion: Among patients with multidrug‐resistant aHT and paroxysmal or persistent AF, concomitant RDN+AF ablation was not associated with better blood pressure control or rhythm outcome in comparison to AF‐only ablation and medical therapy. [ABSTRACT FROM AUTHOR]

Introduction: Phrenic nerve (PN) injury is a rare but severe complication of radiofrequency (RF) pulmonary vein isolation (PVI). The objective of this study was to characterize the typical intracardiac course of the PN with a three‐dimensional electroanatomic mapping system, to quantify the need for modification of the ablation trajectory to avoid delivering an ablation lesion on sites with PN capture, and to identify very circumscribed areas of common PNC on the routine ablation trajectory of a RF‐PVI, allowing fast and effective PN screening for everyday usage. Methods: We enrolled 137 consecutive patients (63 ± 9 years, 64% men) undergoing PVI. A detailed high output (20 mA) pace‐mapping protocol was performed in the right (RA) and left atrium (LA) and adjacent vasculature. Results: The right PN was most commonly captured in the superior vena cava at a lateral (50%) or posterolateral (23%) position before descending along the RA either straight (29%) or with a posterolateral bend (20%). In the LA, beginning deep within the right superior pulmonary vein (RSPV), the right PN is most frequently detectable anterolateral (31%), then descends to the lateral proximal RSPV (23%), and further towards the lateral antral region (15%) onto the medial LA wall (12%). To avoid delivering an ablation lesion on sites with PN capture, modification of ablation trajectory was necessary in 23% of cases, most commonly in the lateral RSPV antrum (81%). No PN injury occurred. Conclusion: PN mapping frequently reveals the close proximity of the PN to the ablation trajectory during PVI, particularly in the lateral RSPV antrum. Routine PN pacing should be considered during RF PVI procedures. [ABSTRACT FROM AUTHOR]

Background: Comparative data regarding the effect of percutaneous and thoracoscopic ablation of atrial fibrillation (AF) on cognitive function are very limited. The aim of the study was to determine and compare the effect of both types of ablations on patient cognitive functions in the mid‐term. Methods: Patients with AF indicated for ablation procedure were included. Forty‐six patients underwent thoracoscopic, off‐pump ablation using the COBRA Fusion radiofrequency system, followed by a catheter ablation three months afterward (Hybrid group). A comparative cohort of 53 AF patients underwent pulmonary vein isolation only (PVI group). Neuropsychological examinations were done before and nine months after the surgical or catheter ablation procedure. Neuropsychological testing comprised 13 subtests of seven domains, and the results were expressed as post‐operative cognitive dysfunction (POCD) nine months after the procedure. Results: Patients in both groups were similar with respect to the baseline clinical characteristics; only non‐paroxysmal AF was more common in the hybrid group (98% vs. 34%). Major POCD was present in eight (17.4%) of hybrid patients versus three (5.7%) of PVI patients (p = 0.11), combined (major/minor) worsened cognitive decline was present in 10 (21.7%) hybrid patients versus three (5.6%) PVI patients (p = 0.034). On the other hand, combined (major/minor) improvement was present in 15 (32.6%) hybrid patients versus nine (16.9%) patients in the PVI group (p = 0.099). Conclusion: Hybrid ablation, a combination of thoracoscopic and percutaneous ablation, is associated with a higher risk of cognitive decline compared to sole percutaneous ablation. [ABSTRACT FROM AUTHOR]

Background: Pulmonary vein (PV) stenosis represents a rare but serious complication following radiofrequency ablation of atrial fibrillation with a comprehensive diagnosis including morphological stenosis grading together with the assessment of its functional consequences being imperative within the relatively narrow window for therapeutic intervention. The present study determined the clinical utility of a combined, single-session cardiovascular magnetic resonance (CMR) imaging protocol integrating pulmonary perfusion and PV angiographic assessment for pre-procedural planning and follow-up of patients referred for interventional PV stenosis treatment. Methods: CMR examinations (cine imaging, dynamic pulmonary perfusion, three-dimensional PV angiography) were performed in 32 consecutive patients prior to interventional treatment of PV stenosis and at 1-day and 3-months follow-up. Degree of PV stenosis was visually determined on CMR angiography; visual and quantitative analysis of pulmonary perfusion imaging was done for all five lung lobes. Results: Interventional treatment of PV stenosis achieved an acute procedural success rate of 90%. Agreement between visually evaluated pulmonary perfusion imaging and the presence or absence of a ≥ 70% PV stenosis was nearly perfect (Cohen's kappa, 0.96). ROC analysis demonstrated high discriminatory power of quantitative pulmonary perfusion measurements for the detection of ≥ 70% PV stenosis (AUC for time-to-peak enhancement, 0.96; wash-in rate, 0.93; maximum enhancement, 0.90). Quantitative pulmonary perfusion analysis proved a very large treatment effect attributable to successful PV revascularization already after 1 day. Conclusion: Integration of CMR pulmonary perfusion imaging into the clinical work-up of patients with PV stenosis allowed for efficient peri-procedural stratification and follow-up evaluation of revascularization success. [ABSTRACT FROM AUTHOR]

Background: This study sought to evaluate the short and midterm efficacy and safety of the novel very high power very short duration (vHPvSD) 90 W approach compared to HPSD 50 W for atrial fibrillation (AF) ablation as well as reconnection patterns of 90 W ablations. Methods and Results: Consecutive patients undergoing first AF ablation with vHPvSD (90 W; predefined ablation time of 3 s for posterior wall ablation and 4 s for anterior wall ablation) were compared to patients using HPSD (50 W; ablation index‐guided; AI 350 for posterior wall ablation, AI 450 for anterior wall ablation) retrospectively. A total of 84 patients (67.1 ± 9.8 years; 58% male; 47% paroxysmal AF) were included (42 with 90 W, 42 with 50 W) out of a propensity score‐matched cohort. 90 W ablations revealed shorter ablation times (10.5 ± 6.7 min vs. 17.4 ± 9.9 min; p =.001). No major complication occurred. 90 W ablations revealed lower first pass PVI rates (40% vs. 62%; p =.049) and higher AF recurrences during blanking period (38% vs. 12%; p =.007). After 12 months, both ablation approaches revealed comparable midterm outcomes (62% vs. 70%; log‐rank p =.452). In a multivariable Cox regression model, persistent AF (hazard ratio [HR]: 1.442, 95% confidence interval [CI]: 1.035–2.010, p =.031) and increased procedural duration (HR: 1.011, 95% CI: 1.005–1.017, p =.001) were identified as independent predictors of AF recurrence during follow‐up. Conclusions: AF ablation using 90 W vHPvSD reveals a similar safety profile compared to 50 W ablation with shorter ablation times. However, vHPvSD ablation was associated with lower rates of first‐pass isolations and increased AF recurrences during the blanking period. After 12 months, 90 W revealed comparable efficacy results to 50 W ablations in a nonrandomized, propensity‐matched comparison. [ABSTRACT FROM AUTHOR]